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VOL. XIII NO. 1 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 PUBLICATIONS CAPTAIN J. S. TAYLOR, MEDICAL CORPS, U. S. NAVY IN CHARGE JANUARY, 1919 (QUARTERLY) WASHINGTON GOVERNMENT PRINTING OFFICE 1919 Navy Department, 'Washington, March 20, 1907. This United States Naval Medical Bulletin is published by direction of the department for the timely information of the Medi cal and Hospital Corps of the Navy. r Truman H. Newberry, Acting Secretary. NOTE. Owing to the exhaustion of certain numbers of the Buixetin 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 X, No. 1, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1917. Volume XII, No. 1, January, 1918. Volume XII, No. 3, July, 1918. Volume VII, No. 2, April, 1913. Subscription Pbice of the Bulletin. Subscriptions should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning January 1, $1 ; for foreign subscription add 25 cents for postage. Single numbers, domestic 25 cents; foreign, 31 cents, which includes for eign postage. Exchange of publications will be extended to medical and scientific organiza tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy. Washington, D. C. ii TABLE OF CONTENTS. Page. PREFACE vii FRONTISPIECE: Thomas Henry Huxley. SPECIAL ARTICLES: Heart sounds and their value. By Lieutenant Commander H. A. Hare, Med. Corps, U. S. N. R. F. . 1 Eliminating the epileptic from the navy. By Lieutenant L. E. Biach, Med. Corps, U. 8. N. R. F 6 The use or serum in lobar pneumonia. By Lieutenant E. W. Gould, Med. Corps, U. S. N. R. F., and Lieu tenant M. Shaweker, Med. Corps, U. S. N 16 Diagnosis and treatment of pneumonia and empyema. By Commander F. A. Assereon, Med. Corps., U. S. N., and Lieu tenant W. L. Rathbun, Med. Corps, U. S. N. R. F 26 Development of specific serum therapy in pneumonia. By Lieutenant W. R. Redden, Med. Corps, U. S. N 36 Flatfoot. By Lieutenant Commander L. R. G. Crandon, Med. Corps, U. S. N. R. F 43 Treatment op flat feet. By Lieutenant (J. G.1 S. B. Burk, Med. Corps, U. S. N. R. F 46 Ear protection. By Commander G. B. Trible and Lieutenant S. S. Watkins, Med. Corps, U. S. N 48 HISTORICAL. .Thomas Henry Huxley (1825-1895). By lieutenant Commander F. J. B. Cordeiro, Med. Corps, IT. S. N., Ret 61 EDITORIAL. Accuracy. —Military titles and military behavior. —Shell shock. 71 SUGGESTED DEVICES: Typhoid prophylaxis cards. By Lieutenant Commander R. B. Henry, Med. Corps, U. S. N 77 A SURGICAL DRESSING TRAY FOR SHIPS. By Lieutenant M. J. Price. Med. Corps, U. S. N 78 A USEFUL FLYTRAP. By Lieutenant H. V. Hughens, Med. Corps, U. S. N 80 Scale for measuring flatfoot. By Lieutenant (J. G.) B. Dunham, Med. Corps, U. S. N R. F 82 CLINICAL NOTES: A CASE OF STATUS LYMPHATICU8. • By Lieutenant E. L. Rice, Med. Corps, U. S. N 85 Some practical and theoretical considerations. By Lieutenant Commander J. J. A. McMullin, Med. Corps, U. S. N. 87 ni 1 IV TABLE OF CONTENTS. CLINICAL NOTES— Continued. Page. Pain in right hypochondrium and pernicious anemia. By Lieutenant Commander H. M. Stenhouse, Med. Corps, U. S. N.. 89 Perforating wound op intestine and mesentery. By Lieutenant G. G. Ross, Med. Corps, U. S. N. R. F 93 Treatment op scarlet fever. By Lieutenant Commander W. C. Newton, Med. Corps, U. S. N. R. F. 94 Illustrative cases of atypical acute abdominal conditions. By Lieutenant Commander G. D. Hale and Lieutenant J. C. Adams, Med. Corps, U. S. N 95 Varieties of hypersusceptibility. By Lieutenant L. K. McCafferty, Med. Corps, U. S. N 98 Varix simulating inguinal hernia. By Lieutenant E. J. Cummings, Med. Corps, U. S.N 103 Appendicitis and ruptured meso-appendix artery. By Lieutenant F. H. Bowman, Med. Corps, U. S. N 104 Unusual wound contamination. By Lieutenant E. A. Stephens, Med. Corps, U. S. N 105 Subluxation of vertebra by muscular action. By Commander I. S. K. Reeves and Lieutenant M. K. Miller, Med. Corps, U.S.N 107 Fracture of the skull. By Lieutenant Commander R. I. Longabaugh, Med. Corps, U. S. N.. 108 Report of case of stenosis of wharton's duct. By Lieutenant J. A. Halpin, Med. Corps, U. S. N 108 PROGRESS IN MEDICAL SCIENCES: General medicine. —Status lymphaticus. —Epidemic of intestinal infec tion. —New pathology of syphilis Ill Mental and nervous diseases. —Temperament and psychosis. War neuroses. —Traumatic and emotional psychosis. —War neuroses. —In stinct distortion 117 Surgery. —Fascial transplants. —Chloralose as a general anesthetic 131 Military, legal and industrial. —Treatment of mustard-gas poison ing. —Conference on medico-military administration. —Illegitimacy in Norway. —Prevention of blindness.- —Aniline poisoning. —Immigration statistics. —Preservation of fruit.—Economic and financial assistance given by the United States 133 REPORTS: SUKOICAL EXPERIENCES AT THE FRONT. By Lieutenant G. G.Ross, Med. Corps, U. S.N. R. F 145 Details of transport service. By Lieutenant Commander R. I. Longabaugh, Med. Corps, U. S. N.. 149 Plan of a regimental field hospital. By Lieutenant Commander C. B. Camerer, Med. Corps, U. S. N 156 The preparation of blood stain at the u. s. naval medical school. By Lieutenant Commander G. F. Clark, Med. Corps, and Chief Phar macist's Mate L. F. Shabek, U. S. N 157 Preparation of identification tags. By Lieutenant Commander R. H. Laning, Med. Corps, U. S. N 157 A death following salvarsan. By Lieutenant R. C. Christiansen, Med. Corps, U. S. N 158 Sanitary report on the Island of Corfu. By Lieutenant Commander H. Shaw, Med. Corps, U. S. N 163 TABLE OF CONTENTS. V REPORTS—Continued. Paw. The march and the shoe. By Lieutenant Commander W. L. Mann, Med. Corps, U. S. N 164 Tuberculin test in young adults. By Lieutenant E. Moody, Med. Corps, U. S. N. R. F., and Lieu tenant C. F. Carter, Med. Corps, U. S. N 165 Bed screens in barracks. By Commander P. S. Rossiter, Med. Corps, U. S. N 167 Influenza on a natal transport. By Lieutenant W. F. McAnally, Med. Corps, U. S. N 168 The treatment op chancroids and the prevention of buboes. By Lieutenant G. W. Millett, Med. Corps, U. S. N 170 Record of the navy recruiting station, Pittsburgh, pa. By Lieutenant C. C. Ammerman, Med. Corps, U. S. N. R. F 171 Strength of the navy 172 BOOK NOTICES 173 NOTICE TO SERVICE CONTRIBUTORS 175 PREFACE. The publication and issue of a quarterly bulletin by the Bureau of Medicine and Surgery contemplates the timely distribution of such information as is deemed of value to the personnel of the Medical Department of the Navy in the performance of their duties, with the ultimate object that they may continue to advance in proficiency in respect to all of their responsibilities. It is proposed that the Naval Medical Btjlletin shall embody matters relating to hygiene, tropical and preventive medicine, pa thology, laboratory suggestions, chemistry and pharmacy, advanced therapeutics, surgery, dentistry, medical department organization for battle, and all other matters of more or less professional interest and importance under the conditions peculiar to the service and per taining to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good of the service, out of the experience and observations of the individual. There are many excellent special reports and notes beyond the scope of my annual report being sent in from stations and ships, and by communicating the information they contain (either in their entirety or in parts as extracts) throughout the service, not only will they be employed to some purpose as merited, but all medical officers will thus be brought into closer professional intercourse and be offered a means to keep abreast of the times. Reviews of advances in medical sciences of special professional interest to the service, as published in foreign and home journals, will be given particular attention. While certain medical officers will regularly contribute to this work, it is urged that all others co operate by submitting such abstracts from the literature as they may it any time deem appropriate. Information received from all sources will be used, and the bureau extends an invitation to all officers to prepare and forward, with a view to publication, contributions on subjects relating to the profes sion in any of its allied branches. But it is to be understood that the bureau does not necessarily undertake to indorse all views and opinions expressed in these pages. W. C. Braisted, Surgeon General United States Navy. THOMAS HENRY HUXLEY. 1825-1895. . R^prd'duced from Garrison's History of Medicine by t tie courtesy of W. B. **• - • Saunders Co., Philadelphia, Pa. U. S. NAVAL MEDICAL BULLETIN. Tol. XIII January, 1919. No. 1. SPECIAL ARTICLES. HEART SOUNDS AND THEIR VALUE. Bj Hobart Asiory Hare, M. D., Lieutenant Commander, Medical Corps. United States Naval Reserve Force. A number of years ago I placed the following words on the fly leaf of the seventh edition of my book on " Diagnosis in the Office and the Bedside : " " In the diagnosis of a given disease it is essential that the physician rest his opinion not upon one or two symptoms, but upon a series of symptoms which when properly put together give him a complete, or nearly complete, picture of the malady. It is as futile for a physician to base a diagnosis upon a single symptom as for an architect to attempt to determine the appearance of a house by seeing one of the stones that has been removed from its walls." I quote these words because at the present time it is of infinite importance to the country as well as to the individual that men really capable shall not be classed as incapable, and because the opinion of an examining physician, if in error, may work great harm. It is not many years since the presence of a murmur in the heart was supposed to indicate cardiac therapy, whereas we now know that many hearts which greatly need treatment give rise to no murmur at any time, and in some instances only when the heart becomes strong enough to make a murmur audible. There is in no examination greater need for putting together all of the symptoms before reaching an opinion than when determining the state of the heart, and I am induced to emphasize this point be- eause many persons have been rejected for service when in reality perfectly fit for it. For the sake of brevity I take the liberty of separating heart cases into groups. First, those in whom a mitral systolic murmur is definite, distinct, constant, and well transmitted, and in whom there is a history of rheumatism more or less remote. These patients undoubtedly have an actual valvular lesion and their good health depends upon ade quate compensation, which is only attained by hypertrophy and the 2 Vol. XIII. HAKE HEART SOUNDS AND THEIR VALVE. utilization of some of their cardiac reserve power. It is hardly necessary to state that such persons should be turned down. They are bad risks for service or life insurance. Second, those in whom a definite presystolic purr, or short murmur, is heard inside the nipple line at about the fourth or fifth rib, accom panied by accentuation of the pulmonary second sound, which mur mur is usually made louder by exercise or a fairly full dose of digi talis. If the heart is not tired out, sharp exercise, like the 100-hop test, usually exaggerates this murmur. When the heart is on the verge of fag, however, sharp exercise may cause this murmur to dis appear and the patient becomes dyspnoeic and distressed. This type is also to be definitely turned down. Third, those in whom there is a definite murmur, diastolic in time and clearly aortic in origin. The apex beat is distinctly displaced to the left, downwards, and the heart is manifestly enlarged. Here again there can be no doubt that the man is unfit for service. Fourth, the individual who has an irritable and rapid heart, with poor development as to the vascular and muscular tissues. All the lines of his body slope sharply from behind forward. The line of the jaw drops sharply, the shoulders droop, the ribs droop, and the knees droop. The figure as he stands presents the lines of a cadaver that hangs from. hook or chain. The apex beat of his heart is diffuse, and there is much apparent thrill to the eye of the observer, but little, or none, to the finger tips. Here is a man who lacks tone in his muscular, vascular and nervous systems. He can not stand stress of any kind, he sweats while being examined, particularly prof usely in the axillary spaces and on the hands. He bleeds readily into his great vessels. In such a case, the heart may be devoid of murmur, of arrhythmia, or any other sign of lesion, but its sounds lack tone. Such a case perhaps should be classed as one of " neuro-circulatory asthenia " of Lewis, but it does not belong to the class called by DaCosta the " irritable heart of soldiers " since in these persons the cardiac state is often due to great physical and mental strain, whereas in the type I have described it precedes strain and is practically a congenital defect. Such a case is well represented by a youth who entered the cavalry. Placed on a horse and ordered to charge over a field, in squadron formation, he lasted the charge but fell off as it ended, in a dead faint. He remained cold and pulseless for some hours. He stated that he had had no sense of fear but that it seemed to him as if he could not get his breath and as if all the blood had left his head. Doubtless this was largely true. His neuropathic vas cular system did not meet the strain of excitement and effort. These cases are of course unfit for service, although a gradual course of neurocirculatory training may greatly improve their value as citi zens. No. X. 3 IJARE —HEART SOUNDS AND THEIB VALUE. At this point we approach the border of what may be called " the land of doubt," namely, as to the value of the systolic murmwr at the aortic cartilage transmitted up into the carotid artery, because while it is true that most of these patients should he rejected, many of them are capable of service, and if examined again it may be found that the systolic hum may have disappeared. If the man is over 30 or 35, or there is a history of syphilis or rheumatism at any period in his life, rejection is needful, particularly if the palpable vessels are thickened. It is not necessary in the types so far discvssed to look for collat eral symptoms of cardiac origin, for up to this point he who runs may read what should be done. But now we come to a very considerable class of cases in which much difference of opinion can be conscientiously adhered to. We. are now in the land of doubt and just as any one in doubt looks for all signs which may guide him well, so is it imperative that he study not one but all the stones which will form the arch upon which the decision will rest. Here again we may take up types. First, the well-built, lithe youth, with no rheumatic history, who presents missed beats or extra systoles, which irregularities disappear upon taking the 100-hop test. At times the disorder of these hearts when at rest, and particularly when they are being examined, is very great, but exercise does not cause dyspnoea. These hearts are often met w ith in athletic youths who have begun to lead sedentary lives and who may or may not be still using the amount of tobacco which it may have been their custom to use when leading an out-door life. Occasionally a short, quick, murmur, inconstant, is discoverable, be cause a valve "does not seat well," to use a machinist's phrase. I have watched cases of this kind for many years after first seeing them and they do not come to grief by strenuous exercise; thus one of them was for a number of years a celebrated hockey player, then the captain of one of the great university foot-ball teams, and for more than a year he has been flying in France where he has won the Croix de Guerre. When I last saw him he had found that the only thing that ever caused cardiac irregularities was lack of exercise. This type is a good risk. When, however, such irregularities occur in men past the fourth decade of life and do not pass away on exer cise or increase on exercise they possess great importance. They may be due to the excessive use of tobacco, but if they are associated with high blood pressure are usually grave in nature and deserve very careful study with particular reference to the effect of exercise, the. condition of the blood vessels, and the state of the urine. None of these cases, however, should as a rule be rejected, unless there are evidences of cardio-vascular-renal lesions, until they have been ex 4 HARE HEART SOUNDS AND THEIR VALUE. Vol. XIII. amined with the aid of the electro-cardiograph, or at least with the aid of the polygraph, since a purely physical test may be given an erroneous value. Second, the type that under stress develops a mitral systolic purr. This type was often seen before the war in football players imme diately after a hard game, and in oarsmen after a contest. This murmur disappears on rest. It is "a safety valve murmur," due to relaxation of the mitral ring. This type, other things being equal, is a good risk. The persistence of this murmur for more than an hour or two, particularly if the person be over 30 years of age, raises a question as to the quality of the muscular fibers forming the ring at the base of the mitral leaflets, and indirectly raises a question as to the quality or ability of the entire heart muscle to withstand strain. Third, the type that under the excitement of a physical test pre sents at a point about 1 inch to the left of the sternum, at or above the nipple level, a short flapping or tapping sound, single or double, not transmitted to the nipple, nor up or down. It is not a murmur but a valve sound ; in one sense resembling, except that it is not so loud, the valve sound heard in a motor when climbing a hill which is a little too steep for the high-speed clutch. I wish to put special stress on this sound, as in my experience it has no more significance as to the pres ence of a heart lesion than the twitching of one of the voluntary muscles justifies a diagnosis of chorea. It is sometimes a sign of nervous stress, and may pass away while the patient is being examined. Exercise may or may not dissipate it. Mental quiet often dissipates it. This is a type of case most frequently turned down without ade quate cause. Twenty grains of bromide a few hours before the next examination, alone or with aconite or digitalis, will often let this man pass another test, but even if this tapping valvular sound, heard in the area described, persists, I have never found it to indicate in capacity of the heart for severe effort. This type should not be rejected. Closely allied to this is a systolic sound, not a murmur, heard, when a towel is used for auscultation, between the base of the heart and the apex beat. It is met with in a nervous person with a rapid heart action and resembles the sound " ching ". Often it is heard better on light pressure than on heavy pressure. I described this sound before the Association of American Physicians some years ago. At times it is like a friction sound with a metallic tone. As a rule it is inconstant and is often lost if the patient lies down. It has no evil import. A cardio-pulmonary murmur, heard below the left clavicle on full inspiration or on full expiration, is without significance as to the heart, although it may in some cases indicate trouble in the lung. No. 1. B ISC II—ELIMINATING THE EPILEPTIC EEOM NAVY. 5 Finally, I would like to emphasize two points, one of which has been especially insisted upon by Sir James Mackenzie, who said : " A perfectly sound heart can give rise to murmurs. If the heart is not otherwise impaired, if it is normal in size, normal in rate, and the response to effort is good, ignore the murmur, it makes no difference where you hear it." From what I have already said it is evident that I do not go as far as this very eminent expert in the study of the heart, but his statement is quoted to emphasize the fact that all unusual heart sounds are not evil things. The second point is to recall that the heart is not an isolated organ independent of the nervous system and the rest of the vascular sys tem, nor is it like a piece of machinery made of unyielding metal. Its muscle fibers have play, they vary with every need of the body in that play. Its valves are not rigid, the bases on which these valves rest are not fixed or rigid, and the chordae tendineae constantly vary in their tension ; so, too, do the musculi papillares vary in their form. Last of all it is as important for health and for service that the ves sels shall be elastic and well controlled as that the heart shall be nor mal, for unyielding vessels weary the heart not only by offering undue resistance but by failing in their own contractility to help in the circulation of the blood, as Ludwig and Brunton showed many years ago. Conversely, a vascular system which relaxes unduly when effort is made also exhausts the heart, which works to excess to keep the vessels properly supplied. ELIMINATING THE EPILEPTIC FKOM THE NAVY. By L. E. Bisch, Lieutenant, Medical Corps, United States Naval Reserve Force. In eliminating nervous and mental diseases from the service, one of the puzzling problems that presents itself to the medical officer is the discovery and certain diagnosis of the epileptic. Naturally, a typical grand-mal attack, actually seen by a physician, ought to pre clude beyond peradventure any doubt whatever as to the nature of the disorder. But, unfortunately, it seldom happens that a medical officer has the opportunity of witnessing a seizure throughout its entire course. As a rule, one's judgment must depend largely upon the reports of a man's shipmates, who are untrained observers, and very often the patient's own account is the only source of informa tion. This latter may bear but little semblance to accuracy because of the man's ignorance of what really happens to him, because of memory defect which is present in varying degree in all epileptics, or because his story may be deliberately colored with a view to bringing about a medical survey. Then, again, epileptic seizures seldom fol low the classical picture drawn up in the textbooks, while, lastly, if 6 BISCH ELIMINATING THE EPILEPTIC FROM NAVY. Vol. XIII. one were to include as epileptic only those having definite convulsive seizures, man)7 incipient cases would go by undiagnosed only to be recognized after the disease had developed in all its possibilities, per haps at a stage where deterioration had already worked incurable havoc with the mentality, and perhaps even only after the epileptic's ever-increasing irresponsibility had done definite injury to himself or his associates. For a year, in the course of neuro-psychiatric duties, the writer has come into direct contact with the epileptic as he appears in the naval service. These cases have comprised men in the detention unit, cases revealing themselves in the training stations, men from the re ceiving ship, men from the fleet and patrol boats, cases sent to the naval hospital, court-martial prisoners, and men returned from over seas. Epilepsy appears in all branches of the service, and one may add here, it manifests itself in all degrees of severity, in all forms, and is recognized or discovered at various stages of development. Epilepsy has always been a mysterious and baffling disease. All sorts of theories have been held as to its causation. Being apparently a disturbance of the nervous system and being attended by some degree of violence in its commonly recognized form —the " fit "—may have led to the idea that it was due to some sort of irritation somewhere in the body, causing in some sort of way a nervous explosion. At any rate, on this vague hypothesis surgical interference has fre quently been resorted to and, I dare say, practically every part of the human anatomy has been attacked. Disturbances of the alimentary tract have received considerable attention and without a doubt de fective chemical digestion, toxic states, secretory anomalies, peristal tic sluggishness, ptoses, dilatations and flexions of the organs are found in many epileptics. Circulatory disorders have been suspected and claim has also been made for the isolation of the " bacillus epi- lepticus." The glands of internal secretion, particularly the pitui tary, have been looked upon as possibly bearing a causal relationship to the disease. Lastly, brain lesions, tumors, hemorrhages—all pres sure phenomena in the sensorimotor region of the cortex—have had their particular advocates. Suffice it to say that the cause of epilepsy remains about as baffling as ever. Operations and treatments along such lines have resulted in benefit in isolated cases, but nowhere has the causal relationship between pathology and symptoms remained constant, logical, and clear. At the present time the exact pathology and pathological physiology of epilepsy remain unknown. Epilepsy has been subdivided in various ways by different authors and perhaps the commonest classification is that of grand-mal, petit-mal, Jacksonian seizures and hystero-epilepsy or psychic epi lepsy. The Navy nomenclature employs but two terms : Epilepsy and Jacksonian epilepsy; presumably grouping grand-mal and petit-mal No. 1 BISCH ELIMINATING THE EPILEPTIC FROM NAVY. 7 together, designating as Jacksonian the "cases of localized spasms, and putting the psychic seizures under the heading of hysteria. A grouping like the latter has at least one merit—its simplicity. Yet if it tends to imply that these conditions are definite and well- defined clinical entities, the assumption is not warranted by our pres ent knowledge of the numerous clinical varieties of the disease. If anything at all certain can be said about this strange malady, one may venture to state that epilepsy is not a single disease with but slightly varying symptomotology. Quite the contrary, epilepsy is strikingly variable in its manifestations. There is no set rule as to the age at which it may appear and scores of cases give a history of the first convulsion from babyhood up into the thirties. It seems to be precipitated by manifold causes from such as " indigestible " food to worry or emotional excitement. Its clinical picture is not exactly alike in any two patients and even successive attacks in the same individual show differences. It is but natural that most consideration has for years been given to the convulsion. Its striking dramatic quality was sure to fix the attention and accordingly treatment has often, and still is, directed to this symptom alone. Yet the muscular paroxysm of epilepsy is not the disease. It is about as scientific to say that the convulsion is epilepsy as to say that a rise of temperature means pneumonia. In many cases a careful study will reveal what might be termed the precipitating or exciting causes of the paroxysms. In some patients it will be certain kinds of food, in others constipation, heat exposure, etc. Simply by removing these causes the frequency of attacks can often be reduced. On the other hand, such therapy, even if the usual administration of bromides and a salt-free and meat- free diet be added, does not bring about a cure. Another type of case in which the apparent cause seems close at hand are the traumatic epilepsies. A man falls down a hatch and afterwards suffers periodic convulsions. One naturally deduces that the epilepsy resulted from the fall. Yet this man may have had epi lepsy before he fell, the accident occurring solely because he became dizzy or unconscious and lost his balance. Furthermore, in such cases even a decompression operation may not effect a cure. Again, a man has a convulsion and somehow we suspect specific disease and do a Wassermann. The test shows a strongly positive reaction. How tempting it is to link the two together and diagnose the case as epilepsy due to syphilis. However, we treat the syphilis, finally render the Wassermann negative, and still the convulsions persist. Surely we have not cured the epilepsy. Undoubtedly there are many similar examples where the precipi tating cause or the apparent cause is treated without avail. On the other hand, cases have responded to treatment where one has been 8 BISCH ELIMINATING THE EPILEPTIC FEOM NAVY. VoL XIII. working completely in the dark because neither exciting causes nor apparent causes could be made out. Munson1 puts it this way, " Therapeutic failure is due in such cases to the fact that the syn drome is not the result of one definite factor but rather to the sum of the activity of other causes besides the apparent cause." In a graphic way he goes' on to express the various factors that combine to produce epilepsy in the following mathematical formula : (a plus b, plus c, plus — , plus m, plus n, plus p, plus — , plus se, plus y, plus z) the brain equals the syndrome. In other words, "the sum of certain known causes of epilepsy (a, b, c) added to certain variable quantities (m, n, p) and to certain unknown agencies (x, y, z), all acting together on the brain, produce (=) the syndrome we call epilepsy." As he states further, the value of such a fanciful formula "em phasizes the multiplicity of factors which may be active in any case ; it shows, too, that since the component etiological factors may differ, there may be an almost indefinite number of etiological complexes at the basis of epilepsy syndromes, and hence points out that to some degree each patient with epilepsy is peculiar to himself and is both similar and different from all others; at the same time, by demonstrating the plural nature of the conditions underlying the syndrome, it indicates a comprehensive mode of treatment and ex plains why treatment along narrow conventional lines is so often unsuccessful." With these viewpoints in mind it is obvious that the number of epileptics surveyed from the service would be conditioned largely upon the medical officers' conceptions of what constituted the condi tion. If older theories and groupings were adhered to comparatively few men would be so classified, especially if to make a diagnosis it should be considered necessary to accurately witness a convulsion. But if a broader interpretation of the disease as a syndrome with multiplicity of causes and determinants were adopted, no doubt many more cases would be classified as epileptic than now appear in the health records. The following table shows the classification of 130 epileptics diag nosed by the author. The chief complaint for which the patient was examined is given in each instance, and the tabulation is made according to ages. The cases are classified according to the exist ing nomenclature which ipso facto emphasizes the conclusive seizure or repeated attacks of dizziness, and whenever there were witnesses to such paroxysms they were interviewed. All cases were given an intensive psychiatric examination, consisting of a complete survey of mental and neurological status, of family and personal history, 1J. F. Munson : Modern treatment of nervous and mental diseases, Vol. II, p. 228. No. X. 9 BISCH —ELIMINATING THE EPILEPTIC FROM NAVY. together with the performance of psychological tests. Those that revealed confusion, memory, concentration, or other defects are noted as showing " mental deterioration." The term " recruit " is restricted to men who had but recently entered a training station. a Sun exposure. Observed by witnesses. XXXXXX | Mental deterioration. Petit-mal. 1 Jacksonian. 1 I X W | X X X X X X X X X X X X X X X X X X ...... XXXXXXXXXXXXXXX xxxx ;\ X X X X X X X ... X ... X X ... X ' : xxxx| X X XXXXXX j X ... X X X X X X X X X X X xxxxx X X X X X X ... X X X X X X X X X X X* X X ... i 16 16u 17 13 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 20 20 Complaint reported. Selected at " mast "—asleep on duty Fainting spell History of epileptic attacks Fainting spells Slow at drills and irresponsible Tremor in both hands— had a convulsion History of nervousness and fainting spells History of fainting spells Had two epileptiform seizures Had a fainting spell. Had a spell in detention Had an epileptiform seizure i Had a convulsion Peculiar behavior Had fainting spell in examination room Had a convulsion in hammock Had a convulsion in hospital Had a maniacal attack Had an epileptiform seizure Had a fainting spell do : Nervous and fainting spells Had a convulsion in dentist's chair Selected at "mast" because he gave peculiar excuses for being over leave History of epileptic attacks History of dizzy spells Had "fainting spell " History of having epileptic attacks do Had an epileptiform seizure Dizzy spells Epileptic attack Ear trouble and fainting spells History of epileptic attacks Fainting spells Had a convulsion Nervousness Failure in preliminary testa Tremor in Lands and positive Romberg Selected at "mast" charged with being over leave Illiterate, slow, and childish History of epilepsy Lazy and shiftless Had" a fainting spell Headaches Fainting spells History of epileptic 88977—18 2 10 BISCH —ELIMINATING THE EPILEPTIC FEOM NAVY. Vo Complaint reported. Fainting spells Had a convulsion History of dizzy attacks Nervousness and history of dizzy spells. Fell in a creek and not knowing now it hap pened Low score in preliminary psychological tests — History of having been in an insane asylum Fainting spell ....do do Dizzy spells Fainting spells History of epilepsy History of epileptic attacks Fainting spells and nervousness History of epileptic attacks Diagnosis of epilepsy in health record Had a fainting spell Inability to control mind and having dizzy spells History of epileptic attacks Diagnosis of epilepsy in health record Selected from sick bay because of fainting spell. Convulsions Had an epileptic seizure Fainting spells do do Had a convulsion in operating chair History of epileptic attacks History of fainting spells Having a convulsion Had a "fit" in his hammock Gave history of epireptic attacks Had three epileptiform attacks Had an epileptic attack in detention Convulsions Fainting spells History of epileptic attacks Had an epileptiform attack Childish and silly behavior and always teased . . Had a convulsion Fainting spells Had an epileptic attack in detention Had an epileptiform seizure Diagnosis of epilepsy in health record Epileptiform attacks Had an epileptiform attack in hammock History or dizzy spells History of epilepsy History of epileptic attacks History- of fainting spells and weak heart Convulsions History of convulsions do X X i X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X - X No. 1. 11 BISCH—ELIMINATING THE EPILEPTIC FROM NAVY. Complaint reported. Fainting spells Convulsions Had a convulsion. M M 26 26 26 26 27 27 27 27 27 28 29 29 29 30 30 30 31 32 32 33 33 33 33 33 33 Pains around heart . 33 History of fainting spells 33 Dizzy spells . Pains in head and eyes History of epileptic attacks... Had a convulsion on board ship Had an epileptic attack in building Selected when asking for advice Pains around heart and fainting spells Dizzy spells History of epilepsy Fainting spells - •- Paine in cardiac vicinity and fainting spells . . History of fainting spells Dizzy spells ■ Diagnosis of epilepsy in health record History of epilepsy fdull and apathetic expres sion Fainting spells Dizzy spells Convulsions Continual headache Fainting spells. History of convulsions Fainting spells X X X 1 X X X X x X X X X X X X X X X SUMMARY. 130 77 Number of cases Number observed by witnesses Number of recruits 85 Number having grand-mal attacks only 66 Number having petit-mal attacks only 13 Number having both grand-mal and petit-mal attacks 51 Number of cases diagnosed Jacksonian 2 Number of cases diagnosed hystero-epilepsy 5 Number of cases due to sun exposure 3 Number of cases in which aura was present 13 Number of cases in which mental deterioration was present 70 In the list only three cases appear in which the precipitating cause seemed to be " sun exposure." One of these was a petit-mal case with no deterioration, although the history and general make-up clearly proved epilepsy. The other two cases showed distinct mental deterioration following repeated major seizures. One would naturally suppose that drilling in the sun would be a very favorable cause in precipitating epilectic attacks in one already predisposed before enlistment. As a matter of fact, many cases of 12 BISCH ELIMINATING THE EPILEPTIC FKOM NAVY. Vol. XI IS. fainting and dizziness while at drills were reported and, although notations of the facts observed and the facts brought out by examina tion were made in the health record, the evidence at hand did not seem to warrant a definite diagnosis of epilepsy according to pre scribed standards. The handicap of not being able to secure a previous history from a reliable source free from bias or design other than that of the pa tient himself was especially forceful in these cases. Many of the patients presented what might be called suggestive epileptic consti tutions, but it was felt that here the risk of wrong diagnosis was too great to recommend medical survey. Undoubtedly some of these " sun " cases were truly epileptic. On the other hand, some undoubtedly adjusted themselves later on and, although of epileptic make-up, their ability to adapt themselves *.o their new surroundings and duties was sufficient to prevent further explosions of the " fit-gun." In nine other cases epilepsy was diagnosed in which there were neither witnesses nor mental deterioration. In these, however, the evidence was positive that an epileptic make-up existed, and this make-up alone, aside from the paroxysms, was considered of suffi cient moment to render the men unfit for service of any kind, if not perhaps even dangerous. And this brings up the question of malingering —so important in a military organization. In diagnosing epilepsy its possibility should be held constantly in mind, especially when seizures have not been observed by reliable witnesses and when no mental defects of any kind are present. The whole question of malingering is a fascinating psychological study but the limits of this paper restrict me to stating merely that in my own experience in the Navy not a single case of epilepsy- simulation was found although it was often suspected. "Dejerine1 found no instance of actual malingering among all the nervous cases seen by him during the first six months of the war." And it is in teresting to quote Buzzard * in this connection. He defines a malin gerer as one " who with perfectly clear and well-balanced mind con fesses to himself quite frankly that for some definite purpose he will assume a certain disability." He concludes that persons of this type are extremely rare. Reference has been made in this paper to the epileptic make-up— in other words, the predisposing groundwork which acts as a favor able soil for the sprouting of essential epilepsy as it is commonly conceived. Clark,2 who has studied epilepsy from all points of view » Dgjerine ; Buzzard : Noted In War and Neurosis, by Capt. C. B. Farrar. C. A. M. C Nat. Com. for Mental Hygiene, 1018. •Clark, L. Pierce: Some Suggestions for More Accurate Mental Therapy in Epilepsy; Jour. Am. Med. Assn., July 27, 1018. No. 1. 13 BISCH ELIMINATING THE EPILEPTIC FROM NAVY. for years and is undoubtedly an authority on the subject, describes this summation of predisposing factors as follows: The epileptic constitution, or make-up, has long been recognized as tlie endur ing mental stigma of essential epilepsy itself. Only recently have studies dis closed that the main tenets of such a character are present years before the nervous disorder of epilepsy is shown in fits. The chief instinctive defects of the potentially epileptic individual are egocentricity. supersensitlveness and emo tional poverty. The potential epileptic is intensively self-centered and fails to project his life Interests into his environment in a normal and healthy manner. Partly because of this innate character fault, he is or soon becomes unduly sensitized to all forms of extra stress and annoying demands. He either ex troverts his supersensitlveness by exhibitions of rage and tantrums beyond those which may be seen occasionally in passionate children, or, he introverts this feeling and represses the feelings engendered by his environmental con flict, causing him to develop a very unstable, irritable and sensitive emotional life. This emotional state paves the way for larger and more difficult adapta tions which he can not meet ; outspoken fits may then occur. Previously en dowed with these defective instincts, the increased demands of adolescence and adult life enlarge the difficulties which such Individuals are compelled to meet until they reach the breaking point in a fit or seizure. A disintegration of habits and character, known as deterioration, occurs more easily, in one thus handicapped by a defective endowment. Therefore, mental or behavior de terioration often precedes actual epileptic seizures for a considerable time. The men entering the naval service are young men and many are still in their adolescent period or have but recently emerged from it. A large number come from farming districts where emotional stresses and life's complexities are at a minimum. Very suddenly new and more exacting duties are thrust upon them; many for the first time have left their homes; their altered method of living and even thinking must needs appear cold and severe. Surely, we have here a very exacting test of an individual's ability to adjust himself. And given an epileptic constitution —a tendency to faulty adjust ment—it is small wonder that many cases are overwhelmed, that something breaks, and that the epilepsy at last appears in its more glaring symptoms. This, it would seem, should adequately explain the relatively large number of epileptics found among recruits. Aside from the " chief instinctive defects of the potentially epilep tic individual " rather well-defined behavior characteristics can be discovered after the convulsions have actually developed. These changes are present irrespective of the frequency of attacks —in fact, constitute the behavior noted in epileptics between seizures —and should be distinguished from the well-known mental symptoms when definite dementia has set in. Such epileptics are generally unreliable. They are irritable, unstable, frequently suspicious, and often fly into a rage at the slight est provocation. Some are good-natured and philosophic but even here there is a tendency toward periods of depression and ill-humor, when they are rude and quarrelsome. The disease necessarily re 14 BISCH—ELIMINATING THE EPILEPTIC FROM NAVY. VoL Xlir. stricts freedom of activity and this narrows the field of interest and makes the epileptic self-centered. Due to the chronicity of the seiz ures the epileptic is constantly reminded that he is handicapped, and often this leads to self-pity combined with hypochondriasis and sen- timentalism. They may develop a sympathy-seeking attitude and, in institutions, distinct laziness is common. To maintain self-respect stern discipline is often necessary while others again are most effi cient and happy under gentle guidance. Religious fervor lacking in true piety is not uncommon. As a rule, the sex feelings of epileptics are easily aroused and by many varied stimuli. Ethical judgment is frequently lowered. Between seizures epileptics sometimes display periods of marked confusion in which they may wander off and lose themselves not unlike the automaticlike states seen during grand-mal attacks. Sudden episodes of maniacal excitement have also been noted as well as periods of exaltation with delusional ideas concerning their own cure. Such episodes may have a marked religious coloring. The heredity of epilepsy also throws interesting light on the con dition, and studies of the family trees of epileptics seem to support the view that the epileptic constitution is a thing that can be transmitted. C. B. Davenport and David E. Weeks,1 have carefully investigated 177 pedigrees of epileptics. These findings would seem to indicate that what is transmitted from the parents to offspring in the case of epilepsy is not something present in the germ plasm, but rather that the inherited germ plasm is deficient in something the presence of which in nonepileptics makes for normality. The summary of conclusions in this study follows : 1. The method of field-study of epileptic families combined with the modern biological methods of analysis of hereditary data constitute a vastly improved means of inquiry into Inheritance of epilepsy. 2. Epilepsy and feedle-mindedness show a great similarity of behavior In heredity supporting the hypothesis that each is due to the absence of a pro toplasmic factor that determines complete nervous development. 3. When both parents are either epileptics or feeble-minded all their offspring are so likewise. 4. The conditions named migraine, chorea, paralysis, and extreme nervousness behave as though due to a simplex condition of the protoplasmic factor that conditions complete nervous development; i. e.. persons belonging to these classes usually carry some wholly defective germ cells. Such persons may be called " tainted." 5. When such a tainted individual is mated to a defective about one-half of the offspring are defective. 1 "A First Study of Inheritance in Epilepsy," by C. B. Davenport and David F. Weeks, M. D., Jour. Nerv. and Ment. Disease, vol. 38. no. 11, pp. 641-670, 1011. The study Is on cases at the New Jersey Stale village for epileptics at Sklllman. IhL BISCH—ELIMINATING THE EPILEPTIC FROM NAVY. 15 6. When a simplex normal Is mated with a defective about one-half the offspring are normal ; the others are defective or neurotic. 7. When both parents are simplex in nervous development and tainted about one-quarter (actually 30 per cent) are defective. 8. The proportion of tainted offspring is not noticeably higher when both parents show the same nervous defect. 9. Normal parents that have epileptic offspring usually show gross nervous defect in their close relatives. 10. While we recognize that epilepsy Is a complex, yet there is a classical tjpe numerically so preponderant that, in the mass, epilepsy acts like a unit defect Epilepsy of long standing always leads to dementia. By dementia is meant gradual deterioration of intellectual and emotional proc esses, marked by sluggishness of thinking, haziness of mental im- igery, lowering of the emotional tone, and memory defect. The per sonality of the patient which differentiates him as an individual dis tinct from others gradually disappears; life becomes an existence ind the end-result is a vegetative state in which the patient must be cared for in every way—fed, clothed, and cleansed —the mind no longer being a dynamic, controlling mechanism, but to all practical purposes little more than a functionless organ. This picture of dementia is not overdrawn but its application must be restricted to prevent misconception. There are various degrees of dementia. It is true that all epilepsy leads to dementia but the rap idity of its appearance and the swiftness of its development depends upon the age at onset of the disease, the degree of native mental en dowment, the frequency and severity of attacks, the efficiency of the treatment employed, and the span of life of the patient Only a comparatively few epileptics live long enough for the severe stages of dementia to become manifest, many being carried off by intercur rent diseases, such as pulmonary tuberculosis, pneumonia, etc. The mental effects of epilepsy, in other words, dementia in greater or lesser degree, may be summarized as follows : 1. Sluggishness of thinking. 2. Lengthening of reaction time. 3. Paucity of associations. 4. Lack of productivity. 5. Haziness of mental imagery. 6. Impaired attention and concentration. T. Narrowing of the field of interest. 8. Monotonous speech and thinking. 9. Impaired judgment, reasoning, and powers of inference. 10. Memory defect marked. (a) Immediate or rote memory often tolerably good but soon failing after a few hours or days, except for daily routine impressions. 16 GOULD AND SHAWEKEB SERUM IN LOBAR PNEUMONIA. Vol. XIII. (b) Remote memory fair, but mainly for vivid impressions of childhood or early life, especially as regards mat ters of personal interest, while matters of general in terest and school knowledge are forgotten. (c) Logical memory uniformly poor. 11. General motor retardation and often clumsiness of movement. 12. General emotional deterioration and inadequacy marked by in difference, lowering of emotional tone, etc. Often certain physical signs are of help in diagnosing a doubtful case of epilepsy. Among these may be mentioned a lifeless disin terested expression : vasomotor disturbances ; tendency to obesity ; scars on the tongue, face, and head; "sore" muscles due to nocturnal convulsions; general awkwardness of gait; and the so-called "epilep tic voice sign." which is described by Clarke and Scripture1 as "an expressionless quality of the voice " rendering the speech monotonous, and instead of there being "the continual rise and fall in melody T the vowels and phrases run along on even tones." CONCLUSIONS. 1. Since the epileptic is a peculiar and unreliable individual at any stage of his development—whether actual convulsions have appeared or not—it would seem that, whenever he can be discovered and diagnosed, he should be considered unfit for the naval service, and recommended to a board of medical survey. 2. The obvious places to weed out such cases are the recruiting and training stations. 3. Special attention should be directed toward a previous history of epilepsy in the patient or his family, to the epileptic make-up, to mental deterioration, and to suggestive physical signs. THE USE OF SERUM IN LOBAR PNEUMONIA. By E. W. Gould, Lieutenant, Medical Corps. United States Naval Reserve Force, and M. SrtAWKKEit. Lieutenant, Medical Corps, United States Navy. The use of serum in the treatment of lobar pneumonia during the past few months at the United States Naval Hospital, New York, has followed the generally accepted belief that it is contra-indicated, except in those cases that have been demonstrated to belong to Type I. It has been very difficult to reach definite conclusions in regard to the value of serum in this particular type, because of various factors which it is frequently impossible to control. In spite of specific orders that, when any case of pneumonia is admitted, strenuous efforts should be made at once to secure a satis- 1 Clarke, L. Pierce, and Scripture, E. W. : The Epileptic Voice Sign ; Med. Rec. New York, Oct. 81, 1908. fel. GOULD AND SHAWEKER— -SERUM IN LOBAR PNEUMONIA. 17 factory specimen of sputum and that it be sent to the laboratory with the request that the pneumococcus grouping be determined, Satisfactory specimens frequently can not be secured, many cases sre admitted several days after onset, and unavoidable delays are frequent. The results of typing are, therefore, received in many cases at or about the time of crisis and no serum is indicated. Never theless, it frequently happens that a day or two and sometimes a longer period elapses before results can be obtained. During the past four months 45 cases of Type I have been ad mitted and of that number 25 have received serum. Four deaths have occurred among cases belonging to Type I since we began to demonstrate the type, and these cases will be further described be low. Although this is a very low mortality rate, great credit can not be given to the serum, for there has been undoubtedly a radical change in the virulence of the pneumococcus of all types during the past few months. During the first quarter of 1918 when 155 cases of pneumonia were treated our mortality rate was 21.93 per cent, while only 4 deaths have occurred in the last 85 cases of pneumonia treated at this hospital. The fatal cases all belonged to Type I. It is not the purpose of this short report to express any opinion in regard to the efficacy of serum treatment, but several cases have re cently shown clinical symptoms and definite results which it has seemed advisable to record. The use of serum has brought to our attention several possible criticisms of the ordinary methods employed and has resulted in the adoption of an apparatus devised and described below by one of our number. In all our cases the anaphylactic reaction is determined by the in tradermal injection of a 1 to 10 dilution of normal horse serum with a normal saline control. The serum used was furnished by the Bureau of Medicine and Surgery and was prepared by two commer cial drug firms. Both the Krumweide and mouse methods have been used in de termining the types, and in all cases in which the Krumweide method was successful the mouse method gave the same determina tion. Case I ; T , Eng. 1c. ; age. 45 years. This case was admitted on the first day of his illness, showing physical signs of consolidation in the left lower lobe. There was considerable cardiac embarrassment and stimulants were necessary. There was very marked agglutination by the mouse method, deter mined on the third day of illness. Serum was at once administered ud one-half hour afterward the patient had a severe chill and his temperature rose to 105°. Two hours thereafter, however, his symp 18 GOULD AND SHAWEKER SERUM IN LOBAR PNEUMONIA. Vol. XIII. toms were markedly improved and he made a rapid and uneventful recovery. The severe reaction and chill in this case was thought to be due possibly to the temperature of the serum injected and led to the more exact method of determining this factor, as described below. Only one dose of serum was given. CLINICAL CHART ...CA5..L_-..J.:T. (name.) ' (MAtWiTY) JEttGJ* (R. 'c Sate.) PNEU' 45 _ W. (AGE.) (COLOR) JULY 1 5 H c: B (OtDtPOOPpOpPS HLMATLK8 f zz r" 5 -0 1 AM&ULANCL3TR.lTCHLKA5[ l 4Pf 120 28 ! 6 no 40 \ 5LD BATH. li I 8 11254 ; x 12 I2f 60 : ! 4 11260 1i / 8 IOC 50 < 12 10430 ii 24 3 4 98 52 : 8 102M i ||4p AM.«te«ANTIPNLUM0C0CCU6 I2£B I1C 5b k E.CT\l 6LR.UM. 2J0 15058 i 12.15 T0 |2« CH|LL i 4 96 52 i 2*? vSPONGL 8 96 54 12 m 22 > 25 4 a so 24 12 74 20 4 72 22 8 66 22 \ 26 5 8 90 ZA 12. 88 22 i 4 80 54 8 82 24 I 27 k 8 80 26 v*n 12 92 26 H 4 90 38 i 8 8fi 56 i\ 26 7 8 12 96 40 i 86 54 4 66 52 i u 8 84 64 I i i Case II; F , M. M. 2c; age, 25 years. This case was admitted on the first day of illness and he was not so seriously ill, although he had distinct signs of consolidation in the left lower lobe. He showed immediate response to the serum, though not so marked as in the preceding case, and four doses were given before satisfactory results were obtained. No. 1. GOULD AND SHAWEKEB SEBUM IN LOBAR PNEUMONIA. 19 Case III ; C , Sea. 2c. ; age, 18 years. This patient was admitted on the second day of his illness, and shewed signs of consolidation in his right upper and lower lobes. He wTas actively delirious, seemed very toxic, required urgent stim ulation, but in spite of several attempts, the typing was not deter- CAflt.-T-T- (MAKZ.) CLIN1CALCHART ...W.. OUtTt) -H 2 e s M r" i .•73 u n i 5TM 28 \ OTKLTCHLR. Cft^L. 8 34 M ✓ oPM-50ccANTIPNLUMOCOCCU5 12 ice 56 v3LR.UM. ie a KM 52 11*5 VM.50ecdI.UAJM. ia IOCiO 11*5 fi.M. DLOOD PHLSA.5II2-564 4 92 2e * 2- P.M. 5L00D PRL55URt.59fr&K / 8 94 24 : V 44-§ P M. 6L00P PR.L»U1U.534H5( 12 96 26 r- ■ s 5^P.M.50co.6LR.UM ;9 a 8 66 26 12 96 56 \ 4 86 50 : L 4^ p.M-50cc .5I.R.UM 8 HO 56 \ .SPONGC 12. ICfi 50 i / BO 4 8 90 52 12. 60 26 4 84 28 —L 8 76 26 2! 5 8 76 24 26 12. 80 L | 4 68 22 8 72 20 12 6 8 66 22 / ; 12 62 24 4 70 20 8 70 20 25 7 8 78 20 ) 12. 78 20 4 78 20 ■ 8 72 ie \ 24 8 8 72 18 12. 72 4 mined until the fourth day of his illness. The serum was adminis tered and a distinct chill followed soon afterward. Within a few hours, however, the symptoms had markedly improved, but the tem perature rose the succeeding afternoon, when another dose of serum, the temperature of which was very closely watched, was given, and all the symptoms rapidly improved. 20 GOULD AND SHAWEKER—SERUM IN LOBAR PNEUMONIA. Vol. XIII. I Case IV ; R , B. M. 2c. ; age, 20 years. This patient was admitted on the first day of his illness with. consolidation in the middle lobe of the right lung. The typing; -was determined by the Krumweide method on the second day, and five CLINICAL CHART (NAME} 3 % (rXtl) :. _i8 w C»CL) • (COLOR.) PNtUMONIA- L06AR,. (bio t Kit) 8 5 s COCDCOOOOOOOOO ft.-LMAR.K5. 5 pi : July. 50 2. 4» 128so / 5ATH tt BO 48 \ -5PONGL 51 5 17 126 42 : \ 4 120 56 / 6 104 as / 12. 104 40 \ 4 10040 \ A DO 56 \ * CIAL -5PONGL .AUG 1 4 8 102 52 i / R. 12. 10442 —1 \ R 4 100 56 —1 / R 6 tt4 42 : \kk •5PONGL 2 5 12. 114 42 1 w 4 114 42 ft 8 3b 54 t IZ 10056 k 4 106 55 R 6«?PM.-T0 7~PM. CHILL fc4b 12666 \r 6* PM.soccANTIPNLUMOCCCCU? 8 IZfl 44 R. 5LRUM. 5 6 IZ 96 22 4 84 26 / 8 72 26 V 12. 84 24 N 4 96 42 4 55PM. 50cc 5t.-R.UM. ! R 6 104 54 1 R. A 7 8 112 52 : IE 92 52 / IZ~N-50cc-5l.BOJM. : < 4 66 52 '\ ft : 60 22 / : L doses of serum were administered. He showed a slight maculo- papular eruption on the second and third days, but no distinct ana phylactic reaction till the twelfth day, when a marked urticarial rash appeared over his entire body. He had a rise of temperature lasting five days and a severe general arthritis. The temperature No. 1. 21 GOULD AND SHAWEKER— SERUM IN LOBAR PNEUMONIA. rose to 104° on the fourteenth day. A blood culture on that day proved to be sterile. The rash persisted for several days, and later resembled closely a severe case of measles. CA-3L-H-H, (WMrj CLINICAL CHART, 5. M % 20 '(*«)' ~nxTt$' PhlLUMONIVLObAR,. JfliLKX-)"" . w (color.) I -:• 73 -a r" -j. o>. to. o- -. i«. w. Q. <n -i EE 7 6 16 2C 11 ec 20 / 4 60 22 ( 6 SO 22 / 25 fl 8 so 20 12 74 2C 4 72 20 6 10 22 BATH 24 6 18 2C 12. 10 20 4 12 18 o 12 18 25 10 a 16 20 12. 14 20 1 4 12 20 e 8fi 20 BATH 2£ II s 7to 18 12. 80 20 : 4 80 20 5 82 20 27 12 a 16 22 12 92 22 4 86 24 8 ico 24 11 I 1 t BATH. 26 15 12 ICC tt 8 (CO J4 12. lot u 4 196 26 | 6 1100 24 -■-t- 2V 14 8I102! 2fc 12^102 5C - 4ioa AO FATAL CASES OF PNEUMONIA, TYrE I, OCCURRING SINCE MAY 1, 1918. Case V ; B . Sea. 2c ; age, 20 years. Case VI ; D , BM. 2c ; age, 29 years. Both of these cases were admitted on the first day of their illness, and the typing was determined early on the third day. One case was given five doses of serum and the second one six doses at intervals of 22 GOULD AND SHAWEKEE —SEBUM IN LOBAR PNEUMONIA. Vol. XHt. 8 to 12 hours. In neither case could we detect any effect from the serum. The area of lung involved was confined to one lobe at the- beginning, but gradually spread till both lungs were involved, and both patients died of cardiac failure with pulmonary oedema. Case VII ; C , Sea. ; age, 19 years. CASH -ET- g,- (NAMILJ CLINICAL CHART. ft.MJfe- £Q_ W..... (HATt) (»CL) (GOUM$ PHLUM0N1A- LOpAL Juw 2 -i X s. $. g. 2 g a 2 8. S. 3 JLLMAUKS o -< r 16 1 IP* no 54 \ oTRLTCHtRCA5L-6tD 5ATH 12. 10? m 4 I2C 42 \ S I2C 4.3 \ ^PONOL 17 2 12 12052 V 1 4 I5C 5b / a 15242 / 12. I2C 40 \ 4 114 42 / 4PM 50«c ANTIPNCUMOCOCCW 6 114 40 / 6IXUM- 12 lot 56 / 1052 P.M. 50cc6LPJJM 18 z 0 96 32 / IO£SAM.«30coSL.RUM 12. ice it U«W6L0OD PR.tiJURL-5-ICH- D-« 4 120 54 V r^s 2^PM bLOODPRZ55URE.-596-D-56 8 102 44 455PM.-50cc-6tR.UM 12 10440 / 45? PM.&L00DPRtS5UKt.-.59t -\>Sk 19 4 6 108 40 / * 12 102 42 \ 4 96 ae \ +P.M 50cc ALR.UM 6 IOC 56 / OPONGL 12 lit. 40 sx 20 a 6 96 34 12 84 50 4 78 28 / 6 00 22 21 b ti 30 22 / 12 64 2S /: 4 54 20 8 54 ?.(. \ ] This patient was admitted on the second day of illness with small area of consolidation in left lower lobe. The typing could not be determined till the sixth day on account of unsatisfactory specimens of sputum. He had then begun to defervesce and no serum was given. Soon thereafter he showed a distinct suppression of urine, became No. 1. 23 GOULD AND SHAWEKER SEBUM IN LOBAR PNEUMONIA. actively uraemic, and died on the 17th day of his illness. A post mortem examination showed large white kidneys with marked paren chymatous changes. Several areas of consolidation had not resolved. No predisposing cause nor previous history of involvement of kidneys could be elicited. QtAMt) CLINICAL CHART ML Mm gNJA-;1S>bA "(cou5r5 i S.LMAR.KO. 1 r». C9 u 5 ',06 25 E>ATH 6 30 22 / ia 102 22 t 4 124 56 ----- •»«. _ CHILL e C6 26 6 36 24 \z 64 22 1 4 92 24 T 8 60 22 i &ATH 6 72 20 i 12. 72 16 4 16 J6 i 8 74 16 I \ 1 8 72 16 ie 72 16 St 4 64 16 6 76 20 \i bATH » 6 72 16 \Z 70 16 ! 4 20 1 ■ 8 fcC 16 6 60 16 12 62 16 ■ 4 70 18 6 56 16 bATH 8 64 20 IZ 68 24 : 66 20 8 89122 V _- i Case VIII; M , Sea. 2c; age, 18 years. This patient was admitted on fourth day of illness with involve ment of left lower lobe and a temperature of 106°. It was impossible to determine the typing till the third day of illness, and no response was detected to the two doses of serum which were given. He died 24 GOULD AND SHAWEKER—SEBUM IN LOBAB PNEUMONIA. Vo on the fourth day of his illness from extension of process to the lung, and consequent cardiac failure. In all of our cases the serum was given in the following ma considering as an ideal method one which would deliver the 6 by the gravity method in high dilution at or slightly above th tient's temperature. A ring stand is used with two rings, one to accommodate a f and the other a serum container. To the funnel is attached th( ductor tubing to the needle. To the container is attached a length of rubber tubing on which is placed a Hoffman clamp, this tubing is placed a dropping device similar to, that used ii Murphy drip method for proctoclysis. A very efficient drop device can be made by employing a discarded 20 c. c. serum syr a two-holed rubber stopper to fit same and a short length of tubing. On the ring stand the dropping device is placed at the of the apex of the funnel or slightly above. A Y-tube from the ( ADMINISTRATION OF SERUM IN PNEUMONIA. 24-1 No. I. GOULD AND SHAWEKEE—SEBUM IN LOBAB PNEUMONIA. 25 ping device connects the conductor tube from the funnel. Below the Y-tube is placed an ordinary hemostat until the vein is punctured and all is ready for administering serum. The conductor tube is 65 inches long from the Y-tube to the needle, 24 inches of which is placed in a container of water at 115° to 117°, about 36 inches from the needle, in order to regulate the tem perature. The tube is interrupted a short distance from the needle and a tube thermometer placed to determine temperature. We have found that it is important to have the temperature very nearly or slightly above the patient's temperature and never below, as low temperatures seem to cause considerable reaction in the form of chill and temporary rising temperature. The toxicity of a foreign pro tein has also been offered as a cause of this occasional chill. How ever, the same phenomenon has been noticed when normal salt solu tion or Fischer's solution has been given intravenously. It has also been suggested that the water used in the salt solution may cause same if not freshly distilled. A 200 c. c. flask is provided for the normal salt solution. This filled flask is inverted into the funnel. It will be noted that the fluid passes into the Y-tube and rises in the dropping device to the level corresponding with the mouth of the said 200 c. c. flask. The serum is placed in the container above the dropping device, 50 to 100 c. c. being given as a dose. The apparatus having been set up and the containers filled, as de scribed above, the arm is sterilized in the usual manner for veni puncture, and a tourniquet applied to the arm above the elbow. A salvarsan or similar needle is convenient to use. After the puncture is made and the blood flows freely from the needle, the tourniquet is removed, the conductor tube is attached, and the hemostat removed. Be certain that all air has been forced out of the conductor tube be fore adapting it to the needle. It will now be noted that as fluid enters the vein, bubbles of air will arise in the salt solution container inverted into the funnel. When this flow is satisfactory, gradually release V. . Hoffman clamp below the serum container, allowing the serum to drop at about 150 drops per minute, depending on the size of the drops. The rate of flow of the salt solution is in inverse proportion to the rate of flow of serum. A small amount of adjusting will be required to control the dilution. By observing the glass Y-tube, the mixing of the two fluids can be seen. After the serum is exhausted, the rate of flow of salt solution will again be the same as before the serum was allowed to drop into the conductor tube. No adjustments are required for the salt solution; it automatically adjusts itself inversely to flow of serum, as indicated above. S8977— 18 3 26 ASSERSON AND BATHBTJN —PNEUMONIA. Vol. XIII. The apparatus is sterilized without disconnecting any parts except ing the needle, the rings on the ring stand having small arcs sawed out so as to allow the funnel and container to be slipped in and out without disconnecting. This same "method has been used for ad ministering salvarsan and other intravenous medication. The advantages of this method are : I. We have a visible index of the rate of flow of both fluids used, any irregularities in the flow being at once apparent. II. The adjustment of the dilution is made with a single Hoffman clamp. III. A careful control of the temperature is obtained. IV. All manipulations of finding vein, etc., are done using salt solution alone, the diluted serum being sandwiched, as it were, be tween the trial flow of normal salt solution and the after flow of the salt solution. After the serum solution has been exhausted, the re maining salt solution washes down the serum which may remain in the tube. V. The serum being introduced high in the tubing gives ample op portunity for thorough mixing of solution. VI. Apparatus is easily assembled from materials always on hand in hospitals. DIAGNOSIS AND TREATMENT OF PNEUMONIA AND EMPYEMA AT THE UNITED STATES NAVAL HOSPITAL, NEWPORT, R. I. By F. A. Asserson, Commander, Medical Corps, United States Navy, and W. L. Bathbhs. Lieutenant, Medical Corps, United States Naval Reserve Force. During the past fall, winter, and spring months the training camps of both services were visited by very serious epidemics of pneumonia. These epidemics were universal, apparently affecting camps located in every section of the country, showing that climate had very little to do with their spread. Numerous articles have been written on the subject, all emphasizing the widespread virulence of the infection and the prevalence of the streptococcus haemolyticus. Rufus Cole (1) in his report to Surgeon General Gorgas on the epi demic at Fort Sam Houston, Tex., divided the cases into acute lobar pneumonia, broncho-pneumonia, and a combination of the two. A large majority of the cases of broncho-pneumonia followed measles and was caused by the streptococcus haemolyticus. Influenza bacilli as well as streptococci were found in the sputum of 13 cases and in 5 cases coming to autopsy, influenza bacilli were present in the lungs of all. The streptococcus haemolyticus was seldom found in the blood stream, and according to McCallum is rarely engulfed by leu cocytes. W. G. McCallum (1) in a pathological study of the pa tients dying at Fort Sam Houston, divides the broncho-pneumonia No. 1. 27 ASSERSON AND RATHBUN —PNEUMONIA. into the usual lobular type and an " interstitial " type. Eleven out of 15 cases studied were of the latter class. McCallum emphasizes the importance of the streptococcus haemolyticus as the causative agent in "interstitial" broncho-pneumonia. This form of broncho pneumonia has been described before, but the importance of the streptococcus haemolyticus in connection with its etiology has been overlooked. McCallum alludes to the " organization of the exudate," which he states is very common in the " interstitial " form and also says that on micrcscopical examination of cross sections some of the areas closely resemble miliary tubercles. He feels that this appear ance accounts fcr many diagnoses of pulmonary tuberculosis made at autopsy following deaths from measles. This is a very important observation, as it exonerates the tubercle bacillus (an organism that needs no mistakes to bolster up its reputation) from at least a small part of its mischief. In a recent letter to Lieutenant Martin B. Hiden, Medical Corps, United States Navy, Major A. G. Wilde, Medical Corps, United States Army, in charge of the camp hospital at Douglas, Ariz., stated that the deaths there have been approximately 25 per cent, which, he said, was about the average mortality in the other Army camps. In cases devel oping empyema he states, without giving figures, that the mortality was very high. The greater portion of his pneumonias and empyemas was apparently due to the streptococcus hnemolyticiis. Most of the cases treated at this hospital came from the Southern States, and a large number (as many as 60 per cent in one command, comprising a brigade) were infected with hookworm. Major Wilde is sure that hookworm, by its devitalizing influences, has been an important factor in connection with the poor reaction of his pneumonia patientsr predisposing them to development of empyema, as 100 per cent of the latter cases had hookworm ova in their stools. Alexander (2) states that at Camp Zachary Taylor definite- changes occurred in the type of the predominating infecting organism^ from time to time since last fall. During September and October, the infection was principally due to one of the various types of pneumo- cocci. Following an epidemic of measles, infection by streptococcus haemolyticus became prevalent, and likewise there was a decided in crease in the percentage of empyemas (30 per cent) at the base hos pital. Alexander found the streptococcus haemolyticus present in the throats of 24 out of 34 men convalescing from bronchitis and infections of the upper respiratory tract, in the dust from the floors of barracks where most of these men were quartered, in specimens of cow's milk, and from the nasal secretions of three out of four sick, horses. The horses were stationed several miles away and apparently had no connection with the epidemic. 28 Vol. XIII. ASSERSON AND RATHBUN —PNEUMONIA. Hamburger and Mayers (3) at Camp Zachary Taylor found hemo lytic streptococci in 52 out of 93 empyema fluids. These organisms were- also found in the blood stream, pericardial pus, lung smears, and the heart's blood. Lieutenant Samuel Kennison, Medical Corps, United States Navy, of the United States Naval Hospital, Newport, R. I., also found these organisms in the blood from the cerebral arte ries at autopsy, and in three cases in the spinal fluid. Our morbidity and mortality from broncho-pneumonia following measles were very low during 1918 as compared with a like period in 1917. The measles patients are protected from droplet infection by a sheet screen attached to the side of each bed, and are also sprayed with argyrol solution a number of times each day. We know nothing about the effect of argyrol upon the streptococcus haemolyticns, hut there is no contradicting the fact that a plentiful supply of this infec tion was present, and broncho-pneumonia was an infrequent compli cation of our patients with measles, only 7 cases developing in 211 consecutive patients admitted to the measles pavilion. From January 1, 1918, to July 23, 1918, 28 cases of broncho-pneu monia were treated at the United States Naval Hospital, Newport. R. I., with a mortality of 25 per cent. This low mortality was evi dently due to our low percentage of infections following measles. Only seven measles patients developed broncho-pneumonia, and four of these died. The majority of our patients were very ill and then convalescence was slow, but most of them were not handicapped by i measles infection and were able to pull through. From January 1 to August 1, 1918, 183 cases of pneumonia, lobai including those with complications of pleurisy, suppurative, wei treated at this hospital with a mortality of 32,1 or 174 per cent.1 Tl total number of deaths from pneumonia, lobar alone (166 cas were treated) , was 19, or 114 per cent.2 The number of cases operat< upon for pleurisy, suppurative, was 50, with 12 deaths, or 24 p cent. Of our pneumonia cases (up to July 23) 3.4 per cent de\< oped tuberculosis, chronic pulmonary. Hamburger and Mayers (3) in classifying their fulminant atypi< lobar pneumonia, described two types based on the prodromes : " Fii those starting with ' sore throat,' ' cough,' and ' grippe ' for a f days, progressing gradually until frank signs of consolidation co be elicited; second, cases starting abruptly, severely with sudi overwhelming prostration and collapse; profoundly toxic; progr ing rapidly to death within three or four days with symptoms profound as to suggest a general sepsis." We had many cases i responding to their hist class at Newport, the majority admitted -v bronchitis acute, influenza, and pleurisy, acute fibrinous. T 1 Five of these patients were found to have pleurisy, suppurative, at autopsy. •This includes eases recovering from pneumonia, but that developed empyema la Mhl. ASSERSON A.ND BATHBUN PNEUMONIA. 29 patients puzzled us a great deal at first until we found that in prac tically all instances the pneumonia was located centrally along the larger ramifications of the bronchi and slowly extended toward the surface. In most of the cases it was possible to locate these lesions by careful comparison of the whispered voice and breath sounds of corresponding areas on the two opposite sides. The distant pecto riloquy and high pitched bronchial breathing could often be made out a day or two before the frank signs of consolidation appeared. Another mistake often made is to depend too much upon the lower lobes, particularly posteriorly in the region of the angle of the scapula, to furnish us the signs we are looking for, when the lesion is so located that the signs are best heard in the axilla, over the upper lobe, or occasionally at the anterior base. This is particu larly true in lesions on the right side. Percussion, inspection, and tactile fremitus were not always helpful during the first stages. Crepitant rales generally appeared fairly early. In the second group of cases these observers noted an extremely high percentage of empyemas. This was not true of our cases corresponding to this group, as most of them had little or no fluid, even when there was extensive fibrinous pleurisy present. The development of effusions in our cases seemed to be an indi cation of an attempt at resistance on the part of the body and our patients of the second class were powerless to assist themselves in the slightest degree from the very beginning. Among those pa tients developing fluid, those with a pleural reaction sufficient to pro duce large quantities of effusion did better than those developing svere fibrinous pleurisies, with but little or no effusion. It seems only reasonable, when we consider the severe pleural shock that «ometimes follows the insertion of a needle into an acutely inflamed pleura, to assume that the prostration, as well as discomfort caused by the constant rubbing of roughened pleurae is very considerable and is bound to have a decidedly bad influence upon the patient's general condition. When these layers are separated, this debilitat ing influence is removed and with a good flow of fluid, the mechani cal effect on the lungs by producing more or less immobility is a therapeutic factor of no mean importance and will be referred to later. According to our observations, the absorption of toxin from the plural fluid is not very great and is more than counterbalanced by the lessened absorption from the immobilized lung. Owing to the layer of plastic lymph coating the pleurae in these cases, it is quite possible that the absorption of toxin is very much interfered with. We have divided our cases into four types : First, uncomplicated lobar pneumonia caused by types one, two, and four pneumococci. that invariably terminated favorably. The temperature reaction 30 ASSERSON AND RATHBUN —PNEUMONIA. Vol. XIII. was often fairly high but the pulse and respiration remained rela tively low during the entire illness. Some of these cases had upper lobe involvement- (In upper lobe pneumonias very low pulse and respiration was noted in a number of cases.) Some of those with upper lobe lesions had a temperature swing resembling that of pulmonary tuberculosis and a few of the cases required careful observation to rule out this disease. Patients of this type occasionally developed pleural effusion, but those going on to empyema invariably recovered with drainage and some were cured by Potain treatment. Second. Same as the second class mentioned above, invariably fatal in spite of any treatment. Both lungs were usually involved and the infection appeared to be of the creeping variety, spreading from one lobe to another until the patient was practically asphyxiated. Most of these cases were haemolytic streptococcus infections or infections of haemolytic streptococci mixed with pneumococci. At autopsy oc casionally only a portion of the upper lobes were found uninvolved. Lieutenant M. B. Hiden, Medical Corps, United States Navy, observed that the blood expectorated by these patients was much darker than in our other cases, apparently due to the amount of lung tissue in volved and the resulting deficient oxygenation of the hemoglobin. Third. Lobar pneumonias that were between the first two classes in severity. The symptoms were severe but not such as would lead one to expect a necessarily fatal outcome. The great majority of these cases recovered. Delayed and false crises were noted in a large num ber of these cases and their convalescence was slow. Fourth. A pneumonia similar to class 3, but with pleural involve ment and complicating empyema. These cases are difficult to handle, but with conservative treat ment, until the pleural sac is well walled off, a very great majority of them can be pulled through. Early operation gives much poorer results and a big reduction in recoveries. After observing the effect of early operations upon our empyema cases, conservative treatment became our routine. Experience at the United States Naval Hos pital, Newport, R. I., in the management of pleurisy with effusion •complicating pneumonia developed the following method of treat ment : The exudate is allowed to accumulate until there is evident me chanical embarrassment of the heart or lungs, when from 200 to <>00 c. c. are removed by the Potain procedure. This operation is repeated from time to time as indicated by symptoms of overloading. Our technic for removal follows : The skin is prepared by painting the area of operation with tincture of iodine. The sixth or seventh interspace in the midaxillary line is generally selected and the tissues along the track of the needle, including the parietal pleura, No.l. ASSEBS0N AND HATHBUN —PNEUMONIA. 31 are infiltrated with a generous amount of novocain (0.5 per cent) in jected through a long, fine hypodermic needle. After waiting for about 10 minutes, a small caliber needle (spinal puncture needles are excellent for this use) is introduced while attached to a syringe containing about 2 c. c. of novocain (0.5 per cent). If the patient complains of pain a small amount of novocain is injected as the needle is slowly inserted, particularly when the parietal pleura is reached. This procedure not only helps to control pain but, in case of an erroneous diagnosis, tends to protect the lung by pushing it away from the needle point. The needle should not be pushed from side to side, after the pleura is reached, unless there is a free flow of fluid. Ethyl-chloride spray is contraindicated, as it fails to control pleural shock. The fluid should be withdrawn slowly and, if the patient . complains of thoracic pain or has a coughing attack, the needle is removed and aspiration stopped for the time being, on the assumption that the pain and cough are due to contact of roughened pleural sur faces. It has been found unwise to remove large quantities of exudate, owing to the pleural shock which occurs when any consid erable areas of parietal and visceral pleura are approximated. This has been the cause of considerable prostration and discomfort, two things that should be avoided if possible. In addition, the resulting increase of cough has a decidedly bad influence on the cardiac action and draws upon the reserve power of the heart. There is also danger of tearing the lung, in case organized pleuritic adhesions are present, when too large an amount of fluid is withdrawn and the lungs are forced down violently by severe coughing. As a result of our experience we feel that the effusion per se has no harmful influence upon the patient's condition that would neces sitate any considerable removal, so its mechanical action has been made use of as a therapeutic measure in the same way as nitrogen is used in the artificial pneumothorax treatment of tuberculosis. We found that pneumonias did very well when the affected lung was collapsed by an effusion, and of late it has been a part of our plan to keep the lung compressed until the pneumonic process was well under control and the effusion had become purulent. The keeping of visceral and parietal pleurae apart during the acute stage tends to obviate the formation of adhesions and thereby facilitates operative procedure when the effusion is ripe for surgical intervention. By the above method it has been found possible to tide over even the very severe pleural cases, provided there was profuse exuda tion. It seems probable that the amount of pleural effusion is a good index of the patient's reacting powers, and a profuse flow should be looked upon, not as a menace to the life of the patient, but as nature's 32 ASSERSON AND RATHBUN PNEUMONIA. VoL XIII. metliod of combating the infection. This should be curbed, during the acute stage, only when nature becomes too radical in her fluid production. In lobar pneumonia we found auscultation of the whispered voice and breath sounds; percussion; inspection and tactile fremitus, with careful comparison of coresponding areas on the opposite sides, of importance as diagnostic measures in the order given. In empyema, cardiac displacement was frequently of great assistance in diagnos ing effusions. Marked flatness, with the characteristic resistance offered to the percussing fingers by fluid accumulations, also pec toriloquy (aegophony) and tympany above the fluid level, were very constant signs. In accumulations filling the left pleural sac, tympany disappeared last in the second and third interspaces, near the ster- • num. Inspection and tactile fremitus were of service. The latter was not always absent over the fluid, as stated in most textbooks, but there was a characteristic relative difference in intensity in favor of the unaffected side. In pneumonia this difference, when accompanied by other physical signs that wrould lead one to expect a marked in crease, is a valuable diagnostic sign of fluid. The breath signs are usually transmitted clear to the base, but comparison of the breathing from the fluid level to the base will show a gradual diminution of the sounds downward. The X-ray was also of service in some cases, but could not be made use of. in severe cases as it was considered unsafe to move them to the X-ray room. On many occasions reflex abdominal pain and tenderness from diaphragmatic pleurisy have been mistaken for symptoms of acute abdominal conditions, such as appendicitis, gall bladder conditions, etc. This error has frequently been responsible for needless opera tive interference and has affected materially the patient's chances of recovery. The following procedure has been found of great service in differentiating between reflex abdominal pain and tender ness caused by diaphragmatic pleurisy and the pain and tenderness resulting from an acute abdominal condition. The abdomen is first examined while the patient is breathing normally and the point or points of maximum pain and tenderness are mapped out. The pa tient is then instructed to take a breath and hold it. If the pain is reflex from diaphragmatic pleurisy the abdominal pain and tender ness disappear until respiration is again commenced. The explana tion of this phenomenon seems to be that when the diaphragm is immobilized there are no afferent impulses of an irritative nature passing to the nerve centers. When the diaphragm is in motion the irritation caused by friction of the roughened pleural surfaces ex cites an afferent impulse that is transmitted to nerve centers lying So.1. ASSERSON AND RATHBUN PNEUMONIA. 38 in close juxtaposition to centers supplying the abdominal wall. This impulse is referred to the abdominal centers and efferent impulses ire ser.l out to the abdominal skin areas supplied by these nerves, producing the symptoms of an abdominal lesion. This sign has been present in 100 per cent of our diaphragmatic pleurisies with reflex abdominal symptoms. In so far as we can rind out, this procedure has never been used before. Reflex abdom inal symptoms occur in tuberculous diaphragmatic pleurisy and i!,t-re have been many abdominal operations performed, only to find normal viscera present. One of the chief methods of diagnosis used :o demonstrate this condition has been tha use of X-ray examina tions to demonstrate diaphragmatic adhesions. We found the history of chill; cough, with bloody expectoration; pleuritic pain; prostration and high temperature; accelerated pulse id moderate dyspnoea to be the most constant symptoms. In ad dition to some of the above symptoms, cyanosis, marked dyspnoea, narked restl ssness, high pulse, great prostration, tympanites, and delinum were always present in the severe type. It was interesting to note that some of our patients with severe pleuritic pain were very uncomfortable while lying on the affected side. Patients with pleurisy, complicating pulmonary tuberculosis, are practically always relieved by lying on the affected side. In the Army camps it was found that a large percentage of pa tients were infected with streptococci in the wards with a few days ifter admission. Cole (1) found 11.4 per cent positive for strepto coccus haemolyticus on admission to the ward ; 36.6 per cent positive 3 to 5 days later, and 56.8 per cent positive in from 8 to 16 after ad mission. Cole says that conditions in hospitals are not unlike those •irrounding puerperal fever and surgical wound infections. While ra measles, raw surfaces do not exist on which infection can occur, this disease renders the respiratory mucous membranes especially T;lEerable to infection. Levy and Anderson (4) feel that the cubical method of isolation is cot successful in protecting measles patients from carriers of ■toptocomis haemolyticus. when they are quartered together in the «me ward. They advise that carriers be segregated in separate 'irds and that throat cultures be taken on noncarriers from time to time to insure that they are still free from this infection. A further precautionary measure that would seem to be of the utmost impor- Unceisthe institution of a more gradual scale of exercise for harden '*/ the men immediately after entering the service. A large number °f our pneumonia patients developed the disease very shortly after •nival at the training station. Many of these men are. thoroughly ^hausted after a long trip on the train, with but little sleep for 48 Ixwrs or more. In addition a great number of them are not accus 84 ASSEBSON AND BATH.BUN —PNEUMONIA. Vol. XIII. tomed to the heavy exercise incident to the training which is started at once. While in this condition they are exposed to heavy doses of infection, which they are totally unable to overcome. Furthermore, many of them are not acclimated, which also predisposes them to infection. It would seem fair to assume that fewer cases of pneu monia would develop if the hardening process was commenced with easier stages. Lynch, Cummings, and Spruit (5) advocate the active immunization of all men (presumably on entering the service) by the administration of streptococcus vaccine, combined with type one and two pneumonococcus vaccine. The medicinal treatment was purely symptomatic. Digitalis and its alkaloids were used for a flagging heart and morphine or codeine for pain, severe cough or restlessness. Tympanitis, always a bad symptom, was controlled by milk and molasses enemata (1 cup of milk and 1 cup of molasses) ; by turpentine stupes and by the admin istration of compound jalap powder in the severe cases. Sponging for high temperatures was found useful. Careful nurs ing and judicious feeding are of the utmost importance and the patient should be given the maximum amount of nourishment that can be assimilated. The drain on the patient's reserve is excessive and a high calory diet, composed of easily assimilable nourishment is of vital importance. The well recognized stimulating properties of food are also an additional indication for its administration in maximum amounts. Except in a very few instances, our patients were able to take very satisfactory quantities of food, if proper at tention was paid to the bowels. The pain of diaphragmatic pleu risy was controlled by a tight abdominal binder. REFERENCES. (1) Pneumonia at Base Hospital. Rufus Cole, M. D., and W. G. McCallum. M. D. .Tour. Am. Med. Assn.. April 20, 1918, p. 1146. (2) Hemolytic Streptococcus Causing Severe Infections at Camp Zachary Taylor, Ky. H. L. Alexander, l.ieut., M. K. C. U. S. A. .Tour. Am. Med. Assn., March 16, 1918, p. 775. (3) Pneumonia and Empyema at Camp Zachary Taylor, Ky. Walter W. Hamburger, Maj., M. It. C, U. S. A., and Lawrence H. Mayers, Lieut, M. R. C, TJ. S. A. Jour. Am. Med. Assn., March 30, 1918, p. 915. (4) The Predisposition of Streptococcus Carriers to the Complications of Measles : Results of Separation of Carriers and Non-Carriers at a Base Hos pital. Robert L. Levy, Capt., M. R. C. U. S. A., and H. L. Alexander, Lieut., M. R. C, U. S. A. Jour. Am. Med. Assn.. June 15, 1918, p. 1827. (5) The Pneumonias: Streptococcus and Pneuniococcus Groups. Charles Lynch, Col., M. C. U. S. A.. James G.. Cummings, Maj., M. R.' C, U. S. A.. Charles B. Spruit. Lieut., M. R. C. TJ. S. A. Jour. Am. Med. Assn., April 13. 1918, p. 1066. No. 1. REDDEN SPECIFIC SERUM THERAPY IN PNEUMONIA. 35 DEVELOPMENT OF SPECIFIC SERUM THERAPY IN PNEUMONIA. By W. R. Redden, Lieutenant. Medical Corps, United States Navy. As early as 1891 Foa and Carbone, Emmerich and Fowitsky, and Klemperer discovered that animals rendered immune to pneumococci produced a serum which caused a passive immunity against pneu mococci when injected into animals or man. From that time until 1910 antipneumococcus serum produced without any conception of groups was used in the treatment of pneumonia in man, with indif- , ferent results. Then Neufeld and Handel in 1910 discovered that there were cer tain strains of pneumococci which fell naturally into one group be cause of common immunological and serological reactions and cer tain other strains which fell into a second group because of common immunological and serological reactions and which were not related to the first group by such reactions. With strains of this latter group Neufeld immunized a horse, whose serum he named Serum Franz. This serum later was found to correspond to the Type II serum of the Rockefeller Institute. The organisms of the first group which Neufeld sent Cole all fell into the Type I group, later developed by Dochez and Gillespie. However, no attempt was made to work out this group problem or to place specific serum therapy on a rational basis until Cole and his coworkers at the hospital of the Rockefeller Institute for Medical Research took up the problem in 1912. Then it was that Dochez and Gillespie, by immunizing rabbits against numerous strains of pneumococci obtained from pneumonia patients, were able to pick out two distinct types and a group which included a large number of races without common immunological characteristics. For convenience they arbitrarily called races that fell into a definite group Type I pneumococcus, those that fell into another definie group Type IT; then because streptococcus mucosus of Schotmuller was known to cause a certain number of lobar pneumonias and because it exhibits the characteristics of a pneumococcus, it was called pneumococcus mucosus and Type III. All pneumococci not included in these three types were designated Group IV. The basis for calling an organism a pneumococcus was bile solu bility, inulin fermentation, methemoglobin formation in the presence cf hemoglobin, and encapsulation. The next logical step was to determine the frequency of occur rence of these types in lobar pneumonias, not only in New York but elsewhere. In New York 150 cases showed the following percentages . 36 REDDEN—SPECIFIC SERUM THERAPY IN PNEUMONIA. Vol. XIII. Type. Number of cases. Percentage. I 57 44 17 32 38 II 30 Ill 11 IV 21 That is, about 80 per cent fell among the so-called fixed types I, II, and III, and about 20 per cent into the IVth or heterologous group. As I have mentioned above, the predominating German strains supplied by Neufeld proved to be of Types I and II. Walker at the Peter Bent Brigham Hospital, Boston, Lewis at the Penn sylvania Hospital, Floyd and myself at the Boston City Hospital, and Lister in South Africa produced similar evidence, to say nothing of the more recent confirmatory evidence from the numerous military camps where correct grouping has been carried out. Following the grouping of cases in New York, the workers at the Rockefeller Institute developed a high titer immune horse serum against Type I and a weaker serum against Type II. Then, by pre liminary protection experiments on mice, established justifiable grounds for specific serum therapy in man. Results with the use of Type I serum against Type I pneumonias in man have proved satisfactory, reducing mortality from about 25 to 30 per cent to about 8 per cent. These results, now more or less universal, have placed Type I antipneumococcus serum in the class of specifics, and make it almost unpardonable for a practitioner to treat a case of pneumonia without attempting to work out the type, and to administer Type I scrum if the organism be of that type. This is further emphasized by the following statistics for New York in 1914. The approximate number of pneumonias was 15.000. The probable number of Type I would be 5,000. Of the deaths due to pneumonia, in all likelihood. 1.500 were of this type. This number of deaths is considerably more than all the deaths from typhoid fever, scarlet fever, and cerebro-spinal fever combined dur ing the same period. (Cole, 1915.) If the Type I serum prevented death in only half instead of three-fourths of this 1,500 one can readily see the justification for Type I antipneumococcus serum. However, the case is not the same with Type II serum. From the beginning the Rockefeller workers found it practically impossible to produce a Type II serum abo%*e one-tenth the titer of Type I serum as demonstrated by protection tests in mice. Moreover the thera peutic results in man showed a less potent serum, for instead of reducing mortality to one fourth of that before serum treament, it barely cut it in two. Then Moore, and Moore and Chesney spent two years or more attempting to enhance the therapeutic value of Type No. 1. 87 REDDEN SPECIFIC SEBUM THERAPY IN PNEUMONIA. II serum, by the use of ethylhydrocuprein, a quinine derivative which had been shown to have a marked germicidal action on pneumococci But it was found that the margin between an effective therapeutic dose and marked toxicity was so small that one could not tell whether the result would be blindness, death, or recovery. Moore himself feels that its use is not justifiable. On the other hand, the Type II antipneumococcus serum produced for Massachusetts by Dr. Kohn at Forest Hills shows a protection in mice equal to the Type I serum produced by the Ro kefeller Institute and the results in the patients look promising. However, it is still too early to make a statement stronger than this. If a patient has Type II pneumonia, give him the benefit of the Type II serum, es pecially if early in the disease, or if extension is going on in the lung tissue. I have seen excellent results. Up to the present time no satisfactory antiserum has been developed for Type III. Wardsworth of the New York State Research Labora tories at Albany, first produced a serum sufficiently strong to use in grouping. In all probability further attempts will be made to make a higher titer Type II serum. Turning to Group IV, one readily recognizes the impossibility of producing a therapeutic antiserum in view of the fact that every Group IV strain produces a serum which has absolutely no effect on any other strain. A brief consideration of some of the .factors involved in producing passive immunity may shed some light on the subject of serum therapy In pneumonias. The standard potency of antipneumococcus serum Type I is measured as fol lows : 0.2 c. c. of the .serum introduced into the peritoneal cavity of a mouse with 0.1 c. c. of a Type I culture, 0.000001 c. c. of which kills a mouse in 24 to 48 hours, should prevent death In that mouse for at least a period of 5 days. Thus far 0.2 c. c. of Type II serum protects against 0.01 c. c. of Type II culture. A curious phenomenon is noted here. If more than 0.1 c. e. of a virulent culture of pneumococci Is Injected into a mouse, no amount of homologous antiserum will save him, thus showing a limit of protective power. Yet as far as active immunity is concerned in all types of pneumococci, the limit of protection has not been reached (Cole), for animals may be actively immunized so that they will stand many times the maximal dose above described. I might say In passing that this indicates excellent possibilities for prophylactic vaccine treat ment in the prevention of the fixed types of pneumonia. It Is evident from the above that there are at least two immunity factors, one which is transferable in serum and a second which may or may not be trans ferable. It would appear that with Type I -serum the second factor is not so essential. That with Type II serum the second is more important, and with Type III absolutely essential. (Cole.) There is another important point which may throw some light on the failure of Type II serum to react as well as Type I. Last year Cole found that empyema fluids resulting from pueumococcus in fection contained large amounts of soluble substances which have the property of neutralizing pueumococcus antibodies. He also showed that when immune serum is administered to patients severely infected with pneumococci, the im mune bodies may also disappear very rapidly; that is. as soon as 8 to 12 hours 38 REDDEN SPECIFIC SEBUM THERAPY IN PNEUMONIA. Vol. XIII. after intravenous Injection, as shown by the disappearance of agglutinins. This disappearance is probably due to the presence of such a soluble substance in the blood. Apparently the serum only becomes effective when these sub stances are neutralized. A study of the agglutination curve of the patient's serum is of value in showing why, in some cases, favorable results have not fol lowed the use of immune serum. Xow it is possible that Type II serum is less effective than Type I, not only because the immune bodies are not so "well developed, but because the power of Type II pneumococcus to produce these soluble substances is more highly developed. Administration of serum. —As soon as a pneumonia patient is seen he should be given 1/10 c. c.' of a 1/100 dilution of horse serum in- tradermully. If there is no reaction to this test within 15 minutes to an hour. 0.5 c. c. of horse serum may be given subcutaneously as a desensitizing dose. The sputum is washed and injected into the peritoneal cavity of a mouse, where the pneumococcus develops rapidly and produces an exudate. This exudate is removed from the cavity at the end of 12 to 18 hours and centrifuged. The clear supernatant fluid contains a specific precipitinogen, which, if caused by Type I, II, or II, pneu mococcus, will precipitate out of the corresponding immune serum a specific precipitin, which shows up as minute white particles or definite flakes, which later settle out and leave a clear fluid. With proper dilutions of sera there is no cross precipitation; in other words, the reaction shows definitely whether the organism belongs to Type I, II, or III. If there is no reaction and the organism is a pneumococcus it is called Group IV. If the case is a Type I or II, 100 c. c. of the proper type serum, diluted with an equal amount of fresh sterile physiological salt solu tion, is slowly injected intravenously, at body temperature, either by a large syringe or preferably by gravity. It is essential that the first 15 c. c. should be given slowly, over a period of 15 minutes, in order to avoid the possibility of a sudden anaphylactic reaction which may not have been evident in the preliminary tests. The remainder of the serum may then be given rapidly enough to finish the amount within a half hour. Usually a chill with a rise in temperature and pulse follows within 30 to 60 minutes the intravenous injection. Although violent at times, it is never fatal. If the case is Type I and the patient is sensitive to serum, it is worth while desensitizing as follows : First give 0.025 c. c. horse serum subcutaneously ; in one- half hour to an hour give 0.05 c. c, etc. ; continue increasing the dose each period until 1 c. c. can be given intravenously, then it is safe to proceed slowly with the whole amount. It usually takes about 8 to 12 hours to carry out this procedure, but in Type I infection it appears to be worth while. No. 1. 39 REDDEN SPECIFIC SERUM THEBAPY IN PNEUMONIA. The second injection of serum should be given about 8 to 12 hours nfter the first, nnd the third about 8 to 12 hours after the second. If by this time temperature, pulse, and respiration have dropped to normal, no further injections need be given. But in the light of present knowledge, it is dangerous to stop short of three doses, even if the symptoms have subsided after the first or second. On the other hand. Cole has given as high as 1,600 c. c. of serum at 8-hour intervals in some of his cases. If the symptoms subside, then appear again, even during serum treu^ment, complications such as empyema, pericarditis, or meningitis, or involvement of other lung tissue must be looked for'. One of these is usually found. While discussing the question of empyema after pneumococcus infection. Cole told me that there has been a definite increase of empyemas in Type I pneu monias after serum therapy, an increase from 1 to 2 per cent up to 16 per cent. In all probability this 16 per cent represents a definite number of cases formerly fatal, but which by aid of the imnfune serum are now able to develop a resistance sufficient to localize the infection in the pleural cavity. May I state here that I believe free drainage of an empyema fol lowing a lobar pneumonia due to pneumococcus is still the proper procedure as soon as pus is found ? For after carefully following the reports from various camps as well as considering the facts presented in previous reports here, it appears that the rapidly fatal empyema cases have been those which developed pneumonia after measles, or those in whom the pneumococcus had not been demonstrated, but whose chest fluids have yielded pure cultures of streptococcus. In both types the pneumonia is usually broncho-, and the causative agent streptococcus. Frequently there has been no demonstrable pneu monia, just a primary streptococcic empyema. Attempts have been made to concentrate the immune principles of the type sera. Gay and Chickering, in 1915, demonstrated that " a water-clear extract of pneumococci added to homologous antiserum produces a voluminous precipitate which carries with it practically all the protective bodies against pneumococcus infection in animals. This precipitate washed and resuspended in saline solution protects as well as whole serum, but contains only 0.09 to 0.34 per cent protein as against the original 6 per cent." However, no use has been made of this concentrated precipitin. Avery has demonstrated that the im mune bodies of antipneumococcus serum are completely precipi tated by 38 per cent to 42 per cent saturation of ammonium sulphate. Yet no use has been made of this fact. It is interesting to note that whereas the diphtheria antitoxin is associated with the pseudo- globulin fraction of horse serum antitoxin, yet the immune bodies of antipneumococcus serum are associated with both the englobulin and the pseudoglobulins. In all probability the time will come when 40 BEDDEN—SPECIFIC SEBUM THEBAPY IN PNEUMONIA. Vol. XIII. these less toxic globulin fractions will be used to combat pneumo- coccus infection. Nature of the infection, —We know that mere growth of organisms does not necessarily mean disease. Note the ever increasing number and varieties of carriers who rarely ever come down with the disease. It was formerly thought that either people carried parasitic organ isms more or less constantly in the upper respiratory tract, and that under conditions of lowered resistance these invaded the blood stream and lungs, or else people carried saprophytic organisms which under certain conditions suddenly acquired virulence and became parasitic with a resultant invasion of the body, or that dis ease was caused by a pathogenic organism different from the ordinary mouth organisms, acquired by the individual from outside his own body. Recent studies, by Avery and Dochez and others, have demonstrated that 'although pneumococci are present in 80 per cent of normal mouths, in no case out of 20 first studied were types I, II, or III found. All were group IV. Later studies showed that patients ill with the fixed types of pneumococci carry the same fixed type in the sputum from a few weeks up to 00 days after crisis. It was noted that delayed resolution or complications such as empyema favored the persistence of the fixed type. It was further noted that people associated with such patients often became carriers of the same type of organism, yet without coming down with the disease. When the type which caused the disease disappears from the sputum, Type IV is frequently, though not always, found. It would appear from the above that in all probability the ordinary mouth variety of pneumo cocci are Type IV: that these are usually saprophytic, but under conditions of lowered resistance, such as exposure or devitalizing work, became parasitic: but that the large majority of pneumonias, as high as 70 to 80 per cent are caused by the introduction of fixed types of pneumococci, which are usually parasitic, though they may remain harmless to certain resistant individuals called healthy car riers; that the chief epidemiological factor of lobar pneumonia is the transmission of fixed types from people recently ill from the disease, or from those associated with them and who have become carriers of the fixed types; that aside from the organism itself, lowered resistance due to exposure, exhaustion, etc., plays an im portant part. Let lis consider for a moment how disease develops. We know that diphtheria bacilli and tetanus bacilli in their growth produce a definite toxic substance both within the body and in the media. Apparently this is a part of the growth process. We also know that the chief symptoms of these two diseases are caused by the elaboration of the toxins and their action on the tissues. But as far No. 1. KEDDEN —SPECIFIC SEBUM THERAPY IN PNEUMONIA. 41 as is known, no such toxin is produced, by the pneumococcus either inside or outside of the body. However, it has been definitely dem onstrated that when pneumococci are ground up with salt solution, or dissolved by sodium cholate, then filtered through a Berkfeldt filter to remove all bacterial bodies, a clear solution of high toxic and hemolytic titre is obtained. This is called pneumococcus hemo- toxin, and has been demonstrated to be a definite preconstructed en dotoxin, and not a toxin elaborated by enzymatic action on the bac teria] protein after autolysis has taken place. In other words the substance is a true endotoxin, as named by Pfeiffer. There is con siderable evidence that the initial symptoms of pneumonia are not due to the dead organisms with the subsequent release of this hemo lytic endotoxin, but that rather the symptoms are produced only when living organisms are actively multiplying. Peabody has demon strated that during the terminal stages of fatal cases of pneumonia there occurs a progressive decrease in the oxygen content and oxygen combining capacity of the blood. This evidently is due to the ability of the growing pneumococcus to transform oxyhemoglobin into methemoglobin. Now if growing pneumococci are able to produce this change in red blood cells merely by contact, by changing oxida tive processes, it is possible they may in a similar way produce other important changes in other tissue cells. It may be that the entire specific action of the pneumococcus on the tissues is in the lung or in the local lesion, and that the general symptoms may then be non specific in character like that produced by any similar local lesion in duced by any cause. This is a bit of Cole's theory. However, Cohn of the Institute has demonstrated by the electrocardiogram that cer tain changes take place in the heart muscle, changes which can be reversed to normal by digitalis. Porter of Harvard has also demon strated that serum from pneumonia patients has a toxic effect on the hearts of experimental animals, which causes death if the hearts are not subsequently perfused with normal serum before the toxic action has gone too far. This would seem to indicate that the endotixin of the pneumococci may play an important role in cardiac failure after or during pneumonia. If this substance causes symptoms which can be demonstrated in the above manner, there is some ground for belief that it may affect other tissues in a detrimental manner. I have already mentioned the fact that certain soluble fixing substances which have the power to neutralize antibodies are also developed by pneumococci. These soluble fixing substances may appear in the urine of pneumonia patients in the form of a precipitinogen which acts the same as that developed in pneumococcus cultures, or in the peritoneal cavity of a mouse injected for typing purposes. That is, it will cause a precipitation in a specific homologous antipneumo- 88977—18 4 42 EEDDEN —SPECIFIC SEBUM THEEAPY IN PNEUMONIA. Vol. XIII. coccus serum. This has been used for diagnostic purposes. When found it is usually a bad prognostic sign. The question naturally arises, how does the specific immune serum act toward the pneumococcus and its products? In the first place. Bull has demonstrated that it clears the blood stream of organisms and causes agglutination; that it opsonizes the organisms so that after agglutination they are phagocyted in enormous numbers. Blake showed that when pneumococci were agglutinated by specific antiserum, methemoglobin formation was diminished or lost. In vitro, antipncumococcus serum inhibits the growth of the homo logous organism, inhibits or markedly delays fermentation of inulin, and the splitting of protein. And lastly, Cole has demonstrated that the. immune serum has a high antitoxin and antihemolytic titre. which in all probability play an important role in combating the strong endohemotoxin. I simply present this data and offer the sug gestion that here is at least one possibility why specific antipneumo- coccus serum is of use in combating type pneumonias. In order not to confuse the grouping of pneumococci, I have dis cussed the. four main groups first. Now just a word about Avery's subgroups of II—namely, Ila, lib, and IIx. All these sub groups are included in type II because of agglutination in type II antiserum, but they are subgrouped because specific serum de veloped for " a " will not agglutinate " b " or " x," nor is there- cross agglutination with specific serum developed for " b " or " x." Moreover, type II serum has no protective action against IIx strains. Type IIx shows another peculiarity which suggests an approach to group IV, namely, each strain is different from every other strain in its immunological and serological reactions. In passing, I might suggest that some of the earlier cases of type II pneumonias were really subgroups of type II, and that the failure to get results with type II antiserum was due, in some degree ai least, to this fact. However, within the past month we treated two cases of type II subgroups with excellent results. Aside from giving an opportunity for serum treatment in favor able types, grouping aids in prognosis for group IV almost always run a mild course or recovers. About one-fourth of type I die, about a third of type II die, and nearly half of the type III die. To summarize, then, the etiological factor in 98 per cent of all lobar pneumonias is the pneumococcus. Eighty per cent fall seriologically into three groups called fixed Types I, II, III. II is further sub divided into a, b, and x. The remaining 20 per cent is called Group IV and is made up of numerous distinct races. Group IV may be found in 80 per cent of normal mouths. But the fixed types are found only in the mouths of those recently ill with such a type or in one who has been in contact with such a type No. 1. 43 CRANDON—FLAT FOOT. case. This points to carriers of the fixed types as the chief epidemio logical factor. About 38 per cent of all cases are Type I ; about 30 per cent of all cases are Type II; about 11 per cent of all cases are Type III. Against Type I an immune serum has been produced which reduces mortality by three-fourths. Against Type II a less potent serum which reduces mortality by about one-half has been produced. All cases of pneumonia should be typed as early as possible in order to give patients the benefit of antiserum, if of Type I or II. Prac tically all cases which fall into these two groups can be given serum without danger. Even if one of the Type I cases shows sensitiveness to the serum, an attempt should be made to desensitize in order to make serum 1 available. Serum should be given as early as possible and in 100 c. c. amounts at eight-hour intervals for at least three doses, intravenously. Probably the action of the growing pneumo- occus plays an important part in producing the local lesion. There is little doubt but that the endotoxin of the pneumococcus plays an important part in the cardiac failures of pneumonia pa tients and may affect other tissues in a detrimental manner. It is likely that the curative power of antipneumococcus serum depends much on its agglutinating action, its opsonizing power, its antitoxic effect, its ability to inhibit the growth of the organisms, and to retard methemoglobin formation. It is also probable that there is an action not measurable by present methods. Serum not only cures but also shortens the course of disease by three to five days. Grouping not only makes serum therapy available but aids in prog nosis, the order of increasing mortality being IV, I, II, III. Experience points to crowded quarters, exposure to severe weather, and devitalizing labor as important predisposing factors in the de- veloment of the disease.1 FLAT FOOT, A NEW STATEMENT OF OID TRUTH. By L. R. G. Ceasdon, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. " Nothing is settled till it is settled right " is as true in the surgical world as in the ethical. Since 1906 the writer has practiced and written on the concept that weak foot, pronated foot, and flat foot should be treated not as an anatomical but as a physiological entity. From the practical side of function and treatment the human foot has no more fixed arch * The writer lays no claim to originality, but has used freely data gathered during a year's stay at the Rockefeller Institute, and from the numerous reprints and lectures pub lished by Doctor Cole and his coworkers. The attempt has been to present briefly the problem of serum therapy in pneumonias. 44 CRANDON —FLAT FOOT. VoL XIII. than the extended hand till the muscles make one. Every detail of our mental attitude toward the care of feet changes if, always, for the word arch we substitute the word arching. In short, as far as examination and treatment go, with certain exceptions, flat foot is not organic but functional only. In 1903 at one large orthopedic hospital, 10 to 15 pairs of plates were made for feet daily; in 1914. 2 pairs were made in the whole year! Except in the practice of those who will not see, the flat-foot plate has gone. So, also, the shoemaker has begun to recognize the human foot not as the stumpy end of a limb, but as a live, flexible, prehensile extremity. Thus, in place of the stiff-shanked shoes which our new Filipino soldiers used to sling over their shoulders on a hike, Army and Navy bootmakers now produce a roomy, flexible shoe which allows all the 23 interrelated joints of the foot a chance to work. The whole surgical world is coming to see anew the demands of the bony and muscular complex of the foot and to restore to it, so far as modern underfoot conditions permit, some of its barefoot freedom. The bare foot on nature's own surfaces—sand, turf, and in forest— comes down on the round unstable heel, falls forward on the outer edge, then the whole plantar surface grasps the surface beneath and pushes backward. The ideal shoe, to allow the simulation of this sequence on the hard planes of man-made surfaces, must have an unstable (rubber or partly rubber) heel, a broad outside curve, a wide toe and is shankless to allow a gripping action by the whole foot. Ideal shoes of this type are made; regulation shoes of Army and Navy approximate it: surgeons approve; those who wear such shoes become disciples; but a definite lack of practical application of this knowledge still prevails in draft boards and enrolling offices. In time of peace or in a country unendingly rich in men, it may be defensible to reject applicants on inspection or on anatomical measurements of their feet, but when the whole man power of a nation is drafted, when so many hundreds of valid disqualifications appear, it is both ignorant and wasteful to reject a man for an anatomical variation in feet which are functionally good. The perfect foot of a baby gives the complete print of "flatfoot." A foot with an arch which appears perfect may have no muscles and collapse on the first hike. The man who has tramped all winter in a logging camp or a professional athlete may have a pronatcd foot and yet can march 30 miles. Excepting for those feet where the astragulus is practically on the ground, the test should be; Does he walk with the splay-footed shuffle of the obviously collapsed foot? If so, reject. If not, can he balance with any degree of steadiness on one foot straight forward, with the other foot curled round the CRANDON— FLAT FOOT. Fig. I. Fig. 2. Fig. 3. Fig. 4. Fie. 5- No. 1. 45 CRANDON—FLAT FOOT. ankle? (Fig. 3.) If he can. so far as the feet are in question, accept him. Men accepted by this standard, with graded training up to the maximum use of the feet, are less likely to be invalided by foot trouble than those taken by inspection only. The care of the foot of the recruit, outside of cleanliness and right shoeing, as described, should include the prevention of that form of .break-down commonly called "flatfoot." This preventive cure should consist in three exercises added to the daily setting-up drill : 1. Stand with feet parallel, about 4 inches apart, with the weight on the outer edge of the feet; let the big toe grasp the ground, " break " the knees slightly ; bend the knees outward as if bowlegged. (Fig.l.) This is the position of greatest stability, unconsciously taken when using binoculars on deck at sea. 2. Stand with feet crossed, the weight divided equally between th& two, then cross the feet in the opposite way. (Fig. 2.) 3. Stand on one foot straight forward, curl the other foot behind the standing ankle and balance. (Fig. 3.) The last two exercises bring into use all the muscles of the leg and especially the intrinsic muscles of the foot. The absurd so-called " military " stance with feet at a 60-degree angle, based only on the whim of Napoleon, contrary to all instinctsr should be abolished. Guard duty in this position precedes a large number of the cases of acute flat foot seen in military practice.1 The treatment of an actually developed case consists in : 1. Rest for a few days with not too much hot bathing (which will reduce muscle tone). 2. The use of the exercises given above in graded amounts, up to 50 times a day. 3. Flexible shoes, preferably low-cut (Oxford). 4. Obstinate cases may call for S-strapping or rubber sponges under the arches for a short time. SUMMARY. 1. Acute flat foot, especially in young men, is not anatomical but is functonal only. 2. It should be recognized in enrolling offices by functional tests and not by inspection. 3. Experience shows that few young men are rejectable for fiat or weak foot. 4. It is to be treated by exercises to restore muscle tone and never by apparatus such as built-up shoes or plates. 1 So far as the naval service Is concerned, the attitude to which the writer very properly objects 1b not assumed to any great extent and plays no conspicuous rfile in tb» production of the disability under discussion. (Editor.) 46 BUBK—PRESENT STATUS OF TREATMENT OF FLAT FEET. Vol. XIII. 5. These exercises (described above) should form a part of daily drill. 6. The so-called military stance (60°) for the feet should be abol ished. THE PRESENT STATUS OF THE TREATMENT OF FLAT FEET. By S. B. Bi-rk, Lieutennnt (J. G.), Medical Corps, United States Naval Reserve Force! The causes of flat feet may be considered as predisposing or con stitutional and local. The constitutional or predisposing causes are usually grouped under (1) congenital (a shortened tendo Achillis diminishes the flexion of the foot in walking and causes weakening of the dorsal structures if pronation of the foot and abduction of the toes do not compensate); (2) neurotic; (3) inflammatory; (4) traumatic; and (5) toxic conditions resulting from altered physiological processes, with the production of an overstrain in using the lower extremities. Occupation, unless accompanied by other conditions, is rarely respon sible for flat foot (Merrill). The local changes are knock-knee, poorly fitting shoes, and such other conditions which produce "toeing out." The latter forces the body weight obliquely on the arch of the foot, producing an inward cross strain. The position of the leg in which the toes fall outside of the line of progression shortens the stride, lessens the important element of thrust of the great toe, and diminishes the force of propulsion. Toeing out produces: (1) External rotation of the legs. (2) Twisting of the knees and straining of the joints. (3) Outward rotation of the femur, which favors backward rota tion of the pelvis on its transverse axis, with elevation of the pubis and a decrease in the normal lordosis. (4) Forward displacement of the hips and shoulders, thereby in creasing the lower thoracic curve, and a stoop-shoulder position is favored. Meisenbach describes two types of flat foot, the flexible and the rigid. The flexible is associated with a low posterior or longitudinal arch, pronation or weakness of the ankle, and a general atonic con dition of the muscles of the leg and foot, the toes usually being straight. There is pain over the metatarsals in the weight-bearing position. The rigid or reversed arch is caused by (1) thickening of the metatarso-phalangeal girdle, (2) apparent shortening of the flexor tendons of the second, third and fourth toes, and (3) the presence of deep-seated callouses on the under surface of the arch. No. 1. BUBK PRESENT STATUS OF TREATMENT OF FLAT FEET. 47 Katzenstein holds that the weakness is primarily in the ligaments. Soule summarizes the pathology as an ultimate change in the astra- galo-navicular articulation, which is readily seen on X-ray examina tion. At the same time he urges an examination of the foot for old inflammations of the tarsus as the underlying factors. The symptomatology depends upon the degree of involvement with the production of pain and the objective phenomena resulting from toeing out. The shoes show an unequal wearing down. The trudging gait and the stooping shoulders are characteristic. In addi tion, the patients are easily fatigued and are mentally apathetic. On taking a tracing in the weight-bearing position the inner margin of the foot is prominent. The treatment depends upon the degree of the flat foot. In all cases attempts should be made to relieve local and underlying constitutional causes. For the mild cases adhesive strap ping, proper shoes, and graded exercise are recommended. These exercises as described by McKenzie are : (1) Patient sitting, leg extended nnd supported just above the ankle. Grnsp the right foot just above the ankle with the left hand. Place the right hand on sole of foot, with thumb pointing townrd the toes, grasp foot firmly, cir cumduct foot slowly as follows : Extension, Inversion, flexion, and everslon. This should be done by the attendant with as much force as can be used without pain, and repeated 30 times. (2) These same movements should be done by the patient without help. (3) Patient standing, toes in and heels out, and about 12 inches apart; rise on toes and press out slowly. Repeat 30 times. (4) Patient standing, feet parallel and 6 inches apart. Raise the inner side of the feet, throwing the weight on the outer side. Repeat 30 times. (5) Patient standing with feet parallel, weight resting on outer side of the feet Walk forward and backward 30 steps, keeping feet parallel and forcing down bail of feet. (6) Patient standing, feet 12 Inches apart and parallel, knees bending and outward pressing. (7) Patient standing, feet 6 inches apart and turned In, rise on toes and walk forward and backward 30 steps, crossing feet and keeping toes In. (8) Stnndlng firm, right lunge forward, neck firm, bend right knee until heel is forced from floor, keeping weight on outer side of foot. Repeat 10 times and do same with the left. (9) Standing, feet parallel, 6 inches apart. Sway slowly forward and back ward on heels and ball of feet, chest active, and chin In. (10) Raise heel 1 inch from floor and walk without bringing heel down, as If heel was painful. This may be done repeatedly with both heels. For the severe cases operative treatment is advised. Katzenstein in jects 0.5 c. c. of 4 per cent formaldehyde into the weak points of the tibio-navicular ligament, with the idea of hardening this ligament, and then puts the foot in a plaster of Paris cast for a month. Local anesthesia is necessary in this treatment. He often gives small amounts of morphine also if necessary. 48 TKIBLE AND WATKINS —EAR PROTECTION. VoLXUI. Meisenbach operates on the rigid type. He performs an osteotomy of the second, third, and fourth metatarsal bones, places a felt pad under the arch, and then a plaster of Paris cast up to the knee. He claims good results, and claims the following advantages for the op eration : (1) The Immediate relief of the symptoms and a dropping off of the callouses. (2) The straightening of the toes, with a high anterior arch and no deform ity of the foot. (3) The metatarsophalangeal joints are not opened and the heads of the metatarsal bones are not resected. (4) It is a bloodless procedure, and the danger of infection is negligible. Arnd transfers the tendo Achillis to a deeper groove chiseled into the posterior aspect of the scaphoid. If the tuberosity of the sca phoid does not protrude enough for the purpose, the articulation between the scaphoid and the astragalus can be opened and a groove dug for the tendon here, suturing the tendon again. The results of this method of correcting have been satisfactory during the 18 months to date. Soule denudes the head of the astragalus and the concave surface of the navicular bone and unites them with an autogenous bone peg from the crest of the tibia. He claims excellent results. BEFEKENCES : 1. Anderson, W. L., Med. Times, New York, 191G, XLIV, 144. 2. Arnd, C, Cor. Blatt f. schweiz Aerzte, 1916, XLVI, No. 34, p. 175 Ab. Jour. Am. Med. Assn., LXVII, No. 14, 1049. 3. Bendixen, P. A., Med. Herald, 1915, XXXIV, 368. 4. Katzenstein, M., Therap d. Gegenw., Dec. 15 ; Jour. Am. Med. Assn., LXVI, No. 7, 543. 5. Lovett, R. W., Pediatrics, 1916, XXVIII, 16. 6. Meisenbach, R. O., Amer. Jour. Orthop. Surg., 1916, XIV, 206. 7. Merrill, W. J., Surg. Gyn. & Obstet., 1916, XXII, p. 366. 8. Packard, G. B., Colorado Med. Jour., 1914, XL, 406. 9. Roberts, P. W., New York Med. Jour., Aug. 28, 1915. 10. Soule, R. E.,-Amer. Jour. Orthop. Surg., XV, 4, 292. EAR PROTECTION. By G. B. Tkible, Commander, and S. S. Watkins, Lieutenant, Medical Corps, United States Navy. Conditions surrounding the present conflict are radically different, so far as the weapons are concerned, from those of any previous time in history. The increasingly large proportion of high-explosive shells, grenades and bombs, and the relatively confined spaces occupied, such as trenches and dugouts, all tend to an augmentation of ear injuries. Last, but not least, the employment of corrosive and No. 1. 49 TRIBLE AND WATKINS EAR PROTECTION. noxious gases has caused a limitation of the available means of ear protection. Injuries to the ear, ni:iy be classified broadly, as: 1. Direct — (a) Loss of tissue. (6) Injury by missiles. (c) Gas injuries, producing irritation or caustic action in the external canal or drum. 2. Indirect — (n) Rupture of drum from changes of pressure. ( 6 ) Commotion of the labyrinth. (c) Deafness from long-continued or excessive noise. (d) Driving in of the foot-piece of the stapes, with an intact drum. All variations and combinations of these types may be encountered. So far as the direct injuries are concerned, no practical method of protection is available against the first two, and some devices may increase the danger by acting as secondary missiles, or by becoming fragmented or embedded in the tissue of the canal. It is likely, however, that with such direct injuries, the ear condition will be but a minor part of the damage sustained. With regard to the third, gas injuries, the corrosive gases, such as chlorine, render the efficacy of metal protectors with delicate springs or parts that should coapt, rather problematical and mustard gas, through its action and affinity for fats and oils, as well as its persistence in these substances, makes useless employment of cotton impregnated in vaseline, or similar substances, and makes it necessary to change rubber protectors fre quently. This opinion is substantiated by the following report from Dr. J. Gordon Wilson to Lieutenant Colonel Milliken, under date of July 20, 1918: 1. In regard to the action of mustard gas on rubber and metal, I had a talk with Stieglitz. The action on copper or any metal is negligible, especially in such dilutions as are used in warfare. At the chemical laboratory of the uni versity it was found that a very strong concentrated solution had no effect on copper which enters into the nmke-up of the protector. If it does anything at all, it forms a thin coating of sulphide, not harmful. 2. The action of the gas on the spring is now undergoing investigation, but it does not appear to have any effect. 3. The rubber of the protector will absorb the gas ; if the rubber be left In the ear long there will probably result injury to the canal, but if at the end of the gas attack the rubber be removed, which can easily be done, and replaced with fresh rubber, which can easily be supplied, there is no fear of injury. 4. As the ear contains usually a lot of fatty matter, sebaceous secretion and wax, the gas, getting into this material and being absorbed, will probably act in a very harmful manner on the canal for an Indefinite period. The ear plug will protect from this, as the gas is not likely to get past the rubber. By far the most important, and those which to a certain degree can be prevented, are the indirect injuries. Rupture of the drum is 50 Vol. XIII. TRIBLE AND WATKINS EAR PROTECTION. Cs a very frequent injury, may occur in any portion, though commonly thought to be more often found in the lower half; whether in the anterior or posterior quadrant, is a matter of dispute. Ruptures are made more easily with a previously existing catarrh, or its sequelae, or in those cases with scars and atrophic areas. Strangely enough with the ruptured drum, or one with a previously existing perfora tion, fewer internal ear complications are found after exposure to heavy detonations. The status of the partial vacuum following an explosion and the role it plays, if an}', in the production of perfora tions, has up to the present remained uninvestigated so far as can be learned. Protection against the above form of damage is theoreti cally very simple, as any agent that will stop the inrush of air and prevent the change of pressure will suffice, and it is believed that no other will. All half-way measures are only relatively useful. Cotton saturated with vaseline or glycerin and compressed, or molded with wax or clay, if air-free, protects. The various plasticine preparations protect against this form of injury. Of the patented devices, those that simulate or are modified ear plugs, and make less pretense of allowing slight sounds and air waves to pass, show excellent results on tests. Among these are the British "Tommy" and the later produc tions of Baum. The lust have been so modified that at present they represent diametrically opposed ideas to the ones originally exploited, and consist simply of a filled cylinder capped, and inserted in the ear. Commotion of the labyrinth, organic disturbance of the internal ear, and interference with the central nervous system and cerebral pathways, are very hard to prevent. The part played by bone con duction is in dispute; the matter has been thoroughly presented pro and con in recent literature, but apparently no decision can be reached. So far as trauma, from changing pressure or intense sound aerially conducted, is concerned, and against changes causing driving in of the foot piece of the stapes as well, protection is secured by interposing an object to break the impact, and the more nearly complete the break is the more nearly perfect the protection. Protec tion against constant noise is, for practical purposes, out of the ques- Baum's Ides! model , (rubber) Ear-prolccior^ No. 1 51 TR1BLE AND WATKINS EAB PROTECTION. tion, particularly on ships. It would involve ear stoppage and insula tion by rubber-soled shoes and rubber gloves. Gradual deterioration of hearing developing from this cause must be considered a profes sional deafness similar to that of ironworkers in general. So far as ear protection can be secured, the conditions surrounding naval warfare are highly favorable for its adoption. The time of an engagement is limited, the element of surprise is practically elimi nated, the question of interfering with the hearing is of little impor tance; the noise around the ship renders sharp distinction in sound out of the question, so that actual protection is the main item to be considered. The explosive effect and disturbance in air pressure would be intensified in close compartments, so that protection must be secured even at the expense of loss of acuity of hearing. One of the most common methods of protection, and that shown in nearly all pictures taken at the front where batteries are engaged, consists in stepping back, half opening the mouth, and stopping the ears with the fingers, probably one of the best methods of protection, but naturally not practicable for those being shelled. Cotton is in common use in nearly all services, and while tests show.that it affords scant protection when used dry, practical experience seems to indi cate that it is of some value: its efficacy undoubtedly depends to some extent upon the individual and his skiH in successfully intro ducing it so as to exclude air. Cotton-wool or lamb's wool was used as a means of protection in the British Navy, and reported April 26, 1916, as follows: For protection of hearing, cotton-wool or lamb's wool is chiefly relied upon. This simple method is still found to be the best for general purposes, and the great majority of officers iind men still continue to prefer it. The wool should be upplied in layers or flakes, nnd should not be rolled into a hard ball. The men are Instructed to keep (heir mouths open during exposure to the noise of gunfire. The Mallock-Armstrong patent ear defender is supplied to ships, nnd any officer or man c:m provide himself with this contrivance on payment. Though In theory the Mallock-Armstrong defender should give better results than wool, experience does not show that it is in any way superior as a protec tion, though possibly orders may be heard more distinctly with it than with wool. The objections to the Mnlloek-Armstrong defender are its rigidity and the difficulty of insuring an accurate fit. Cotton possesses the advantages of simplicity and cheapness, and for use in a campaign of rapid movement, it is probably the most practical measure, though surpassed in tests by other substances. In the tests carried out by Guild at Ann Arbor, it showed up very poorly, the excursions or tambour tracings being 56.50 mm. using dry cotton plugs, while they were only 61.67 mm. with the ear open. Water- soaked cotton gave a reading of 1.17 mm., glycerin-soaked cotton 0.35 mm., and vaseline-soaked cotton 0.30 mm. The results of experi ments here and at Indianhead will be tabulated later. 52 TBIBLE AND WATKINS—EAR PROTECTION. Vol. XIII. The Elliott Perfect ear protector has been more or less extensively used in the Navy for several years, and has given a certain amount of satisfaction. The principle underlying these patented protectors, with the exception of the " Tomm}7," and the old ear stopple of Frank, is the production of a sort of double chamber, guarded in some cases by p. valve, or with the inlet and outlet at right angles, or guarded by a tortuous channel. The idea is to admit ordinary sounds, but to interfere with the free entrance of intense and powerful air waves and sound vibrations. The theory seems correct, but experience and practical results do not show the protection desired. The Elliott " Swimmer " differs from the " Perfect " ear protector, in that the central column is not perforated, and it is supposed to be water-tight. Theoretically, it should give excellent protection, and does show up better than the " Perfect." Guild's experiments showed an excursion cross- sectioN M~A Ma 1lock - Armstrong % Dummy Mr-A Wilson ^Micheldon l.Swimmer Safety Elliott E Cross sect. ft on the register of 48.77 mm. with the " Swimmer," as compared to 54.G5 mm. with the " Perfect." Both have the disadvantage of act ing as secondary missiles, and the same criticism applies to the next type patented under the name of " Safety," which is very similar to the Elliott types, and on superficial examination differs from the Elliott " Swimmer " only in that the discs are perforated to admit air waves, these perforations being so situated that the under ones are 90° on an arc away from the upper. The discs are not fixed, and it can readily happen, that they may rotate, so that the holes are in a straight line, one above the other. On similar principles is the obturator of Verain, a French device, which is an ovoid pro longed at one end by a conducting cylinder. Air enters at a small orifice, which leads into an interior chamber, where the effects of vibration are supposed to be diminished ; air escapes through a small No. 1. 53 TMBLE AND WATKINS EAR PROTECTION. orifice leading out at right angles to the entrance. None of these could be secured, and no experiments were carried out with them. The Mallock-Armstrong ear defender has been used quite exten sively by the British. It consists primarily of a body resembling an ear speculum, closed off by two screens of fine wire gauze, and be tween them a vibrating membrane. This device was gotten up by Mallock for his own personal use at the Armstrong Gun Factory, and has been used by their employees for a number of years with satisfactory results. Its relative value in the Guild experiment was 1.02 mm. compared to G1.67 mm. with the ear open. The "Tympan- ophile " which might be considered a French counterpart, consists of a metallic mounting, with a hard rubber speculum attachment, having mounted over the entrance a thin, mica disc. None could be obtained and no record of their tests could be foimd. The Wilson-Michelspn may be considered representative of another group, based upon a valve action which is theoretically so adjusted, that waves produced by detonation, will cause the valves to move in ward and close the inlet. The entrance is protected by a fine wire gauze, and the portion to be inserted into the external canal is covered by a layer of rubber sponge. In Guild's experiments, the excursions with the Wilson-Michelson, measured 13.42 mm. Against this type, there are many disadvantages; rust, dirt, corrosive gases or liquids, would all interfere if not destroy the valve action, and the protector itself could easily become a secondary missile. The Perd-Son is similar in construction, having a small concave aluminum disc, supported by a spring. It was devised with the idea of allowing ordinary sounds to pass wthout diminution but to arrest loud sounds, and violent displacements of the air. It is open to the same objec tions and probably more than the Wilson-Michelson. The next group embraces the. "Tommy," and similar non-per forated ear protectors, made of rubber for the most part, and mak ing no pretense of allowing direct transmission of sound waves. The " Tommy " is patented in Great Britain and France, and con sists of a hollow, soft rubber bulb, resembling a miniature nipple, or rubber cap of a dropper. In the Ann Arbor experiments, the ex cursions on the registering paper were only 0.27 mm., surpassing in theoretical protection the wax cone and impregnated cotton. The Baum as now made, consists of a fluted rubber bulb with a sort of flange or collar, and the top is covered with a thin, rubber mem brane. As made in the tests reported, it consisted of a similar shaped contrivance made of oiled silk or muslin, and was impracticable, not durable, and unless filled with silk floss or made of double thick ness, did not protect. A gelatine capsule was tried out, following an idea reported from the French service, but was of no use as it shattered from a simple 54 Vol. XIII. TRIBLE AND WATKINS— EAR PROTECTION. concussion produced by pistol shot. Various mixtures of wax and clay have been recommended, and undoubtedly protect. One in use Monture meialliyue Larnede mica. Le tLjmpznophile Conduit de caoutchouc Le Perd-Son Caoutchouc Obturateur a chamBfe de detente. ©-1=3 Jamnn EarDrum Protector. in the Italian Navy, consists of yellow wax with 36.4 per cent of liquid vaseline. They are issued in cone-shaped gauze bags. Xo. 1. 55 TRIBLE AND W ATKINS EAR PROTECTION. The matter of protection of the hearing of aviators or others obliged to work around aeronautical engines has been considered, and Lieutenant Colonel C. W. Richardson, forwarded some protectors to Engineer of Tests, Aeronautical Engine Testing Laboratory, and a copy of his report is inserted. Similar experience was had at a naval air station and the medical officer recommended plugs of treated cotton, whose effect would be practically the same as cotton and vaseline. The possibility of the constant use of an ear protector with comfort is rather slight. From : Engineer of Tests, Aeronautical Engine Testing Laboratory. To: Bureau of Steam Engineering. Via : Officer in Charge, Engineer Officer and Commandant, Navy Yard, Wash ington, D. C. Subject : Report of test of Wilson Ear Protector, Bauni Ear Protector, ana Elliott Ear Protector. , 1. The ear protectors noted above were tested as follows: (a) Wilson ear protector. Pair No. 1 was given to one of the men wiir* instructions to use during live-hour test of Curtiss 200 horsepower motor, i', of the noisiest motors in use. At the end of 1J hours the protectors had to be removed, the man complaining of a headache and stating that there was practically no reduction In sound as compared with the unprotected ear. Pairs Nos. 2, 3. and 4 were tested by three different members of the labora tory force. The protectors were used in close proximity to the engine for short periods of time. In every case the result was unsatisfactory, the reduction of sound as compared with the unprotected ear being very slight. Besides being ineffective, these protectors are very uncomfortable to wear and are apt to full out of the ear. (6) Bauiu ear protector: One pair of these was tested by use in close proximity to the engine for short periods. This protector gave absolutely no reduction in sound over the unprotected ear ; therefore, further tests were not conducted. It also has the serious disadvantage that it required special in struments to Insert and remove it. (c) Elliott ear protector: This protector was tried out by using In a flve- hour test of the Curtiss 200 horsepower engine. At the end of the test, the user complained of a headache and only a slight reduction In sound over me unprotected ears. These protectors were also used close to the engine ior short periods by three other members of the laboratory force. The reduction in sound was found to be less than when ordinary absorbent cotton was used. It is more convenient to use and slightly more effective than the other two types. None of the above ear protectors are suitable for use In testing airplane en gines. Ordinary dry absorbent cotton is as effective as any of them. Cotton, soaked with vaseline. Is the most satisfactory protector that has been found at this laboratory. DESCRIPTION OF MECHANICAL TESTS FOR EAR PROTECTORS. These tests were made at the United States Naval Medical School. Washington, D. C, and at the United States Naval Proving Ground, Indianhcad, Md. 56 Vol. XIII. TRIBLE AND WATKINS EAR PB0TECT10N. The following ear protectors and substances were tested. The tests were made during the firing of a United States Marine Corps revolver and the following guns: 3 in. 50, 4 in. 50, 13 in. 50, and 14 in. 50. The apparatus used for the tests consisted of a human auricle and membranous canal (resewed to a rubber tube, 2 inches long and one- fourth inch in diameter) removed from a cadaver, an Eyster tam bour, and a kymograph with a revolving drum and smoked paper. The auricle and membranous canal were connected by means of a piece of rubber, and glass tubing to the tambour, 10 inches long, which in turn was so set up that the aluminum lever (or needle) recorded on the smoked paper as the drum of the kymograph slowly revolved. All connections of the tubing were made air-tight with wax and carefully tested to prove it. ^The revolver tests were made at the United States Naval Medical $f hool. AVashington, D. C. In some of these tests a small hemi sphere of rubber 1$ inches in diameter was used, instead of the auricle, to collect the concussion waves. In all of this group of tests a large wooden partition, measuring 7 feet by 4, by £ inch was used to protect the tambour membrane from waves other than those transmitted through the ear protectors. It was placed lengthwise upon a concrete floor and made steady by means of heavy crosspieces at each end. The crack between it and the floor was filled with closely packed soil on each. A hole one-half inch in diameter was bored at a height of 1 foot from the floor and on an equal distance from each end. The auricle was placed against this hole on one side of the partition and the apparatus on the other side of it, the rubber tubing passing through the above-described hole, which was just wide enough to permit passage of the tubing without constriction. There was a layer of closely packed soil 1 inch thick between the concrete floor and the kymograph, and also the iron stand holding the tambour. On the other side beneath the auricle a wooden block was set up, which was used as a rest for the revolver when firing. With this arrangement no external concussion waves affected the tambour, as was proved by the following test. The auricle was completely plugged with wax. and a number of shots fired with the revolver in the same position as in the tests of the ear protectors. Xo excursion of the tambour lever was recorded in the tracings. Then the wax was removed and very definite excursions of the lever were recorded in the tracings. Thus, it was proved that the partition completely protected the apparatus from external concussion waves and that there was no perceptible vibration of the floor. Also, it proved that the above-described apparatus successfully registered the concussion waves. The position of the revolver in the tests was with the muzzle 2 inches outward and 1 inch behind the auricle. No. 1. 57 TREBLE AND WATKINS—EAB PHOTECTION. All of tha above-named protectors and materials were in turn inserted carefully in the auricle and a number of shots fired while each was in place. Also, records were made without anything in the auricle, in order to determine the maximum excursion registered and for comparison. (The records will be described later.) The tests with the guns were conducted at the United States Naval Proving Grounds, Indianhead, Md. The same apparatus was used as in the revolver tests, but the partition was discarded. Because of the great increase in air pressure and vibration during the firing of heavy guns, it was found necessary to entirely inclose the apparatus in a box, with only the auricle on the outside. A small hole one-half inch in diameter was made inside of it, through which ran the rubber- tubing connecting the auricle with the tambour. The box measured 3 by 2^ by 2 feet and was made of wood three-fourths inch thick. On the side opposite to the small hole there was a door which swung from the top. All seams were tightly covered over with strippings and the entire inside of the box, including the door, was lined with heavy felt 1 inch thick. (The iron stand which held the tambour was firmly fixed in place and there was a platform upon which the kymograph rested.) On the bottom there was a layer of felt 2 inches thick, underneath which was a heavy cardboard. The door was so arranged that it could be quickly closed and tightly locked. The entire outside of the box was covered with heavy tar paper to pro tect it against the weather. In all of these tests the box was placed on a concrete foundation of 4 or more feet in thickness, and during the firing of the 13 and 14 inch guns it was on a separate concrete brick foundation of about 15 feet thickness. This box was found to be practically proof against concussion and vibrations, for when the ear was completely stopped with wax practically no excursion (ex cept one-half mm. when the heavier guns were fired) of the tambour lever were made on the tracings. The same ear protectors and substances as were used in the revolver tests were tested with the heavy guns and in the same way, except for the use of the box instead of the wooden partition, and that the distance of the apparatus from the guns was, of course, much greater than from the revolver in the tests with it. Because of the limited number of shots fired with these guns, only two or three were fired with each ear protector in place. Also because of the small num ber of shots fired (or the rapidity of the firing) from the 1, 5, 6, and 7 and 16 inch guns, tests were not made with these guns. Again, more records could not be made because many times the firing was at plates to test them on the shells when, of course, it was impractical to carry on the tests. Using the rubber bell as a collecting agent, firing the Marine serv ice revolver, fixed charge, 2 inches out, and 1 inch behind bell, using a 88977—18 5 58 TEIBLE AND WATKINS^-EAB PROTECTION. Vol. XIII. t cotton packing, six charges, caused tracings ranging from 28,106 microns to 38,585, an average of 31,832; cotton saturated with vase line had a variation from 1 to 3 mm., an average of 1.917 mm. Cotton and glycerine had a range from 3 to 6 mm., averaging 3,666. Cotton impregnated with wax, a tracing ranging from 0.978 to 1.931, an aver age of 1.333. Taking the patented protectors, under these conditions, the Wil- son-Michelson varied from 2,311 to 9.546 microns, averaging in six shots 6,349f, Baum, original type from 15,691 to 32,771, averaging 23,147§, Mallock-Armstrong from 18,320 to 25,459, averaging 22,661$ , while the " Tommy," gave a negative tracing ranging from -9,435 to 17,210. (Below the line.) On checking the work, under the same conditions, using first, a gela tine capsule, no diminution could be noted ; in fact, there was an exag geration of the tracing ranging from 29,858 microns to 37,054 and this broke in many fragments. Wilson-Michelson ranged from 2.259 to 6,488, plain cotton, from 5,760 to 21,068— while nothing in collecting bell gave tracing ranging only from 7,674 to 14,305. The Elliott under these conditions and in this series gave from 1,997 to 2,465 microns. Baum again ran very erratically, ranging from 1.734, one tracing, to 32,621. Mallock-Armstrong ranged from 19,977 to 28,939, while no protector gave a tracing of only 17,437 to 22,882. It can be readily seen that an accurate approximation of human conditions, or a relatively constant finding, could not be secured, but the idea was merely to conduct a comparative examination to determine the efficiency of each as a means of protection, under iden tical circumstances. Cotton impregnated with glycerine, vaseline or wax showed up well ; the " Tommy " cut off sound waves so effectu ally that it gave a negative pressure resulting from the partial vacuum. Approximating human conditions so far as possible, except in an in vivo experiment, which naturally is impossible, the dissected human auricle was next used as a sound collecting agent, other condi tions being identical with the foregoing. Using the Baum original type in 14 successive shots, a varia tion ranging from 2,429 to 14,279 microns was recorded. Mallock- Armstrong. five shots, gave from 2,245 to 6,867, Elliott from 0.689 to 2,516, plain cotton from 4,372 to 7,186, Wilson-Michelson from 4,696 to 8,954. There was no protection from 26,407 to 28,512, while using cotton and vaseline. In two series of shots, one showed practically no excursion, and the second a slight negative pressure, while the " Tommy " showed practically no excursion. This record is consid ered to be the most accurate of all, the variations in excursion with no protection were slight, and the results of the individual tracings No. 1. TBIBLE AND WATKIN8—EAB PROTECTION. in a series varied but slightly, except in the Baum, which as origi nally made was extremely light and practically impossible to main tain in accurate position. Transferring the work to Indianhead, where the tests were carried out in the manner noted above, the first series was run with a 3-inch, 50-caliber fixed charge ; distance, 18 feet. The following results were obtained : The "Tommy," two tests, averaged 10,952 microns; cotton and vaseline, two tests, averaged 14,148$; cotton and wax, two tests, averaged 14,316; Wilson-Michelson, two tests, averaged 19,025$; Elliott, " Perfect," two tests, averaged 29,571$ ; Baum, " Uncle Sam," averaged 40,502$ ; no protection, 50,432 ; Mallock- Armstrong, 54,302. This last gave evidence of very little protection. Under these con ditions, same membrane, Elliott " Swimmer," gave in another test, 21,415, somewhat better than the Elliott "Perfect"; Safety gave 20 mm.; Wilson-Michelson, 8,690 microns; no protection, 37,172; cotton and vaseline, 26,532. Using a new drum, the results varied; wax averaged 11,004; cotton ran 22,401; Wilson-Michelson averaged about 17' mm.; Mallock-Armstrong, 27,692$; "Tommy," 20,652; El liott, 19,664. In another series, cotton showed up best with 16,535; cotton and vaseline, second, with 17,808; cotton and wax, third, with 19,521; Elliott, fourth, with 19,677; Baum, double thickness, fifth, with 20,- 798; " Tommy," sixth, with 21,005$ ; Wilson-Michelson, seventh, with 31,648$; Baum, single thickness, eighth, with 34,851$; Mallock-Arm strong. ninth, with 51,061; while no protectors ranged from 38,898 to 52,001. The cotton in this case was undoubtedly very firmly packed in. One series of tests was made, using the various types of Baum's. as then designed, and in his presence in order to demonstrate the technique used. This was done with a 3-inch 50-caliber gun. dis tance 18 feet, Buum double thickness; ranged from 8,125 with cap, to 21,247 microns; no protection showed a tracing of 32,724, one test, and 33,354 another; three tests with the "Safety" gave an nvc:;.ge of 13,521. Fourteen-inch, 50-caliber, at 19 feet, gave the allowing records: Microns. " Tommy " 34, 404 Cotton and wax 42,239 Cotton nml vaseline 44,287 Elliott 51,861 Microns. Wilson-Michelson 53. 288 Safety 56,137 Cotton 56,151 No protection 53, 047 From this, it can be seen that very little protection was afforded by anything except the "Tommy." and the cotton wax or cotton vase line. Plain cotton and the Wilson-Michelson registered actually higher than no protection ; the Elliott was slightly under. Another test with the 14-inch. 50 caliber, at 90 feet, gave the following . 60 TBIBLE AND WATKINS —EAB PROTECTION'. Vol. XIU. Microns. "Tommy'." 29,164 "Tommy"1 30,893 "Tommy"1 33,820 Baum, double thickness and with rim 41,571 Microns. Baum, "Uncle Sam" 48,132 Baura, single thickness 47, 173 Baum, double thickness 41,663 Mallock-Armstrong ' 42,724 Mallock-Arnistrong ' 49,000 These tests differ to some extent in results from those reported by Guild, of Ann Arbor, who was a pioneer in this work, and to whom great credit is due. From a practical standpoint, endeavor was made to try out various types of protectors around the guns, distribu ting them to the men engaged in work with them. The results were rather contradictory, some of them appeared to like the Baum, as it was then made, chiefly because of the ease with which it was worn. It is apparently not possible to wear many types of these protectors with comfort. The Mallock-Armstrong showed up particularly badly in these tests, and the Wilson-Miehelson did not perform as well as expected. Cotton and vaseline, cotton and wax, and cotton and glycerine to a less degree, show that they afford protection against changes of pressure. Of the patented protectors, only one. the " Tommy," was a consistent performer and is the only one that can be recommended as a result of these tests. For use on shore with landing parties, or with the Marines serving in the Army, or in any capacity in those likely to be exposed to the action of mustard gas, protectors containing oil or fats, and probably wax, are unsuitable. This probably applies to clay as well. This leaves only those made of rubber, since other gases with a heavy chlorine clement would render metallic protectors unsuitable, and, in addition, such pro tectors or similar ones, such as the Elliott or the " Safety," could act as secondary missiles. It is impossible to delay the tests further, to work out the new Baum, which is made of rubber. It should be satisfactory, as the design and principle are good. Up to the present, it is only possible from a standpoint of safety, simplicity', and cheap ness, to recommend the " Tommy." Great credit is due to Rev. Father Torndorf, of Georgetown Uni versity, who kindly put the instruments of his laboratory at our dis posal, and who so accurately made the measurements of the various tracings. Lieutenant Commander F. P. Hough, Medical Corps, United States Navy, cooperated in this work up to the time of his detachment from the naval proving grounds. Lieutenant Colonel C. W. Richardson, Medical Corps, United States Army, has worked in conjunction and along similar lines in the Army for the past year, and his conclusions as reported to the Surgeon General of the Army are in favor of the " Tommy." Experimental work with animals was contemplated, but found impossible owing to pressure from increased office work, due to the great number of war workers who, as members of the enlisted personnel, are entitled to treatment. •Averaging 31.294J microns. 'Averaging 45,862 microns. HISTORICAL. THOMAS HENRY HUXLEY. (1825-1895) By F. J. B. Cobdbibo, Lieutenant Commander, Medical Corps, United States Navy, retired. Thomas H. Huxley was born in Ealing, a suburb of London, the son of a schoolmaster. He received a little schooling in the public schools, but got most of his education from his father, his brothers-in- law, who were physicians, and from his own efforts. He said that at 12 years of age he used to get up before dawn, pin a blanket round his shoulders, light a candle, and sit up in bed reading Hutton's Geology. "He discussed all manner of questions with his parents and his friends, for his quick and eager mind made it possible for him to have friendships with people considerably older than him self." "As I grew older my great desire was to be a mechanical en gineer, but the fates were against this, and while very young I began the study of medicine under a brother-in-law. But though the In stitute of Mechanical Engineers would certainly not own me, I am not sure that I have not all along been a sort of mechanical engi neer. The only part of my professional course which deeply inter ested me was physiology, which is the mechanical engineering of living machines; and notwithstanding that natural scienc? has been my proper business, I am afraid there is very little of the genuine naturalist in me." In 1841 he went to live in the East End of London, where he func tioned as assistant to the district physician for the poor. This was preliminary to "walking the hospitals of London" in order, finally, to obtain his medical degree. He says, " It so happened that the shortest way between the school which I attended and the library of the college of surgeons, where my spare hours were largely spent, lay through certain courts and alleys 9 or 10 feet wide, with tall houses full of squalid drunken men and women and the pavement strewed with still more squalid children. The place of air was taken by filthy exhalations and the only relief to the general dull apathy was a war of words—filthy and brutal beyond imagination —usually ending in a general row. Nobody would have found robbing me a profitable employment in those Gl 62 HISTOBIOAL. Vol. XIII. days, but I used to wonder why these people did not sally forth in mass and get a few hours eating and drinking and plunder to their hearts' content before the police could stop them and hang a few." We can hardly doubt that it was the practice then, as it is to-day, for young medical students, when visiting in such quarters, to make learned diagnoses, consisting of two Latin terms, which were followed by elaborate prescriptions in which the drugs were compounded, secundum artem. We get a glimpse of the sound common sense which was ever the basic characteristic of Huxley's mind, in the fol lowing: Of one of his visits in these slums, he says, "After due examination, even my small medical knowledge sufficed to show that my patient was merely in want of some better food than the bread and bad tea on which these people were living. I said so as gently as I could, and the sister turned upon me with a kind of choking passion. Pulling out of her pocket a few pence and half -pence, she said, ' That's all I get for 36 hours' work, and you talk about giving her proper food.' " Huxley was now attending lectures at Sydenham College in prepa ration for the matriculation examination at the University of Lon don. He attained considerable success, winning, besides certificates of merit, a prize —his first prize —in botany. Speaking of these stu dent days, he says : " I worked extremely hard when it pleased me and, when not, I was extremely idle or wasted my energies in wrong directions. I read everything I could lay my hands on." He was particularly interested in physiology and, recognizing that this study was nothing more than the physics and chemistry of living bodies, delved deeply into these branches. He had not been deeply grounded in mathematics or physics, but one of the matters which he speculated upon much in those days was the possibility of free energy, or perpetual motion. He says: "I remember how my long-brooding perpetual-motion scheme had been working upon me, depriving me of rest even, and heating my brain with chateaux d'Espagne. I finally tremblingly betook myself one afternoon to the Royal Institution and asked the porter, ' Is Dr. Faraday here?' 'No, sir; he has just gone out.' Strange to say, I felt relieved, but as I was hurrying out a little man with a brown coat came in at the glass door. ' Here is Dr. Faraday,' he said, and he turned to me and courteously inquired what I wished. ' To pre sent to you a matter, if your time is not occupied,' I said. ' My time is always occupied, but step this way.' He examined my drawings, but did not think my plan would answer. Was I acquainted with mechanism —what we call the laws of motion? He said that, were perpetual motion possible, it would have occurred spontaneously in nature and would have overpowered all other forces. I saw it was all up with my poor scheme and, after trying a little to explain, in No. 1 HISTORICAL. 63 the course of which I certainly failed in giving him a clear idea of what I would be at, I thanked him for his attention and went off as dissatisfied as ever." We have here a truly historical incident. We can picture in our minds the room in the Koyal Institute. The great physicist, entirely impersonal and unaffected with any sense of his own importance, courteously and patiently listening to the earnest young man whom he knew to be entirely astray in the field in which he was supreme. The young man, who was destined later to contribute fully as much to science as his kindly adviser, going away " dissatisfied " but not crushed. He adds, " I do not appreciate the force of his objection, but did not feel competent enough to discuss the question. However, he exorcised my devil and he has rarely come back to trouble me since." Huxley now. after having passed his M. B. examinations at the University of London, obtained a commission as assistant surgeon in the Royal Navy. After some months at Haslar Hospital, he was detailed to the Rattlesnake, which was about to be sent out to New Guinea on an exploring expedition. Besides his strictly medical duties he was to do work as a naturalist. It is a curious coincidence that, like two other leaders in science, Charles Darwin and Joseph Hooker, their close friend Huxley be gin his scientific career on board one of Her Majesty's ships. He lived in the gun room (steerage) with the middies, some of whom were hardly yet in their teens. A man in the midst of a lot of boys with hardly any grown-ups has an unenviable position, but one of these middies, writing afterwards as Captain Heath, said that " Hux ley's constant good spirits and fun, when he was not absorbed in his work, as well as his freedom from any assumption of superiority over them, made the boys his good comrades and allies." The Rattlesnake did not return to England for four years, and during that time Huxley was able to keep contented by hard work He made a great number of drawings of various kinds of animals and sent a number of scientific papers to England, but worried greatly about the latter, as no word ever reached him as to their fate. There were times in the monotony of the cruise when he envied greatly those who were actively engaged in the work of surveying when he could do nothing. His diary and his letters home were intensely human. He writes: " Of all extant lives, that on board a ship-of-war is the most arti ficial —whether necessarily so or not is a question I will not under take to decide —but the fact is indubitable. How utterly disgusted you get with one another ! Little peculiarities which would give a certain charm and variety to social intercourse under any other cir cumstances, becomes absolute sources of pain and almost uncon 64 HISTORICAL. Vol. XIII. trollable irritation when you are shut up with them day and night. One good friend and messmate of mine has a peculiar laugh, whose iteration in our last cruise nearly drove me insane. There is no being alone in a ship. Sailors are essentially gregarious animals, and don't understand at all the necessity under which many people labor —I among the rest—of having a little solitary converse with oneself occasionally. Hence all sorts of petty intrigues, disputes, grumblings, and jealousies which to the eye of an ' idler ' give to the whole little society the aspect of nothing so much as the court of Irenaeus in Kater Murr's inestimable autobiography." He thus describes sea life in the Tropics: "For weeks, perhaps, those who were not fortunate enough to be living hard and get ting fatigued every day in the boats were yawning away their ex istence. Rain ! rain ! encore et toujovrs —I wonder if it is possible for the mind of man to conceive anything more degradingly offensive than the condition of us 150 men shut up in this wooden box and being watered with hot water as we are now. Moving about in the slightest degree causes a flood of perspiration to pour out; all energy is completely gone, and if I could help it I would not even think ; it's too hot. It's too hot to sleep and my sole amusement con sists in watching the cockroaches which are in a state of intense excitement and happiness." On returning to England Huxley found that his scientific papers had been duly received and much appreciated. The Royal Society shortly took steps to publish them under Huxley's superintendence. He was made a fellow of the Royal Society (F. R. S.) and the next year was awarded the Royal Medal for his work while on the Rattle snake. He had now been in the Navy eight years and he was forced to choose between a career in pure science or remaining in the service. Happily, after much deliberation, he decided for the former. It was a momentous decision and he knew very well that it meant for him a life of strenuous toil and incessant fighting. The mere existence of a man of science at that time was apt to be precarious and from his intimate acquaintance with the leaders of English science he knew that such a life must be one long battle in which he must expect to take and give many heavy blows. His life, in fact, was one long fight, but there was nothing he delighted in more than a fight for truth. He only demanded fair play and the only com plaints he ever made were when this was not forthcoming. Before leaving the Navy, he had, in 1852, delivered his first lecture at the Royal Institution and had sent his Memoir on the Morphology of Cephalous Mollusca to the Royal Society. Writing of this to a friend, he says : " It is perhaps the best thing I have done, but I do No. 1. HISTOBICAL. 65 not know whether they will print it or not. That will require care ami a little maneuvering on my part. You have no notion of the intrigues that go on in this blessed world of science. Science is,I fear, r o purer than any other region of human activity, though it should be. Merit alone is" very little good ; it must be backed by tact and knowledge of the world. I am sure if the paper I have sent in is referred to the judgment of my particular friend , it will not be published. He won't be able to say a word against it, but he will pooh-pooh it to a dead certainty. The necessity for these little stratagems utterly disgusts me. I am so utterly unable to comprehend this petty jealousy, but I see that is determined not to let me rise, or any one else, if he can help it. Let him beware. On my own subject I am his master and quite ready to fight half a dozen dragons. And, although he has a bitter pen, I can match him in that department also." And he adds, " Science in England does everything but pay. You may earn praise, but not pudding. Last year I became a candidate for a professorship at Toronto, and pre sented many testimonials, but have heard nothing of the business. I believe the chair will be given to a brother of one of the Canadian ministry. Such a qualification as that is, of course, better than all the testimonials in the world." Huxley's life now became one of so many interests and his work was so diversified, that to follow his purely scientific investigations alone would give a very inadequate impression of his labors. Great as was the impression left by those researches in purely scientific cir cles, it is not by them alone that he made his impressions upon the mass of his contemporaries. They were chiefly moved by something over and above his wide knowledge in so many fields — by his pas sionate sincerity, his interest not only in pure knowledge but in hu man life, by his belief that the interpretation of the book of nature was not to be kept apart from the ultimate problems of existence; by his love of truth, both theoretical and practical, which gave the key to the character of the man himself. One of the most extraordinary intellectual combats which the world has ever witnessed, took place in England 30 years ago. It was the celebrated religious controversy which Huxley started by his lepeated attacks on systemic theology. As in all such controversies, it was out of the question that he should have convinced the church men, but it marks a great advance that those churchmen should have abandoned their attitude of former times, viz. that their position being absolutely unassailable, there was nothing to argue about. They admitted with Huxley that where the truth was concerned all sincere and honest arguments were permissible, and they answered his arguments to the best of their ability. It is further much to '.he credit of all the participants that they displayed usually the greatest 66 HISTORICAL. VoL XIII. courtesy and the highest breeding. They gave and took hard blows, uut always in a knightly manner. There was a time when Huxley's pointed thrusts would have been answered by the faggot and torch. It was during this controversy (hat he added the word " Agnostic. " to the English language. What astonishes us most in Huxley's life is his ceaseless and untir ing energy, both mentally and physically —his enormous capacity for work. The popular idea is that genius is spontaneous and that it accomplishes its work automatically —that some men are born great, others achieve greatness, while still others have greatness thrust upon them. In scientific matters, nothing could be further from the truth. The outstanding difference between the giants of science and their lesser brethren seems to be their capacity for withstanding strains, both physical and mental, of which the latter are incapable. Xewton, when asked how he was able to make his extraordinary dis coveries, replied, "By intending my mind." In other words, his was what would have been an everyday mind, had it not achieved great ness through the discipline of hard work. And so, in looking over Huxley's busy life, we find that for 13 years he was examiner in physiology in the University of London, Hunterian professor of com parative anatomy in the College o± Surgeons, Fullerian professor of physiology in the Royal Institution, and an officer in so many other institutions, both public and private that the list is bewildering. We can get a slight idea of some of his activities from a letter written to Charles Darwin in 1863. " You ask me what I am. doing, so I will enumerate a few of them : A. Editing lectures on Vertebrae skull and bringing them out in the Medical Times. B. Editing and rewriting lectures on elementary physiology just delivered here. C. Thinking of my course of 24 lectures on the mammalia at College of Surgeons next spring and making investigations bearing on same. D. Thinking of and working at a manual of comparative anatomy (may it be d d), which I have had in hand these seven years. E. Getting heaps of remains of new labyrinthadonts from the Glas gow coal field, which have to be described. F. Working at a memoir on Glyptodon based on a new and entire specimen at College of Surgeons. G. Preparing a new decade upon fossil fishes for this place. H. Considering writing up a lot of Indian fossils. I. Being blown up by Hooker 1 for doing nothing for the Natural History Review. K. Being bothered by sundry editors just to write articles " which you know you can knock off in a moment." 1 Sir Joseph Hooker, the great naturalist. No. 1. 67 HISTORICAL. L. Conscious of having left unwritten letters which ought to have been written long ago, especially to Charles Darwin. M. Ten or twelve people taking up my time all 'day about their own affairs. N. O. P. . . . W. X. Y. Z. Societies, clubs, dinners, evening parties, and all the apparatus for wasting time, called ' Society.' Finally pestered to death in public and private because I am believed to be what they call a ' Darwinian.' " His ideas on medical education arc as valuable now as they were when given, and there could be no more competent judge. Strange to say they have never received any attention. He had a good knowledge of mathematics and physics and he recognized that the exact science of " mechanics " was the substratum upon which the more inexact sciences must perforce rest. He was generally credited with being a hard examiner, but he says " I have asked for some knowledge of the physics and mechanics of the human body and I have been met with a talk about cells. I declare to you I be lieve it will take me two years at least of absolute rest from the business of examiner to hear the word " cell," " germinal matter," or " carmine," without a sort of inward shudder. It is a comparatively easy matter to learn anatomy and to teach it; it is a very difficult matter to learn physiology and to teach it. It is a very difficult mat ter to know and to teach those branches of physics and those branches of chemistry which bear directly upon physiology. . . . . . . I do not believe that all the talking about and tinkering of medical education will do the slightest good until the fact is clearly recognized that men must be thoroughly grounded in the theoretical branches of their profession, and I would cut down these branches to a very considerable extent. The next thing to be done is to go back to primary education. The great step toward a thorough medical education is to insist upon the teaching of the elements of the physical sciences in all schools, so that medical students shall not go up to the medical colleges utterly ignorant of that with which they have to deal ; to insist upon the elements of chemistry, and the elements of physics being taught in our ordinary and common schools, so that there shall be some preparation for the discipline of the medical colleges. And if this reform were once effected you might confine the " Institutes of Medicine " to physics as applied to physiology —to chemistry as applied to physiology —to physiology itself, and to anatomy. Afterwards, the student, thoroughly grounded in these matters, might go to any hospital he pleased for the purpose of studying the practical branches of his profession. But you may say, " This is getting rid of a good deal; you are get ting rid of botany and zoology to begin with." I have no doubt they 68 HISTOBICAL. VoL XIII. ought to be got rid of as branches of special medical education. They ought to be put back to an earlier stage and made branches of general education. I believe that comparative anatomy ought to be abso lutely abolished. Make it part of the arts teaching if you like, but abolish it. I recollect that when I was first under examination at the Univer sity of London, Dr. Pereira was the examiner, and you know that " Pereira's Materia Medica " was a book de omnibus rebus. I recol lect my struggles with that book late at night and early in the morn ing—I worked very hard in those days—and I do believe that I got the book into my head somehow or other, but then I will undertake to say that I forgot it all a week afterwards. Not a trace of the knowledge of drugs has remained in my memory from that time to this ; and really, as a matter of common sense, I can not understand the arguments for obliging a medical man to know all about drugs and where they come from. Why not make him belong to the Iron and Steel Institute, and learn something about cutlery because he uses knives? " Huxley's greatest service was, of course, the placing of the doctrine of evolution upon an impregnable foundation. Broadly, this doctrine is that after the earth had acquired, on its long evolution from the original nebula, conditions where life was possible, such life did ap pear in its most primitive forms, and that from these primitive be ginnings our present fauna and flora have gradually evolved. The palaeontologist does not concern himself with the actual beginnings of life, for he recognizes that no records of such an actual beginning could possibly have been preserved, but only in tracing the gradual development of such records as exist. It is natural that mankind should have believed until yesterday, as it were, that all the different types of animals and plants which we find upon the earth were created originally exactly as they are now and that they will persist forever in their present forms. Even such learned naturalists as Buffon and Cuvier could find no other explanation and looked upon every animal and plant as a special creation. Tn other Words, there was an instant when these organisms were nonexistent and an in stant directly after when they possessed their present unalterable forms, and, according to the Scriptures, they wort all created at the same time, or practically so, in various groups. Palaeontology showed that many of the forms which once existed no longer exist, and that many other forms did not come into ex istence until long after certain other forms. Hence it was evident that if every form was the result of a special creation, the:o creations were not simultaneous but distributed over immense periods of time. As long as it was generally held that all science (or knowledge) must be based upon the biblical account of the creation, there was N«. 1. 69 HISTORICAL. an irrepressible conflict between "science" and "religion," and science was forced to stand still and deny the evidence of its senses under various dire penalties. As Huxley says, "It is, indeed, a conceivable supposition that every species of rhinoceros and every species of hyena in the long success- sion of forms between the Miocene and the present species was separately constructed out of dust, or out of nothing, by supernatural power; but until I receive distinct evidence of the fact, I refuse to run the risk of insulting any sane man by supposing that he seriously holds such a notion." In many cases there was evidence of a gradual and almost, insensi ble change of one form into another, but in many more instances all " links " of evidence were entirely wanting and seemingly undiscov- erable. Granting the probability or only the possibility of a gradual chain of descent, it was a priori evident that many of the links must have been irrevocably destroyed and lost forever. But it was the work of evolutionists, by slow and painful toil, to build up these chains wherever possible, and in this Huxley did yeoman service. Of the links still existing, but as yet undiscovered, it will take cen turies of the most difficult labor before a majority of them are un earthed, and many of these can never be unearthed. Nevertheless, the science of probabilities, upon which, after all, all our positive knowledge is founded, tells us unmistakably that all forms of life, our own included, have developed from simple and primitive forms through a long chain of gradations over immense periods of time. " If that is contrary to religion," said Huxley. " then so much the worse for religion." It would be impossible in a sketch like the present one to give a list of even his more important papers and scientific activities. These were each separate insets into the general mosaic of his life- work. Likewise to give a record of his degrees and honors, and the various positions he occupied in learned societies of the most diverse character would be to present a catalogue which would weary the reader. But more important than these things is an appreciation of the character of the man, which alone made his work possible. In his mind no compromise was possible between truth and untruth. His passion for truth 1 was his strongest characteristic, with complete dis regard of personal consequences in uttering unpalatable facts. Against authorities and influences he published his "Man's Place in Nature, " though warned by his friends that to do so meant ruin 1 Once when writing a eulogy of a dead friend, he Raid, " The only serious temptation to perjury I have ever known, has arisen out of a desire to be of some comfort to people I cared for In trouble. Mrs. Is such a good devoted woman, and I am so doubt ful about having a soul, that It seems absurd to hesitate to peril It for her sake." 70 HISTORICAL. VoL XIII. to his prospects. The lie from interested motives was only more hateful to him than the lie from self-delusion or foggy thinking. With this he classed the " Sin of faith," as he called it—that form of credence which does not fulfill the duty of making a right use of reason: which prostitutes reason by giving assent to propositions which are neither self-evident nor adequately proved. Truthfulness, in his eyes, was the cardinal virtue, without whicK no stable society can exist. He wrote: "Warfare has been my business and my duty," and when he died, unlike the great mass of individuals whose existence is entirely immaterial as regards the progress of mankind, he left the world distinctly richer. EDITORIAL. ACCURACY. One is sometimes forced to believe that Lord Bacon's famous dic tum : " Writing maketh the exact man " is more honored in the breach than the observance. One of the startling surprises, and it must be said also one of the pleasant disappointments, of the writer's early service in the Navy was the discovery that one could be guilty of truly appalling errors and of many sins of omission and still go unpunished. The outsider often has an exaggerated idea of the severity of Navy discipline. Perhaps after all the discipline is severe as regards the punishment inflicted but the people higher up considerately omit to act upon all of the omissions of the people lower down. " I hate that accurate, methodical fellow," you say. " This other chap is careless and absolutely unreliable, but I love him." Very true; but if you robbed the first man of his accuracy you would still dislike him, and if the second man mended his ways he would be just as lovable. Virtue is not a crime, but it is very unattractive in uncongenial people. Many young officers turn up their noses at paper work and disdain to take pains with regard to reports. " I am a surgeon, not a clerk," says one. " I'm hanged if I will drive a quill all day for anybody," says another. The former is often less of a surgeon than he is pleased to suppose and might perhaps be of some positive value in the world if he had in him the making of a good clerical assistant; the latter might be in real danger of suspension if he did write. Recently in looking over some hundreds of death reports and health records it was astounding to note how common were errors due to carelessness and how willing medical officers were to sign their names to papers they had not read over, or that charity pre sumes they had not read over. If accurate reports were wanted merely for dry statistical charts, one could perhaps forgive the man who is guilty of errors, but reports are for something more than the annual statement or the weekly bulletin. Accuracy in the tabulation of facts and phenomena and in their proper interpretation is the basis for any legitimate inferences to be drawn from them. Every clinical case inaccurately reported and every record failing to make its significance clear have to be thrown out by the seeker after truth. An incident of sickness and treatment which might furnish a strik 71 72 EDITORIAL. Vol. XI II. ing illustration and convincing argument in some important advance in the profession is often useless as evidence in the form, in which it is reported. A concrete example may make clear the far reaching and often unexpected result of an apparently trivial omission. A certain medi cal officer desiring to reply to the frivolous charge that anesthetics were not competently administered in the Navy undertook to look up the number of deaths following anesthesia in the service and it was naturally incumbent upon him to discriminate between the effects of the operation itself and the effects of the preexisting condition on the anesthesia. Naturally in a limited number of anesthetizations the cause of death in the case of two or three patients affects the per cent enormously. In one report many details were omitted and doubt was entertained as to the actual cause of death. It was care fully stated that death occurred at 3 p. m., but there was no state ment as to the hour at which the operation had taken place. As a mere death certificate the document was clear enough and the writer of it doubtless had an opinion of his own as to what killed his patient, but it contained no data of value for the investigator. Failure to make the necessary entries in a health record resulted recently in a young man's getting no less that eight inoculations against typhoid fever within a period of six months. He was a recruit for war service, a college man, and evidently a chap with something more than the ordinary allowance of good nature. Appar ently the subject of these repetitions assumed that they were a part of the Navy routine and in the spirit of true discipline endured them without complaint. Later a civilian physician treating him for some obscure form of jaundice stumbled upon the history of these repeated inoculations and tried, not without a show of reason, to i , establish a genetic connection between the antityphoid treatment and the disturbed gall bladder. Had the patient or physician been given to what the Italians call pettegolezza there might have been results "to the prejudice of good order and discipline." Parentheti cally it may be remarked that, if our figures can be relied on, there is no 'evidence of any increase of jaundice or gall bladder infection in our personnel since antityphoid vaccine was introduced into the Navy. It would be interesting if one could go further and declare that cystic disturbances have actually been less prevalent since the antityphoid injection became general in view of the important role played by Eberth's bacillus in gall bladder infection. The medical officer should make it a point to be painstaking, me thodical, and accurate in all written reports. If he can not have that larger view of the question which these paragraphs aim to inspire then he should have sufficient personal pride to make his reports carefully. Most of us have pride, but we often discredit ourselves No. 1. 73 EDITOBIAL. through not understanding how and when pride may properly modify conduct. Many a man is reticent of speech and slow to com promise himself by uttered words, thus passing for wise until he puts on paper some vulgar, ungrammatical or impossible statement and signs his name to it. Those who heard the spoken word forget or .forgive it or better still die and so become unable to cherish it against him, but the written word may remain to provoke mirth or scorn or pity from generation to generation, whether he referred to the deep Palmer arch, or spoke of a recommendation for waifer of physical defects, or described a movement in space as horizontally upward. JIITITAKY TITLES AND MIMTABY BEHAVIOB. By a recent ruling staff officers are henceforth to be addressed by the titles of their rank. The discussion of the wisdom and pro priety of this radical innovation has no place here, but, as it was undoubtedly intended to enhance the standing and facilitate the per formance of duty, some reflections on the altered situation may be in order, and it is certainly pertinent to consider whether the change in question involves an obligation for the staff officer to modify his conduct in any particular. For years it has been the contention of many members of the medical corps that their position in the Navy entailed duties essen tially different from those discharged by physicians in civil life. It has been insisted by many and perhaps felt by all that if a doctor was a member of a military organization he necessarily had a certain military status in that body and had a right to a clear definition of his duties in respect to all and not merely in respect to part of his duties and that justice was not done him if there was not official recognition of all of them. Being, necessarily, from his very presence on board a participant in military drills, having frequently to per form duties by no means medical (for example, sitting as member of a court-martial) and having to receive and give orde/3, even though the latter were in a restricted field, he deserved the full recognition of his military status. Whatever the justice of this and other claims might be there was one argument which could too often be properly advanced against them. The doctor brought with him from civil life much of that dislike for business, for orderliness, for methodical procedure which is a common failing of physicians. The medical officer did his duty by the sick but often chafed under military restrictions and require ments and neglected or escaped them whenever he could. The un- military spirit was often most conspicuous in matters that related to his own corps. The younger men, who of course consider them- 88977—18 6 74 EDITORIAL. Vol. XIII. selves vastly superior in knowledge to their seniors in years, liked to think that they were all doctors together and could simply relax and lay aside military etiquette when there were no outsiders present. The doctor who was scrupulously careful to salute his executive officer or the commanding officer on board ship felt no compunction in pass ing his corresponding superiors in the hospital with a friendly nod, a wave of the hand, a grimace, or a familiar jest. When differences of professional opinion arose the medical officer was prone to say to himself and even to say aloud that a doctor was a doctor and that in the matter of treating the sick rank did not count. This may or may not have been the proper spirit but it was in marked contrast to the attitude maintained by the medical officers to their superiors in the line whose orders were always received with respect and deference even when they derived their source from vested authority rather than from special knowledge, and it was in marked contrast to the bearing of the best military men. The best military men not only render what is due to their superiors but have the moral courage to exact what is due from their subordinates. In a word, medical officers constantly showed that while they understood discipline and were able to observe military etiquette toward those in other corps they regarded these things very lightly among themselves, and yet they showed surprise or resentment if others declined to make careful the distinctions toward them which they themselves laid aside in their dealings with each other. It never seemed to occur to them that or ganizations and bodies of men, just as is true with individuals, are taken by others at their own valuation. When an assistant surgeon was ordered to duty as the relief of a medical inspector, while other officers at the station where he reported were carefully assigned ac cording to rank, the effect upon them was to emphasize the fact that rank was a secondary consideration in the medical corps, and the conduct of medical officers often bore out this belief. As a Nation we are not inclined to attach much weight to the externals of military life, forgetting that supposedly minor details of outward bearing are often the index of vital things under the surface. The man who despises the essentials of military organization and is incapable of conforming to them should not masquerade in a uniform. The med ical officer, alas, needs too often to be reminded of the old saying about the depravity of those feathered folk who are careless as to the hygienic standard of their own nests. What we owe to others we also owe to ourselves. A proper sense of dignity includes our corps and our calling. Whatever we render to Caesar we should render also to Herod. No. 1. EDITORIAL. SHELL SHOCK. Those whose good fortune may not take them to France and even those who may never be called on to treat a case of this kind should attempt to gain some idea of its nature. Whenever a case of nervous disorder is returned from the American Expeditionary Forces abroad the fact gets out through relatives and friends and makes an impres sion on the local community to which the patient belongs. Medical officers are likely at any time to be asked questions on the subject and so they should be fully informed about it. There are so many sad truths about' the Great War that it is most undesirable for any false ideas to gain credence and circulation in regard to it. In another section of this magazine an attempt has been made to present the views of a number of authorities on the subject of so- called shell shock. This term is objectionable, if taken to mean that a condition resembling traumatic shock and one involving some molec ular disturbance of brain matter or nerve elements results from the near-by explosion of a shell, but it hits the popular fancy and would do well enough for popular use if it were made clear that it simply typifies the whole complexus of disconcerting, overwhelming expe riences of modern war tending to bring out any latent nervous insta bility or weakness and to break down the acquired fortitude necessary to' endure hardships and trials greater than any previously known in war—experiences operating with especial force on a civilian sol diery whose whole mode of life has been subjected to the most radical change. SUGGESTED DEVICES. TYPHOID PROPHYLAXIS CAEDS. By E. B. Hbnby, Lieutenant Commander, Medical Corps, United States Navj. Naval Instructions, Article 3212, provide that : " Typhoid prophy lactic shall be administered to all persons upon their first entry into the Navy or Marine Corps," and that " The only acceptable evidence of administration of the prophylactic shall be the entry on the health record signed by the medical officer." In spite of the above, out of the last 500 health records received on the receiving ship at Norfolk, Va. (not including records of recruits or others due to receive the prophylaxis after arrival here), 64, or more than 12 per cent, were defective in that they contained no entry of the administration of the typhoid prophylactic, or only an incomplete entry. Sometimes an entry of this kind is found : " States that he re ceived typhoid prophylaxis on the U. S. S. John Doe, in March, 1918," a statement doubtless entirely correct, but which, in view of the second paragraph of instructions quoted above, is valueless as evidence. In a case of this sort the medical officer has no choice but to administer the prophylactic, and men frequently complain tEat they have been compelled to receive several series of injections be cause of defective records and through no fault of their own. In other instances the instructions have been strictly complied with and the entries carefully made, but the health records have been lost. It is manifestly unfair to such a man to compel him to take the injections again, and yet there is nothing else to do, there remaining no record of the previous administration. Incidentally, this useless revaccination results in much waste of valuable vaccine. The remedy is simple ; let an order be issued directing that every man already in the service who has received the prophylactic be given a certificate of prophylaxis, with dates of injections as gath ered from the health record, and that every man inoculated in the future be furnished with such a certificate at the time of inoculation. The men should be enjoined to carefully preserve these cards and informed that they must be shown in order to get liberty ; then they will take care not to loose them. 77 78 vol. xii r. PRICE — SURGICAL DRESSING TRAY. For the medical officer the situation would be much simplified, as he would have only to direct that prophylaxis cards be shown at muster to learn the number of men still unprotected. Below are the facsimiles of two cards in use on the receiving ship at Norfolk. One is a certificate of prophylaxis, and the other a "temporary" card for issue to men pending the arrival of health records, or while undergoing inoculation. No man can go on lib erty unless he has one or the other of these cards in addition to his liberty card. THE RECEIVINO SHIP AT NORFOLK. TYPHOID PROPHYLAXIS CARD. (Name "in full.')" (Rate.) let Dr 2d Dr 3d Dr C. P. Vac Date THE RECEIVING SHIP AT NORFOLK. TYPHOID PROPHYLAXIS CARD. (Name In full.) (Rate.) TEMPORARY. Not good after. A SURGICAL DRESSING TRAY FOR TRANSPORT AND HOSPITAL SHIPS. By M. J. Price, Lieutenant, Medical Corps, United States Navy. With the increased transportation of wounded from overseas re quiring extensive and repeated surgical dressings, there is a great need for some type of a portable dressing tray that can be handled with dispatch in crowded surroundings. With this in view the following tray has been devised for use on board the U. S. S. Northern Pacific, and has met with such satisfac tion that two are in constant use. The tray consists of a box made of one-half-inch pine. It is 28 inches long, 17 inches wide, and 6 inches deep. (Fig. I.) The back part of the tray is divided into seven equal compart ments, 3J by 3J by 6 inches. The left side is subdivided into four spaces 5$ by 5f by 6 inches. At the right side are four divisions 2§ by 3 by 3 inches. Brass handles are located on either side. Projecting from the left side of the tray is a roller for adhesive tape. (Fig. I.) Two iron bands, 1 by 1J inches, extend from the front of the box around the bottom and end at the back in two hooks. These hooks HANDY TRAY FOR SURGICAL DRESSINGS TO BE USED ON TRANSPORTS. ETC. 70-1 No. 1. PRICE—SUKGICAL DBESSING TRAY. 80 HUGHEN8 —USEFUL AND INEXPENSIVE FLY TRAP. VoL XIII. have a radius of f inch, extend 1^ inches above the level of the box and are padded. These iron bands are placed 2-£ inches from either end of the box. (Figs. II and III.) Extending between the iron strips on the posterior surface of the box and flush with the bottom is a rubber strip 2$ by f inch. (Fig. III.) In use the hooks are attached to the upper rail of the bunk and the rubber strip acts as a bumper against the lower rail of the bunk. From past experience we have arranged our trays as follows : The four large spaces are used exclusively for sterile dressings and band ages. The after compartments hold: Zinc oxide paste; 01. tere binth; alcohol sponges; Dakin's Sol. or eusol; tongue depressors; applicators; sterile Carrel and drainage tubes; sterile gauze drains and packs. The smaller right-hand spaces contain: balsam Peru; thymol iodide; talcum; and smaller bottles of silver nitrate, iodine and potassium permanganate, etc. The big compartment contains 20 to 30 sets of sterile instruments and one instrument tray. This dressing tray can easily be modified to suit surroundings and should prove a great time saver. A USEFUL AND INEXPENSIVE FLY TRAP. By H. V. Huohens, Lieutenant, Medical Corps, United States Navy. The sanitation officer of Camp Lewis, Wash., whose name I do not recall, when here in the early summer stated that he was using discarded boxes for making fly traps. An accurate description of the type of trap made by him was not obtained. From his sugges tion that discarded boxes be used we perfected the trap shown in the accompanying illustration. We compared this trap with others and found that it caught a larger number of flies, everything else being equal, than the other traps. The trap is simple and inexpensive, costing about 45 cents when copper wire is used and 30 cents when common iron wire is used. The cost is less for smaller boxes because of the smaller amount of wire required. Any kind of box may be used in the manufacture of the trap. The smaller traps, being about as efficient as the larger and costing less, are preferred. The construction is simple. An opening one-half inch deep is cut on all sides of the bottom of the box, starting about 3 inches from the corners. This space is to be used for baiting the trap as well as for the flies to pass in. A hole 2 inches in diameter is bored near the top and one corner of the box for emptying the flies, should it he desired to do so. This hole is covered by a piece of board about No. 1. HUGHENS—USEFUL AND INEXPENSIVE FLY TEAP. 81 3 inches square, fastened to the top by a screw. I consider it un necessary to empty the trap of flies, because it works much better btSHtUtb bv Arr*r. fusion H. v. Hupmc-u. c. U. bUMtlU bV H. T b£.LL. when dirty and full of flies. The flies when trapped only live four or five days. A piece of screen is cut an inch longer than the length 82 DUNHAM—SCALE FOE MEASUBING FLAT FOOT. Vol. XIII. of the interior of the box and wide enough to form a roof, the ridges of which will come about the center. The screen is then tacked in at ends and sides of the box. Next some one-fourth by one-half-inch strips are mitered and tacked around the edge of the screen in such a way as to pull it taut. The screen is tacked over the top, the one- fourth by one-half inch is mitered and tacked around the edge. Along the ridge of this inside screen one-fourth inch holes are made about 1 inch apart by taking a pair of pointed scissors, clip ping one wire and turning the scissors, making the round hole. The platform is made about 2 inches wider and longer than the box and is nailed to the box at all corners. Trap may be painted green and stenciled " Sanitation." SCALE FOE MEASURING FLAT FOOT. By B. Dunham, Lieutenant, Medical Corps, U. S. N. R. F. The device illustrated below has been employed at the recruiting office in Buffalo with marked success. It effects a saving of time and gives accurate, uniform results. 1. DESCRIPTION OF 6CALE. (n) A right angle piece (ale, Fig. I) consisting of a horizontal arm (ab) and a vertical arm (he) with graduations on left edge. (6) A vertical sliding piece (dc. Fig. I) with graduations on left edge pro duced to right in arcs of circles radiating from end d and with lines radiating from end d. (c) A diagonal piece {fg, Fig. I) sliding laterally to right and left and slid ing upward and downward between ends d and c. (d) The opposite side of the scale is similar in all respects to that of the view presented. (e) It has been found that the scale constructed of metal (German silver) Is preferable to celluloid. 2. OPERATION OF SCALE. («) Have the applicant stand on a smooth table in a good light. To measure the left foot, for example, grasp the scale at c (FMg. Ill) between the index finger and thumb of the left hand. Stand to left of applicant and with right hand posteriorly to ankle palpate the scaphoid tubercle (r) with the right index finger. Place and keep the lower end of scale d (Figs. II and III) opposite tubercle r, and depress scale abc to the surface of the table (hh). (6) With the third and fourth fingers of the left hand (Fig. IV) hold the base ah to surface of table and with the right hand slide bar fg along slot In scale ab until pin k is opposite the center of the prominence formed by the articulation of the great toe with the first metatarsus (Fig. II). (c) With the right index finger (Fig. IV) palpate the lower border of the internal malleolus and depress bar fg until the lower edge is opposite the lower border of the Internal malleolus (Figs. II and IV). As constructed the lower No. 1. 88 DUNHAM—SCALE FOE MEASUBINO PLAT FOOT. edge of bar fg, produced coincides with the line pm connecting the lower border of the Internal malleolus p with the lower tubercle m of the first metatarsus (Feiss line). 3. READINGS OF SCALE. (a) Feiss measurement: This is the depression (rn, Fig. II) of the scaphoid tubercle below the Feiss line and is equivalent to the reading at point o on the A scale de on which n Is the point of tangency of the lower border of the bar fg (Feiss line) with the circle whose radius Is rn and whose arc is no. (6) Height of arch : This is the elevation (rft, Fig. II) of the scaphoid tuber cle above the weight-bearing surface of the foot or plane of the table hh and Is equivalent to the reading on scale 6c opposite the lower end of scale de. CLINICAL NOTES. A CASE OF STATUS LYMPHATICUS. By E. L. Ricb, Lieutenant, Medical Corps, United States Navy. Lieut. C. C. N., age 29, was and had been in good health when he was given one-half cubic centimeter of standard United States Army typhoid bacterin containing paratyphoid A and B about 4 o'clock on the afternoon of August 13. 1918. The bacterin was given under the subcutaneous tissue of the left arm over the deltoid, and he neither complained nor demonstrated any symptoms of shock, but during dinner he complained of a headache and indefinite hot and cold flashes in his lower limbs. Without eating as much as usual he left the table and went to his room, after which he was not seen during the evening. Nothing unusual occurred in his room, but one of the officers thinks that he went to the bathroom and vomited about 11 p. m. The following morning he did not come to breakfast, and some one went to his room about 7.30 a. m., where he was found dead in his bunk. I arrived at the ship about 8.45 a. m. and the body had not been touched. He was lying on his back in a comfortable position, one hand resting on his abdomen, the other at his side, the fingers relaxed. His pupils were equal and normal, and neither the tongue nor lips had been bitten, nor were there any signs of a struggle or of violence about the body. There was still considerable warmth along the under surfaces, and T thought that he had been dead for four or five hours. Ecchymotic hemorrhages had filled the subcutaneous tissues of the back; there were smaller areas on the posterior surfaces of the but tocks and legs, and the ecchymoses extended up over the neck and face, the body being in a position of dorsal decubitus. At 4 o'clock that afternoon, August 13, I did an autopsy in the officer's room, and found a complete picture of status lymphaticus. The body was that of a well-nourished male weighing 185 or 190 pounds, and of an apparent age of 30. Excepting for the large sub cutaneous hemorrhages there were no unusual external marks. I roted a small wart on the right sternum and a 4-inch linear scar on the right shin that had no significance. Subcutaneous fat was heavy, 85 86 Vol. XIII. BICE—A CASE OF STATUS LYMPHATICUS. and the muscles of the abdomen were not well developed. The heavy muscles of the chest were dark red in color. There was no excess of fluid in the abdomen or pleural cavities, and the lungs were free from adhesions. There was a small excess of straw colored fluid in the pericardium, the right heart showed some dilatation and the musculature was flabby, but there was no hypertrophy. All valves were normal except the aortic and they showed some thickening of no importance. The aorta was strikingly small in contrast with the size of the man, and measured 6 centimeters in circumference. There were several atheromatous patches in the arch, and one of them encircled the right coronary, but the coronary was patent throughout its length and showed no evidence of sclero sis, nor was there any sign of an embolus. The thymus was large, thickened, and extended down over the right auricle. On cross section it was congested and meaty. Its di mensions were: Length, 7 cm., width, 4.8 cm., with an average thick ness of 1 cm. to 1.2 cm. The lungs showed no fibrosis and were crepitant throughout, but they were dark on section and full of blood. Stomach and intes tines were normal, the mesenteric glands were large, and the spleen was twice its normal size, dark red and bloody on section, and the follicles were prominent. The liver and kidneys were congested, but otherwise normal. I cut down on the brachials, femorals. and carotids. None of them Mere more than two-thirds the normal size, the right brachial being the smallest, and none of them were sclerosed. To summarize: The lymphatic system showed hypertrophy and the thymus was very prominent in this change. The heart, although dilated, was not larger than normal, and the whole arterial system had been dwarfed. An atheromatous change beginning in the arch of the aorta had not extended to the kidneys and the smaller vessels. The exciting cause of death was the first injection of triple vaccine, but since we know that the body tolerates well the foreign protein contained in dead typhoid and paratyphoid bacilli, there was no true anaphylactic reaction, and the cause of death was a toxemia which might have, during the course of the next two or ihrae months, been induced by any of the infectious fevers or follicular tonsillitis with the same fatal results. At the same time that Lieut. N. received his injection of typhoid bacterin, 18 other men were given injections from the same ampoule, with no unusual symptoms or abscess formation, and since the bac terin was not cloudy, we must conclude that it was sterile. That remaining in the ampoule was immediately discarded, and to culturo it was impossible. No. 1. McMULLIN —PRACTICAL- THEORETICAL CONSIDERATIONS. 87 I have no library and no access to the recent literature, hence refer ences can not be submitted, and my conclusions may be wrong. Without being able to read the French literature, we are pretty well isolated over here, and depend upon the quarterly Bulletin and the confidential bulletins for our recent information.1 SOME PRACTICAL AND THEORETICAL CONSIDERATIONS. By J. J. A. McMuclin, Lieutenant Commander, Medical Corps, United States Navy. There are certain points which may profitably be emphasized in connection with the widely different topics of dengue fever, the transfusion of blood, the intravenous injection of oxygen, epididy- motomy, urethroplasty, and lastly lesions of the brain following external injury, and erroneously attributed to fracture or dural hemorrhage. (A) Dengue. —The cause of dengue is unknown. The general be lief is that it is caused by a filterable virus. Transmission of the disease through the culex fatigans seems to be a well-established fact. Demonstrated facts are immeasurably better than theories, but I would like to advance the idea that dengue is due to some protein poison in the salivary secretion of the mosquito, which is injected by the mosquito into man, causing sensitization; and that some time later the man is bitten by the mosquito having a similar protein in his salivary secretion, and that this particular protein produces the sym'ptoms of the disease. Perhaps a somewhat similar explana tion may be advanced for smallpox, mumps, measles, trench fever, etc., substituting insects other than the mosquito as the carrier of the anaphylatoxin or foreign protein. A fact connected with dengue, which is not mentioned in the text books, is enlargement of the spleen, occurring usually about the time of the secondary rise of temperature. The patient should lie on his back, flex his legs, relax his abdominal muscles, and breathe deeply in and out through his mouth. If carefully and properly sought for the edge of the spleen will glide back and forth over the ends of the fingers. Sometimes the spleen is markedly enlarged. It is not possible that the enlargement of the spleen noted is due to error in diagnosis or because the patient had previously had malaria. The writer observed an epidemic of dengue in a draft of men all of whom had recently arrived from the United States, had never had malaria, and showed the text-book symptoms of dengue —the initial chill or chilly sensation, erythema, the pains and aches, the " saddle- 1The health record shows that typhoid prophylaxis was administered on board the V. S. S. Sterrett, June, 1914. 88 McMULLIN —PRACTICAL-THEORETICAL CONSIDERATIONS. VoL XIII. back " temperature curve, the morbilliform eruption, and the leuko- poenia. (B.) Transfusion of blood. —Medical publications are teeming with articles on the transfusion of citrated blood. Transfusion is much abused, but it has come to stay, especially in acute hemorrhage I recently gave an exsanguinated patient a transfusion of de- febrinated blood, and feel certain that the measure was life saving. Aboard ships or in out-of-the-way places, if no sodium citrate is available, the blood of the donor may be collected, allowed to clot, and the clot broken and strained. In otber words, defibrinated blood, which has not been mentioned very much recently, is a useful sub stitute for whole blood. In the service some definite arbitrary plan for grouping blood should be adopted, and each officer and man should hare his blood group ascertained and stamped in his health record. (C.) Intravenous injection of oxygen. —Various experiments have been performed by the writer, which prove that oxygen may be slowly injected into the veins of animals without harm. Anyone who has given very much intravenous medication can vouch for the fact that the injection of small amounts of air intravenously cause no harm. Intravenous oxygen is suggested in the treatment of gas poisoning, anaerobic infections and pneumonia. (D.) Urethroplasty for stricture of the urethra.—Operations for stricture of the urethra are less common than formerly, because there are fewer strictures, and also because surgeons prefer to dila.te stric tures with sounds rather than to cut them. The operation of urethro plasty is not new, but the results are so satisfactory that after divid ing a stricture in external urethrotomy the insertion of a fascial flap should be a matter of routine. I recently used a fascial flap in an impermeable stricture of the membranous urethra. The stricture was divided longitudinally, a piece of fascia was cut from the perineum, the edges of the divided urethra separated, and the piece of fascia united to the cut urethra by a continuous suture of fine chromic gut. The catheter was left in the urethra 21 days. The result was most satisfactory. (E.) Epididymotomy. —This operation is not sufficiently employed in the service for gonorrheal epididymitis. The saving in sick days and damage to the service would be stupendous if it were generally carried out. In our cases we most frequently find pus in the globus minor. Physical examination often shows adhesions of the skin and underlying tissues to the testicle or epididymis at the point of maxi mum inflammation. The best results are obtained at the beginning of an attack, before free pus is formed. The epididymis is incised in several places with a small knife. The tunica vaginalis is invariably turned inside out, No. 1. 89 STENHOUSE —PAIN IN HYPOCHONDBIUM. and sewed back of the epididymis. There are usually numerous ad hesions uniting the tunic to the testicle. A small rubber drain is in serted for two or three days. (F) Lesions of the brain erroneously attributed to fracture or dural hemorrliage.—These cases are of medico-legal importance, be sides being at times puzzling from the standpoint of diagnosis and treatment. The last case of this sort which came to my notice was a white man 50 years old who had been in a fist fight and who bore no marks of external violence at the end of the fight except a right ■'black eye." Shortly thereafter he suddenly developed an incom plete right hemiplegia, with aphasia, but was not unconscious. Sys tolic blood pressure 160, diastolic 65, temperature 98, pulse 84, respira tion 20. Physical examination showed more marked sensory than motor paralysis on the right side, but on examination of the heart a loud diastolic murmur was heard at the aortic cartilage, and there was dullness over the arch of the aorta. The diagnosis of aneurism of the arch of the aorta and cerebral embolism was made. The fol lowing day the fluoroscope showed a large aneurism of the arch, which confirmed the physical examination. The blood and spinal fluid were positive to the Wassermann test. Lange's colloidal gold test gave a typical paretic curve. The possibility of rupture of damaged cerebral vessels from in creased blood pressure during or shortly after a fight, or the possi bility of an embolus from a valvular vegetation or a clot from an aortic aneurism, causing paralysis, unconsciousness, or death under similar circumstances is of vital medico-legal importance. I re cently gave testimony in a case of this sort which saved an innocent man from being convicted of homicide. PAIN IN HYPOCHONDBIUM WITH PERNICIOUS ANEMIA. By H. M. Stbnhouse, Medical Corps, United States Navy. Ah S., ship's cook, 1 C. ; age 39; native of Canton; 15 years in United States Navy. Reported at sick bay, December 3, 1917, com plaining of pain on both sides of the belly, which seems worse after eating; he has no appetite, had a chill on the previous afternoon, and vomited once or twice during the night; he had no cough; he weighed 125 pounds on enlistment. Physical examination.—Nothing worthy of note was found in the heart or lungs; he was slightly jaundiced; tongue was heavily coated and breath foul; no swelling of his feet or ankles; belly tender beneath the ribs on both sides; spasm of right rectus on palpating near the gall bladder; liver dullness extends up to fifth i. c. s. in 8S977— 18 7 90 Vol. XITI. STENHOUSE —PAIN" IN HYPOOHONDRIUM. midaxillary line; unable to detect downward enlargement because of muscle spasm; spleen not palpable; temperature, 98.8 F.; weight 107.5 pounds. Previous history and family history. —fiays he has had dysentery three times. Seven years ago he had "sore teeth and sore eyes." No previous attacks of pain in the belly. Entry on the health record of "chancroid" in 1914. No other entries in the health record. Mother still alive and well. Father, who was alcoholic, died at 42. One brother died of "bubo." One sister died at birth. Patient is married and has one child 9 years old and well. Wife is well and has had no abortions or children born dead. Discussion. —Pain and rigidity, as found in this man, might mean gall stones, liver abscess, syphilis of the liver, hypertrophic cirrhosis, and possibly malignant disease. The history alone favors either syphilis of the liver or liver abscess. Gall stones seemed improbable because there was no history of any previous attack, nor was there the intense pain, frankly expressed, radiating out from the gall bladder, as in a case of gallstone colic. The " sore teeth and sore eyes," which the patient mentioned, the history of " chancroid," and the racial incidence of syphilis, make one consider this seriously. The chill and the pain over the left side might lead us to inquire about malaria; but the absence of splenic enlargement tends to dis courage that idea. It looked more like a case of beginning liver abscess than anything else. The history of dysentery, the pain, the enlargement of the liver upward, the chill, and the slight fever; the jaundice, and the preponderence of pain over the liver all pointed to this diagonosis. 313 'S3iisvu*d iviavnvw 'ONiiddiis 'sm3D Q3U oaivsnanN noiivniiaivxs aooia ♦.V - •- • 0 & ,% N».l STENHOUSE —PAIN IN HYPOCHONDBIUM. 91 Laboratory findings.—These made the diagnosis even more diffi cult. On December 5, 1917, the leucocytes were 18,000. Temp, was 99. On December 6, the white count showed 16,000; but to add to the difficulties, nucleated reds, stippling, and other signs of red- cell degeneration were found along with tertian malarial parasites in the stained smears. The red count was 3,400.000. Hb. 75 per cent. Urine was of high specific gravity, small in amount (400 c. c.) ; no sediment, no albumen or sugar. Feces: Ova of clonorchis sinensis, Ascaris, and Trichiuris found ; no ameba motile or encysted. On these findings a tentative diagnosis of pernicious anemia was made. But what was causing the anemia ? The most likely answer to this question seemed, " rapid destruction of red cells in the liver from some process due to the small fluke." The anemia proved to be progressive, while the leucocytosis gradu ally fell to a normal white count. By the 17th the reds had fallen 5 6 7 a IO 11 12 13 1+ «r 1 i ! : * M- A i : : : : : . ■ : i : to 1.200,000. Hb. 70 per cent. Fowler's solution was being given with the hope that it would serve the double purpose of stimulating red-cell production and at the same time exert some destructive in fluence on the flukes. It was also believed that it would to some extent combat the malaria. On the 17th and 18th a large dose of quinine was given. This was followed by chilly sensations, ringing in the ears, dizziness, and enuresis. On the 20th the patient was no better. Although no 92 STENHOUSE —PAIN IN HYPOCHONDRIUM. VoL XIII. ameba had been found 30 miligrams of emetin was given to note the effect. The pains, which had subsided somewhat, returned, as did the rigidity over the right rectus. The temperature remained around 99 without any great change from day to day. On the 20tl a course of santonin was given. No worms were passed. On the 21st santonin was given again. On the 26th there were signs of improvement. E. b. c, 2,920,000. Hb. 75 per cent. Leucocytes had fallen to 11,000. Whether this was the actual turning point we do not know. Possibly he would have recovered without further medication. On the 26th the patient was seen by Dr. McCartney, an American doctor at Chungking, who advised a mixture of iron with 4 grains of quinine to the dose t. i. d. He did not favor the beginning-abscess theory. The prescription was given as advised. On December 30 Dr. S. Sakamoto, medical officer of H. I. J. M. S. Toba, was asked to give his opinion on the case. He went over the man carefuly and emphasized the following points: (1) Liver enlargement, (2) ane mia, (3) icterus. He believed the fluke infection of the liver respon sible for the anemia. Outcome.— January 7, 1918, Kbc 3,800,000; Hb 85 per cent; leuco cytes, 8,700. January 26, 1918, Rbc 4,230,000; Hb 80 per cent; ap petite good ; walks about considerably. February 2, 1918, salvarsan, 0.6 gm. intravenously. February 16, 1918, returned from French hospital. February 18, 1918, Rbc 4,800,000; Hb 80 per cent; clon- orchis and ascaris in stools. The future for this man does not seem bright, certainly not so far as total recovery is concerned. But the case illustrates the great resistance that the Chinese exhibit against the inroads of disease. The man may live along in moderate health for a number of years. This case, along with contemporaneous observations on the Yangzte River, has awakened the writer's interest in the question of the multiple effect of a number of infections on a living organism. One who knows China will readily appreciate the fact that an in dividual in his lifetime must be inoculated with all manner of in fections. At some time or other in life he therefore lias malaria, smallpox, tuberculosis, typhoid, and in fact everything there is in the country in the way of disease. He takes each infection as a matter of course, unless it results in gangrene of the face, loss of eyesight, paralysis, or other quite evident complication. It is impossible to think that a Chinaman can reach adult life without thus accumulating antibodies and immunity against all manner of maladies to which the ordinary white man would doubt less succumb. That accounts for the statement which medical offi cers on Yangzte gunboats like to repeat : " Perform any operation on No. 1. 93 BOSS—PERFORATING WOUND OF INTESTINE. a Chinaman and he will get well. Do the same thing to an Ameri can and he will die." This man had a history of chancroid in 1914. He may have had syphilis. He had malaria, intestinal parasites, and it appears a nuke in the liver. He seems to have had a secondary infection resulting in inflammation and leucocytosis. And he gives a history of dysen tery. He had a combination of several things which for a time seemed to thrive, a sort of symbiosis. Then the bodily resistance be gan to respond to the calls made upon it, and either the opposite effect from symbiosis ensued, the parasites starved out some dis turber, or else we must give credit to the medication for eliminating the offender. PERFORATING WOUND OF INTESTINE AND MESENTERY. By O. G. Ross, Lieutenant, Medical Corps, United States Naval Reserve Force. F. G., B. M. 2d class, age 25, from U. S. S. Bridge. Admitted January 11, 1918, at 10 a. m., to United States Navy Base Hospital, Brest, France. On January 11, at 9 a. m., while working in the gun room aboard ship in the harbor of X, a .45-caliber Colt automatic was accidentally discharged, the bullet striking the patient in the right lower abdo men after having passed through the chest wall of another sailor. The wound of entrance was one-half inch to the inner side of and 1 inch above the anterior superior spine of the ilium. The bullet ranged downward, inward, and backward. Patient was in a mild state of shock. Temperature 97.4, pulse 108, respiration 26. He showed evidence of acute anemia, presumably due to hemorrhage. The abdomen was opened at 11 a. m. by a right rectus incision just outside the linea alba. On opening the peritoneum, blood and intes tinal contents escaped. The small intestines were delivered into hot towels and nine holes in the ilium and two rents in the mesen tery were discovered. The holes were closed by through and through sutures of catgut and oversewn by Lembert sutures of linen thread. Further examination disclosed a hole in the sigmoid, which was closed by the same method. The bullet was not found, although it was certainly in the patient's body, there being no wound of exit. The pelvis was drained by a rubber tube and cigarette drains. The wound of entrance was treated by debridement. Before closure the wound was sprayed with dichloramin-T, 7£ per cent. The patient had a rather stormy convalescence due to suppuration along the drainage tract and to a sharp attack of acute bronchitis. Bowels moved on the third day. On the 10th day he was put on full diet. The wound healed slowly by granulation. He was dis charged to full duty April 2, 1918. 94 NEWTON —TREATMENT OP SCABLET FEVER, Vol. XIII. Two of the openings in the ilium were about 2 inches apart and their closure seriously diminished the lumen of the gut. It was a grave question whether to resect this portion of the gut or to be satisfied with the closure. The lesson we learned from this case was that the reparative power of the small intestines is very considerable, and that what seemed to be an almost complete occlusion of the lumen was sufficient for this man's physiologic needs and permitted a complete recovery. NOTES ON THE TREATMENT OF SCARLET FEVER.' By W. C. Niwtox, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. It is very interesting to observe how successfully cross-infections may be prevented by the employment of the unit system. In the in stitutions visited cross-infections have occurred only when inexpe rienced attendants were employed. The use of antiseptic solutions and gaseous disinfectants is slowly giving away to the cleanliness which follows the generous use of soap and water, fresh air and sunshine. Formaldehyde gas is used in some institutions for disinfection of mattresses and blankets. Place, of Boston, is very enthusiastic over results obtained by doing tonsillectomies in the early days of scarlet fever. This was done quite accidently at first. A few cases having been operated upon during the incubation period, it was noted that these patients had a smoother convalescence, in that there were fewer ear, heart, and kidney com plications. So, encouraged by these facts, a number of cases were operated on during the febrile stage which also did particularly well. These were selected cases with obviously hypertrophied tonsils and large adenoid growths. There were no operative complications such as hemorrhage or sepsis following the procedure. There was no case of lung abscess. The use of the naso-pharyngoscope is a most efficient means of detecting areas of diseased tissue —adenoids, turbinates, etc., and upon the removal of these infective areas the muco-purulent discharge will cease, whether from anterior nares or naso-pharynx and tht patient may be released from quarantine much earlier than would otherwise be possible. At the Boston City Hospital and at the city hospital at Providence, it is a universal rule that patients sick with scarlet fever, of however mild a type, should remain in bed at least three weeks in order to avoid kidney complications. 1 Extract from report of inspection of contagions hospitals at Boston, Newport, and Providence. H». 1. HALE AND ADAMS—ATYPICAL ABDOMINAL CONDITIONS. 95 It would seem that the use of the Moshier speculum should be more universal, for in no other way can a satisfactory culture from the larynx be made in cases of laryngitis, which present the symp toms of expiratory distress. Such cases are worthy of the most careful consideration and the presence or absence of the Klebs-Loffler bacillus must be demon strated. Dr. Place believes that neglected cases of diphtheria with marked edema of the neck, pallor, prostration, and rapid pulse should receive a dose of 70,000-80,000 units of antitoxin given intra venously. He has never seen a case of anaphylactic shock follow the use of large doses of serum. Dr. Richardson at Providence is allowing his patients a fairly generous proteid diet during the convalescence of scarlet fever, and the cases that are allowed white meat and fish show no increase in the number of cases of nephritis as compared with those recovering from the disease that have been placed on a fairly free meat and egg diet. XLLtTSTBATIVE CASES OP ATYPICAI ACUTE ABDOMINAL CONDITIONS. By G. D. Hale, Lieutenant Commander, and J. C. Adams, Lieutenant Medical Corps, United States Navy. In the diagnosis of acute abdominal conditions requiring prompt surgical interference there is probably no class of cases of more inter est to the medical officer and more commonly met with than that composed of appendicitis, peritonitis, and intestinal obstruction. While this group is by no means the only class of surgical cases met with in the service, yet it is fairly typical of those requiring prompt surgical measure and with which every medical officer should con stantly be familiar, both as to the correct diagnosis and the necessary surgical procedure. Ordinarily in making a diagnosis the information is derived from the history of the case, the symptoms, the physical findings, and the laboratory findings, all of which in the typical case tend to point to a clear diagnosis. The other group of cases, the atypical, may be classified as follows: (1) Those in which the history of the case is obscure or confusing; (2) those in which the symptoms are wanting or possibly contrary; (3) those in which the physical findings are confusing; (4) those in which the laboratory findings may prove negative or confusing; and (5) the group in which there are few symptoms and physical findings together with negative laboratory findings. It is to the last two groups that particular attention is called, and the following illustrative cases are reported : Case No. 1.—B.—R. H., private, United States Marine Corps. Ad mitted June 17, 1918, complaining of slight nausea and pain on right 96 HALE AND ADAMS—ATYPICAL ABDOMINAL CONDITIONS. Vol. XIII. side. Patient stated that he vomited once before coming to sick bay. Physical examination disclosed a distinct tenderness on right side in appendix region. No rigidity and no history of previous similar attack. Otherwise the physical examination was negative. Temperature on admission was normal. Pulse, 68. W. B. C. 13,400. Differential count showed 67 per cent polynuclears. A warm enema was given and no food was allowed. On the following day, June 18, patient rested well, having been much relieved by the enema. Tenderness over appendix still present. Very little rigidity. W. B. C. 12,800. Pulse and temperature remained nor mal. June 19, condition apparently improving. W. B. C. 6,600. Tem perature and pulse normal. S. S. enema daily. June 20, patient in excellent condition. Has not vomited since admission. Pulse remains around 68. Temperature normal. W. B. C. normal. Owing to the persistent tenderness and slight rigidity over ap pendix it was decided to operate. At operation two-thirds of the appendix was found to be in a gangrenous condition. There was a well-defined local peritonitis, well walled off and containing a small quantity of sero-purulent fluid. The appendix was ligated and removed but no attempt was made to invaginate the stump. The abdomen was drained. Patient ran an uninterrupted and rapid convalescence. The interesting point in this case is, of course, the abdominal con dition found at operation, with such few diagnostic signs. Case No. 8. —H.—E. F., private, United States Marine Corps, age 33. Admitted May 1, 1918, complaining of abdominal cramps, nausea, and vomiting. Patient vomited a large quantity of clear green fluid a few minutes after admission, and stated that the cramps and vomiting began the previous evening. Examination shows a well-nourished and developed man. Gen eral tenderness over entire abdomen but no distention and only slight rigidity in epigastric region. Reflexes normal. Temperature 98, pulse 60. Laboratory findings: W. B. C. 19,600. D. C. . Polys. 72 per cent Urine negative. Past history : Acute appendicitis July 28, 1917, and appendix re moved at United States Navel Hospital, Mare Island, Cal., same date. Restored to duty in 23 days and had been well since. History other wise negative. Patient was given soapsuds enema, which returned with good results. No food allowed. May 2, patient continues to vomit bile-tinged fluid. Vomitus de void of fecal odor. Soapsuds enema and gastric lavage with relief No.l. HALE AND ADAMS —ATYPICAL ABDOMINAL CONDITIONS. 97 of cramps. Abdomen still tender but no rigidity or distention. General appearance of patient excellent. Pulse 60. Temperature normal. W. B. C. 18,400. May 3, general appearance of patient good. No change in physi cal signs. Vomited twice during forenoon. Temperature normal. Pulse 70. W. B. C. 22,000. May 4, no vomiting for 36 hours. Soapsuds enema returned clear. Temperature normal. Pulse 98. W. B. C. 9,000. Proctoclysis given at regular 4-hour intervals to relieve thirst. Albumin water and chicken broth given toward evening. May 6, on the sixth day after admission patient appeared bright but showed signs of exhaustion. Has not vomited for 72 hours. Has been taking liquid food for past two days. Temperature normal. W. B. C. normal. Soapsuds enemata continue to return clear. Ab domen tender but soft. During the early part of the afternoon patient vomited profusely. The vomitus contained all the food eaten the previous day. No fecal odor. It was decided to operate, and in transferring patient to hospital he vomited a large quantity of decidedly fecal matter for the first time since admission. At operation the upper part of the small intestines was found moderately distended. A double obstruction was disclosed, caused by two firm omental bands. The first obstruction, just below the duodenum was only partial, while the second, situated about 5 feet lower down, was quite complete. Following operation, for the first week, patient ran an irregular temperature ranging from 100 to 102 ; pulse 120 to 130, which grad ually returned to normal. June 21, to duty well. The points of interest in this case are the confusing laboratory findings, the mild general symptoms, and the delay in fecal vomiting. Case No. S.—S.—private, United States Marine Corps, age 20. Patient reported complaining of constipation and dull pain over entire abdomen. The symptoms had existed for several days. Past history otherwise negative. Examination showed a well-nourished young man with a decidedly prominent abdomen which was tender but soft. All other physical signs were normal. Temperature was normal. Pulse, 78. Urine normal. Blood examination normal with exception of hemoglobin per cent of 75. During the next four days abdomen became rapidly more dis tended, with very definite signs of fluid. Tapping and removal of 3.500 c. c. of clear fluid gave relief. No masses or other abnormalities could be made out in the abdomen either before or after the removal of the fluid. The temperature reached 99.2 on two evenings, but the remainder of the time it was normal. 98 McCAFFEBTY —VARIETIES OP HYPERSUSCEPTIBILITY. Vol. XIII. Examination of the fluid showed a preponderance of lymphocytea. No erythrocytes and only a very few polynuclears were seen. No organisms could be found. The albumen content was exceedingly high. The patient was in excellent condition throughout, but on account of the commencing reaccumulation of the fluid in the next few days he was transferred to a naval hospital. The interesting point in this casa is the presence of a large amount of fluid in the abdomen of a young man apparently in good health. An exploratory operation or animal inoculation would probably have confirmed the tentative diagnosis of tubercular peritonitis, but these methods were not possi ble in camp. Recent report from the hospital, 14 days later, stated that the man was in excellent shape, although the fluid seemed to be increasing. No operation had been done nor were there any labora tory findings to report. The above cases demonstrate the fact that diagnosis should not only mean the determination of the disease or malady but should also take into account the severity of the illness. In other words, how sick is the patient ? In the typical case it is usually possible to arrive at a correct diagnosis, but the actual seriousness of the case is often never determined until operation, when the pathological findings will often prove most serious. In this respect there is of course no possi ble means of describing a method whereby the seriousness of the con dition can be determined and undoubtedly the most dependable resource in an instance of this kind is experience. The apparently mild cases, also the obscure and atypical, should be the ones to receive the greatest care and attention and should be re garded with suspicion. They are the ones which should receive the special attention of the experienced medical officer lest operation be postponed too long. VARIETIES OP HTPEKSTISCEPTIBIIITT: THREE CLINICAL CASES. By L. K. McCaffekty, Lieutenant, Medical Corps, United States Navy. The following are selected from the many interesting cases seen at the United States Naval Dispensary, Washington, D. C, from Jan uary to July, 1918 : Cane I. Angio-neurotic edema, or Quincke's disease. —This patient was referred to the naval dispensary by a relative in the Marine Corps, who desired to know if his condition would prevent him from enlisting in either branch of the service. He is a civilian, 24 years of age, single, white ; nationality, Hebrew ; occupation, business. K». 1. McCAEFERTY —VARIETIES OF HYPERSUSCEPTIBILITY. 99 His main complaint was of local swellings, limited in extent and of transient duration. His family history is entirely negative. Past . history elicits nothing of importance, as the patient has never been seriously ill in his life. The present illness began two years ago when the patient noticed a swelling on his arm about the size of a hen's egg, which came on insidiously and remained for several hours. There was no pain con nected with it, and if it had not been in a prominent place he would never have noticed it. There was no change of color over this swell ing; when pressed small indentations would remain for several min utes, although this was not a true pitting as seen in edema. One morning two years ago the patient awoke and to his surprise found his scrotum markedly swollen, being about the size of a coconut; this frightened him so that he consulted a physician. At another time he had an engagement to play golf the following morning, but when he awoke, to his astonishment, both hands were swollen three times the ordinary size so that the patient was unable to bend his fingers. On one occasion his tongue swelled to such an extent that he was unable to contain it within his mouth. As the patient says, u practically every feature of the face has undergone a similar fate." There has been no premonitory sign nor any disturbance of the gastro intestinal tract accompanying these attacks. Except for the un sightly swelling, the condition would probably never have caused him difficulty, unless the larynx were involved. Preceding each one of these attacks there was a history indicative of an error in diet, which will be discussed subsequently. On physical examination we found a robust, healthy man, some what plethoric. His examination was entirely negative throughout. Urinary and blood examinations were negative. Wassermann was negative. The special laboratory tests proved to be quite interesting and important. As we saw from the clinical history that certain foods produced this transient edema it was therefore advisable to test the patient's susceptibility to certain food proteins. There were given intradermally minute amounts of protein from the hog, such as pork, ham, and lard, and soon after administration, the patient gave a positive cutaneous reaction. Fish, crab, lobster, and chicken were also tried with positive results. Lamb, veal, beef, and egg were tried with negative results. This proved conclusively that the patient was hypersensitive to the above articles of diet, both intradermally and when ingested in large amounts. It might be added here that soon after the protein was given intradermally there appeared a small papule surrounded by an ery thematous areola. This was considered a positive reaction. 100 McOAFFEETY —VARIETIES OF HYPEESUSCEPTIBILITY. Vol. XIII. As was said in the beginning of this paper, the patient came to us for our opinion as to his fitness for military service. We therefore had to reject him, as it would be practically impossible for him to secure the necessary diet in order to maintain a normal life. Case II.—This case is very closely allied to Case I, being another example of anaphylaxis. The patient is a male, age 24 years, occupation, sailor, who pre sented himself to the dispensary complaining of severe headache. The usual routine examination was made and nothing remark«able was found, except hypertension. We prescribed aspirin, grains v, at once, and within one hour the patient returned to the dispensary, appearing quite alarmed about himself. At this time he was complaining of shortness of breath, a sensa tion of pressure over the top of his head. He said his scalp felt tightly compressed and that his face felt flushed. He also had a severe pain over his epigastrium. The skin over his body felt warm and there was a sensation of itching present. On examination we found the patient quite nervous, having a marked tremor of his lips, tongue, and hands. He spoke rather anxiously, having some trouble in articulation. His face and neck presented a diffuse erythema. There was some edema around his naso-labial fold, lips, and tongue. His lips ap peared quite cyanotic. On the trunk, upper and lower extremities, palms, and soles of feet was a pronounced urticarial eruption. The urticarial wheals were so diffuse that the tip of the index finger could not be placed on the cutaneous surface without overlapping an urticarial papule. The papules were white on their summit with , an erythematous areola. The intervening cutaneous surfaces were erythematous. Some of these lesions appeared on the face and neck, but were not so numerous. Intense itching accompanied the appear ance of these lesions. There was a marked tachycardia; the heart sounds at apex were rather distant. The diastolic phase was reduced to such an extent that it was quite hard to distinguish first and second sounds. The blood pressure at this time showed a systolic of 170 mm. Hg. and a diastolic of 110. This whole picture developed in two hours after the ingestion of 5 grains of aspirin. The condition had never occurred before, but the author produced the same picture twice since. The patient gave no history of this idiosyncrasy in his family. The whole picture disappeared within 12 hours. The eruption gradually faded so that there was no trace 12 hours thereafter. The epigastric pain was relieved by sodium bicarbonate. The tachycardia and cyanosis disappeared soon after he returned home and reclined. No. 1. McCAFFEKTY —VARIETIES OF HYPEHSUSCEPTIBILITY. 101 There was another interesting feature which was discovered while we were making the routine examination, namely, hypertension. The patient is 24 years of age, of very good habits. He has never worked with lead in any form nor is there any history in his family of early degeneration of the cardio-vascular system. He has com plained occasionally of headache, nausea, and dizziness, all of which could be ascribed to this hypertension. On physical examination we found the cardio-vascular system entirely negative. Repeated examinations of the urine have been negative. Eye grounds are entirely negative, thus ruling out any encephalopathy condition. Wassermann was negative. The only finding was a systolic pressure averaging around 170 mm. Hg. and a diastolic pressure of 100 mm. Hg. by the auscultatory method. We have had him under close observation for two months, taking blood-pressure readings three times a week at different times during the day. The finding always remained practically the same. The etiology of this condition is quite obscure, as we have been unable to find any pathological condition to account for this hyper tension, except a vague vasomotor disturbance and a tendency to a neurasthenic state, both of which might produce this so-called idiopathic hypertension ; but the hypertension in either one of these conditions would probably not be permanently present, nor would we expect to find the diastolic pressure quite so high. There was a suggestive thyroid enlargement which might possibly produce this hypertension, but the various authorities disagree as to the blood-pressure findings in hypertrophy of the thyroid. Whatever the etiological factor is, the fact remains that he has a hypertension, which was not discovered on entrance to the Navy, and only accentuates the importance of auscultatory blood-pressure readings, both systolic and diastolic, when a recruit is examined. It is hardly possible that his hypertension will be reduced to normal, as we have placed him on a meat-free diet, moderate exer cise, and potassium iodide for some two months, and it has made no appreciable change. In all probability he will eventually be sur veyed from the service, an unnecessary procedure had the blood pressure been taken on his first examination. Case III. Hay fever.—This case is of interest merely from the point of view of desensitization treatment and because it falls in the same group as cases I and II. He is 36 years of age, a marine by occupation, of good habits, and married. His complaint is hay fever. The family history is nega tive, as there is no tendency to hay fever or asthma. The past history is essentially negative. The present illness began at the age of 12 years, when late in the summer the patient developed the typical symptoms of hay fever. 102 McCAFFEBTY—VABIET1ES OF HYPEBSUSCEPTIBILITY. Vol. XIII. He had paroxysms of lacrymation, rhinitis, and laryngitis through out August, September, and sometimes late in October. These attacks were present late each summer unless he sought another climate, either in Europe or by the seashore. In 1915 he visited Dr. Robert Cooke in New York City, who began his pollen protein tests upon him to determine which one he was sensitive to. These tests were carried out as follows : One would take the various pollen proteins, and after making an extract of them with normal salt solution a minute amount would be given intradermally. Wherever there occurred a subcutaneous, reaction it would be called positive to that particular pollen protein. By ophthalmic test we would determine the degree of sensitiveness. This would be the plant to which the patient was hypersensitive, and to what degree. It was found by intradermal injection that this patient was sensi tive to ragweed. As ragweed is one of the plants whose pollen pro duces hay fever, especially in this case, the patient was given desensi- tization treatment for this plant. This treatment is best given in small subcutaneous injections one© weekly until 12 doses are given, gradually increasing the dose each time, usually beginning the treatment about six weeks prior to the onset of symptoms and continuing throughout the season. This will produce an active immunity in many cases, but occasionally slight symptoms occur. At the present time I am administering the pollen protein extrac tion of ragweed to this patient, and have been doing so for the past six weeks, and up to the present time he has shown no symptoms, nor did he show any symptoms in 1915, 1916, and 1917 while under the treatment of Dr. Cooke, of New York. It may be added here that this active immunity which is produced will usually last one or two seasons, but by the third symptoms arise unless prophylactic treat ment is again begun. In summarizing Cases I and III it can be stated that they are due either to a toxin or to a protein reaction in sensitized indi viduals; in other words, anaphylaxis. In Case II the reaction is due to a drug which may be classified under hypersensitiveness. Dunbar maintains that the protein of the pollen in hay fever is a toxin belonging to the albumen group, but Cooke, of New York, and others are inclined to believe it a true anaphylaxis. Assuming, then, that any individual, for reasons still unknown, has become naturally sensitive to some protein or drug, the production of symptoms is readily understood. Many believe the reaction is cellular and not humoral. For example, the clinical reaction depends largely on the cells that are sensitized. Thus we have in hay fever a sensitization of the mucous membrane of the eyes, respiratory tract, together N«.l. CUMMINGS —VARIX SIMULATING INGUINAL HERNIA. 103 with a general cutaneous sensitization, whereas in urticaria follow ing aspirin the sensitization is essentially in the cells of the epi thelium. In angio-neurotic oedema the sensitization is of the con nective tissue cells in the subcutaneous tissue. While each case is distinct, producing different symptoms, they may all be classified tinder anaphylaxis or hypersensitiveness. REPORT OF A CASE OF VARIX SIMULATING INGUINAL HERNIA. By E. J. Cumminos, Lieutenant, Medical Corps, United States Navy. Several months ago my attention was called to the report of a case of saphenous varix simulating a femoral hernia, written by E. H. Richardson, of Baltimore, published in the April number, 1J>18, Annals of Surgery. Since the report of his case I have had the good fortune to come in contact with a case of varix simulating inguinal hernia. Like Richardson's case, this one is also the con fession of a mistaken diagnosis. The patient was a young man 21 years old, admitted to the sur gical service of the United States Naval Hospital, Washington, D. C. The diagnosis on admission was right inguinal hernia. In the region of the right inguinal canal there was a definite swelling pbout the size of a small hen's egg, which showed some increase in size when the patient changed from the recumbent to the standing posture. The swelling apparently took up the entire length of the inguinal canal, transmitted an impulse on coughing, but could not be reduced by taxis. In the recumbent position the tumefaction, though reduced in size, stood out prominently. The history of the condition is interesting, inasmuch as the patient firmly states that he was never aware of the existence of any swell ing until about one week previous to the time of entrance to the hospital. There were no subjective symptoms associated with the existence of the swelling. No varicosities were noted in either leg. For the preoperative diagnosis two views were shared : One, that the tumefaction was an inguinal hernia; two, that the tumefaction was an encysted hydrocele of the cord. Commander H. F. Strine, Medical Corps, United States Navy, operated, making the usual incision as for inguinal hernia directly over the mass. In the subcutaneous tissue lying directly over the inguinal canal and slightly above the external ring a circumscribed mass of fatty tissue and dilated veins was encountered. The lower limit of the mass was about the level of Poupart's ligament. The mass was excised and reserved for pathological inspection, the report later showing the tissue consisted chiefly of dilated veins. To insure against the possibility of an associated hernia, the external oblique 104 BOWMAN —ACUTE APPENDICITIS WITH HEMOBRHAGE. Vol. XIII. was split, and no sac being found, a hernia suture with a cord trans plant was then done. The vein involved was unquestionably the superficial epigastric with some adjacent tributaries. The condition was indeed unusual, and I must frankly say that the possibility of a varix never entered our heads. After a careful search of the literature in an endeavor to find re ports of other cases, I have only been able to find one writer who has reported a somewhat similar case. A French writer has published two cases of lymphatic varix simulating inguinal hernia under the title " Pseudo hernies inguinales dues a des varices lymphatiques des op erations qui conviennent et qui peuvent etre faites avec succes." It is interesting to note that the writer in his dissertation on these cases states that the tumor, which descended into the scrotum as far as the testicle, had all the characteristics of an inguinal hernia containing a small quantity of fluid. The condition also led observers to believe that there was adherent omentum in the sac. There have been re ported several cases of varix of the superficial epigastric vein, of which I have appended references. None of these cases, however, of varix of the superficial epigastric vein have simulated hernia. HEFEKKNCES. Lucas Champlonniere : Assoc. Franc, de chir., Proc. Verb., Paris, 1904, XVII, 662-661. Roth, A. H., and Guide, A. : New York Med. Jour., 1905, LXXXII, 851-854. Somnier, G. : Philadelphia Med. Jour., 1902, X, 201. McGavin, L. : Proc. Roy. Soc. Med., London, 1910-11, IV, Chin, Sec. 51. Richardson, R. R. : U. S. Nav. Med. Bull., 1910, IV, 196. ACUTE APPENDICITIS COMPLICATED BY IDIOPATHIC HEMORRHAGE FROM RUPTURED MES0-APPENDIX ARTERY. By F. H. Bowman, Lieutenant, Medical Corps, United States Navy. P. S., fireman, second class, was admitted to the United States Naval Hospital, New York, N. Y., on July 16, 1918, with the follow ing history : Previous history. —The patient stated that as far back as he could remember he had had attacks of cramplike pains, similar to the present one in character, but that they had always passed off within a few hours. With these attacks he had never had nausea or vomiting nor elevation of temperature. Present history. —On July 16, 1918, the evening of the day of ad mission, the patient was walking along the street, when he experienced a severe, cramplike pain over the entire abdomen. This pain was general at first but soon became localized in the epigastric region. No No. 1. STEPHENS—WOUND CONTAMINATION WITH GONOCOCCUS. 105 nausea or vomiting was present, but the patient experienced a feeling of fullness in the upper portion of the abdomen. He went to bed and, in order to relieve the pain, drank a considerable amount of whisky, but without any relief. The pain became more and more intense. He was then brought to the United States Naval Hospital, New York. On admission his temperature was 97.6 F., his pulse 84, and the respirations were 20. His skin presented a pale ocher color. Lungs and heart were negative. The abdominal walls showed no marked rigidity, but there was an arc of decided tenderness over McBurney's point. Dullness was marked in both flanks. Urine negative. Blood count: white cells 6,200; polynuclears 62 per cent; lymphocytes 34 per cent; eosinophiles 1 per cent; transitionals 3 (200 cells counted). July 17 : Operation. Ether anesthesia. Righ rectus incision. The abdomen was found filled with blood, both fresh and clotted. The bleeding point was located in the meso-appendix, near the base, in i* ruptured vessel. The appendix showed an inflammatory area at the base with much congestion of all the blood vessels in that loca tion. All other organs were negative. The bleeding vessel was ligated and an appendectomy performed. Wound closed. The patient made a rapid recovery. AN UNUSUAL CASE OP WOUND CONTAMINATION WITH THE GONOCOCCUS. By E. A. Stephins, Lieutenant, Medical Corps, United States Navy. History.—F. M. D., age 27 second lieutenant, United States Army, received September 23, 1918, for passage to the United States. In a French hospital on July 21, 1918, he had an amputation of the right thigh following a gun-shot wound. The following morning hot normal saline solution was, according to the patient's own statement, given subcutaneously in left thigh ; the solution was too hot, result ing in a burn of that area. Two days later the superficial tissues sloughed, leaving a second degree burn. The burn was circular and about 3 inches in diameter. He had gonorrhea at 17, but has had no active symptoms since then. Examination. —The stump of the right thigh has entirely healed except for a small, oval, granulating area about one-half inch in size. The wound is clean and has made good progress since the amputa tion. On left thigh, anteriorly in the middle third, is a circular area 3 inches in diameter, with an angry, granulating base and under mined edges, the result of the burn from hot saline solution, men tioned above. The base is covered with thick yellow pus but is with out any distinctly offensive odor. The wound has drained profusely 88977—18 8 106 STEPHENS—WOUND CONTAMINATION WITH GONOCOCOUS. Vol. XIII. since the beginning, eight weeks ago. A burning sensation has been present almost continually during the past five weeks and at times it has been very painful. There has been no tendency toward healing. Smears made from the pus revealed Gram negative, intracellular diplococci. Some of the leukocytes contained 8 to 12 pairs. The smear was made primarily in order to do a bacterial and cell count. A count of 10 fields showed an average of 120 pairs of diplococci and an abundance of pus cells per field. The nuclei of the polymorpho nuclear cells were not destroyed. A few pairs of diplococci were found extracellularly but no other organisms were present. Cultures on ordinary media at 37° were negative. Cultures on blood serum and blood agar were negative. It did not ferment glucose. The organism grew slowly as minute dew-drop colonies on blood streaked agar. It was agglutinated by serum from a known gonorrhoeal blood. Complement fixation test was not done. It seemed to me reasonable to identify this organism as the gono- coccus. Smears of the healing stump showed a few staphylococci but no diplococci. " Smears from the anterior urethra were negative. The anterior urethra was irrigated with sterile water, the washings caught upon return and centrifuged. Examination of sediment revealed no organ isms. Successive smears of urethra and urinary sediment following prostatic massage were negative. Course and treatment. —Dichloramine-T was used for four days with no material change in bacterial count or cell count. Silver ni trate in 10 per cent solution was then applied, followed by wet dressings of silvol 10 per cent for three days. Organisms per field 35, pus cells 28. Ten fields counted. Discharge has lessened con siderably. Same treatment continued. Four days later there were organisms per field, 7; pus cells, 4. Discharge scanty. October 5, 1918, smear shows two diplococci per field and an occasional pus cell. The wound has stopped draining. Healing has progressed, until now only an area about one-half inch in diameter remains. Conclusions. —While it is true that the identification of the organ ism is not absolute, nevertheless the only other organisms, the meningococcus and micrococcus catarrhalis, have been excluded as etiologic factors. The gonococcus will attack any mucous surface, but its appearance in a wound of this nature has been rare. It is probable that the moisture and warmth beneath the undermined edges furnished a suitable medium for their growth. The source of contamination can only be problematical. It is fair to assume that the urethra of the patient does not harbor the organ ism, although the proximity of the lesion to the penis would make contamination from that source easy. VoL XIII. BEEVES & MILLEB— SUBLUXATION OF CEBVICAL VEBTEBBA. 107 It has been shown that the gonococcus can be transmitted by un clean dental instruments.1 This organism is known to have little resistance to drying or exposure to air, yet one can easily imagine how a highly virulent germ could be quickly transmitted by means of the fingers of a careless attendant or nurse. The patient has been dressed by scores of attendants, and during a rush period in the hospital the wound remained uncovered for two weeks. The result following more specific treatment confirms the opinion that the infection was Neisserian. There is no ground for assuming that the infection might have been hematogenous. A CASE OF SUBLUXATION OF CEBVICAL VEBTEBBA BY MUSCULAB ACTION. By I. S. K. Reeves, Commander, and If. K. Millee, Lieutenant, Medical Corps, United 'States Navy. N., R. C, F-3c, was walking down a low incline on board the U. S. S. Delaware on September 2, 1918, when both his feet slipped. He fell flat on his back and in order to prevent injury to his head threw it forward with a jerk. He immediately noted severe pain " in the bone " of his neck with complete loss of motion in the cervical vertebrae. Guarding his head against movement he turned in. The next morning the pain was so severe that he reported for treatment, When seen he walked with great caution, holding his head rigid be tween his hands with face looking a little to the right. The facies showed great suffering and anxiety. The muscles of the neck were rigid and a distinct prominence could be felt to the left of the middle line and above the sixth cervical vertebra. Any attempt to manipulate the head casued such pain that the patient was anesthe tized. Under the anesthetic the fifth cervical vertebra appeared to be in unilateral subluxation forward, the left side being pushed forward until its posterior edge passed the anterior of the sixth and the upper articular surface of the sixth cervical vertebra became prominent. The motion in the cervical region was much limited even under com plete anesthesia. To reduce the subluxation the face was turned to the right, the head abducted and rotated backward while traction was made. At the stage of backward rotation a distinct snap was felt by both the operator and assistant, the latter at the time having his finger on the prominence of the sixth cervical. The deformity disappeared and motion became normal. When the patient recovered from the anesthetic he could move his head in any direction, but flexion caused 1 Mayhew, J. N. : Gonococcus Infection of the Mucous Membrane of the Oral Cavity. Jour. Am. Med. Assn. Apr. 27, 1918, p. 1223. 108 HALPIN —STENOSIS OF WHAETOn's DUCT. VoL XIII. severe pain. The patient was kept in bed until the next day, when he could walk a bit with caution, having a splint of reinforced plaster from occiput to mid-dorsal region. For several days motion of the head caused some pain, but the patient soon made a complete recovery. REPORT OF A CASE OF FRACTURE OF THE SKULL. By K. I. Lonoabaugh, Lieutenant Commander, Medical Corpa, United States Navy. Q. K., corporal, Company G, Three hundred and sixty-seventh In fantry, was brought to the sick bay on June 15, 1918, having been in jured in a row over a crap game. Another soldier during the progress of this row seized a bayonet by the blade and drove the ring which fits over the rifle barrel into R.'s forehead. The bayonet guard was so firmly embedded that the assailant was obliged to call upon another soldier to help him pull it out. R. walked up two ladders to the sick bay accompanied by other soldiers but unaided. Examination showed a hole in the frontal bone, a small trickle of blood down the face, but no symptoms that would point to brain injury. Under ether I explored the wound, which was almost centrally located in the frontal bone, the uninjured roof of the frontal sinuses, mostly the left, forming the lower margin. The depressed and roughened edges of bone were removed. The probe disclosed fragments of bone at a depth of about 1 inch in the left frontal lobe. These I proceeded to remove as gently as possible. Two were approximately about one-half inch square and very rough and there were several smaller ones. The dura was so badly lacerated that it was not possible to make any attempt at sutur ing it. A piece of rubber dam was laid in the wound and a cigarette of rubber dnm brought to the surface. Recovery uneventful. Rubber dam removed after 48 hours. Transferred to a hospital in Franco after five days; wound entirely closed. No loss of memory, or in fact any symptoms of brain injury apparent. Inquiry at the above hospital one month later shows this man as cured and with no bad after results. My reasons for reporting this case are: (1) To again invite atten tion to the amount of trauma and abuse the frontal lobes will with stand without any discoverable symptoms; (2) to show again how promptly the dura takes care of injuries to it, even where the surgeon is unable to offer it help. REPORT OF CASE OF STENOSIS OF WHARTON'S DUCT. By J. A. Halpin, Lieutenant, Medical Corps, United States Navy. Patient E. H., age 27, sea. 2c, entered hospital with "diagnosis undetermined, probably mumps." He stated that some two weeks No.l. HALPIN —STENOSIS OP WHABTON's DUCT. 109 before, about the 10th of November, 1917, his jaw suddenly became swollen and painful while he was eating. Reporting at the sick-bay he was isolated for mumps and transferred to this hospital for isolation, observation, and treatment. Between meals he noticed that the swelling of jaw receded slightly, but as soon as he began to eat a mass appeared just below jaw and rapidly extended upward on the face. It was painful to the touch and felt hard and indurated. On admission to hospital the right side of face was swollen, tense, and tender on pressure. Examination revealed a hard mass just below the ramus of jaw which extended upward on the face to about the region of the angle of jaw. He was given a piece of dry toast to eat, and while masticating same this mass began to swell rapidly. Examination of mouth and teeth was negative. The temperature, pulse, and respiration were normal. A fine lachrymal probe was introduced into Wharton's duct, which was found to be constricted about 1 inch from the external orifice. On withdrawing the probe and at the same time applying pressure on the submaxillary gland a large amount of saliva was expelled, the gland collapsed, and only a small mass about one-half an inch in size was left. The probe was then reintroduced and an X-ray taken, which showed that no stone was present either in the gland or duct and that only a stenosis existed. This condition of swelling after the ingestion of food continued for two days, and each day a larger probe was introduced into the duct and it gradually dilated until after the fifth day it remained patent and saliva did not accumulate in the gland, but was expelled through the duct into the mouth during the act of mastication. As far as I can trace the history of the case, this is the first time - that such a condition has occurred. There is no history of trauma, infection, or injury. The only incident apparently bearing on the case is a severe attact of tonsillitis six months ago. The infectious process may have extended down the duct where an inflammation was set up unnoticed by the patient, and the consequent proliferation may have caused narrowing of the duct. On the other hand the sud denness of the onset casts some doubt on this explanation. The case is interesting from (1) The negative history with sudden onset; (2) the rarity of the occurrence; and (3) the ease with which the condition could be mistaken for mumps, as it was in this particu lar case. PROGRESS IN MEDICAL SCIENCES. Reviewebs. Lieutenant Commander R. B. Henby, Medical Corps, United States Navy. Lieutenant Commander W. A. Bloedobk, Medical Corps, United States Navy. GENERAL MEDICINE. Gabbaqhan, E. F. Status lymphaticus. Illinois Med. Jour., October, 1918. The writer reviews the history of the subject from the time of Felix Plater, in 1614, down to our own time. Carl Eokitansky con sidered that the abnormal enlargement was almost entirely restricted to children and it was associated with the general enlargement of the lymphatic system, rickets, and enlargement of the brain. Many cases of sudden death without apparent cause were shown by autop sies to be connected with enlargement of the thymus gland. Sudden death during the course of surgical narcosis established for tonsil lectomy and the removal of adenoids can be explained in this way. In 1895 Kundrat reported 10 cases of death during or after anesthesia collected from the autopsy records of Vienna which all showed a distinct lymphatic diathesis. All showed enlargement of the thymus, of the spleen, and of the retroperitoneal and cervical glands. The follicles at the base of the tongue were prominent, the tonsils were enlarged, and the heart muscle was flaccid. While the possible exist ence of status lymphaticus is the cause of sudden death in children operated on for defects of the naso-pharynx, the abnormality is of a more general interest in connection with the administration of diph theria and other antitoxins to adults. Much attention was attracted to this subject on the occasion of the sudden death of the son of Prof. Langerhans, of Berlin, after the injection of a small dose of diph theria antitoxin. The post-mortem examination gave evidence of the existence of status lymphaticus and death was ascribed to this tmveo by prominent pathologists consulted. Hassler reported in the California State Journal of Medicine for May, 1917, a case of great interest. The health department was called upon to administer a prophylactic dose of diphtheria antitoxin to a 7-year-old boy whose sister had been ill with diphtheria and had ill 112 GENERAL MEDICINE. Vol. XIII. been removed to an isolation hospital. The boy was apparently in sound health. One thousand units of a standard brand of antitoxin were injected under the skin. Ten minutes later the child was seized with violent cramps, had difficulty in breathing, and died in the midst of what his mother called " a severe convulsion." It should be noted that on the previous day this boy's sister, the actual sufferer from diphtheria, had received 2,000 units of the same antitoxin by intravenous injection, followed in 24 hours by an additional 1,000 units. At the post-mortem examination of the boy the existence of status lymphaticus was clearly demonstrated. As a direct result of this fatal case, the health department of California now requires the written consent of parent or guardian prior to the administration of antitoxin to the child. Furthermore, the sanitary inspector must remain in close touch with the patient for at least one hour after the antitoxin is given. The author recites other interesting cases and comments upon the lamentable fact that in all the cases recorded the existence of status lymphaticus was clearly demonstrated after death. He points out that an effort should be made before operating on children and before administering sera or antitoxins to discover the presence of status lymphaticus by looking for abnormalities of tongue, tonsils, and pharynx. Investigation of the child's previous health may disclose a history of attacks of dyspnea. Some writers claim that a large area of dullness may be found to the left of the manubrium sterni. Friedlander maintains that an enlarged thymus may be diagnosed by the use of the X-ray. Until recently thymectomy was the only curative measure available, and according to the statistics of Parker these operations had a mortality of 33$ per cent. Now it is claimed that the roentgen ray is not only of great value in diagnosis but is a therapeutic measure which can be used with safety. In' 100 cases in Cincinnati, reported by Friedlander, there were but four deaths. The dose depends upon the severity of the case, and in mild cases a single exposure is often sufficient and leads to improvement within 48 hours. Salisbury, B. I. Epidemic of an unknown intestinal infection. Proc. Med. Assn. of the Isthmian Canal Zone. Meeting of February 17, 1917. The author describes in detail the mysterious epidemic of gastro intestinal disturbance which occurred in the Panama Canal Zone shortly after the Christmas holidays, and was at once regarded as due to the dietary indiscretions with which the modern world is in the habit of celebrating the birth of Christ. The first case to appear did not suggest the development of an epidemic, and therefore a correct count of the cases was not made from the beginning, but it is estimated N». 1. 113 GENERAL MEDICINE. that 450 adults and 250 children were affected, the cases being about equally divided between the Atlantic and Pacific ends of the canal. The figures given include cases from the crew of the U. S. S. Charles- ton, which was at that time at anchor in the harbor of Colon. The tiajority of the patients were white people. Among the children the girls affected outnumbered the boys, but of the adults more males were affected. Fully one-third of the men on the U. S. S. Charleston were taken sick. Many of the cases were mild, and did not entail the cessation of work. The symptoms were headache, loss of appetite, slight fever, general malaise, pain in the abdomen, mild bronchitis, and pharyngitis; vomiting was rare, and was usually a sequence to the ingestion of oil. ■The severe cases were admitted to the hospitals and for a majority of them the diagnosis of appendicitis had been made. The onset was marked by colicky pain in the abdomen, fever ranged from 100° to 103 F. and an exaggeration of the symptoms previously named. The marked prostration and toxicity amounted almost to a typhoid state in the case of many children. Tenderness in the right lower abdominal quadranf was marked and there was decided rigidity of the right rectus. In 13 of the cases a distinct mass could be palpated in the region of the appendix. The leucocytes ranged from 10,000 to 50,000 and the lymphocytes in uncomplicated cases ranged as high as 75 per cent, the small cell variety preponderat ing. Blood cultures were made for the patients with a high tempera ture. They were all sterile except three, which showed streptococcus. Acetonuria and indicanuria were present, the former being most pronounced among the children. The ordinary case ran its course in from one to four weeks, be ginning with an elevation in temperature, commonly 102° to 103 F. (39° to 39.5 C), and remaining so for a few days, then becoming intermittent in type, lower in the morning and rising in the evening, and finally becoming remittent and then normal in the average case by the second week. With but few exceptions these patients seemed and felt quite comfortable, complaining only of headache. After the fourth day about 50 per cent of the children had mucus, pus, and less frequently blood in the stool ; a diarrhea developed in some, and these represented the most severe cases among the children. At the onset of the epidemic many cases were operated on for appendicitis and these all recovered, 14 of the operative cases with palpable masses in the abdomen, which proved to be enlarged gland* of the mesenteric and appendix region. Six men of the U. S. S. Charleston were operated on for supposed appendicitis, but the con dition of the appendices demonstrated that the symptoms were not traceable to the incriminated organ; of the three cases whose cultured blood showed a streptococcus, two were from the U. S. S. Charleston. No diagnosis was agreed upon. Typhoid fever was excluded by 114 GENERAL MEDICINE. Vol. XIIU the high leucocyte count. The colon bacillus infection would show in the blood cultures. The first step in the treatment was isolation. The 450 men of the Charleston were examined and 143 suspects were put in camp at Coco Solo. At some of the military bases the soldiers were pro hibited from swimming, as some of the cases had manifested their first symptoms just after coming out of the water. The diet was limited to liquids. The preliminary purge was followed by an ex hibition of alkalies, bismuth and an intestinal antiseptic. In con clusion the author declines to make a diagnosis, but considers that the symptoms resulted from infection rather than from poisoning. In the discussion which followed the reading of this paper Dr. L. B. Bates laid stress upon the fact that sections of the appendices and glands did not show any streptococcus. He considered it estab lished beyond a doubt that the cases were not typhoid or paratyphoid in spite of the gross appearance of the gut. He pointed out that the epidemic of influenza with symptoms limited to the gastrointestinal tract was unknown. Major Russell thought that the symptoms were particularly suggestive of a severe disease and one that is not sup posed to affect human beings, namely, hog cholera, and he adverted to the fact that the bacillus of hog cholera is not the etiological agent in hog cholera, but merely the secondary invader. Wabthin, A. S. The new pathology of syphilis. Ain. Jour. Syph. July, 1918. The author has conducted extensive investigations into the patho logical anatomy of syphilis and has brought forth facts regarding the microscopic pathology of latent syphilis which are of great interest. The statements in our own textbooks concerning the pathology of this infection are based almost without exception upon the occur rence of the gumma, and syphilis of an organ is said to be frequent or rare according to the frequency of gumma of that organ. Virchow in 1858 clearly distinguished the simple inflammatory and the gummatous lesions of syphilis and showed for the first time the part played by this disease in producing inflammatory conditions of the most varied organs and tissues. This article really laid the foundation for the modern knowledge of the pathology of syphilis obtained since the spirochete was discovered. But his separation of syphilitic lesions into the two types made little impression upon the syphilology of the next 40 years. As the relationship of tabes and paresis to syphilis became more evident during the next two decades the conception of "post syphilitic," " metasyphilitic," and " parasyphilitic " processes arose in explanation of this relationship. Fournier was chiefly responsible No. 1. 115 GENERAL MEDICINE. for the use of this term and for the view that a large number of pathologic conditions bore a definite relationship to syphilis, but were not syphilis and were not necessarily caused by it. With the discovery of the etiologic agent of syphilis in 1903, it was to be expected that a change would take place in our concepts of the pathology of the disease. Parasyphilis has disappeared as the various parasyphilitic affections have been shown to be active syphilis with living spirochetes still present in the affected tissues. The author has demonstrated that the gumma is not the type of lesion of late or latent syphilis, and that the viscera are involved in all cases of latent syphilis, not by gummatous processes, but by specific inflammatory processes, eventually fibrosis, usually mild in character, but acquiring pathologic importance because of their pro gressive character. In studying the pathology of congenital syphilis, the author has shown the constant presence of spirochetes in the hearts of cases of congenital syphilis dying before or at birth, the occurrence of focal fatty changes in the myocardium due to the colonization of the organism, and of a specific type of interstitial myocarditis due to the same cause. In acquired syphilis it was not possible to demonstrate the presence of spirochetes so readily, but the demonstration of the organism was successful in such a large number of cases as to make the specific syphilitic nature certain. In the progress of these studies the author found specific inflam matory lesions of spirochete localization in the myo-, endo-, and peri cardium, the large arteries, nervous system, liver, pancreas, adrenals, testis, prostate, prevertebral, and mesenteric tissues. These lesions vary greatly in size from minute collections of cells to larger infiltra tions just visible to the naked eye. Every stage of development, from early active lesions to complete healing and fibrosis was ob served; but no case was found in which there was no active lesion. Complete healing throughout the body was never observed. The author gives a detailed description of the lesions of latent syphilis in the various tissues of the body. In the nervous system the most constant changes were those found in the meninges. In practically every case of latent or clinical syphilis autopsied some degree of thickening of the meninges was found. Focal infiltrations of lymphocytes and plasma cells were found in both brain and cord in cases not regarded clinically as paresis or tabes. The character of these minute scattered lesions is precisely identical with those found in the brain and cord, in paresis "and tabes, the difference being only those of number and degree. This raises the question as to whether every case of syphilis is not, 116 GENEBAL MEDICINE. Vol. XIII. to a slight degree, at least, a paretic or a tabetic. Similar infiltra tions were frequently found in and about the spinal ganglia, spinal nerves, and the sympathetic nerves and ganglia. The heart in every case showed microscopic lesions characteristic of spirochete localization, and in this organ more frequently than in any other has the spirochete been demonstrated. The essential lesion of cardiac syphilis is an interstitial myocarditis characterized by in filtrations of lymphocytes and plasma cells along the vessels between the muscle fibers. All of the author's cases of angina pectoris were syphilitic. Clinically these heart lesions showed disturbance of rhythm of every variety. " Functional " murmurs were common. The clinical picture in all was that of an insufficient heart. The majority died a cardiac death as shown by hypertrophy and dilatation of the heart, and the chronic passive congestion of lungs and other organs. The chief pathological findings at autopsy were those of myocardial in sufficiency ("fibroid heart") without, in the great majority of cases, accompanying valvular lesions. The aorta when examined microscopically showed in every case of old syphilis characteristic syphilitic infiltrations in its media and adventitia. The author insists that no positive exclusion of syphilis of the aorta can be made without a microscopic examination. The pancreas in all of the old cases of syphilis showed a greater or less degree of atrophy and interstitial fibrosis. Syphilitic pan creatitis may be a common cause of diabetes. The adrenals showed characteristic infiltrations of plasma cells and lymphocytes in all cases of known and latent syphilis. The liver showed chronic passive congestion and atrophy in every case. In all male cases the testes showed varying degrees of atrophy and fibrosis; many of the cases had complained of premature loss of sexual desire. Changes in the kidneys were found in practically all cases. The proportion of cases of chronic parenchymatous nephritis was very striking. It appears then that syphilis as a latent infection is much com moner than generally supposed and the author estimates that about one-tenth of all deaths occurring in the United States can be attrib uted to syphilis. It is further evident that infection with syphilis means spirochete carrying in many, if not all cases. The spirochete carrier is immune to new infection only as long as he carries spirochetes. The author states that he has never seen pathologically a cured case of syphilis. Ne. l. 117 MENTAL AND NERVOUS DISEASES. The syphilitic is pathologically " damaged goods," and the damage is a progressive one. The author arrives at the following conclusions : 1. The gumma is not the essential typical lesion of old or latent syphilis. It is a relatively rare formation; and the great majority of cases of syphilis run their course without the formation of gum matous granulomata. 2. The new pathology of syphilis is based upon the demonstration that the essential tissue lesion of either late or latent syphilis is an irritative or inflammatory process, usually mild in degree, charac terized by lymphocytic and plasma-cell infiltrations in the stroma, particularly about the blood vessels and lymphatics, slight tissue proliferations, eventually fibrosis, and atrophy or degeneration of the parenchyma. 3. These mild inflammatory reactions are due to the localizations in the tissues of relatively avirulent spirochetes. 4. Syphilitic inflammations of this type occur in all tissues and organs, but are most easily recognized in the nervous system, heart, aorta, pancreas, adrenals, and testes. 5. The syphilitic is a spirochete carrier. In this respect the spirocheta pallida is to be classed with the trypanosome, the malarial organisms, lepra and tubercle bacilli, streptococcus, etc. 6. Syphilis tends to become a mild process, but at any time the partnership between the body and the spirochete may become dis turbed and tissue susceptibility or virulence of the spirochete become increased so that the disease again appears above the clinical horizon. 7. Immunity in syphilis depends upon the carrying of the spiro chete. A price is paid for this immunity in the form of the defensive inflammatory lesions previously described. 8. Syphilitic death occurs most frequently in males between the ages of 40 and 60. Chronic myocarditis is the most common form of death due to syphilis. 9. The pathologic diagnosis of syphilis is essentially microscopic. Only in a relatively small number of cases are the gross lesions (tabes, gumma, aortitis, etc.) typical enough to be recognized by the naked eye. (W.A.B.) MENTAL AND NERVOUS DISEASES. Rogers, A. W. The relation of the temperament to the psychoses. Wisconsin Med. Jour. September, 1918. The author adverts to the history of the classification of tempera ments and holds that we have advanced considerably beyond the point where varieties of temperament were restricted to the san 118 MENTAL AND NEEVOUS DISEASES. Vol. XIII. guine, the lymphatic, the bilious, and melancholic and he declares that the extreme optimist is just as incapable of forming sound judgments on any proposition in life as the pessimist. The extreme optimist inclines to egotism and recognizes no difficulty as unsur- mountable. When people of this type are patients, while their phy sical functions may be excellent, in other respects they incline to vascular disturbance which manifests itself in mild cerebral conges tion and the tendency to insomnia. Just as the men of sanguine temperament may develop periodic states of exaltation, so men of pessimistic temperaments have states of undue uneasiness and de pression. These individuals tire easily and will be bothered by de pressing dreams whose effects extend into the waking hours. They are discouraged by trifles and are overwhelmed by events which the average person meets with pleasure. In this type there are alter nating varieties of depression and exhilaration with an intervening period of normality in between. Temperament and personality not only influence the functional psychoses but play a part in the de velopment of the organic mental disturbance known as paresis, though this form of insanity is invariably due to syphilis. Temperament plays a large part in the development of the psy- choneuroses of war.' The author cites a series of 100 cases of war psychoneuroses and of 100 cases of somatic injuries produced on the firing line. In 74 per cent of the first series the family history of neurotic or psychotic stigmata, including insanity, epilepsy, alco holism and nervousness was obtained. In 72 per cent of that series the patients themselves gave evidence of a very neuropathic con dition. The author concludes his interesting paper with the declaration that while heredity plays a permanent part in temperament, parents, teachers and physicians can do much to mold the individual make up by proper training and education. Kennedy, F., Salmon, T. W., Roussey. G., Holmks, G., and Marie, P. War neu roses. War Medicine, Am. Red Cross, Paris, August, 1918. In the able report of the meeting of the Research Society of the American Red Cross in France, June 28-29, 1918, published in No. 1, vol. 2 (August, 1918), of War Medicine, there is an interesting symposium on war neuroses. Major Foster Kennedy, R. A. M. C, criticizes the term " shell shock " as inaccurate and misleading and calculated to do harm, as conferring a brevet of respectability on symptoms which though not necessarily blameworthy actually represent a certain degree of inferiority from the point of view of military efficiency. He admits the extreme difficulty in many cases of positively excluding a minor coexistent physical injury, but points No. 1. 119 MENTAL AND NERVOUS DISEASES. out the extreme rarity of generalized psychoneuroses in soldiers suffering from gross physical wounds. In the normal soldier fear is consciously or unconsciously submerged beneath loyalty to officers, regiment, and nation, dominated by ideals. In the victim of so-called " shell shock " personal considerations have obtruded themselves through and obscured the gregarious instinct. Maj. Kennedy holds that the distinct interval so common between the date of the sup posed physical injury and the manifestation of the symptoms under discussion proves the psychogenetic character of those symptoms and points out how readily unwise suggestion from medical officers may tend to originate or perpetuate somatic symptoms of psychic origin. He points out that among enlisted men a single external catastrophe is the exciting cause of psychic manifestations, whereas in officers these are more often the result of prolonged strain and mental con flict. He lays stress on the extreme importance of accurate technical knowledge on the part of the medical attendant. Suggestion plays so important a role in the disorder under discussion that any doubt on the part of the medical officer as to whether he is handling an organic or a functional trouble is sure to be reflected in the patient and tends to intensify the nervous weakness. Therefore the first step in curative treatment of these cases is a definite and positive diagnosis. This strengthens the hand of the physician and contributes in no small degree to restoration of inhibitory power in the patient. Maj. Kennedy rejects the term " hysteria " as unsuitable because it has a different meaning for patients and doctors. He favors the use of the simple word " nervousness " to designate all neurotic manifes tations seen in war, and believes that such a term would appeal to the sense of discipline in armies and by promoting proper public opinion would be of prophylactic and therapeutic value. The diag nosis would be divided into " nervousness (sick) " and " nervousness (wounded)." In conclusion the author alludes to the physical changes, such as disturbed cardiac rhythm, dyspnea, and reduced alkalinity of the blood, which often accompany violent emotional disturbances. Lieutenant Colonel Salmon, Medical Reserve Corps, United States Army, spoke of the importance of (1) a rational attitude toward these disorders on the part of the medical officers, line officers, enlisted men, and the general public; (2) careful selection of the human material brought across the Atlantic for the war; (3) determination that everything undertaken at this time shall aim not to prove or dis prove a theory but to restore or conserve fighting men for the line. He recognizes the importance of having patients suffering from war neuroses reach the hands of experts in the earliest stages and the danger which attends the admission of such cases to the general wards of a hospital. When patients are ready to return to their 120 MENTAL AND NEEVOUS DISEASES. VoL XIII. organizations or detained after cure through administrative reasons, it is undesirable to have them transferred to ordinary convalescent camps, as there is then a tendency to recrudescence of symptoms. Major G. Rousey (professor in the Faculty of Medicine of Paris), speaking of the psychoneurological disturbances affecting the limbs during war, adverted to the reflex disturbances associated with secondary phenomena, which may be considered as phases of hysteria. They develop in subjects who give evidence of a special psychic condition which existed previously or else was acquired or accentuated by the actual circumstances under which they lived at the time of the disturbances. This psychic condition gives rise, on the occurrence of traumatism or some other slight commonplace factor, to the appearance of motor disturbance of a hysterical nature. Should such an influence be exerted on a limb whose circulation is normal or without incurable muscular lesions the motor trouble may be the only symptom, and it is pithiatic. If, on the contrary, it develops in a previously abnormal circulatory field acquired or accentuated by military life, it may give rise to secondary phenomena. Lieutenant Colonel Gordon Holmes, R. A. M. C, speaking on the treatment and management of the psychoneuroses in armies, dwelt on the serious waste of man power liable to occur if steps are not taken ( 1 ) to check the development of neuroses; (2) to relieve with promptness the functional and nervous symptoms which appear. After showing the importance of this subject from the point of view of society, and the likelihood that many of the cases of war neuroses returning to civil life will become social parasites and lay a heavy moral and financial burden on the country, he quotes a statement made in the British Parliament to the effect that more than 20,000 men have been invalided from British armies with so-called " shell shock." A large proportion of these men were evacuated from the army before it was generally recognized that early and vigorous treatment under rigid military discipline is indispensable. The proportion of recoveries is smaller when active therapy is delayed. In 1916 neurological centers were established in army areas and as near the front as safety per mitted to enable treatment to be given before the symptoms became fixed and organized. This permits of prompt return to fighting units. When patients pass through a series of hospitals and con valescent camps and come under the care of officers not fully ac quainted with their previous conditions a recurrence or remission of symptoms is likely. Cases of slight concussion, though they may be abnormally emotional and present the symptoms common to concus sion, usually require only a brief period of rest and light duty under the medical officer's direct supervision. If instead they are herded among men with severe neurotic manifestations they are liable No. 1. 121 MENTAL AND NEHVOUS DISEASES. through subconscious minicry to imitate their associates and develop the symptoms suggested by them or their surroundings. Prof. Pierre Marie inclined to a slightly different view from that propounded by the English and American speakers. He said that in the first year of the war French neurologists had inclined to consider war neurosis without concomitant mark or injury on some part of the body, especially the skull, as an indication of malingering or at least of the refusal on the part of the soldier to meet his full obligations. A wider range of view had led to the opinion that cases of commotion might be neither neuropaths nor malingerers. Marie believes that without any local lesions commotion may be caused by organic altera tions of the nervous centers which can be observed by such clinical methods as lumbar puncture. The spinal fluid may or may not con tain blood. The albumen content may be increased or the number of cells reduced. In a considerable number of cases there is a slight tendency to hyperglucosis. He believes in the existence of a diffuse micro-traumatism, that is a traumatism involving only the micro scopic elements. Db Fubsac. J. R. Traumatic and emotional psychoses. Am. Jour. Insan. July, 1918. The following paragraphs are quoted from this valuable article: " Traumatic psychoses " and " mental disorders supervening at the occasion of traumatism " are not the same. It is proper * * * to exclude those post-traumatic mental disorders which, by reason of their clinical manifestations or a char acteristic morbid anotomy, find their place in a definite pathological group, such as general paralysis, dementia precox, or a constitu tional psychopathic state. In such cases we are dealing not with traumatic psychoses but with general paralysis, dementia precox, or a constitutional psychopathic state in the etiology of which the trau matism has played a part the importance of which is variable and for the most part merely contributory and indirect. It has, however, also been customary to include among traumatic psychoses the many cases in which mental disorders have broken out after a traumatism which is in itself but slight, perhaps insig nificant, but which is accompanied by an intense emotional shock. This is an abuse of language. The effectual cause here is the emo tional shock. The physical trauma is nothing; the psychic trauma— to use an expression which is more than a mere figure of rhetoric- is everything. This is true to the extent that mental disorders ob served in cases of this sort are identical in nature, in severity, and in their course with those known to be produced by a violent emotion acting alone, i. e., independently of any somatic injury. The term 88977—18 9 122 MENTAL AND NERVOUS DISEASES. Vol. XIII. " traumatic psychoses " in application to these cases is, therefore, in appropriate and should be replaced by the term "emotional psy choses." Emotional war psychoses (so-coMed shell shock). —Explosions oi projectiles or mines are capable of producing in subjects, showing outwardly no wounds or only insignificant wounds, neuropsychic symptoms more or less severe and lasting. The cases of this sort fall into three groups. In the first group, the soldier is thrown by the explosion, with a resulting injury to the brain, either by fracture of the skull or by concussion, direct or indirect. The explosion has simply played the part of an agent of propulsion. The neuropsychic symptoms pre sent no special character and vary according to the lesion which has been produced. In the second group there is no external violence. The subject presents signs of a cerebral or spinal lesion, generally a paralysis (hemiplegia, monoplegia, paraplegia). Lumbar puncture reveals the presence of blood in the cerebro-spinal fluid. One deals hen. with a hemorrhage in the central nervous system, which must be con sidered a direct effect of the explosion, that is to say, of the changes of atmospheric pressure resulting from the enormous liberation of gases produced by the instantaneous combustion of the explosive substance. It is not the same with cases in the third group, which is by far the largest. Here there is no external violence, no hemorrhage, no sign whatever of any organic lesion. The victim of the explosion, generally an excessively emotional subject, exhausted by the hard ships of the campaign, perhaps just recovered from a more or less severe illness, loses consciousness. For two or three days he remains in a state of confusion, most often accompanied by dreams. Then he becomes lucid, but remains asthenic, emotional, living over again in his dreams his past terrors, and complaining of headaches and dizzi ness. This state may disappear in a few days, or it may persist for weeks or months, with or without complicating functional symptoms centering upon some organ, region, or function (deaf-mutism, par alyses, contractures). These conditions, of which some have tried to make a sort of psychosis peculiar to war, were at first attributed to cerebral or cerebro-spinal concussion, hence the expression " shell shock," by which they have been designated. This interpretation is erroneous and the concept of concussion in relation to cases of this sort inappropriate. The explosion has not only physical effects, but also a psychic one, which consists in an emotional shock. In certain cases this emotional shock dominates the situation to the point of being alone responsible for the neuropsychic symptoms which a hasty and super No. 1. 123 MENTAL AND NEBVOUS DISEASES. ficial consideration at first placed in relation to cerebral concussion ; and it is because both give rise to an emotional shock that the ex plosion of a shell and a terrifying sight find expression in the same syndrome. The war psychoses which have been called shell shock are nothing but emotional psychoses, and they might best be studied under the name " emotional war psychoses." The etiology of emotional war psychoses comprises, accordingly,, all the factors capable of producing an emotional shock : Explosions- of projectiles (shells, bombs, aerial torpedoes, hand grenades), mines, ammunition stores; terrifying sights (cadavers, conflagra tions, etc.) ; imminence of danger; death of comrades; and injuries (wounds, contusions, sometimes concussion in the correct sense of the word) , for the most part not of a serious nature. These different factors, whether acting alone or in combination, show no efficacy except as they light upon a soil prepared in advance to undergo their action, a predisposed soil. The predisposition re sults most often from a constitutional defect consisting in emotional instability. "The individuals destined for shell shock are, before all, the emotionally unstable in whom the constitutional peculiarity has mostly manifested itself in their lives at occasions of painful emotion, and who react to events of the war as they have reacted to events of ordinary life, but in a manner infinitely more intense, be cause the excitants are infinitely more powerful." In the mild cases the symptomatology of emotional war psychoses is reduced to a brief dazed period; the subject is for a moment stunned, dull, inert, speaking in monosyllables, his voice scarcely audible, articulation indistinct and hesitating. At the end of a few hours, sometimes one or two days, of rest he returns to his usual condition. Where the disorder assumes a certain gravity one can distinguish, as in ordinary emotional psychoses, two phases: The first, acute (phase of confusion), the second, subacute (psychasthenic phase). The natural course of emotional war psychoses, as of emotional psychoses in general, is toward recovery. It is necessary, however, to make some reservations. I have seen, in four cases, chronic psychoses follow an explosion of a projectile or a mine: two general paretic syndromes, classical in their clinical manifestations, one dementia prsecox, and one chronic hallucinatory psychosis. It is quite possible that in cases of this sort we are dealing with simple coincidences. An individual about to develop general paresis, dementia prsecox, or a chronic hal lucinatory psychoses may, like any other, become the victim of a shell explosion and show emotional phemonena. As the latter dis appear, the signs of the chronic psychosis appear and develop. If 124 . MENTAL AND NERVOUS DISEASES. Vol. XIII. the explosion has played a part in the etiology, it is infinitely prob able that the part is but a contributory one. It has but opened the way for a morbid process long prepared either by an infection (syphilis) or by a constitutional predisposition, or by any other pathogenic factor. " * * * Nothing in all that we know of the etiology of mental diseases would justify the proposition that a purely emotional shock or an explosion could have for its consequence general paresis, demen tia praecox, or a chronic hallucinatory psychosis. One might at most attribute to it the value of a contributing cause, but one could go no further than that. It is conceivable that an emotional war psychosis, like an ordinary emotional psychosis, might develop into a delusional state centering about a prevailing fixed idea. In such a case the idea of damage sus tained through an explosion or any other cause would become the fundamental fixed idea upon which the delusional state would de velop. I have as yet not met with a case of this sort and I know of none published in the literature. But it would surprise me if such cases did not develop. It is probable that they will be seen spring ing up after the cessation of hostilities. Finally, it should be recognized that there are patients in whom the syndrome characteristic of the second period lasts a year or longer. I know a case of emotional psychosis—by purely emotional shock—which has lasted over two years without any appreciable improvement or change. Is it, then, possible for the course of emo tional war psychoses to be toward incurability ? I should withhold an affirmative answer. I should even say that I do not believe it. There exists at the present time a factor by which the prognosis of emotional war psychoses is radically biased ; it is the war itself. The prospect of returning to the front constitutes, for many of the emo tionally unstable, an obstacle to recovery of such power that it is im possible to say if it alone might not suffice to keep up the neuro- psychic symptoms and to impart to the disease the appearance of chronicity which has been noted in some cases. The fate of these patients will not be settled until peace has been signed. The treatment varies, naturally, according to whether the disease is in its first or second phase. In the first phase, rest in bed, quiet, reconstructive medication. The treatment here suggests itself. The indications are not so simple in the second phase, which we have designated the psychasthenic period. At first these patients were treated like ordinary psychoneuras- thenics ; that is to say, medically, utilizing all the dietetic, medicinal, and physical therapeutic resources available to medical art. Now, it No. 1. 125 MENTAL AND NERVOUS DISEASES. has happened that in the medical organizations at the front, where the equipment is necessarily meager, the patients recovered rapidly and, in the majority of cases, were at the end of a few days well enough to rejoin their company ; whereas in the hospital units in the rear, which are far more completely equipped, in spite of diets, douches, and electric currents of all forms and all strengths, the symptoms dragged on tediously, the patients remaining months in the hospital and often, after a cure obtained with difficulty, relapsing either in the course of convalescence or shortly after return to duty. This experience has been constant and, though apparently paradox ical, is readily explained. First of all, that which has been found in ordinary emotional (pseudo-traumatic) psychoses holds true for these victims of the war. A treatment which is too medical, if not followed by prompt and notable improvement, results in anchoring in the mind of the patient the notion of a grave pathological condition and in the development of hypochondriacal tendencies which are so often a part of the emo tional syndrome, whether the latter be due to a common occurrence in ordinary life or to an event of the war. The idea of a grave patho logical condition becomes quite naturally associated with the idea of damage sustained for the future as well as for the present ; and just as a subject of an accident in times of peace can become obsessed with the preoccupation with indemnity to be turned over to him, so the subject of a war accident, exaggerating, like the first, his physical and mental damage, worries about the future, is often upheld in his hypochon driasis by ill-applied commiseration of those about him and the more or less interested pessimism of his relatives, and ends by hypnotizing himself with thoughts of retirement and pension; these then become obstacles to recovery, and in this way develops a sinister war case, in every way comparable with the sinister cases of ordinary accidents. But aside from factors causing aggravation or preventing recov ery, which are common to all sinister cases of whatever origin, we nave to consider, in connection with emotional war psychoses, a fac tor peculiar to them alone. Recovery means more or less prompt return to the trenches. This prospect appears natural to the soldier who has remained at the front. It is otherwise with the one who has been evacuated to the interior. " By keeping the patient at the front one leaves him in the atmosphere of a combatant, in contact with the features which impart to this atmosphere its peculiar char acter—simplicity, and sometimes" even restricted conditions of mate rial existence, rigid discipline, close proximity of danger. He re mains in the environment to which he has more or less fully be come adapted. By evacuating him to the interior one breaks this contact and destroys the adaptation. When, upon recovery, he re 126 Vol. XIII. MENTAL AND NERVOUS DISEASES. turns to the trenches, he has to readapt himself. One can conceive how this readaptation. painful for many, may prove impossible for some. It will prove impossible, notably for the emotionally unstable, in whom a morbid imagination stirs up. amplifies immeasurably, and converts into obsession tragic spectacles of the war, causes him to live over again the fears once experienced, and projects into the future the terrors of the past. This is true of the graver cases of '•shell shock" and explains the fact that recurrences occur almost always at the end of convalescence or shortly after returning to quar ters, yet without one being thereby justified in speaking of simula tion. The subject sees himself on the way back to the trenches, and. owing to an emotional and imaginative erethism, this perspective revives the elements of the shell shock syndrome." Accordingly, subjects affected with emotional psychoses should be kept on psychiatric services at the front. The confused phase once passed, and the patient having become lucid and accessible to favor able suggestion, he must be convinced that he is due to get well, and that because he is due to get well he is not evacuated to the interior. This psychic therapy, associated where necessary with medication or such physical therapeutic means as may be available under the conditions (cacodylate in general weakness, electricity in deaf- mutism, paralysis, and all other pithiatic manifestations), will lead to a rapid recovery and an early return of the soldier to his company. Nevertheless there will always remain a certain number of sub jects who, by reason of a particularly marked emotional instability, will not get well quickly. The first indication in these cases is to segregate them from the others, oh whom they can have but a de plorable influence, or if their isolation is not readily practicable, to evacuate them. The hospitals in the interior will, consequently, continue to receive victims of emotional shock. They should be treated as patients, but as nervous patients, subject to military discipline, and not as insane and irresponsible for their acts. In the interior, as at the front, the principal part in the treatment falls to psychotherapy. The patient must be convinced that the symptoms which he presents are curable, quickly curable; he must be made to note the progress he has made: and he should be granted the privileges he asks (visits, walks, participation in common amuse ments, etc.) only as rewards for further progress, and, as the crown ing reward for complete recovery, a' real convalescence. One should avoid, as the worst danger, giving him a glimpse of the possibility of retirement, especially retirement on a pension —this would but switch him on a sinister course. No. I. 127 MENTAL AND NERVOUS DISEASES. The patient, as has been said, should remain a soldier, subject to discipline. He should keep his uniform and should maintain a cor rect bearing. He should remain in touch with superiors, toward whom he should observe the same deference as if he were normal. Finally, as was very properly recommended by Grasset. he will gradually be placed on the road back to a soldier's life by being made to take part in military drill in formation under command of noncommissioned officers. This military therapy—the association of these two words has nothing in it that is shocking—is essential. It is enough that the soldier has lost his adaptation to life at the front. It would be a grave error to let him lose also his adaptation to military life. When the pathological condition has lasted many months, when the emotional balance remains gravely affected, and when hope of an early cure has to be given up. what course should be taken? Retirement should not be considered. * * * the patient must * * * be kept in the Army. But he must also be elimi nated from hospital wards, where his presence constitutes for the really sick a cause of discouragement and for the others encourage ment in persisting. What. then, should be done? Certain subjects when sufficiently improved, can be transferred to the auxiliary troops. This solution commends itself particularly for the older retired men or men of the old auxiliary troops who have been— though to but a slight extent —brought into the service of the Army. For the others, for those who retain grave symptoms and must still be in institutions, it will be best to provide services for chronics, a sort of lazarettos, where they might be kept until a solution for their case might become available; that, is to say, until the end of the war. However, it is probable that if not more than a minimum of the emotional psychoses are evacuated into the interior, and, if, in the hospitals which receive this small number, the authorities will pro ceed with firmness and prudence, this remnant of incurables or, more correctly, pseudo-incurable, will be quite limited. Payne, C. R.. and .Telliffe. S. K. War neuroses. Jour. Nerv. and Ment. Dis., September, 1918. The authors, in the course of an article on war neuroses and psy- choneuroses, call attention to the fact that new types of wounds and casualties in war, due to new types of weapons and new methods of attack, have lead to new methods of treatment and new surgical pro cedures designed to cure, and they call upon specialists in diseases of the nervous system to rise in a similar way to the demands of the situation to-day and develop curative treatment for mental and nervous cases, since the time has passed when the community would 128 Vol. XIII. MENTAL AND NERVOUS DISEASES. consent to the presence in its midst of cases of this type as though it were proper to pass them over untreated as mere anomalies, while men who had suffered loss of a limb or some mutilating wound were made the recipients of the most painstaking attention. They call attention to the fact that '; in one sense the war has presented no new problems in this element." "Though there are no new forms of psychic disturbances there are these causes of many varieties, which do not exist in times of peace, when often a latent psychoneurotic disposition is not brought to the test and the danger of such a breakdown has been quite ob scured. These special and very trying situations produce sometimes marked psychoses but often of a curable nature, because they repre sent only inability to adjust to such extraordinary demands and con ditions and to withstand their constant pressure. It is so also with the psychoneuroses many times. They, too, represent not a chronic nonadaptability and nonresistance, even a latent one, but rather fail ure only temporary and more easily readjustable to withstand in the face of cumulatively trying conditions." They very pertinently suggest that " Perhaps something could be done in our training camps to establish a better psychic adaptability and an increased resistance power. Of course all the physical train ing tends to that, but reports prove that it has not always been well regulated to that end. It has sometimes tended in just the opposite direction." Cobe, D. E. "Instinct Distortion" or "War Neurosis." Lancet, London. Au gust 10, 1918. The distinction is made between functional nervous disorders due to environment and those which are not. Hysteria and war neurosis belong to the former category. Neurasthenia or functional nervous disorder brought about by exposure of the nerve cells to prolonged poisoning by the products of microorganisms and certain reflex neu roses belong to the latter. Under the strain of modern warfare two emotions are called into frequent violent activity, the emotions of fear and disgust. These emotions are sudden and intense and insist upon being given free play, but are forbidden both by the idealistic conceptions acquired during childhood and early life and by the vigorous punishment they would receive from one's fellowmen. In modern warfare men constantly face hazards which render death almost a certainty. Normally constituted men then experience fear and under ideal conditions of such a position would run away. How ever, self-respect and military discipline prevent this normal end result and men proceed to fight in direct disobedience to their in stinct. The emotion of savage anger against the adversay would be No. 1. 129 MENTAL AND NERVOUS DISEASES. helpful if it were felt with any intensity. Disgust at the unaccus tomed sights and sounds of conflict is not allowed to manifest itself so that under its conditions the main powerful instinctive activities are distorted. The author accepts MacDougall's classification of the seven pri mary instincts, but considers that they should not be separated by any hard and fast line. These instincts are : 1. The instinct to run away under the emotion of fear. 2. The instinct to fight under the emotion of anger. 3. The instinct of repulsion under the emotion of disgust. 4. The instinct of curiosity under the emotion of wonder. 5. The instinct of self-abasement under the emotion of subjection. 6. The instinct of self-assertion under the emotion of elation. 7. The parental instinct under the emotion of tenderness. These seven primary instincts may be divided into two groups, the impressions of one group reinforcing each other and antagoniz ing those of the other group. • In one of these groups may be placed the emotions of fear, disgust, and self-abasement with their associ ated impulses; in the other anger, self-assertion, wonder, and tender ness. The sense of inferiority, combined with disgust, strengthens fear and the emotion to run away. On the other hand, fear may be diminished by anger and the sense of superiority, and now the tend ency of modern war is to give play to the emotions of the first group without developing those of the second and to produce emotional tone without the associated impulses. It is harmful to the proper functioning of the nervous system and liable to produce functional disorders of this system to suppress the emotion which normally should follow its associated impulses. The author makes the interesting observation that while normally the conative aspect of an instinct follows the emotional aspect, it is equally true that the performance of appropriate action tends to produce the associated emotion. The clenching of the hands and the setting of the teeth help to induce the feeling of anger. He asserts that patients suffering from war neuroses have always, at one time or another, experienced fear. In the early, untreated, and acute ;ases the fear may be obvious and openly expressed. As the patient improves, fear is present only during sleep and the terror dreams are an important factor in the case. A relatively different type of case was observed in Mesopotamia and in India in 1916. It was characterized by complete indifference to surroundings and current events. The mental state was one of dullness and inertia. The sufferers from this form of neurosis were the victims of monotony and routine; of the deadness of country, camp, occupation, and food. Here the emotion of wonder in the instinct to curiosity had been in complete abeyance. 130 MENTAL AND NERVOUS DISEASES. VoL XIII. The: author makes these distinctions between hysteria and war hysteria and war neurosis. Clinical manifestations of hysteria re sult from the improper suppression of a tendency inherent in every one and determined by our position in the scale of evolution; it is manifested as the result of an emotional activity which is normal as far as the emotion is concerned. War neuroses, on the other hand, follow the improper strain on the emotions themselves, causing the wrong emotional tone and disturbing the bodily mechanism which is associated with the conative aspect proper to the emotion con cerned. The diagnosis of instinct distortion or war neurosis is usually easy. It may be made in the case of any patient without organic disease who shows symptoms of nerve irritability and in whom also the element of fear is or has been present. Where distortions of nerve irritability exist and there are no signs of fear, either in the waking hours or in dreams, the war neurosis is in the late or habit stage and the terror dreams were present at the beginning of the illness. If no such history is obtainable the case is one of sugges tion-hysteria. The treatment of instinct-distortion neurosis is simpler and more successful than the treatment of hysteria because with the latter one treats symptoms, but the underlying hysterical conditions con tinue through the patient's lifetime. The harmony of the nervous system can usually be restored without much difficulty, provided the symptoms have been corrected before the distortion has amounted to the magnitude of habit. This point emphasizes the necessity of early treatment. When all ideas of war as an imminent factor have disappeared the more troublesome of these symptoms will be done away with and the patient will become a useful individual in his surroundings. The patient should be removed from the fighting area, and he must be impressed from the start by the assertion that his ultimate recovery is certain. When he has arrived at the ultimate base the patient should be put to bed in a quiet ward, preferably in company with two or three other patients while the active stage continues. The writer employs trional with or without aspirin to promote sleep. The medical attendant should see the patient fre quently, and at each visit should reiterate the assurance of complete recovery. With the first signs of improvement convince the patient, that he still has power in his legs by making him take a few steps every day. As insomnia passes and the dreams become less painful the patient should leave the ward each day and begin to mix with other patients. By this time special measures should be instituted to correct special defects, such as disorders of gait, tremors, dis ordered speech, and mental depression. These require carefully No. 1. 131 SURGERY. regulated exercises and reeducation. For the mental depression "therapeutic conversations" are indicated. In the "therapeutic conversations" the atmosphere of "doctor and patient" should be in abeyance. Tact and ingenuity should be used. It is usually not hard to discover what the patient has on his mind. Many sources of worry are irremovable, but depression due to obtrusive symptoms can often be removed by occupation in experimental workshops. To convince the patient that he is not utterly disabled always lessens the depression. Graduated exercises offer the best hope' in cases of rapid heart action and other affections of the sympathetic system. SURGERY. Baixeuil, L. C, and Jack. W. D. Fascial transplants in war surgery. Ann. Surg. July, 1918. The authors call attention to the use of fascial transplants for repair of deformities, the result of fibrous overgrowth following wounds attended with much tissue destruction, whether traumatic or from infection. They report 50 cases operated on successfully, in cluding painful adherent scars of the extremities (with and without involvement of the muscle tissue and tendons), muscle hernias, and a hernia of the synovial membrane at the knee joint. The authors have also applied grafts to the dura, and they consider the method suited to all classes of plastic surgery. The operation is divided into four steps : * JL The resection of the scar. 2. The liberation of the muscles and the margins of its aponeurosis. 8. The cutting of the graft, its application and fixation. 4. The reconstruction of the subcutaneous tissues and skin. The scar and all unsound tissue are completely excised ; the muscle is freed from its fascia. A graft of suitable size is obtained from the fascia lata, which is reached through an incision along the outer aspect of the thigh 28-30 em. in length. This is placed in a sponge soaked with warm saline, while the fascia lata is united with mattress sutures of catgut, and the skin is sutured. The graft is anchored in the fascial breach by sutures of 00 catgut at four points, after which it is united all around by a continuous suture of the same catgut, and the subcutaneous tissues and skin are united by ordinary methods. The part is immobilized in plaster for ut lecst 10 days. A number of cases are reported in detail, with illustrations of the different stages. (R. H. B.) 132 Vol. XIII. SURGERY. Chloralose as a general anesthetic. Dr. W. F. Durand, scientific attache of the American Embassy, Paris, reports that at a recent meeting of the French Academy of Sciences Dr. Charles Kichert presented a paper detailing his experi ences with chloralose as an anesthetic especially available for use in cases of traumatic shock or extreme weakness resulting from loss of blood. In 1893, in conjunction with M. Henriot, Richert brought forward a new substance, which he designated chloralose, obtained by com bining glucose with anhydrous chloral, and he established the fact that it possesses special hypnotic properties in doses much smaller than were needed to produce sleep with chloral, while its use by intravenous injection caused prolonged general anesthesia. This substance came into more or less general use for the production of anesthesia in animals used in laboratories, because it did not eliminate the reflexes, diminish the force of the heart, or lower arterial tension. In 1894 A. Pinard gave it to some of his patients to relieve the pains of labor without impairing the contractile power of the uterus. Absorption in the digestive tract is so slow and irregu lar that results were not very satisfactory when chloralose was given by the mouth. Recently Richert has employed chloralose in 50 cases to produce general anesthesia for surgical operations. The chlora lose is given in saline solution with or without the addition of very minute quantities of chloral and sodium bromide. The ordinary injection is made in a vein of arm or foot. The solution consists of 7.91 grams to the liter of common salt and 6 grams to the liter of chloralose. About 350 cubic centimeters, a total of 2.1 grams of chloralose, may safely be given. Doses of 2.5 and 2.75 grams of chloralose have been given, and 3 grams represent the maximum dose for safety. The injection is made in the usual manner through a sterile rubber tube, through which the liquid runs slowly, the container not being raised higher than 1 meter above the patient. The fluid enters the vein through a fine metallic needle. The injection should last about six minutes. It causes no pain, nor reac tion, nor discomfort. The patient drops off to sleep without know ing it. At the end of the injection anesthesia is complete. Immo bility is not concomitant with anesthesia. Rhythmic, automatic, choreiform movements are characteristic of the action of chloralose. Half an hour after the injection the movements cease, and it is then time to operate. Sometimes the rhythmic movements do not cease in half an hour, but anesthesia is complete, nevertheless. Thus chloralose has an advantage over other anesthetics that it does not destroy medullar tonicity. It is an advantage to have the reflexes spared and at the same time violent movements may be No. 1. MILITABY, LEGAL AND INDUSTRIAL. 133 checked by the addition of 6 grams of chloral hydrate and 24 grams of anhydrous sodium bromide to each liter of chloralose solution. The patient wakes only at the end of 5 to 8 hours after a profound sleep marked by heavy breathing. He awakes without nausea, headache, or any recollection of pain and showing a good appetite. There is often profuse perspiration. Kichert summarizes the advantages and disadvantages of the new anesthetic. Chloralose is absolutely without toxic effect upon the heart and does not lower arterial pressure, in contradistinction to other anes thetics which weaken the cardiac systole and reduce arterial pres sure. These facts make chloralose peculiarly appropriate for use in operations of great severity or where the patient's condition is alarming from excessive hemorrhage or many and serious wounds (naturally in such cases chloral and bromide of soda are not added). Eichert considers the administration of chloralose without danger, though it may and often is attended with certain inconveniences. In the first place a certain variability in the results has to be ad mitted. Chloralose seems to be in a way an indicator of latent nervous troubles. Sometimes its administration causes extreme agi tation and sometimes absolute calm results. Elderly patients do not stand it so well as young patients. Manifestly when the in travenous injection is complete there is no suspending the prodecure, as in the case of inhaled anesthetics. In 10 to 15 per cent of the cases observed (particularly on patients 50 years of age or more) there is an exaggerated secretion in the nose, pharnyx, etc. There may be spasm of the glottis, labored, difficult breathing, while the tongue tends to fall back into the larynx and fill it up. Breathing is noisy, difficult, and convulsive; the patient inclines to become cyanotic. The large increase of bronchial secretions is an unfortunate feature of its use. However, from the point of view of safety no comparison can be made between an injury to the respiratory system and to the heart. The writer recommends that chloralose, though he considers it harmless, be reserved for very severe cases. MILITARY, LEGAL AND INDUSTRIAL. Amantea, G. A new treatment for lesions due to dichlorethyl sulphide. Poli- clinico, Rome. September 22, 1918. Following extensive study of the subject and experiments both on animals and upon himself with mustard gas, the author reports excel lent results from the use of topical applications of silver nitrate. Without pretending to furnish the chemical formula of the reaction 134 MILITABY, LEGAL AND INDUSTRIAL. . Vol. XIIL that occurs when the two substances are brought together, he believes that the formation of a silver chloride demonstrates the decomposi tion of the yprite and consequent loss of toxic power. This is true whether the skin wet with dichlorethyl sulphide is treated immedi ately or only after a lapse of one to nine hours. Even after the skin is blanched the employment of a silver nitrate solution hinders vesica tion ; if the blistering has begun the process is arrested. Instead of using, as has been done in the past, ether, chloroform, or alcohol to remove the excess of dichlorethyl sulphide, Amantea pre fers to mop the affected part with a cotton sponge soaked in the silver solution, working centripetally from the margins. When the excess of poison has been sponged off, the surface may be painted with silver or sponged with a fresh tuft of moistened cotton. No chlorine-con taining substance should be employed. For ordinary cutaneous surfaces a 3 to 5 per cent aqueous solution is indicated. For lesions of the eyes a solution of -0.25 per cent strength is used to flush them out, or a 1 per cent solution may be cau- 'tiously instilled. Open wounds are treated with these weaker solu tions, and if they are very extensive and deep it may be proper to restrict the silver applications at the margins and introitus. Research Society of the American Red Cross in France. Conference on surgery in battle areas. Session of September 6, 1918. Paris, France. At the meeting of the Research Society of the American Red Cross in France, participated in by representative medical men from the military forces of France, Great Britain, and America, a number of questions wei"e propounded to those in attendance regarding the various problems connected with the handling of the wounded and the answers appended to the questions given below report the con sensus of opinion of the meeting, but many of those present dis agreed with the findings. I. PROBLEMS RELATING TO ORGANIZATION. 1. Personnel of a standard surgical team: (a) Surgeon. (6) Assistant physician. (c) Anesthetist (nurse or M. O.). (d) Two hospital corpsmen. 2. How many tables shall be allotted to each team ? Two. 3. What is the best arrangement of hours for a considerable pull! Twelve-hour shift most practical. 4. What is the best means of transport teams? Nc. I. 135 MILITARY, LEGAL AND INDUSTRIAL. Ambulance. 5. Shall teams furnish any instruments or apparatus? No. 6. What shall be the proportion of X-ray operators? One to three teams. 7. What shall be the proportion of general nurses in the operating room? Two nurses to three or four teams. 8. Shall each surgeon be responsible for the aftercare of his cases ? Ideal, but impossible. 9. Shall there be a day and night chief of surgical service ? Yes. 10. Under whose direction shall the resuscitation team work? Consulting surgeon. 11. Shall abundant reserves of teams be in readiness? Yes. 12. What is the most available type of mobile unit for purely tem porary emergency reinforcement? Field Hospital (American,). Auto-chir (French). Tent section of filed ambulance (British). II. PROBLEMS RELATING TO WAR WOUNDS. 1. In cases suitable for primary closure it has heretofore been agreed that patients should remain under the care of the operating surgeon until there is sound healing. Are there any new facts sug gesting a modification of this principle ? Yes; when possible; but for transportation every wound wide open. 2. If a suturable case must be evacuated and if there is opportunity for making surgical revision before evacuation shall the surgeon in troduce stitches, leaving them untied or shall the wound be left wide open without stitches placed ? Wide open; without sutures, tied or untied. 3. Shall such wounds be protected by dry sterile gauze? Or shall an antiseptic dressing be applied ? If so, what antiseptic ? Dry gauze. No standard antiseptic treatment. The French strongly advocate the gauze dressing. 4. Shall wounds be packed with gauze? No; unless for hemmorrhage. 5. Shall splints be placed on limbs having wounds of the soft parts only? Yes; wounds of nerves and tendons when sutured. 136 MILITABY, LEGAL AND INDUSTRIAL. VoL X1IL 6. Is a bacteriologic examination of the wound required in mak ing primary suture during the period of contamination, which usually lasts from 10 to 12 hours? No. 7. If, owing to rush, no surgical treatment of a wound can be given before evacuation, shall the wound be covered with dry sterile gauze only? Shall any antiseptic be used ? If the latter, what? Dry sterile gauze only. 8. If there is a larger number of wounded than the surgeon can give a complete revision to, shall he give ideal treatment to as many as he can, leaving the remainder of the wounded unaided, or should he distribute his services among all, giving everyone a better chance for survival of life and limb but not a maximum of good result ? Complete in selected cases. Triage must be good —greatest good to greatest numbers. 9. In the latter case would the surgeon take the time to scrub and clean the field, or would he merely make provision against retention of wound secretion, make prophylactic incisions to provide against future tissue tension, deep infection, etc.? No. 10. Shall there be evolved a "battle" technique as well as a " peace warfare " technique ? Yes. 11. In battle stress shall the surgeon with the ripest experience and the most matured judgment do operations, or shall he utilize his experience and judgment in making important decisions; in advanc ing less experienced operators; in directing treatment of critical cases; in deciding the schedule of operating —in short, acting as a surgical manager operating with bis head, not his hands? With Ms head and to superintend triage. 12. Shall the wounded receive morphia? Yes. 13. If inexperienced anesthetists are used in emergency, what method of giving ether anesthesia is safest ? Ether-drop method on gauze. III. PROBLEMS RELATING TO THE LIGHTLY WOUNDED. 1. Shall the lightly wounded be segregated and dealt with inde pendently of the seriously wounded? Yes; v)hen push is on. 2. Shall they be kept in the forward area ? No; unless needed as donors for transfusion. 3. Suggest a Ford-factory plan of dealing with them. Not discussed. No. 1. 137 MILITARY, LEGAL AND INDUSTRIAL. 4. Shall they claim the attention of the best surgeons under the best conditions, or otherwise? No; except for organization. Maonusson, L. Laws regarding illegitimacy in Norway. U. S. Department of Labor, Children's Bureau. The Norwegian illegitimacy law of April 10, 1915, is a radical measure, and the principles laid down in it are in the nature of a return to those recognized in the early folk law of Norway, under which the illegitimate child had a qualified right of inheritance from the father and enjoyed substantially all the legal family rights of the legitimate child. These rights of the illegitimate child were, however, wiped out about the middle of the seventeenth century and were not fully restored and enlarged until the passage of the law of 1915. The most radical change made by this new legislation consists in putting the burden of establishing paternity and fixing the obliga tion of maintenance upon the State instead of upon the mother as under the act of 1892. The mother of an illegitimate child is re quired by law to report the facts to the local authorities, and the court will then summon the alleged father to answer the charges. For the first time an attempt is made to establish paternity as a biological fact, which when established carries with it all the obli gations of legal paternity; failing in this, and merely establishing the fair presumption of paternity, the law puts upon the alleged father the obligation of maintenance or economic support of the mother and the child. Further changes consist in (1) requiring the economic support to accord with the means of the better situated of the parents and not with their average means; (2) extending maintenance until the child has completed 16 years of age instead of 15, and in some cases even beyond that period; (3) equalizing the burden of contribution by requiring contributions from the mother if circumstances of wealth justify that; (4) requiring the contribution of benefits to the mother for three months before confinement and also during confinement; (5) payment of special nursing expenses for nine months after birth if the child is with the mother. The law fixes certain minimum and maximum amounts for these contributions to prevent abuses in local administration; (6) forced collection of contributions on the initia tive of the State and not that of the mother as formerly. Changes in the laws of succession give full rights of inheritance and transmission to an illegitimate child in the line of the father and the father's heirs next of kin. and a child of an illegal or void mar riage is granted legitimacy. 88977—18 10 138 MILITARY, LEGAL AND INDUSTRIAL. Vol. XIII. The property relations of husband and wife are changed to pre vent any child which may be born out of wedlock from inheriting the property of either spouse which has been brought into the marriage by the other. A change similar in intent is made in the divorce law by which the innocent party may demand the division of the com munity property in such a manner that the illegitimate child of the other shall not inherit the property. The grounds for divorce are also enlarged to include the birth out of wedlock of a child whose paternity can be definitely established by law, but not if merely the presumption of paternity can be established, which latter carries with it the obligation of maintenance only. The law on the rights of parents and children, July 6, 1892, is merely changed to conform to the changes made by the illegitimacy law in the corresponding rights of legitimate children. The amend ment makes no change in the legal status of legitimate children. The act on the care and maintenance of children, which applies both to legitimate and illegitimate children, provides for State care and supervision for destitute mothers and children whose fathers neglect to make the contributions for their maintenance. It is based on the assumption that there will be mothers who will get no con tributions because the father has absconded or because he has no property. Such State contributions do not carry with them the stigma and loss of certain rights of citizenship attaching to poor re lief, as there is no fault on the part of the mother or the child. These contributions, commonly termed maternity benefits, are payable by the local authorities from local taxation. The general administration of this series of laws is by the depart ment of social affairs, commerce, industries, and fisheries (departa- mentet for sociale saker, handel, industri og fiskeri), which issues orders to supplement the law and acts as a central clearing house for the information of local police courts and other authorities which are directly concerned in enforcing the law. The immediate administra tion of the law is through the police authorities in the counties and in the lesser rural subdivisions whose activities are in turn supervised by the amtmand of the larger political divisions. The amtmand appoints the police authorities referred to. .Besides the department of social affairs, the department of jus tice is concerned in the administration of the act to the extent of court processes involved, the issue of citations or summonses, and punishing violations against certain provisions of the law, such as taking the child out of the country without leave, absconding, or failing to contribute. The ecclesiastical department is concerned with the registration of births. The medical department provides the State physicians, who act as chairmen of the local boards of health, whose duty it is to su No. 1. 139 MILITARY, LEGAL AND INDUSTRIAL. pervise all foster children and to oversee the activities of midwives and physicians and secure reports from them when attending births of illegitimates. Special advice on the medical and medicolegal aspects of problems connected with the adjudication of paternity may be sought from the State medicolegal commission. (W. A. B.) Fbench, W. J. Prevention of blindness, Work of the State indnstrial accident commission. California State Jour. Med. August, 1918. The National Safety Council estimates that there is one worker killed every 15 minutes, day and night in the United States and one injured every 16 seconds, day and night. This gives us more than 30,000 killed and about 2,000,000 injured. It is estimated that out of this number there are 200,000 eye injuries. The National Com mittee for the Prevention of Blindness states there are 100,000 blind persons in the United States and that more than 50 per cent are needlesly blind. There are, in round figures, 1,000,000 employees in the State of California. There are 300 industrial injuries each working day, in cluding Sundays, in the State. We thus have approximately 100.000 industrial injuries each year in California. In 1914. 1915, and 1916 there were 23,451 eye injuries. Of this number 549 were permanent injuries and 22,902 temporary injuries. There were 11 cases of total blindness. The medical and compensation costs for these eye in juries will be about $788,000. It is impossible to give a definite amount at this time, because the 11 cases of total blindness call for life pensions, and we have simply computed the amounts that would be paid the injured men, based on the mortality tables used by the insurance companies. The time lost by the 22,902 temporary in juries was 234.2 years. This means, that we found just what each man lost; one man might lose a day from work, another man a week, and another man six months, and so on. We added the total together and got the 234.2 years. We have in California 26 eye in juries each working-day and the number will grow larger as there is an increase in the total of employees, especially when we consider the large groups of men that are employed in the shipbuilding plants who are more likely to sustain eye injuries because of the con tinual chipping of steel and the use of emery wheels and machinery used in the construction of ships. The Industrial Accident Commission advocates the wearing of goggles whenever workmen are liable to have their eyes injured. An individual pair of goggles for each man is advised because of the advantage of interesting him in what is practically his property and for the further good reason that men naturally object to wearing 140 MILITARY, LEGAL AND INDUSTRIAL. Vol. XIII. goggles that have been promiscuously used. The use of masks is urged for welders and babbitters. These goggles and masks are so strongly constructed that they not only fit the eyes but have shields at the side of each lens to prevent flying chips from entering the eyes from the sides. Harrington, T. F. Anilln poisoning. Boston Med. and Surg. Jour. October 17. 1918. The author describes poisoning by anilin occurring in the industrial plants of Massachusetts. The manufacture of anilin in this country is one of the direct results of the war, anilin and allied sub stances having previously been imported almost exclusively from Germany. There is a distinct danger of poison in connection with the manufacture of anilin and there has been a sufficient number of cases in Massachusetts to make it possible to speak definitely on the treatment and consequences of such an accident. Anilin or anilin oil (amido-benzene. C„Hr,NH2) is a colorless fluid turning dark on exposure to light and air. It has a slightly irritating aromatic odor, volatilizes at room temperature and boils at 182 C. Anilin is manufactured from coal tar, which is a mixture of benzene, toluene, xylene, etc., all volatile poisons. Benzene treated with nitric and sulphuric acid forms nitro-benzene, itself poisonous, and nitro benzene is reduced to anilin by means of iron filings and hydrochloric acid. Important colors are made by the action of nitrous acid on anilin and allied aromatic amins. Pure anilin does not cause poisoning but pure anilin is not em ployed in the industrial arts. What is usually known as anilin is a mixture of amido-benzene with meta-toluidin, paratoluidin, and ortho-toluidin and xylidin in varying proportions. Poisoning from anilin and its derivatives occurs in the manufacture of all dyes, drugs, photographic materials, rubber goods, etc. The poison may be ab sorbed through the unbroken skin by direct contact or through satu rated clothing, by inhaling vapor and dust or by swallowing dust with food or saliva. Toxic symptoms may follow the inhaling of from 1 to 0.25 gram of anilin. The effect is greater in warm work rooms or during hot, sultry weather. Anilin produces a destruction of the red blood corpuscles. Pallor followed by a striking bluish color, especially in the lips, is the initial symptom. Next come lassi tude, and a sense of fullness in the head. Slight mental confusion, difficulty in swallowing, weakness and rapidity of the pulse, subnormal temperature, headache, dizziness, nausea, dyspnea, unconsciousness, convulsions, coma, and death. The No. 1. 141 MILITARY, LEGAL AND INDtTSTEIAL. more chronic cases of poisoning by anilin are marked by anemia, headache, tinnitus, vertigo, disorder of digestion, and cramps in the muscles. Skin eruptions also occur. The changes in the blood are characteristic. The spectroscope shows a band which comes close to that of metahemoglobin. There is a transient leucocytosis reaching from 30 to 40 thousand. Megalo- blasts, nucleated reds, and basophilic granules appear in the circu lating blood and in the bone marrow. Small repeated doses of anilin cause an increase in the number of red corpuscles, and a reduction of polymorphous leucocytes. Hemoglobin and color index are re duced. In the later stages hemoglobinuria is characteristic. In acute cases the first step in treatment is the removal of the patient to the open air and keeping him awake. The heart should be stimulated by black coffee and camphorated oil and the inhalation of oxygen. The patient should also be stimulated by warm saline solu tions injected under the skin or into a vein. The prevention of poisoning is important. The factory or work shop should be well ventilated, all dust and fumes being thoroughly removed. Vacuum sweeping is better than dry sweeping and the workrooms should have ample washing facilities. The hands should be protected by long sleeves and gloves. Respirators should be worn and the workmen should be forbidden to eat in the workrooms or store rooms. All persons handling anilin should be taught the early signs of poisoning. Immigration Statistics. Monthly Review, U. S. Bureau of Labor Statistics. March, 1918. Immigrant aliens admitted into the United States in specified months, 1913 to 1917. 1917 Month. 1913 1914 1915 1916 Por cent Increase Number. over preceding month. 46,441 44, 708 15, 481 17, 293 24, 745 19.9 59, 156 46, 873 13, 873 24, 740 19, 238 22.3 96, 958 92, 621 19, 263 27, 586 15,512 19.4 136, 371 119, 885 24, 532 30, 560 20, 523 32.3 137, 262 107, 796 26, 069 31, 021 10, 487 48.9 176, 261 71, 728 22, 598 30, 764 11, 095 5.5 July 138, 244 60, 377 21,504 25, 035 9, 367 15.6 126, 180 37, 706 21, 949 29, 975 10,047 7.3 136, 247 29, 143 24, 513 36, 398 9, 228 8.2 134, 440 30,416 25, 450 37, 056 9,285 6 104, 671 26, 298 24,545 34, 437 6, 446 30.6 95, 387 20, 944 18, 901 30, 902 142 Vol. XIII. MILITARY, LEGAL AND INDUSTRIAL. Immigrant aliens admitted into and emigrant aliens departed from the United States, November, 1916 and 1917. Hace. African (black) Armenian Bohemian and Moravian Bulgarian, Serbian, Montenegrin — Chinese . Croatian and Slovenian Cuban Dalmatian, Bosnian, Herzegovinian . Dutch and Flemish East Indian English Finnish French German Greek Hebrew Irish Italian (north) Italian (south) Japanese Korean Lithuanian Magyar Mexican Pacific islander ." Polish Portuguese Roumanian Russian Ruthenian (Russuiak) Scandinavian Scotch Slovak Spanish Spanish- American Syrian Turkish Welsh West Indian (except Cuban). Other peoples Not specified Admitted- Novem ber, 1916. 720 150 43 7G 153 32 154 Total. 866 9 3,604 942 4,642 1, 342 2,009 1, 908 2,046 492 5, 531 741 15 71' 72 1,683 Novem ber, 1917. 406 :!0 :S in 112 5 31 Departed. 283 173 40 408 94 2, 576 1,516 33 1, 104 160 91 102 OS no 320 108 12 S20 258 5S0 144 105 344 345 55 130 776 20 10 5 84 Novem ber, 1916. 52 58 9 110 5 730 324 2 350 127 IS II 71 12 34,437 6, 446 244 3 2 101 15 207 46 83 614 178 218 51 131 13 210 561 1, 327 112 13 12 50 6 325 5 542 503 214 1 334 50 7 9 20 23 26 804 Novem ber, 1917. 150 100 OK 252 125 1 125 2 38 4 1, 140 77 412 30 520 ' 33 231 265 2, 476 131 6 3 I 58 1 205 521 9 100 8 140 250 38 214 00 9 10 11 47 10 7, 164 8, 136 Dubham, H. E. Preservation of fruit. Brit Med. Jour. June 22, 1918. Fruits may be preserved for a more or less indefinite period by bottling or canning as jam, by making into paste, or by simple drying. Some fruits may be kept for months if properly stored. The author, who is the president of the Fruit Growers' Association of Hereford shire, suggests that as the making of jam in factories is now largely under Government control the manufacturers should be required to No. 1. 143 MILITARY, LEGAL AND INDUSTRIAL. make a declaration as to the substances other than the fruit named used in making the jam. Thus if the basis of jam is the pulp made from apples, plums, or vegetable marrow, the named fruit serving more as a flavoring agent, these facts should be declared. Jam is supposed to afford a ready means of adding vitamines and other avail able food substances to the diet in winter when fresh fruit is not available. Where fruits are pulped and kept and later recooked the vitamines may not be lost. The so-called " currant jam," supposed to be made solely from sound fruit and sugar, is often obtained simply by the use of pulp combined with apple or vegetable marrow with currant flavoring. At this time when economy in sugar is vital the following notes have an unusual interest. When water without sugar is used in bottling, a diffusion takes place until an equilibrium is established. The individual fruits then become little more than tasteless bags, and can only be served at table when mashed into a puree. It is therefore necessary to make juice from some of the fruit and use it to fill up the bottles. The juice may be prepared by cooking some of the fruit in a small amount of water and squeezing the residue through a cloth by means of the fruit press. The paste from fruit can be made into sauces for puddings, etc. To prepare an apple paste cut up the apples and cook with the least possible amount of water. When soft, after culling, pass through a fine cloth or sieve. Now continue the cooking with constant stirring until reduction is complete. Reduction is indicated when the wooden spoon used for stirring will stand alone in the pulp. If sugar is available, add from one-tenth to one-fifth of the weight of the pulp. Pour the pulp into well greased baking trays and place them to dry in a slow oven or in bright sunlight. Then the residue may be rolled or cut up into squares and stored in paper bags or cardboard boxes in a dry place. Tomatoes are to be boiled without breaking the skin, the water drained away completely and seeds and skins are then to be removed. Add salt, cayenne, and allspice. The puree is then slowly reduced to a thick jam, poured into trays, dried, and rolled up. This paste keeps well. The simple drying of fruit needs no elaborate outfit. The ordinary baking oven serves for drying fruit on a simple scale. When dried to hardness the fruit will keep perfectly in paper bags. Fruit to be dried should be of good size, free from defects, and ripe or nearly so. Fruit which is not perfectly ripe may be spread out on trays made of gauze or wood and kept over the range for a few days. For the first dryinp the temperature should not exceed 115° to 120 F. For the second or third heating the temperature should not exceed 150 F.. and for the final a temperature of 160 F. is the maximum. If the 144 MILITARY, LEGAL AND INDUSTRIAL. Vol. XIII. temperature is too high the skin of the fruit breaks, the sticky juice runs out, and a general mess results. At the end of each day's drying the oven may be allowed to cool for a little. The fruit should be left in over night. On the next day the fruit is taken out and cooled. It is well to leave the oven door ajar at night, and this must be done during the day when the fire is on. It is essential to have intervals of cooling between the temperatures in the oven. Potatoes, young broad beans, and green beans dry rapidly and give a good product. Paris Chamber of Commerce. Economic and financial assistance given by the United States. Bulletin of Information, Paris. September, 1918. No. 86. In the course of a year— July 1, 1917, to July 1, 1918—10,000,000 tons of foodstuffs were exported to the allies, including 150,000,000 bushels of wheat. The cereals sent from America to France between May, 1917, and May, 1918, represented sufficient bread for 11,000,000 Frenchmen for a whole year, and the voluntary restrictions made throughout the country enabled the States to place 840,000,000 pounds of provisions at the disposal of the allies. The steel exports for the year ending June 30, 1918, amounted to a thousand million dollars, against $621,000,000 only in the preceding year. In May, 1918, copper exports figured at $29,065,347. In 12 months, thanks to the launching of special cistern boats, the exports in benzine, paraffin, and petroleum amounted to 650,000 tons. The United States before the war had never loaned to any foreign States. The total of their advances to the allies now exceeds six thou sand million dollars. REPORTS. SURGICAL EXPERIENCES AT THE FRONT.' By G. G. Ross, Meutenant, Medical Corps, United States Naval Reserve Force. Under orders from Admiral Wilson, two operating teams from United States Navy base hospital No. 5 left for Paris on the morning of July 18. Upon our arrival in Paris at 8 p. m. we received verbal orders to report to United States Army base hospital No. 2, where we operated all night. The following morning we were ordered to field hospital No. 12 at Pierrefonds, arriving there by ambulances at 8 p. m. There were approximately 700 wounded lying on stretchers on the ground awaiting operations. All had been fed and tetanus antitoxin had been administered. The hospital was situated in a small hotel, the onty available building in the town. The operating room was located in the dining room of the hotel and allowed space for three tables with barely room for the litters to pass between. The sterilization consisted of boiling instruments over a gasoline stove. The autoclaves were heated and the water boiled by the same method. They had a gasoline engine which supplied power for the electric light and the X-ray outfit. The speed of operating was hampered at night by the difficulty of selecting and transporting patients to and from the operating rooms, as lights were prohibited owing to the fact that the hospital was being bombed at regular intervals. The work continued for five days and nights, teams working on 12-hour shifts. On one occasion Drs. Curl and Eoss operated for 18 consecu tive hours. The wounds were massive and associated with more or less severe hemorrhage, loss of skin, muscle, and bone. The most hopeless cases were the wounds of the head and abdomen. In one shift, one table had occasion to do three intetinal resections and one anastomosis between the ileum and transverse colon, the cecum having been shot away. The through-and-through wounds of chest were not operated unless the wound was large and the pleura opened. Here the blood was allowed to escape, ragged ends of rib removed, packed with gauze, and the muscles and skin brought together by sutures. Every wound of the extremities, buttock, or loin spaces was treated by mechanical cleansing (debridement), and antisepticized by chemical means, iodine or Dakin solution being used. Foreign bodies, 1 From report received from United States Navy Base Hospital No. 5. US 146 BEPOBTS. VoL XIII. shell fragments, bits of clothing, bullet (rifle, machine gun, and shrapnel) were removed when quickly located. Every wound re ceived on the battle field is potentially or actually infected with the organisms of gas gangrene, and so every wound is allowed to remain wide open, the incision must be very large, and the debridement thorough. The last 36 hours at Pierrefonds were devoted to the care of Scottish troops who had been sent in to relieve the First and Second Divisions of our Army. The English authorities requested the hospital to remain, as their hospital equipment had not caught up with their rapidly moving troops. We received 32 Scots, wounded at night by a bomb dropped on their column by a Boche aeroplane. The target was supplied by a Scot who struck a match to light his pipe. Eight of them were killed, and the balance, 32, we looked after. We also operated on a number of Hun prisoners after having cared for our boys and the Scots. A German officer upon whom we operated, and who had been lying on the field for four days before he was found, told us that in Germany the general opinion was that France was in the war to secure Alsace-Loraine, and the Americans " for souvenirs." . About 3,500 men passed through this station in six days, about 300 of whom were operated on. The average operations per patient were not less than two, such as double amputations, multiple shell wounds, compound comminuted fractures of several extremities, or multiple of the same extremity, etc. The function of a field hospital is to care for severe wounds and the nontransportables, but under the conditions we had to meet we were doing the work of an evacution or base hospital. On July 30, 1918, United States Navy operating team No. 1 was ordered to evacuation hospital No. 6 at Chateau Thierry, and team No. 2 was ordered to evacuation hospital No. 7 at Coulommiers. As the Army had no means of transportation at hand we were sent out in automobiles supplied by Navy headquarters in Paris. We arrived at Chateau Thierry, but, as we were unable to locate No. 6, we were assigned to field hospital No. 116 for the night, and worked at the operating table until midnight. One of our nurses, Miss Hurst, con tinued on duty all night and handled instruments for three teams, and. on one occasion, three abdominal sections were going at the same time. We found No. 6 the following morning and reported to the com manding officer, Colonel Baker. For 12 days we operated in 12-hour shifts, and during the last period were on duty for 24 hours. Neither the cases brought to Chateau Thierry nor to Coulommiers were of so severe a nature as at Pierrefonds, the field hospitals be tween us and the line having cared for the nontransportables, such as abdominal cases and bad head injuries. There were comparatively No. 1. 147 REPOETS. few amputations necessary. The most important work consisted of debridement and chemical sterilization of the wounds and placing the man by position or apparatus in condition for comfortable and safe transportation. For wounds of the extremities and especially of compound fractures of the femur and humerus, the Thomas splint is the best method for the field. It is easily applied and is very efficacious, but when improperly applied is very painful. Many cases came to us with the splint improperly placed, and the man thereby suffering unnecessary pain, especially at the instep and heel, the extension having been applied over the shoe. One must be chari table, however, because the work had been done under shell fire, a sufficient excuse for haste. We were surprised at the number of men whose large vessels had been shot away and who had not bled to death. We had occasion to ligate the femoral in Hunter's canal twice, to ■control by hemostats the internal pudic twice, the radial once, the brachial twice, the perineal once, the posterior tibial twice, the com mon femoral once, and the deep and superficial palmar arch twice. In all these cases a well-formed thrombus was present and hemorrhage had been checked, although most of these men had traveled from 15 to 20 miles in an ambulance. A very serious problem is the use of the tourniquet. It is usually applied on the field and it may be hours or even a day or two before the man can be brought to an operating unit. The day and hour of the application of the instrument should be noted on the man's field card and he should be transported to the rear with the greatest expedition, for after six hours' constant con striction it becomes a serious menace. One case we amputated had had a tourniquet on for 48 hours. Most of the men had been given tetanus antitoxin on the field or at the advanced dressing station and the fact was noted on the field card, or by a " T " painted on the forehead. No case passed through the stations without having this matter checked up. The result is that tetanus is practically eliminated as a battle risk. Many of the wounds contained maggots, but while such a wound presents an un pleasant appearance, maggots are not detrimental to the wound, as they attack only the dead and devitalized tissue and bacteria. The elimination of tetanus has been offset by the ever present anaerobic gas bacilli, as every wound involving muscle is potentially so infected and the surgery of the wound must be approached with this fact in mind. It is not a difficult diagnosis to make. The odor of the wound is very characteristic, as is its appearance. The odor is a peculiarly sweet sickening smell, and when associated with a wound having the appearance of grayish-yellow slough and muscle that is dark purplish red and lusterless, and which does not contract when touched, and which when cut gives the sensation of going 148 BEPOBTS. Vol. XIII. through soft mush, the diagnosis is established. Associated with the other symptoms there is an area around the wound which gives a crackling sensation to the finger, due to the presence of gas and this area shows discoloration varying from a curious gray dead look to that of subcutaneous ecchymosis. Experience has taught that the circular-chop amputation is the most practical method and gives a higher percentage of recoveries. In the presence of the universal gas gangrene infection flap ampu tation is prohibited. The final results of chop amputations, if the Martin method of treating the stump is correctly carried out, is ex cellent and assures the patient the maximum use of an artificial limb. In some cases of amputation of the thigh in the upper third in the presence of gas gangrene, it was necessary to make long lateral incisions with debridement. Penetrating wounds of the skull are very serious injuries as the fragments of the shell or bullets carry with them pieces of bone which are driven into the brain sub stance. Their removal requires great care and patience, as well as special skill and training. There is usually a great loss of brain substance. These cases should be drained and the scalp wound left wide open after debridement of the edges, and the final surgery be longs to specially equipped hospitals farther back from the line. To spend three hours in doing a finished brain operation in a front-line hospital, when scores of. patients are waiting for the operating table, seems entirely out of place and is depriving men, who offer a much better prognosis, of an opportunity for recovery. We saw several through-and-through wounds of the lower abdo men, in which the missile had traversed the bladder without opening the peritoneum. In one case the bullet had entered anteriorly and made its exit in the buttock near the crest of ilium. Through the tract, urine was escaping in a constant dribble, constituting perfect drainage. The patient was not operated upon, but evacuated to a base hospital. One very unusual case came to Dr. Curl. A man was hit by a bullet which struck the cap of a shell in his bandolier, exploding it in his left lumbar region. The badly distorted shell case and bullet were removed from the loin space and back, the wound given debride ment, and left open. The peritoneum was uninjured. It is unnecessary to open and pare all through and through wounds caused by rifle or machine-gun bullets. The comparative size of the wound of entrance and exit will be the deciding factor. If the wound is caused by a bullet at the height of its flight when it has steadied down to a revolving motion, it will perforate soft tissue and bone with a minimum of destruction and the wound of exit will be but little larger than that of entrance. If, on the other hand, the bullet strikes the man at the beginning or toward the end of its No. 1. 149 REPORTS. flight, it will be wobbling as well as rotating and will cause a tre mendous destruction of tissue, causing severe comminution of bone and purification of muscle and fat and shredding of the connective tissue planes. Here the wound of exit is much larger than that of entrance and will give the appearance of an explosive force. This class of wound should be freely opened, pared, and cleaned by anti septics, for it is the wound which presents the most favorable oppor tunity for the development of the gas gangrene bacilli. All through-and-through wounds caused by shell fragments should be treated by free opening and debridement and left wide open with drainage. , Several cases of narrow escape from death or very severe wounds came to our notice. One case complained of severe pain in his neck. There was a slight wound on the side of the neck, and just below it, firmly bound by a bandage was a shell fragment 3 by 2 by 2 inches, causing pain by pressure. Another man, Lieut. S., had a shell frag ment, roughly, 2 cubic inches in size, resting in a pocket of skin on the abductor side of the arm. The humerus was uninjured, the brachial artery was intact. Another man had a machine-gun bullet enter just below the right eye, fracturing the floor of the orbit, pass ing through the superior maxilla, around the side of the neck, and lodging in the muscles in the mid-line of the posterior surface of the neck. DETAILS OF TRANSPORT SERVICE.1 By R. I. Lonqabacgh, Lieutenant Commander, Medical Corps, United States Navy. It is probable that every medical officer on transport duty has been reporting details of his work as they arose, because the situations we are handling present so many new aspects. However, the assembling of many ideas and suggestions will in time make it possible for the authorities to lay down certain rules of conduct that will be of great assistance to any of our men assuming the duty for the first time. With this in view I am inclosing two form letters which I had printed on board, one for the commanding officer of troops and his various commanding officers and the other for the medical officers of the Army. In addition, I have managed to hold a "get-together meeting" with each of these sets of officers when they came aboard, for the purpose of having them thoroughly understand in detail the ends for which we are working and realize the cordial relations which we desire to have exist.- 1 From Report of IT. S. S. America of April 20, 1018. The marked disparity In the ships, both as to capacity and internal arrangements, has made It Impossible to lay down hard and fast rules for the administration of the medical department of naval transports. 150 BEP0BT8. Vol. XIII. The senior medical officer has also submitted to me a list of the medical officers under him, together with any specialties they may have been following, and in this way we have been able to give all seriously sick special consideration through consultations. As an. example of this, Drs. Stellwagen and Dorrance, both of whom are Philadelphia men well known to the service, consulted with me on several occasions on the way over. Our sick list varies between, say, 20 and 100 persons, depending- upon conditions. Among these sick are many men requiring liquid diets and special diets. In the past it has been the custom to make use of canned soups as part of this diet. We now carry some canned soups for emergencies, but we learned that, with the large number of troops aboard, the serving of soups to them as part of their ration was impracticable, and the bones were therefore a loss. We, in the sick bay, took advantage of this situation by having the paymaster make fine rich soups for the sick from the bones, thus we not only save our canned soup but, in addition, we get something much more palatable. However, the question of diets for the sick does not yet satisfy me. I believe that as a new departure the department should in some way secure cooks for the sole purpose of running the sick bay diet kitchens and preparing such special dishes as from time to time may be ordered on board transports, especially on the return voyage. This much is certain, at no other place in the service would we attempt to care for a large number of sick without special provi sions as to cooking for them. Through the efforts of Captain C. N. Fiske, Medical Corps, United States Navy, we now have access to practically all of the good clinics in New York. I laid before the commanding officer the following plan to be followed in port and he immediately gave it his hearty approval : The officer of the day to be on duty during the entire 24 hours, the relief officer of the day on duty during working hours. The remaining two junior medical officers are to be excused from quarters and to, attend the clinics. As a check they report to me the clinics attended and the number of hours spent therein. In order to show our appreciation of the efforts of Capt. Fiske I intend to submit to him each time upon departure a copy of this report. Speaking of the duties of the medical officers, another plan, which I have passed on to some other transport surgeons, is that at sea the officer of the day is on from 8 a. m. to 8 p. m. and the night is divided into three watches, which are stood at the sick bay. During each watch our medical officer accompanied by a medical officer of the Army makes an inspection of troop spaces to assure himself that men are sleeping under proper conditions. We have found that the presence of a medical officer at the sick bay at all times while troops No. I. 151 REPORTS. are aboard has not only created a very favorable impression, but has assured the sick prompt and complete attention. In dealing with the soldieis it has been our plan as far as possible to avoid direct orders to them. On all inspections we are accom panied by an officer of the Army, who issues such orders as we nitty desire. We seem to feel that the soldier recognizes the uniform of an Army officer and obeys promptly, whereas he is unfamiliar with our uniform and it means nothing special to him. Then, too, it gives the Army officer a feeling that he is something more than a figurehead and stirs up a lively interest in his job. From my viewpoint the Transport Service is at the present time the most important field for a naval surgeon. It therefore seems to me that he' should be encouraged and helped to gather together and train a most efficient personnel and that once his system is estab lished and getting results it should not be disturbed. For instance, during my first trip so many duties fell upon me personally that I found I lost what Dr. Fiske so aptly described as "the big point of view." On this trip, therefore, I began to train Lieu tenant Dearing, Medical Corps, United States Navy, as sanitation officer. He has been performing the duties most satisfactorily, has been able to work out to completion many small details which origi nated with me, and has made many valuable suggestions himself. Between inspections of troop spaces with the Army officers, which take the entire morning, and inspection of crew spaces and the ship in general with the first lieutenant, taking up the afternoons, he has been kept very busy. In all this, however, his medical work has not been forgotten, for he is given an opportunity (which he is glad to have and seizes) to continue to work on the medical side of the ward. As many hospital corpsmen as can be spared are ordered while in New York to attend the special courses provided by the com mander of the cruiser force. In addition, while on board we have arranged for two classes daily on the return trips, when work is light, and have placed some of the reliable men as " heads of depart ments " on the surgical side, on ward management, paper work, dis pensary work, etc., under the immediate supervision of the pharma cist. We expect to continue these trained men in their special jobs and have them train other men as fast as the men can absorb the work. Naturally we have been endeavoring as far as possible to coop erate with the executive officer and assist in all matters relating to sanitation, for his duties are heavy. The inclosed bill of cleaning instructions is a sample of one which we got up for posting in every troop compartment to give the Army cleaning details a concise idea of what is expected of them and the extent of their work. 152 BEPOBTS. VoL XIII. Troop Compartment F-6. The following allowance of cleaning gear and buckets Is made to this com partment : Three swabs for cleaning the deck. Three scrubbing brushes for the deck. Three brooms. Three buckets for scrubbing and cleaning, blue. Three buckets for sputum and vomltus, black and white. One trash can. Daily soap allowance of one-half bar of salt-water soap. One spray pump. All pumps, buckets, etc., are marked with the number of the compartment and shall not be used in any other except in authorized cases. The daily allowance of soap, toilet paper, etc., shall be obtained from the issuing room, Just aft of the troop's canteen, on D deck. Brooms and scrubbing brushes shall be kept Inverted In the wooden rack when not in use. Swabs must be kept hung up in the wooden locker and the buckets and hand scrubbing brushes stowed in this locker when not actually In use. The black and white spit buckets shall be distributed In the compartment as needed. Under no condition shall cleaning buckets be used as spittoons or spit buckets be used for cleaning purposes. Trash cans shall be emptied at the Incinerator on the starboard side of D deck, aft, as soon as filled. Pump for spraying the deck will be found hanging near the swab rack. This pump shall be brought to the ship's dispensnry on B deck for filling and for Instruction as to Its use. Officer in charge of this compartment shall be responsible for the cleanliness and sanitary condition of the following items: Entire compartment. Shower No. 5, with urinal. Stairs leading to E deck— No. 20. Scuttle-butt. Sanitary Instructions. Immediately after breakfast all the lower bunks shall be taken out or lashed up to the middle bunk to leave room for proper cleaning. All rifles, equipment, clothing, etc., shall be picked up off the deck and piled neatly on the bunks. At 9.30 a. m. all men except the cleaning detail shall go on deck for exercise and remain there at lenst an hour. During this time the cleaning detail shall clean the compartment and ladders according to following instructions: Thoroughly spray the decks with cresol solution. Sweep thoroughly, being careful to include all nooks and corners. Shave the soup into small chips and put into the water. Scrub tiie deck and ladders thoroughly, using plenty of water and " elbow grease." This scrubbing shall include all ladders, corners, and spaces between the frames and shall extend up on the walls to a distance of at least 1 foot. Swab up the deck with the swabs, getting it as dry as possible. At 3 p. m. spray the deck again and sweep thoroughly. The swabs shall be taken to the cleaning room just aft of No. 1 sick-call quarters on E deck, thoroughly boiled and cleaned once a day. No. 1. 153 REPORTS. INSTRUCTIONS FOB CLEANING UBINAL AND SCUTTLE-BUTT. Urinal shall be cleaned every day. Wire gauze shall be taken out, laid on the deck, and thoroughly scrubbed with lye solution. The trough shall be scrubbed with soap and water on the inside and outside. TO CLEAN SCUTTLE-BUTT. Keep the drip pan free from tobacco, paper, and other refuse. The metal cones Bhall be removed (unscrewed) and thoroughly scrubbed and polished on both sides every day. U. S. S. Amebica. INFORMATION FOB THE COMMANDING OFFICES OF TROOPS, COMMANDING OFFICEBS OF DETACHMENTS, AND MEDICAL OFFICEBS, RELATING TO 8ANITABY AND OTHER MATTERS. The following information as to rules for sanitation on board this transport ire the result of careful thought and consideration. A copy will be furnished: the commanding officer of troops, the commanding officer of each detachment aboard, and each medical officer in order that all may immediately know and Institute the sanitary measures which must be carried out. GENEBAL. Prior to embarkation Army medical officers at the port of embarkation detailed there for that purpose carry on a very thorough examination of the men to weed out sick and start with only healthy men. Close attention In carrying out the following sanitary rules and early detection of disease must be' observed if you expect full healthy units upon arrival at the port of debarkation : 1. Every man to take a shower dally. 2. Every man to change his underclothes at least once during the voyage. 3. All troops to spend at least an hour and a half dally on deck, erich man bringing his blankets to be aired. Commanding officers to see that men receive 30 minutes of physical exercises during this period. In fact, oblige your men to stay In the open as much as the weather will permit. 4. The troop spaces to be sprayed, swabbed, and otherwise thoroughly cleaned by your cleaning details while the above (par. 3) Is In progress. This In addi Hon to the ordinary routine sweepings twice daily. 5. Inspection of all men and their effects twice weekly by your medical and commanding officers to weed out sick and be sure that men are keeping them selves clean and not harboring disease. During the airing on deck this can be carried on most successfully. ' 6. All men to sleep " heads and points " to prevent as far as possible spreading of infections by coughing. 7. See that your men sleep properly covered and that above all they are not allowed to sleep on the decks or anywhere else unless properly protected. 8. The eating of food in berthing spaces Is strictly prohibited, and, in fact, food will not be served In rooms or other unauthorized places unless so ordered by the senior naval surgeon in cases of sickness. 9. See that your men do not close the ventilators or stuff their clothing into them to stop the flow of air. 88977—IS 11 154 BEP0BT8. VoL XIII. 10. Army regulations require the protective vaccination of ail men prior to embarkation. Despite the preliminary examination there have been " last minute " requests for vaccinations, because although the men declared they had been protected, the records did not show It. The commanding officer of troops therefore will cause to be submitted to the Senior Naval Surgeon within five days of sailing either (a) a statement that all men have been protected or (6) a list of the men whom he desires vaccinated. 11. Upon arrival in foreign waters the following are required for all men who are to be sent to hospital: (1) Service record, (2) field equipment, neatly packed (and barrack bag when possible). If barrack bag is not available, com manding officers should arrange to have them secured when sorting out baggage at port of debarkation and sent to the hospital later, properly tagged. No rifle or pistol ; no bayonet. I do not give a receipt for the man, his service record or his effects, for I simply turn them over to the hospital as I receive them. The general plan is that he is returned to you directly from hospital as soon as well. CARE OF BEBTHING SPACES, DBINKING FOUNTAINS, WASH BOOMS, LATRINES, URINALS, ETC. 1. Reliable guards to be stationed day and night at each drinking fountain, in each wash room, latrine, and urinal to see that they are kept clean and no nuisances committed. 2. The cleaning details for the troop spaces, the latrines, urinals, wash rooms, etc., to be permanent for the trip so that they will be able to cooperate more intelligently. Each detail to be in charge of a noncommissioned officer, who in turn will be held strictly accountable to the police officer and to any Army medical officer acting as sanitation officer for the proper carrying on of his work. 3. Troops spaces to be sprayed, swabbed, and thoroughly cleaned as pre viously described while troops are on deck. 4. Water-closet seats to be scrubbed with lye water (or 5 per cent formalin) daily. Seats are hinged or under side can be easily scrubbed. 5. Wash basins and troughs to be thoroughly scrubbed each morning with soap and water and troops Instructed to clean basins after using. 6. All spitting on decks to be watched for and punished. (In this connection .the drinking fountains seem to be favorite place for expectoration.) 7. Drinking fountains to be scrubbed thoroughly with hot 5 per cent formalin once daily. Note. — Spray pumps for spraying compartments, soap for cleaning, brooms, swabs, toilet paper for latrines, etc., are under the care of the first lieutenant of the ship. See him and he will arrange for the issue of these things to you. On the port side of the ship on E deck, just forward of the troop's galley and officer's scullery are two wash tubs with lots of hot lye water and a wringing machine for the cleaning of swabs. See that the cleaning details find this place and keep their swabs clean. U. S. S. America. MEMO FOB MEDICAL OFFICEBS OF THE ABMY ON BOABD. The regulations under which the naval medical staff is acting (and which also covers you) have been promulgated by the Surgeon General of the Navy after consultation with the Surgeon General of the Army. The regulations make the senior naval siirgeo.i responsible for the sanitation of the ship, and also for the routine care of all men who are sick enough to require treatment other than first aid. These regulations also place at his disposal the services of any No. 1. 155 BEP0RT8. or all of the medical officers of the Army on board, together with the hospital corps, sanitation corps, etc. I therefore desire that the senior Army surgeon on board keep in most intimate touch with me to advise and cooperate con stantly so that the highest degree of medical efficiency may be maintained. With this end in view the following rules, which experience seems to indicate are good, have been laid down : (a) The senior naval surgeon to be furnished within 24 hours after em barking a roster of all persons of the Army Medical Service on board. (6) From these persons the senior Army surgeon will make suitable per manent details of enlisted men for work in the sick bay en route. (c) He will have a commissioned officer report to the senior naval surgeon for duty as sanitation officer, supervise and report upon all Army sanitation, and carry out any special orders which may from time to time be given him. (d) He will detail Army medical officers for duty as medical officers of the day and for night watches 8 to 12, 12 to 4, and 4 to 8, In company with the Junior medical officers of the Navy; these night . watches to be stood in the office of the medical officer of the day, adjoining the sick bay. le) He shall cause a venereal Inspection to be made one week after sailing to discover such cases as may have appeared since embarking. Sick call will be held daily at 8.30 a. m. and at 3.30 p. m. by such Army medi cal officers as the senior army surgeon may detail. A small black desk and locker (with red cross) is provided at the after end of each mess hall. The senior army surgeon will have a reliable hospital corpsman stationed at this place (sleeping there nights) to look out for sick, to find Army medical officer on duty, etc. This hospital corpsman to have the Army medical officer of the day see all sick before sending them to the sick bay. The cabinet contains only the simplest articles, for it is to be desired that all really sick men be sent to the sick bay for treatment. All dressings (no matter how trivial) will be sent to the sick bay. The sick-call desk is provided with a Navy prescription pad and with blanks (copy attached). The Army medical ADMISSION CARD, WHICH THE PATIENT TAKES TO SICK BAY. Name in full Co E Age Natiyity_. Tentative diagnosis Bat Service, yrs Rank Reg Reg. No U. S. Army (A) Admit to ward, date Tentative diagnosis Final diagnosis Final disposition (B) Treat and return to duty. Diagnosis Per No Per No_-_ Other treatment Per No Date Surgeon, U. S. N. Do not soil or bend this card. officer holding sick call may prescribe things other than those in the locker and send his man to the dispensary for the medication. In this connection, however, attention is invited to the fact that special vigilance is demanded in order that 156 Vol. XIII REPORTS. men may not be treated for " a slight headache " who have meningitis or for " mild sore throat " who have diphtheria. Endless trouble has resulted from careless filling out of the attached card form, particularly errors in spelling the patients' names. In all cases you send to the sick bay for possible admission, please fill in the top four lines carefully and sign your name and rank In the fifth line. In addition on the back of the card record the temperature, pulse, and respiration. Unless a case is particularly urgent it will not be received at the sick bay until seen by an Army medical officer and the form properly filled out All the official papers (Form 52 and others connected with your men who are on the sick list are made out by us and forwarded to the Navy Department and by them to the War Department) so that the data you furnish must be correct. It has been found to create endless confusion to have too many medical officers in the sick bay and in my office. Medical officers of the Army therefore must not enter the sick bay to work upon or examine patients or the office of the senior naval surgeon unless specifically requested to do so by him. The foregoing plans were formulated after consultation with other Army medical officers on other trips -with the idea of giving you something tangible to work upon immediately, so that the best possible sanitation and general medi cal cooperation would be had from the start, for after all the health of the troops must be our first consideration. FLAN OF A REGIMENTAL FIELD HOSPITAL. By C. B. Ca merer. Lieutenant Commander, Medical Corps, United States Navy. Fl E.LD HOSPITAL 4 TH. ILL^IHEWT U . S M.G. DE.CJL POIMI ClUAUTAUAMO bM, LU&A. blawu by «/ohu. a. UE_w&Aue_iuo.rV H. v. s u. rtAotD bv m.t.e>. 6ATH,. trfMtWCWpW — ' 1 1S.TT0U. TtUT. *iTA I ft£iiT*L•rru.e.utuiuu). 14 weut much. Z lt(,iHtUTfcLm^lODr 6FFK.I. 15 wtitifhiy t,bUSS~ 5 MiX fMJ,E0l!r V"LT£LT. -'U<*UWULUUiD. 4 lift fNjftAltf QJtAtTilX t UCIMtUTAL KLA6~ ft j DtuTAL 141011. -tyAuiir. * 4 C P.H.H9JJ*»_TE.Lr, * UlUV- <-AlU\ , 7 VtUElUL TtMT- • tLKJUL U^ITrOLLTl ;>; t Mt.0U.AL MALI(.SlUI.Ue.kJ^ES L1TTLA-Lit-*-. Bf.l OttUTIU^ LOOHC/CULUU). O WATLLLC0LF_A_, XVI4IUAI.WALI. X 6AUALLfl»H0llFlLTtlu "$l FltLI HOSHTAL fLA4_ tm -TWAftLM-iC. ^Vll ClOTHtX LlUt. CT-i-OTf. ntL» HWHTAL WSH Vl. •lUUULLATOir. MAIU CAHf 100vir- The accompanying plan shows the arrangement of the field hos pital of the Ninth Regiment of United States Marines, at Deer Point, Guantannmo Bay, Cuba. The field hospital is 100 yards away No. 1. 157 11EPOHTS. from the main camp on one side and 200 yards away from the in cinerators on the other. The isolation ward consists of two hospital tents, erected on the point to leeward of the quarters for hospital corpsmen and does not appear on the plan. The latrines are 60 yards away from the camp, at the foot of the cliff and built over the waters of the bay. The water supply is derived from the naval station and at present, owing to the prevalence of typhoid fever in the vicinity and the poor condition of the plumbing system at Guantanamo, the water is boiled before use. REPORT OK THE PREPARATION OF BLOOD STAIN AT THE U. S. NAVAL MEDICAL SCHOOL. By O. P. Clauk, Lieutenant Commander, Medical Corps, and Chief Pharmacist's Mate L. F. SnABEK, United States Navy. For the past few months we have had considerable difficulty in the preparation of blood stains. American dyes were used and the polychroming was carried out by the use of silver oxide after the method of Balch or that of Wilson. So many batches of the stains proved unsatisfactory that we decided to try repolychroming them instead of throwing them away. For this purpose we used sodium bicarbonate after the method of Wright, using 1.75 grams of the finished stain to 100 mils of \ per cent sodium bicarbonate solution. The stains that had been unsatisfactory were readily repoly- chronied despite the fact that eosin was present as well as methylene blue. In order to see what the action might be we tried mixing untreated methylene blue, bac. (1 gram) and untreated eosin y. w. s. (0.5 gram), then polychroming with solution of sodium bicarbonate 100 mils \ per cent, container being placed in the Arnold sterilizer for one hour. Polychroming was readily brought about. After polychroming, the usual method of Wright was followed : Filtration, saving filtrate, and drying it. For use 0.3 gram are dissolved in 100 mils of methyl alcohol. We are in hopes that the stain will have as satisfactory keeping qualities as when made with foreign dyes. PREPARATION OF IDENTIFICATION TAGS. By B. H. Laming, Lieutenant Commander, Medical Corps, United States Navy. The supply of powdered asphaltum was exhausted but identifica tion tags had not been made for all the officers and men of the U. S. S. South Carolina and as it was important to complete the work 158 Vol. XIII. REPORTS. we decided to experiment with other materials. Pharmacist Mc- Callum (T.), United States Navy, went on a voyage of discovery in Norfolk, Va., and returned to the ship with some so-called " dragon's blood," printer's ink, and asphaltum varnish which he had gotten from a printer there. Pharmacist's Mates, third class, Osuch and Lyons experimented with these materials and perfected a method of making the imprints on the monel metal which is easier and cheaper than the regulation method. I understand that the pow dered asphaltum is scarce and difficult to obtain at present and I would recommend the method with dragon's blood, asphaltum varnish and printer's ink as an alternative or substitute. I have not been able as yet to ascertain the composition of dragon's blood. The method worked out by Pharmacist McCallum and Pharmacist's Mates, third class, Lyons and Osuch is as follows : 1. To prepare the ink to make finger prints take 2 grams of powdered dragon's blood and add it gradually to 6 grams of printer's ink and stir thoroughly until there is an even mixture. To this mix ture add gradually about 15 drops of asphaltum varnish and stir well. z 2. To prepare the ink for the name prints take 10 grams of asphaltum varnish and add 2 grams of dragon's blood and mix thoroughly, then add to this mixture enough turpentine so that it will flow freely from the pen. 3. To prepare the acid mix the HC1 and HN03 in the following proportions: One-quarter part HC1, one part HNO., and two parts H20. Use about 200 c. c. of this preparation to 50 tags. To make the tag proceed as in the regulation way, inking the finger print with No. 1 preparation, printing name, rate, etc., with No. 2 preparation, dusting both sides with the dragon's blood, blowing off the excess, heating over flame until prints take a glossy appear ance, then immersing in No. 3 to finish the etching. After coming out of etching acid the tags have a dirty appearance, and to polish them, immerse the tags for about 2 minutes in a solution of equal parts of HNOa and H20. HISTORY AND AUTOPSY FINDINGS IN A CASE OF SALVARSAN ADMINISTRATION. By R. C. Christiansen, Lieutenant, Medical Corps, United States Navy. Before discussing the case at hand it is considered advisable to briefly review the literature pertaining to the untoward effects and the cause of the same following the administration of salvarsan and neosalvarsan. Very soon after the introduction of these compounds by Ehrlich clinicians realized that their use was attended by a certain factor of No. 1. 159 EEP0ET8. danger, severe symptoms of shock, and even death occurring in a percentage of cases. Wilcox and Webster have divided these symptoms into three classes" as follows : 1. Slight; nausea and vomiting, rise in temperature of 1 to 2 de grees, headache, diarrhea, and occasionally albuminuria. 2. Severe; an exaggeration of the above symptoms with rigor, pain in the limbs, hemorrhages from the mucous membranes, dysp nea, weak, thready pulse, coma or delirium, and occasionally an urticarial rash. 3. Symptoms of acute arsenical poisoning; observed in cases re ceiving a second dose before the arsenic contained in the first has been excreted. In as much as arsenic is chiefly eliminated by the kidneys, individuals suffering from some form of nephritis are the type of patients concerned in this class. An idea of the frequency of severe and fatal reactions may be obtained from the following reports, selected from the voluminous literature pertaining to this subject. Ellis obtained severe reactions in 50 per cent of a large series, the exact number not given. One case developed severe nausea, which persisted for four days. Ormsby and Mitchell report 28 severe reactions in 127 injections of neosalvarsan. Most of the patients complained of a taste and smell of ether as well as of gastrointestinal and nervous symptoms. Moody reports a death following the injection of neosalvarsan. The patient was a woman in poor physical condition. Coma de veloped in 12 hours, and she died 4 days later. The autopsy was negative. Kerl reports the death of a young male and attributes the fatality to a weakened condition of the circulatory system due to the abuse of alcohol. Kahle reports a death following the use of neosalvarsan, the autopsy showing acute nephritis. All of these observers are of the opinion that the present supply of both drugs is much more toxic than the original German prepa ration. This is emphasized by Fleet Surgeon Kilroy's report of 1913. Kilroy administered salvarsan to 1,000 patients, with no deaths and a very small number of severe reactions. The causes of the reactions may be conveniently grouped under two headings, those relating to the patient and those having to do with the preparation used. Certain individuals apparently have an idiosyncracy for arsenical compounds. Wechselman in 1910 pointed out that healthy young adults may succumb and at autopsy show slight or no pathological changes. 160 REPOET8. Vol. XIII. Patients suffering from organic heart disease or an impaired car diovascular system due to alcohol or long standing lues are especially prone to develop severe reaction. A number of instances of encephalitis following the injection of these drugs to cases of advanced cerebral syphilis are recorded. By far the most important cause of profound shock or death is an impaired kidney function, due to an acute or chronic nephritis. Ar senic compounds act in two ways in such cases. As noted above, they may exhibit a cumulative action, due to delayed excretion. A uremia and intoxication may develop due to an acute nephritis caused by the action of the compounds on the kidneys if these organs are already impaired by an old process. Brown and Pierce have proved that all arsenic compounds used therapeutically are capable of producing nephritis in animals when injected in doses considerably below the lethal. Salvarsan and neo-salvarsan are both complex chemical compounds and unless carefully made by experienced chemists can contain very toxic substances. Both of the drugs as obtained on the market contain some amino-oxyphenol arsenoxid, usually less than 1 per cent. On exposure to the air or from improper preparation this oxidation prod uct is rapidly formed. Amino-oxyphenol arsenoxid is some 20 times as toxic as the hydrochloride salt. It is for this reason that the drug can not be used after being dissolved for any length of time. Early workers attributed many severe reactions to the use of im pure water. Yakinoff points out that if the water used contains bac teria or their proteins, the addition of salvarsan renders these pro teins toxic and the solution becomes 2 to 8 times as toxic as normally. This is essentially the " wasser fehler " theory of Wechselman. Neisser and others believed that the symptoms were due to the ac tion of the endotoxins contained in the bodies of the treponema and liberated when these organisms were destroyed. Numerous workers have proved that exactly the same syndrome may occur in nonluetics and can be produced in animals. To summarize, severe reactions are due to an unusually toxic prep aration. To quote Wechselman, " insufficiency of the kidney and not hypersensitiveness of the brain is the point of the entire question of salvarsan fatalities." Following is a report of an unusually interest ing case of death after the second dose of salvarsan : M. V. M., pharmacist's mate, third class; age 24; white. Enlisted from New York February, 1914, and was transferred to the naval hospital at Canacao, P. I. History uneventful until October 23, 1914, on which date he con tracted gonococcus infection of urethra, which ran an unusually severe course. On recovering he was transferred to the U. S. S. Brooklyn. Gives a history of repeated sprains of joints. No I 161 REPORTS. May 23, 1916, developed gonococcus arthritis of sacro-iliac and both ankle joints, and was transferred to the naval hospital at Yoko hama, Japan. Bedridden until July 9. History at this time of ex cessive alcoholic indulgence. On September 20, 1916, was discharged from hospital but still had slight trouble with ankle joints. Transferred to the receiving ship at San Francisco. While on this duty he had a reputation among his shipmates for habitual alcoholic and sexual excesses. On one occasion a corpsman saw his companion administer to him an infusion of digitalis while he, M., was partially intoxicated. He complained frequently to other corpsmen of being short of breath and of palpitation following any unusual exertion. On field days he was forced to rest frequently due to symptoms noted above. He withheld this history from the medical officer on being admitted to this hospital (Mare Island). Heart examination negative; urine was not examined. December 28, 1917, admitted to this hospital with a relapse of old urethral infection. December 27, 1917, following Christmas leave, he developed a chancre on glans. Wassermann at this time was negative On January 15, 1918, he complained of intense headaches, necessi tating the administration of morphine. He was given mercury iodide pills gr. $ t. i. d. and mercury inunctions drachms i once daily. Headaches cleared up under this treatment. January 18, 1918, Wassermann double plus. Secondary rash well developed. January 21, 1918, given 0.6 grams salvarsan. Has a moderate re action with nausea and anorexia. January 28, 1918, given 0.6 grams salvarsan, at 10 a. m. Twelve other patients received salvarsan from the same packages on this date. No other severe actions resulted. At 1 p. m. had a severe chill with sweating lasting 45 minutes followed by fever 102° and weak pulse. The same evening he complained of air hunger and was delirious at times. January 29, 1918. Complained of feeling of suffocation and dis tress over entire chest. Considerable amount of dark bloody ma terial coughed up. During the day he vomited bile and stained material, and complained of intense pains in knees, calves, and toes. At times he was delirious. During the afternoon 350 c. c. of urine were voided. At 9 p. m. he became convulsive and it was necessary to restrain him. Ten minutes later death occurred. Autopsy report.—Subject is a well-developed, muscular, young adult. Lividity and rigor mortis present. A large chancre with indurated margin present on glans. Skin and membranes are other wise negative. Usual median incision reveals a fair amount of sub 162 REPORTS. Vol. XIII. cutaneous and omental fat. No excess of fluid in peritoneal or pleural cavities; a slightly excessive amount in the pericardial sac. The heart had stopped in diastole; the right auricle is moderately dilated. A milk plaque 5 cm. in diameter is present on the anterior aspect of left ventricle. The musculature of the heart appears lighter in color than normal and is rather flabby in consistency. The coronary arteries appear normal. Both cusps of the mitral valve are distinctly thickened, especially at the area of approxi mation ; thi§ thickening is well organized. No acute vegitations are present. The valve was apparently in a functioning condition. The remaining valves appear normal. The first portion of the aorta shows numerous small areas of very early atheromatous degenera tion. These do not appear to be syphilitic in origin. Microscopi cally the musculature shows numerous small areas of fibrosis. There is no fatty degeneration present. The lungs are voluminous and did not collapse when the chest was opened. No pleural adhesions. The surfaces are dark red in color; the entire lungs are firm, less crepitant than normal, and on palpation water-logged. On sectioning a considerable quantity of blood-tinged fluid escaped. No evidences of tuberculosis noted. The liver appears slightly enlarged and is softer and lighter in color than normal. On section the surface is a light yellow, uniform throughout. The lobules are not discernible. Microscopically the nuclei of the cells around the central vein stain poorly and contain many fat droplets, denoting early central necrosis. The spleen is normal in size, but distinctly softer than normal. The Malphigian bodies can not be seen. Microscopically this organ is negative. The appendix is about 8 cm. long and presents an acute kink. It is firmly bound to caecum. No evidences of acute process are pres ent. The remainder of the gastrointestinal tract is negative. The kidneys are normal in size ; the capsule strips easily ; on sec tion the capillaries of the cortex and medulla are very distinct. Mi croscopically the tubules appear normal. The capillaries of the Malphigian bodies and the tubule capillaries are intensely con gested. There is a large number of red cells present in the intes tinal tissue. The ureters are normal. The bladder contains 100 c. c. of dark urine. No pathological changes. The prostate is enlarged; on section no abscess forma tion is noted. Microscopically it shows an excess of fibrous tissue; also small areas of scar formation. The tubules of the testes strip normally; microscopically negative. Post-mortem diagnosis: Chronic myrocarditis. Chronic produc tive endocarditis, affecting mitral valve. Edema of lungs. Early No. 1. 163 REPORTS. central necrosis of liver. Acute hemorrhagic interstitial nephritis. Chronic prostatitis. Chronic appendicitis. The cause of death in this case was doubtless the toxic action of the arsenic on a heart weakened by the valvular condition and the myocarditis. Both of these conditions are easily explained by the history of gonococcic bacteraemia. It is probable that a cumulative action occurred, as the nephritis and central necrosis of liver point to this. Had the individual had an idiocyncracy to the drug, the first dose should have been followed by more severe symp toms. The preparation of salvarsan injected may have been slightly more toxic than usual, but the fact that no very severe reactions occurred in the other 12 patients tends to invalidate such an assump tion. SANITARY REPORT ON TEE ISLAND OF CORFU. By. H. Shaw, Lieutenant Commander, Medical Corps, United States Navy. According to official figures obtained at the mayor's office the present population of the city is 30,000. No epidemic diseases are prevalent at this time. It is estimated that 15,000 Serbians died here from cholera and typhus two years ago. Malaria is endemic. There is much poverty in Corfu, and the price of food is exceed ingly high, which may in part explain the immorality and many degenerate practices so common here. According to the observations made at the meteorological bureau of Corfu the maximum temperature for 1917 was during the month of August 35.2 C. and the minimum temperature was in December ber — 1.1 C. During eight months of the year the prevailing winds are south-southwest. In the city of Corfu the anopheles mosquitoes are rare, but in the country and in marshy districts they are very numerous. Both flies and fleas abound and are the source of much annoyance. Cock roaches, bedbugs, and lice are present in large numbers. The city is practically without sewerage but has good natural drainage. There is a varying elevation above sea level of 50 to 100 feet. There are numerous good camping sites in the country, but in the city itself the only vacant space is the esplande, which has an ex tent of about 15 acres. No definite information is available in regard to the quantity of the water supply but His Britannic Majesty's consul reports that it is ample for the present population. The quality of the water is excellent. It is collected from uncontaminated sources in the hills and brought to the city by a system constructed by the English during their occupation of the island. Purification of the water does not seem necessary. 164 Vol. XIII. REPORTS. The quality of the food is very poor and it is very expensive. Bread is made principally from maize. Meat can only be procured in small quantities, mutton being the commonest variety and retailing at about 70 cents a pound. At this writing coffee can not be bought in the open market. Sugar sells at several francs per pound. Tea costs 8 francs per pound. Beef when obtainable costs $1.40 per pound. Eggs cost 10 cents apiece. Fortunately fruit is abundant and of good quality, and cheap. Medicines can be obtained in small quantities from the numerous drug stores in the city. There are two large buildings suitable for use as emergency hospitals. One of them is the former residence of Prince Andrea, of Greece, known as Mon Bepos, and located in the suburbs. The other is the governor's palace which stands in the heart of the city. The quarantine regulations which obtained under the Greek Government are no longer in force since the English and French assumed the jurisdiction of the place. There are no provi sions for cremation, and bodies can not be disinterred until three years after sepulture, police permission being necessary. The Eng lish have a small cemetery just beyond the city limits. The languages commonly spoken in Corfu are Greek, French, and Italian. THE MARCH AND THE SHOE.' By W. Tj. Mann, Lieutenant Commander, Medical Corps, United States Navy. It appears to be almost impossible to give too much attention to the care of the feet. There has been some work done on this subject at this station, and it is our desire to devote more time to this im portant subject. The post surgeon has kept in touch with the ortho pedic department of the United States Army and has utilized to some extent the results of their studies of this question. At present the entire command are having their feet measured and the measurements are being recorded in the enlistment record for future reference in drawing new shoes. The process is as follows : (a) The size of the shoe the man is now wearing in heavy marching order is recorded; (b) the foot is measured by an automatic measuring device, which gives the length and width; (e) then the inch stick measurement is used as a check; and (d) finally the results of the above are verified by the actual fit of the shoe by an experienced shoe fitter. The data obtained from the last three sources correspond very closely. The size of shoe now being worn by some of the men was found to be one-half to two sizes shorter than the actual foot measurements. 1Extract from monthly sanitary report, June, 1918, Marine Training Camp, Quantlco, Va. No.l. 165 REPORTS. The results of this series of foot measurements strongly indicate that the company commanders have failed to personally supervise the fitting of shoes, as is required by Marine Corps regulations. A comparison of the foot measurements of the hospital corps with the marines showed that the hospital corps averaged a half size smaller and almost one width narrower. This was presumably due to the fact that the marines have done more inarching and have developed the military foot to a certain degree. The hike of the artillery regiments to Fredricksburg and return furnished some interesting data for observing the effects of misfitting shoes and improper footwear. It is interesting to note that these 1,000 men on the fifth day of the hike made the entire trip from Fredricksburg to Quantico in one day, a distance of 31 miles, carry ing the heavy pack and rifle, a total weight of about 40 pounds, nearly the entire distance. This was rendered possible by the stamina and morale of the men in withstanding a large degree of foot injuries without incapacitation. About 90 per cent of the men presented some form of foot trouble. In many cases the cause was the lining of the shoe wrinkling or becoming torn and worn, creating roughened places which causes friction. In about 40 per cent of the men, injuries were noted about the tendo Achillis. The chief source of this trouble seemed to be the leggings, either due to a misfit about the ankle or caused by the leggings becoming wetted with perspiration and " wilting," forming wrinkles which rubbed the back of the leg. In about 25 per cent of the cases, blisters were present on the great toe. This was possibly due to the pattern of the Marine Corps shoe. It seems to be universally accepted that the Munson last gives the most desirable results. This type of shoe permits the great toe, the ball of the foot, and the heel to act in a straight line (" Gibson " line). In the Marine Corps style of shoe the great toe is bent slightly outward, and this often results in injuries to the inner side of the toe. It also acts to some extent in preventing the maximum leverage action of the big toe. It is proposed to have one of the medical officers of each of the regiments which are to be formed at this station designated as " regimental orthopedic surgeon," who will formulate the necessary rules and regulations for the care of the feet. THE INTRACUTANEOUS TUBERCULIN TEST IN YOUNG ADULTS. By E. Moody and C. P. Carter, Lieutenants, Medical Corps, United States Naval Reserve Force. A great deal of work has been done within the past few years to prove the relative efficacy of the various skin tests for tuberculosis 166 REPORTS. Vol. XIII. with the result that a vast amount of literature on the subject has been published. Veeder and Johnston (1) working with children in St. Louis found that the skin tests were of undoubted value and drew the conclusion that the intradermal test was of somewhat greater value than the ordinary von Pirquet test. Bass (2) has recently verified their conclusions on a large series of children in a New York City orphan asylum and states emphatically that the intradermal test is of much the greater value of the two. He also went to a great deal pains to prove that the positive intradermal reaction was not the result of a particular skin sensitiveness other than the actual reac tion to tuberculin. Wittich (3) does not believe that there is specific value in the skin tests in adults for differentiating between infection and disease, while Kyan (4), reporting on the modified Detre test, feels that a great deal can be expected from skin tests in the adult in both diagnosis and prognosis. Our series is reported, not because we think that any special conclusions can be drawn from our observations, but because we feel that such material as was used for this test—that is, young men between the ages of 18 and 25 who have passed at least two rigid physical examinations before their admission to this hospital and who have been under careful observation since their transfer here— should prove valuable for such work in establishing normal stand ards and in the hope that it may be of value to others carrying out similar work. We have used as a standard test the intradermal injection of TTJ4nr mg. of old tuberculin given in -^ c. c. of normal salt solution. Observations were made at the end of 8, 24, and 48 hours, and only those cases where the reaction appeared within the first 24 hours and reached a maximum redness in 48 hours were considered positive. The positive reactions were verified by a second test, and by a positive von Pirquet. The results in all cases are shown in Table No. 1 and the results classified according to disease in Table No. 2. Table No. 1. Total number of cases 187 Positive clinically (tuberculosis) 8 Positive intradermal 10 Positive von Pirquet 12 Positive intradermal and von Pirquet 7 Positive intradermal, von Pirquet, and clinically 6 Positive von Pirquet, negative intradermal 4 Positive von Pirquet, negative intradermal, positive clinically 1 MAIN DRILL HALL AS A DORMITORY, TRAINING STATION, SAN FRANCISCO, CAL. I ' i v DRILL HALL WITH SCREENS ON EACH COT TO PREVENT SPREAD OF DISEASE BY SNEEZING AND COUGHING. 1B7-1 tfo. 1. REPORTS. 167 Table No. 2. Positive intrader mal and von Plr- quet. Diagnosi Number of cases. Positive intrader mal. Positive von Pir- quct. Pneumonia 8 7 38 60 12 11 32 6 13 7 8 7 Skin disease (Bcabies, ringworm) 1 1 Syphilis 2 1 1 1 Total 187 10 12 7 It is interesting to note that the cases clinically positive gave positive reactions to both tests. Cases considered clinically positive were diagnosed either on fairly positive chest findings borne out by the X-ray, temperature reactions, etc., or by the finding of the tubercle bacilli in the sputum. Thirty-three cases reacting negatively to both tests were given jtJ'fo- and mg. of old tuberculin subcutaneously and the tempera ture recorded carefully for 48 hours while the patients were in bed. None of the 38 gave positive reactions. REFERENCES. (1) A'eeder and Johnston: The Frequency of Infection with the Tubercle Bacillus In Childhood. Am. Jour. Dis. Child., lx, p. 478. (2) Bass: Cutaneous and Intracutaneous Tuberculin Tests. Am. Jour. Dis. Child., xv, p. 818. (3) WIttich: Comparison between Skin Tuberculin Tests. Am. Rev. of Tu berculosis, I, No. 11, Jan., 1918. (4) Ryan : Tuberculin as a Diagnostic Test of Tuberculosis In Man. Jour. Am. Med. Assn., lxx, p. 982. BED SCREENS IK BARRACKS.1 By P. S. Rosbitbr, Commander, Medical Corps, United States Navy. The accompanying illustrations show what has been found to be a very satisfactory sneeze screen for use at this station. One of the pictures illustrates the method of berthing in the main drill hall prior to use of the sneeze screens. In this method men are berthed head and feet on 5-foot bunk centers. With a sneeze screen heads are all in the same direction. 1 Fxtrnct from rteport to Surgeon General. Oct. 10, 1918. 168 Vol. XIII. REPORTS. The screen is cheap and simple in construction, easily erected, and very efficacious. It consists of unbleached muslin, 1 yard wide, tacked to three 1-inch uprights 4 feet long. During the day these are rolled up and stowed or aired on the air-bedding racks. At night the screen is unrolled and fastened by clothes stops to the legs of each bunk When pitched in rows as shown in the photograph, it has been found that stopping the outboard head upright of one to the outboard foot upright of the next bunk tautens and strengthens the line. INFLUENZA OH A NAVAL TRANSPORT. By W. F. McAnally, Lieutenant, Medical Corps, United States Navy. During the past six months we have treated over 100 cases of influenza and pseudo-influenza. These occurred in the proportion of about 30 per cent of the former and about 60 per cent of the latter. At no time did the disease tend to assume an epidemic form, which fact is possibly due to the thorough prophylaxis which is insisted upon. A typical case of influenza occurs after an incubation period of one to three days. The attack is generally marked by a chill of greater or less severity, followed by fever ranging from 101° to 104° or higher. The patient complains of aching pains in the trunk and extremities, headache, and general malaise. He looks and feels sick. Upon examination, in practically every case of our series, there has been found a more or less severe inflammation of the nasal mucous membrane and tonsillar rings; in some few cases there has been a distinct streptococcic tonsillitis, which was generally very obstinate to treatment and persisted even after the original influenza had cleared up entirely. These symptoms generally appeared on the third or fourth day of the disease. The treatment has been generally very satisfactory and was prac tically the same in all of our cases, i. e., rest in bed, free catharsis, Do- bell's solution or a 1 per cent solution of chlorazene as a gargle every two hours, aspirin grs. x and sodium bicarbonate grs. xx t. i. d., together with the subcutaneous injection of influenza bacterin mixed (Mulford), a primary dose of 1/2 c. c. being given upon admission and followed at four-day intervals by two or three secondary doses of 1 c. c. each. Following one, or in some cases two, injections of influenza bacterin and the general treatment as outlined, most of the typical cases were generally discharged to duty in three or four days. Injections of 1/2 c. c. of the bacterin upon admission, followed at four-day in tervals by injections of 1 c. c. has been productive almost invariably of exceedingly good results. From one to six hours after the primary No. 1. 169 REPORTS. injection there is a more or less severe exacerbation of the symptoms, but we have yet to see a case in which a serious reaction occurred. In the second type of cases, which we have called pseudoinfluenzal for want of a better name, our treatment has not given such good results, although they were seemingly the result of a much mildei infection. The following case illustrates this type : C— Frank, admitted to the sick bay July 15, 1918, complaining of sore throat, slight headache, and muscular pains; temperature, 100.4° ; there was a slight inflammation of the nasal and pharyngeal mucous membranes; heart and respiration normal. Treatment: Bed; magnesium sulphate, oz. li. aspirin, grs. x, sodium bicarbonate, grs. xx t. i. d. ; Dobell's gargle; silver nitrate (10 per cent) locally to throat t. i. d. Influenza bacterin 1/2 c. c. was given subcutaneously upon admission. There was apparently no reaction after the bacterin injection. July 16, 1918: There is very little change; temperature, 99.8 '; patient still feels badly, with aching pains in legs and headache. July 19, 1918: Improving slowly; temperature ranging from 99.8° to 100.2°; tonsillar rings and tonsils inflamed; influenza bacterin 1 c. c. injected s. c. ; no reaction; no muscular pains nor headache. July 23, 1918: Discharged to duty. No symptoms other than a slight redness of the tonsillar rings; slight variations in temperature from normal to 99.3°. Treatment continued. This case was mild throughout; there were never any severe mus cular pains nor headache; fever was low, and the respiratory symp toms were not marked. It and all the cases of this type resembled influenza very closely, except in the severity of the symptoms; fur thermore, all these cases of pseudoinfluenza give very little or no reaction to the influenza bacterin, and the course of the disease has. not been influenced by it. In our series of over 100 cases careful records were kept in only about 25 instances. While this number is entirely too small to be a basis for any definite statements, and while the cases were not worked out bacteriologically in the laboratory, it seems that we are justified in the following conclusions : 1. There are two varieties of infection giving practically the same train of symptoms, the only difference being in the severity of the process, one of these being influenza, with the classical symptoms and due to a specific infection. The other, pseudoinfluenza, seem* to occupy a position midway between a " cold in the head " and influenza and is not due to the same infectious agent. 2. That for the treatment of influenza we have a specific bacterin,. which in our hands and when given in a primary dose of 1/2 c. c. subcutaneously, followed by one to three secondary doses of 1 c. c. each, has given very satisfactory results, patients rarely remaining 88977—18 12 170 VoL XIII. BEPOBTS. in the sick bay over three to five days. Also, that this specific bacterin has no appreciable effect upon cases of the pseudoinfluenzal type. The above results would have been more satisfactory had we been able to follow up our cases bacteriologically, and it is hoped that some one will report a series of similar cases in which this data will be available. THE TREATMENT OF CHANCROIDS AND THE PRETENTION OF BUBOES. By Q. W. Mills tt, Lieutenant. Medical Corps, United States Navy. The object to be gained in the treatment of chancroidal infection is twofold. First, to heal the ulcer; second, to prevent the forma tion of a bubo. The time spent in hospitals from chancroidal in fections is largely due to infections of the inguinal lymph glands, and not due primarily to the lesions on the penis. When an ulcer is cauterized with heat or a strong reagent there is much necrosis of the surrounding tissue. In a short time this cauterized dead tissue affords a splendid medium for the growth of the organisms which are present in the vicinity. This secondary infection in many cases is as bad or worse than the first one, due to the fact that the tissues have lost their power of resistance. As a result the infection spreads to the lymph channels and is carried to the inguinal glands, and a bubo is formed. The majority of buboes contain sterile pus, or pus containing a mixed infection mainly of staphilococci or streptococci. In the ex amination of 24 consecutive cases of bubo, 20 contained staphilococci as the prevailing organism, and 13 contained only staphilococci or staphilococci and streptococci. Many observers have failed to find the Ducrey bacillus in the bubo, while some observers have with drawn the pus and inoculated it and failed to produce the character istic soft sore. All these facts tend to point toward the theory that buboes are usually formed by secondary infection of the ulcers. During the months of April, May, and June, the cauterization treatment was used on all cases of chancroid infection entering the United States Naval Hospital, Canacao, P. I. The number of sick days due to buboes during this quarter were 540. The total number of sick days for this quarter w*is only 4,150; therefore over 13 per cent of all the sick days were due to buboes. During the month of July cauterizing was not done, but after thorough cleansing of the chancroids with hydrogen peroxide or bichloride of mercury, they were treated with a 10 per cent solution of copper sulphate, and after 5 or 10 minutes a dusting powder, preferably aristol, was ap plied or they were dressed with a wet antiseptic dressing. The sore should be dressed in this manner night and morning, or oftcner. During this month we had only "<! sick days due to buboes, while No. 1. 171 REPORTS. practically the same ratio of chanchroid cases entered the hospital. Of course, cases entered with buboes, but the ratio of these were the same for each of the months. The object of this treatment is to keep the ulcer clean and not allow secondary infection to progress. Copper sulphate will kill the chan croid infection and by the use of wet dressings or an absorbent pow der the secondary infection is not allowed to progress. Where th 3 patient has been circumcised or where an ulcer is on the outer surface of the foreskin I apply a shield made with wire screen and adhesive tape. With a shield of this nature no dressing need touch the ulcer and it can drain freely or be kept clean and dry with a little dusting powder, without removing the shield. Anyone can make a shield of wire screen and adhesive tape to keep the patient's clothing and dressings away from the ulcer. It can be held in place by a piece of adhesive tape attaching it to the penis or by a bandage passed around the abdomen and around the hips just below the gluteal muscles. This treatment not only helps in the prevention of buboes but also hastens the cure of chancroids. BECOBD OF THE NAVY RECRTTITrNG STATION, PITTSBURGH, FA. By C. C. Am merman. Lieutenant, Medical Corps, United States Naval Reserve Force. Summary of recruiting statistics at Navy recruiting station, Pittsburgh, Pa., for 5 year ending June SO. 1918. Week end Examinations. Enrollments. ing- United United States Reexamin United United States States Naval Reserve ation and Total. States Na< al Reser e Total. Navy. Force. special. Navy. Force. Apr. 6 65 45 2 112 23 18 41 13 31 123 12 166 22 70 92 20 29 155 16 200 17 79 96 27 24 199 14 237 11 117 128 May 4 31 174 21 226 20 87 107 11 36 220 8 264 23 129 152 18 66 195 10 271 27 101 128 25 63 227 20 310 34 109 143 June 1 51 404 13 468 32 225 257 8 109 525 634 61 236 297 15 68 173 19 260 22 68 90 22 38 185 11 234 16 77 93 30 81 185 14 280 49 82 131 Total... 692 2, 810 160 3,662 357 1,398 1, 755 Previous examin ations . . 10, 715 1, 927 2,780 15, 422 3,343 922 4,265 Total . . . 11,407 4, 737 2, 940 19, 084 3,700 2, 320 6,020 172 Vol. XIII. REPORTS. Number of applicants for United States Navy 11, 407 ^Number of applicants for United States Naval Reserve Force 4, 737 Total applicants examined 16, 144 Number of special and reexaminations 2, 940 Total number of examinations made 19, 084 Total applicants accepted 6, 936 Total applicants rejected 8, 436 Waivers requested, approved 515 Waivers requested, disapproved 257 772 16,144 Grand total applicants accepted 7, 451 Grand total applicants rejected 8, 693 16,144 Accepted applicants enrolled 6, 020 Accepted applicants failed to enroll 1, 431 7,451 Per cent of applicants accepted, excluding waivers 43 Per cent of applicants accepted, including waivers 46 Per cent of examined applicants enrolled 37 Per cent of accepted applicants enrolled 80 Smallest number of examinations in a day, C. C. Ammerman None. Largest number of examinations in a day, C C. Ammerman, (June 4. 1918) 182 Largest previous number examinations in a day, C. C. Ammerman, (December 14. 1917) 139 Largest number of examinations in station 1 day (June 4. 1918) 2 medical officers 274 Smallest quarter, number applicants examined (September 30, 1916) 210 Largest quarter, number applicants examined (June 30, 1918) 3, 501 Lowest per cent applicants accepted for quarter (December 31. 1914) 26 Highest per cent applicants accepted for quarter (March 31, 1917) 60 Cost of medical officer's examination per applicant $0. 69 Cost of medical officer's examination per enlistment $2. 20 STRENGTH OP THE NAVY. The following figures give the actual strength of the Navy as calculated on October 22, 1918 : Regular Navy Naval Reserve Coast Guards: Commissioned officers Warrant officers Lighthouse Midshipmen (Naval Academy) Public Health Service: With Sanitation Division, United States Navy On Coast Guard vessels. United States Navy. . Nurse Corps: Regular Reserve United States Naval Reserve Force Coast and Geodetic Survey Officers. 9,962 21,072 227 435 244 2,115 13 2 260 B23 546 12 Men. 218,251 282,000 5,953 888 70 No. 1. 173 REPORTS. Marine Corps: Regulars Reserve Warrant officers Judge Advocate General: Prisoners, officers and men Total Grand total. 37,762 | 576, 5 614, 711 BOOK NOTICES. Textbook of Practical Therapeutics, by H. A. Hare, M. D., B. Sc. Seven teenth Edition. Lea & Feblger, Philadelphia, Pa., 1918. To those familiar with previous editions of this work it is needless to detail its merits. Suffice it to say that the new issue is thoroughly up to date and covers the latest advances in therapeutics. The Carrel-Dakin treatment, ambrine, antitetanic serum, antipneu- mococcic serum, the treatment of hay fever, etc., are fully discussed. Surgical Treatment, by •/. P. Warbasse, if. D. W. B. Saunders Co., Philadel phia, Pa., 1918. The second volume of this work has appeared and amply fulfills the promise of the first. This is a full and comprehensive presenta tion of modern surgical diagnosis and treatment, the technical steps of operative procedures being given more in outline. An unusually good book. The Suboekt or Oral Diseases and Malformations, by G. Van J. Brown, D. D. S., if. D., C. M., F. A. C. S. Third Edition. Lea & Febiger, Philadel phia, Pa., 1918. Textbook of General Bacteriology, by E. O. Jordan, Ph. D. Sixth Edition. W. B. Saunders & Co., Philadelphia, Pa., 1918. Urology, by E. L. Kcyes, jr., if. D., Ph. D. D. Appleton & Co., New York, 1917. This excellent and handy volume merits a place in every medi cal library. It is full without being diffuse, the author having the happy faculty of making his meaning clear in a few well chosen words. Equilibrium and Vertigo, by L. Fisher, M. D. J. B. Llpplncott Co., Philadel phia, Pa., 1918. Medical and Surgical Therapy. Edited by Sir Alfred Keogh, K. C. B., G. B., LL. D., if. D., etc. D. Appleton & Co., New York, 1918. This book will be of real service in every general hospital. Each of the five volumes is devoted to a special subject —infectious dis 174 BEPOBTS. VoL XIII. eases, neuroses, wounds, fractures, bones and joints —the list of the authors of the text containing such well-known names as Ombredanne, Broca, Vincent, Abrami, Leriche, Babinsky, Roussey, and others equally famous. The work is a translation of the major part of a series of French manuals and thus presents the views and details the experience of a number, though by no means all, of the brilliant workers who have done so much to restore to France that leadership in surgery held at the beginning of the nineteenth century. NOTICK TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing and wide margin 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 letterhead, numbered paragraphs, and needless spacing between paragraphs, all of which require correction before going to press. The Bulletin endeavors to follow a uniform style in headings and captions, and the editor can be spared much time and trouble and unnecessary errors can be obviated if authors will follow in the above particulars the practice of recent issues. This is not only important in special articles, but still more so in reviews. The greatest accuracy and fullness should be employed in all citations, as it has sometimes been necessary to decline articles otherwise desirable because it was impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors in orthography in many contributions is conclusive evidence that authors often fail to read over their manuscripts after they have been typewritten. Contributions must be received two months prior to the date of the issue for which they are intended. The editor is not responsible for the safe return of manuscripts and pictures. All material supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. Only the names of actual reviewers for a current number appear. The Bulletin intends to print only original articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assumption that they have net appeared previously and are not to be reprinted elsewhere without an understanding to that effect. 1 175 o 3 i - i VOL. Xlll 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 PUBLICATIONS CAPTAIN J. S. TAYLOR, MEDICAL CORPS, U. S. NAVY IN CHARGE APRIL, 1919 (QUARTERLY) WASHINGTON GOVERNMENT PRINTING OFFICE 1919 Navy Department, Washington, March 20, 1907. This United States Naval Medical Bulletin is published by direction of the department for the timely information of the Medi cal and Hospital Corps of the Navy. Truman H. Newberry, Acting Secretary. NOTE. Owing to the exhaustion of certain numbers of the Bulletin and the frequent demands from libraries, etc., for copies to complete their files, the return of any of the following issues will be greatly appreciated : Volume VII, No. 2, April, 1913. Volume X, No. 1, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1917. Volume XII, No. 1, January, 1918. Volume XII, No. 3, July, 1918. Subscription Price of the Bulletin. Subscriptions should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning January 1, $1; for foreign subscription add 25 cents for postage. Single numbers, domestic, 25 cents ; foreign, 31 cents, which Includes foreign postage. Exchange of publications will be extended to medical and scientific organiza tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy, Washing ton, D. C. n TABLE OF CONTENTS. Face. PREFACE v SPECIAL ARTICLES: The pathology of pneumonia accompanying influenza. By Lieutenants (J. G.) E. W. Goodpasture and F. L. Burnett, Med ical Corps, U. S. N. R. F 177 Mental examination of recruits. By Lieutenant L. E. Bisch, Medical Corps, U. S. N. R. F 198" Treatment of military offenders. By Lieutenant Commander A. L. Jacoby, Medical Corps, TJ. S. N. R. F.. 229 Extraction of metallic foreign bodies. By E. Robin, M<§decin I ere Classe 237 New methods in amputations and prosthesis of the lower limbs. By Lieutenant Commander R. G. LeConte.Medical Corps, U.S.N. R.F.. 244 Education and sanitation aboard ship. By Commander W. S. Pugh, Medical Corps, U. S. N 254 HISTORICAL: Jean Dominique Larrey 267 Extract from a surgical memoire by Baron Larrey. Translated by Captain G. A. Lung, Medical Corps, U. S. N 275 EDITORIAL: The lesson of job's war horse 283 SUGGESTED DEVICES: Sanitary drinking fountain. By Lieutenant Commander D. S. Hillis, Medical Corps, U. S. N. R. F. . 287 Clinical charts in health records. By lieutenant (J. G.) J. J. Cancelmo, Medical Corps, U. S. N. R. F. . 287 System of clinical records. By Captain W. B. Grove, Medical Corps, U. S. N., and Lieutenant G. B. Crow, Medical Corps, U. S. N. R. F..." 288 A DRESSING FOR WOUNDS. By Lieutenant Commander C. W. C. Bunker, Medical Corps, U. S. N. 291 CLINICAL NOTES: Abdominal wounds from hand grenade. By Lieutenant J. M. Emmett, Medical Corps, U. S. N 293 Fracture of spine of tibia. By Lieutenant Commander G. G. Ross, Medical Corps, U.S.N. R.F... 294 Fracture of pelvis. By Lieutenant Commander G. G. Ross, Medical Corps, U. S. N . R. F . . . 295 Chronic rheumatism cured by appendf.ctomy. By Lieutenant R. H. Michels, Medical Corps, U. S. N. R. F 296 A CASE OF MYELOID LEUKEMIA. By Lieutenant E. R. Ryan, Medical Corps, U. S. N 297 Pericardiotomy. By Lieutenant Commander L. R. G. Crandon, Medical Corps, U. S. N. R. F 299 A CASE OF KERATOSIS PLANTARIB. By Lieutenant J. M. Perret, Medical Corps, U.S.N 300 Influenza with unusual complications. By Lieutenant (J. G.) F. G. Folken, Medical Corps, U. S. N. R. F.. - 301 in IV TABLE OF CONTENTS. PROGRESS IN MEDICAL SCIENCES: Page General medicine. —Diagnosis, treatment and prophylaxis of malaria in Brioni —Epidemic lethargic encephalitis— Encephalitis lethargica — Syphilitic aortitis —The pathology of the streptococcal pneumonias of Army camps—The venereal problem and the war—The cocaine habit. Surgery. —Sterilization of wounds by electro-ions — Abscess of thyroid following septico-pyemia from otitis —Acute perforations of the abdominal viscera—The use of paraffin for drainage in surgery —Surgical technic in orthopedic surgery 307-320 Pathology, bacteriology, and animal parasitology. —Laboratory diag nosis—Detection of spirochetes— Gonococcus infections 321 Eye, ear, nose and throat. —Tests for malingering in defective hearing — Ocular anaphylaxis 334 NOTES AND COMMENTS: The third resuscitation commission. — Lecture course at Great Lakes, 111.—A department of physical training —The Germans and the scientific workers of Lille—Physical education —Transportation of sick and wounded —Traumatic rupture of the spleen—Officer-material school at Princeton —Wanted, a diagnosis 337 REPORTS: Hospital administration. By Captain G. A. Lung, Medical Corps, U. S. N 347 Removal of wounded prom U. S. S. "Northern Pacific." By Commander E. H. H. Old, Medical Corps, U. S. N 349 On board a torpedoed transport. By Lieutenant Commander E. E. Curtis, Medical Corps, U.S.N 351 Influenza at the U. S. Naval Hospital, Washington, D. C. By Rear Admiral R. M. Kennedy, Medical Corps, U. S. N 355 Notes on post-influenzal pneumonia. By Lieutenant (J. G.) A. M. Burgess, Medical Corps, U. S. N. R. F., and Phar. Mate E. J. Staff, U. S. N. R. F 356 Diphtheria at the U. S. Naval Academy. By Lieutenant J. E. Houghton, Medical Corps, TJ. S. N., and Lieu tenant (J. G.) D. G. Richey, Medical Corps, U. S. N. R. F 359 Influenza at Pensacola. By Lieutenants J. M. Perret, and C. M. Shaar, Medical Corps, TJ. S. N . . 365 Training school for nurses in Haiti. By Chief Nurse L. D. Jordan, U. S. N 378 Observation of candidates for the listener's school. By Lieutenant F. B. Galbraith, Medical Corps, U. S. N 380 BOOK NOTICES 391 UNITED STATES NAVAL MEDICAL SCHOOL LABORATORIES. Additions to pathological collections 393 NOTICE TO SERVICE CONTRIBUTORS 394 PREFACE. The publication and issue of a quarterly bulletin by the Bureau of Medicine and Surgery contemplates the timely distribution of such information as is deemed of value to the personnel of the Medical Department of the Navy in the performance of their duties, with the ultimate object that they may continue to advance in proficiency in respect to all of their responsibilities. It is proposed that the Naval Medical Bulletin shall embody matters relating to hygiene, tropical and preventive medicine, pa thology, laboratory suggestions, chemistry and pharmacy, advanced therapeutics, surgery, dentistry, medical department organization foi battle, and all other matters of more or less professional interest and importance under the conditions peculiar to the service and pertain ing to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good.of the service, out of the experience and observations of the individual. There are many excellent special reports and notes beyond the scope of my annual report being sent in from stations and ships, and by communicating the information they contain (either in their entirety or in parts as extracts) throughout the service, not only will they be employed to some purpose as merited, but all medical officers will thus be brought into closer professional intercourse and be offered a means to keep abreast of the times. Reviews of advances in medical sciences of special professional interest to the service, as published in foreign and home journals, will be given particular attention. While certain medical officers will regularly contribute to this work, it is urged that all others cooperate by submitting such abstracts from the literature as they may at any time deem appropriate. Information received from all sources will be used, and the bureau extends an invitation to all officers to prepare and forward, with a view to publication, contributions on subjects relating to the profes sion in any of its allied branches. But it is to be understood that the bureau does not necessarily undertake to indorse all views and opinions expressed in these pages. W. C. Braisted, Surgeon General, United States Navy. U. S. NAVAL MEDICAL BULLETIN Vol. XIII. Aran, 1919. No. 2. SPECIAL ARTICLES. THE PATHOLOGY OF PNEUMONIA ACCOMPANYING INFLUENZA. By E. W. Goodpasture and F. L. Bdenett, Lieutenants (J. G.), Medical Corps, United States Naval Eeserve Force. During the present epidemic of influenza, as in similar epidemics of the past, the most frequent and grave complication of the infec tion has been pneumonia. It is estimated that the mortality in this form of the disease among patients treated at the United States Na val Hospital, Chelsea, Mass., since last August, will be between 25 and 30 per cent; while in the similar epidemic of 1889-90 the mor tality in cases of influenza pneumonia in Boston, as recorded by Mason, varied for different ages between 29 and 45 per cent. The relation of influenza to the inflammation in the lungs, so fre quently accompanying it, was a problem of particular interest to pathologists and bacteriologists in the last great pandemic of 1889-90, and the observations at that time gave rise to opposing views as to the nature and cause of the pneumonia. The differences of opinion were occasioned by the variety of inflammatory changes found in the lungs at autopsy and from the lack of uniformity in the results of bacteriologic studies. Cultures from; the lungs demonstrated in numerous cases the presence of well known microorganisms, par ticularly pneumococci and streptococci ; and each of these organisms was proposed by a group of observers as the cause of the pulmonary inflammation. Weichselbaum, and with him probably the majority of investigators at the time, attributed the pneumonia to the pneumo- coccus, while Finkler and Ribbert, finding streptococci in the lungs of several cases, considered the broncho-pneumonia which they observed identical in form with the lesions present in pulmonary erysipelas, due, as they thought, to the same microorganism. Corresponding to these two views the character of the inflammatory exudate was de scribed as " croupous " when associated with pneumococci and " ca tarrhal " with streptococci. In fact the idea that influenza pneumonia was exclusively due to a mixed or secondary infection became so firmly established, accord 177 178 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. ing to Leichtenstern, that the opposing hypothesis of a primary in fluenza pneumonia advocated by him in 1889, was criticized by many bacteriologists as groundless. From clinical and anatomical evi dences he, at that time, stated " there is a primary influenza pneu monia that is an inflammation of the lungs produced by the poison of influenza." Four years later, primary influenza pneumonia was described by Pfeiffer in His publication announcing the discovery of the influenza bacillus. Inasmuch as the lesions, recorded by him as the type of pulmonary inflammation caused by this organism, differ in certain respects from those observed by certain other investigators and from the disease as it is manifesting itself in the present epi demic, his description will be presented in some detail. With the naked eye he found the lungs studded with a great num- i ber of lobular areas, in the centers of which were pinhead to pea- sized yellow spots elevated above the surrounding dark red tissue. These lobular areas were separated by air-containing tissue or coa lesced forming a secondary, apparently lobar consolidation, but still on close examination showing the characteristic structure of lobular pneumonia. The lesion was easily distinguishable from uniform lo bar consolidation. With a little pressure greenish yellow droplets of thick, tenacious pus could be squeezed from the cut bronchi. In smears and in stained sections of lung tissue, great numbers of in fluenza bacilli were found within the leucocytic exudate in the cen ters of the pneumonic areas and on the bronchial walls, while in larger bronchi, various organisms, including streptococci and pneu- mococci, were present. Microscopically the centers of consolidated areas were found full of pus cells which filled the alveoli and septa, so that the architecture of the lung was obscured. The alveoli about the periphery of the consolidated areas contained large round, often pigmented cells. In the central portion fibrin was completely absent, and at the periphery occurred at most only in small strands. The ab sence of fibrin he considered the typical difference between " croup ous " and influenza pneumonia. The bronchial walls were infiltrated with wandering cells. In explanation of the lobular distribution of the pneumonic areas, Pfeiffer conceived the inflammation to extend directly into the alve oli from a diseased bronchus, consequently influenza pneumonia, as he found it, was a typical lobular pneumonia with a " catarrhal " exudate in which were numbers of influenza bacilli. As to the complete distinction of pure " croupous " and influenza pneumonia, since the discovery of the influenza bacillus, there is little or no confusion either from a clinical or pathological stand point. The anatomical features of difference are presented by Rib- bert as follows : " The cut surface of the consolidated lung with in fluenza pneumonia is smooth, not granular, the exudate soft, very No. 2. GOODPASTURE AND BURNETT PNEUMONIA. 179 abundant and poor in fibrin ; even with lobar consolidation the cut surface has a lobular configuration and the individual lobules are not altered in the same degree." Croupous pneumonia, however, superimposed upon and accompanying influenza, is often confusing; and there are considerable variations in the descriptions of the char acter of inflammatory exudate in true influenza pneumonia. Thus, while Pfeiffer, Beck, and Wassermann describe an exudate consist ing of pus cells and little or no fibrin as typical, Weichselbaum found, in the neighborhood of purulent broncho-pneumonic areas alveoli in which fibrinous, serous, or hemorrhagic exudate predomi nated. And Leichtenstein, while admitting that the influenza bacil lus can produce a fibrinous as well as a catarrhal inflammation, con siders the numerous instances of croupous pneumonia accompanying influenza due to a secondary invasion by pneumococci. Thus it appears to have been admitted that the influenza bacillus of itself is capable of producing a pneumonia which, though typi cally lobular in distribution, may at times become lobar by coalescence of focal areas of inflammation while still maintaining a lobular struc ture ; that the pulmonary exudate which its injury calls forth may be simply catarrhal —that is, composed of leucocytes with little or no fibrin —or may be predominantly fibrinous, hemorrhagic, or serous in certain areas. It is well established that in a high percentage of cases the anatomy of the lungs is more complicated by reason of a secondary infection with pneumococci, streptococci, and less fre quently other pathogenic microorganisms. Among these complica tions are described croupous pneumonia, abscess formation, gangrene, and occasionally caseation, where a latent tuberculosis is incited to increased activity by the disease. Since the present epidemic of influenza made its appearance in the first naval district in August many deaths have resulted from the disease, and in all of 30 cases autopsied at this naval hospital ex tensive pneumonia was present in both lungs. In 83J per cent of these influenza bacilli were isolated from the lungs either in pure cul ture or associated with pneumococci, Types I, II, III, or IV, strep tococci, staphylococci, or micrococcus catarrhalis, as reported by Lieutenant J. J. Keegan, Medical Corps, United States Navy, in September. Since this report Lieutenant Keegan has increased the number of cases from which influenza bacilli have been obtained from the lungs, and with his permission the complete list, with bacte- riologic data, is presented here. 180 GOODPASTURE AND BURNETT —PNEUMONIA. Vol. XIII. Cultures from the lungs. Num ber of cases. Influ enza Pneumo- coccus. Strepto coccus vlrl- dans. Strepto coccus hemo- lyticus. Micro coccus catar rhal Is. Staph; lococ cus aureu. bacil lus. 1.... + 2.... + — — — — — 3.... + — — — — — 4.... + 5.... + — — _ — — 6.... + 7.... + + (ID — — — — 8.... + + (ID — — — — 9.... + + (IV) — — — — 10.... + + (ID — — — — 11.... + + (ID — — — + 12.... + + (ID — — — + 13.... + + (ID — — — — 14.... + + (IV). — — — + 15.... + + (III) — — — — 16.... + + (IV) — — — — IV.... + _ _ _ _ 18.... + + (II) — — — _ 19.... + + (I) — — — — 20.... + + (IV) — + — — 21.... + — — — + 22.... + — — — — + 23.... + — — — — + 24.... + — — — — + 25.... + — - — — + 26.... + 27.... — _ _ + — — 28.... + — — + — — 29.... + — — + + + 30.... + — — — + + 31.... — — — + — — 32.... + + (IV) — + — — 33.... — — + + — 34.... + 36.... + 36.... + + (IV) — — _ 37.... + +(III- IV) — — — — 38.... + + (IV) — — — — 39.... + + (III) — — + — 40.... + — — + — — 41.... + + (IV) — — — — 42.... + — — + — 43.... — — — + — . — 44.... + — — + — + 45.... + — — — — + 46.... + + (IV) + — + — 47.... + — — + — — 48.... + — — + + + 49.... + — + — — 60.... + + (IV) + — — 51.... + — — + — — 62.... + — — — + 53.... — + (IV) — — + — 54.... — + (IV) _ — + — 55.... + - + — — 66.... + + — - - — Dura tion of pneu monia, In days. 4 4 4 2 15 Ifi in 7 9 4 12 Blood culture. Pneumococcus. Do. Do. Micrococcus catarrhalis. Pneumococcus. Do. Influenza bacillus, staphy lococcus. Streptococcus. Do. No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 181 Cultures from the lungs—Continued. Num ber^! Influ enza bacil lus. Pneumo- coccus. Strepto coccus virl- dans. Strepto coccus hemo- lyticus. Micro coccus catar- rhalis. Staphy- loco- cus Dura tion of Blood culture. aureus. pneu monia in days. 57.... 58.... 59.... 60.... 61.... 62.... 63.... 64.... + + + (IV) - - - - + + + + + (III) 1 1+ 1 1 1 + (IV) + (IV) - + t + Autopsies were performed upon the first 30 cases in the above chart ; and this study is based upon observations of the pathological anatomy of influenza, especially the pulmonary lesions, as presented by these individuals post mortem. They were all young men of strong physique betwen the ages of 18 and 30. The autopsies were performed from 2 to 10 hours post mortem, usually within 6 hours. UNCOMPLICATED INFLUENZA PNEUMONIA. A reference to the foregoing chart shows that the lungs in six cases, or 20 per cent of the 30 autopsied, yielded pure cultures of the influenza bacillus, while 15, or 50 per cent, were associated with pneu- mococci; 4, or 13J per cent, with streptococci, and the remainder with \/ other micro-organisms. These cultural results do not indicate accu rately the accompanying pathologic changes, for in the four cases 1 from which staphylococci appeared in cultures, the condition of the lung in gross and microscopically indicates that these organisms were probably contaminants, and the lesions associated with the influenza bacillus alone. However, by correlating the cultural results with the pathologic changes and the micro-organisms demonstrated in sec tions, it is possible to describe the pulmonary lesions in two groups, separating the inflammatory changes associated with the influenza bacillus alone, from those in which secondary organisms modified the pathology. The first group, in which the influenza bacillus was alone or pre dominantly present, includes cases varying in the duration of clinical evidences of pneumonia from 2 to 16 days. The appearances of the lungs and the pathologic processes at work in them are very different in the two extremes. It is consequently necessary to describe them more or less separately, at the -same time correlating them and fol lowing the consecutive stages. In each instance the pneumonia has been bilateral, and the lobes of both lungs involved to a greater or lesser degree. The inflammation 182 GOODPASTURE AND BURNETT PNEUMONIA. Vol. XIII. in the upper and middle lobes was always less extensive than in the lower, and the anterior portions less than the posterior. The middle lobe is spared to a greater extent than any other, though it, too, may be extensively infiltrated. The lungs of the early stages of pneumonia associated with pure cultures of the influenza bacillus are quite similar in the type of in jury and reaction present, though there is great variety in the pre ponderance of inflammatory elements in various portions of a single lung or lobe. There is commonly a moderate serous effusion in one or both pleural cavities amounting to 50 or 250 cubic centimeters. The fluid is clear and has the color of blood-stained serum. The pleural surfaces are smooth, shiny and wet, though occasionally a thin, granular fibrinous exudate may be seen by reflected light over limited areas. Often numerous small, red, discrete, or confluent pleural hemorrhages are present over consolidated portions, especially pos teriorly on the surface of the lower lobes. One or both lower lobes in most instances appear completely consolidated, and the posterior and inferior regions of the upper lobes have a similar appearance. The consolidation in these lobes and in the middle lobe are characteristi cally patchy in distribution. Patches of consolidation measuring 2 to 5 centimeters can be seen and felt in the anterior and lateral portions. The consolidated regions of all lobes appear externally grayish purple to dark reddish purple, the lower and posterior re gions being darker than the upper and anterior. The intervening air-containing tissue is emphysematous, more expanded than the con solidated areas, edematous, more or less, and pinkish or yellowish purple in color. The emphysema is quite striking, the individual air vesicles being readily discernible. The lungs are heavy and cut surfaces drip freely a blood stained fluid, with which they are in large measure saturated. In consolidated areas purple fluid runs from the bronchi when slight pressure is applied and exudes from the surface generally. This markedly edema tous condition is constant in the early stages and is present in a great part of the otherwise unconsolidated emphysematous tissue. The cut surface of a consolidated lobe is smooth and glistening, slightly translucent in certain parts where the exudate is most fluid. It has a dark reddish or grayish purple, fairly uniform color, but always some portions, more often centrally located, are darker purple, more firm, and less fluid in content. Hemorrhagic areas involving one or more lobules are found here and there. Toward the periphery the lung may appear grayer, and the structure of the open alveoli and bronchioles is very evident when the surface is blotted. Such areas are semitranslucent and have the appearance of a saturated sponge of delicate architecture. Excepting that such variations in the char- •aivanxa amid qnv 39vhhhow3h jo svsav tasivanosNOO AT3±3idwoo sacn hsmch •Nou.vana SAva t> jo viNOwnaNd vzNarndNi 'i aivid 9,.40,>i i*/>i »» 11 1j u i Hut^uBrluiosiy ,,.... m,| P«" •innwdpoof) No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 183 acter of exudate are obvious, no especial relation of the inflammation to bronchi is evident in the acute lobar inflammation. Gross sections, through partially consolidated lobes and through isolated areas of consolidation, may and usually do show evident relation of the in flammation to bronchi. One finds small, discrete, grayish-purple areas (up to 1 cm.) of consolidation grouped about a bronchus and slightly elevated above the surrounding tissue, or there may be a more diffuse consolidation occupying and extending from the region of a bronchus. These vary in color ; some are gray and grayish purple, others hemor rhagic. Such areas represent older lesions than the more extensive lobar inflammation, as indicated by the protocol given below. The mucous membranes of the larger bronchi are dark reddish purple in color, while those of smaller branches may appear pale and smooth. Their content is serous, and no pus is anywhere evident. The following protocol is appended because the progress of the pneumonia as recorded clinically may explain in part certain differ ences in the anatomical appearance of the lesions in various areas. In this case the first evidences of pneumonia were detected clini cally four days before death. The lungs are extremely wet and boggy. Both are voluminous and extensively consolidated. Not withstanding the extensive consolidation, it is remarkable that there is so little evidence of pleural involvement. Clinically the pneu monic process began in the upper portion of the upper right lobe, yet the pleural surface here is as smooth, moist, and devoid of visible exudate as the remainder of the lung. Both lower lobes are espe cially consolidated posteriorly ; also most of the upper left and right lobes, the middle lobe being almost free. The only evidences of pleural inflammation are found over the widespread consolidated regions. These consist of subpleural hemor rhages varing in appearance from minute innumerable purplish-red dots, over which the pleura appears smooth and shiny, to fairly extensive irregular red areas (2 to 3 cms.) over which the pleural surface by reflected light is faintly granular. The extensive edema of the lung generally is indicated by the wet, shiny, boggy appear ance of the surfaces. Between the lobes of the lung the edema is very apparent as a watery effusion in the loose subpleural connective tissue. Cut section through the consolidated areas in the right upper lobe where the pneumonia began presents a very wet surface and there are fairly well circumscribed patches of consolidation along indi vidual bronchi parallel with their course. Although these patches are fairly distinct, they fuse to a certain extent. They average one-half cm., and are slightly elevated above the surface and when the excess of fluid is scraped off they are finely granular, irregularly round and grayish purple in color. The thin-walled bronchi do not appear to be dilated; their walls are collapsed and pale gray. The larger 184 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. bronchi are extremely congested. The alveolar tissue between the elevated patches is filled with fluid, has a solidified appearance and when pressed exudes a bloodstained serum. The unconsolidated portions are quite emphysematous. The lower right lobe, where pneumonia next became evident clinically, is almost completely con solidated, extremely wet and boggy. The inflammation seems to have spread more rapidly than in the upper lobe. The consolidation appears to be bronchial in distribution. The larger branches of the bronchi are surrounded by a wide zone, dark purple in color and granular on the surface. Between these areas the tissue is slightly depressed, paler purple and smoother. More fluid can be expressed from the intervening tissues than from the firmer areas, bu^ no air is present. The cut surface of the lowerfIfeft lobe, where the inflam mation last appeared and consequently not more than two days old, shows an even more uniform and diffuse type of solidification. The tissue is elastic and very wet, and one can not discern a definite bronchial distribution, though certain groups of lobules are darker purple and firmer than others.1 One is led to infer from such a case that in the areas of earliest extension from bronchi into alveoli there is more resistance to the injury of the infection than later in the disease. This is indicated by the circumscribed broncho-pneumonic patches representing the first lesions. Later the process spreads more rapidly and diffusely elsewhere, the exudate becoming less cellular. A still more rapid progress may result in a fulminating inflammation of an entire lobe, the exudate being largely serous, fibrinous, and hemorrhagic, the content of the various inflammatory elements varying some what in different areas. In sections studied microscopically from this early stage of pneu monia it is more evident than in gross that a general bronchitis, and especially bronchiolitis, precedes the infiltration of alveoli. One finds in unconsolidated areas bronchioles filled with an exudate composed of polymorphonuclear and mononuclear leucocytes, with varying amounts of fibrin and amorphous hyaline material. The mucosa may be intact or desquamated and ulcerated. The infundib- ula and air vesicles subtended by the bronchiole may contain an exudate of leucocytes with little or not^fibrin, forming a small focus of broncho-pneumonia. More characteristic of this stage of in flammation is a lesion of the walls of certain infundibula and air vesicles in the neighborhood of and within the latest areas of con solidation. A hyaline membrane partially or completely covers the walls of these air spaces. The membrane is irregular in thickness, sometimes stratified with occasional cells within narrow clefts. It tends to be thickest over the angles of the wall, though it may be so abundant as to fill an alveolus. There is no epithelial lining be- a E : o P N O 3 No. 2. GOODPASTURE AND BURNETT —PNEUMONIA. 185 neath; and it may be continuous with strands of fibrin. Its ap pearance gives the impression that it is composed essentially of fused threads of fibrin. This lesion is not uniformly distributed throughout the lung and is most prominent in the neighborhood of recent areas of consolidation, disappearing or becoming obscured with the advance of the inflammation. In the larger areas of lobular pneumonia and in the diffusely con solidated lobes there is a severe and widely destructive injury which has spread rapidly through the lung, destroying the epithelial lining y of alveoli, rupturing capillaries, and often in large foci completely destroying alveolar walls, rendering the pulmonary structure un recognizable. The air spaces are filled with coagulable fluid, fibrin is deposited in membranous fashion along alveolar and infundib ular walls or in a delicate or dense network within the lumina, the interstices of which contain serum, erythrocytes, and leucocytes in varying proportion. Where the injury is most severe a large area is filled with erythrocytes, fibrin, scattered epithelial cells, and remnants of alveolar walls. Elsewhere the capillaries are engorged with blood and erythrocytes are escaping in great numbers by dia- pedesis and vascular rupture. The proportion of leucocytes varies, but at this stage they do not constitute a conspicuous part of the picture. The majority are polymorphonuclear, though there is a relatively large number of mononuclear cells of various kinds, some of them desquamated epithelium and wandering phagocytes, others lymphocytes. In older foci of pneumonia, leucocytes are the predominant inflamma tory element, with small amounts of blood and fibrin, but in the dif fusely consolidated patches or lobes of short duration, serum, fibrin, and red blood cells are most conspicuous. Especially prominent are the large areas of hemorrhage from capillary rupture. Large mononuclear phagocytes containing blood pigment are frequently observed within these patches. Where the alveolar walls are more intact, leucocytes and erythrocytes lie beside the capillary channels from which they have escaped. In certain areas numerous focal necroses of alveolar walls, with fibrinous thrombi plugging the capillaries and fragmentation of nuclei, are observed. The smaller bronchi present older lesions than those within the alveoli. They contain plugs of leucocytes, fibrin, and hyaline material, and their epithelial lining is partially or completely ulcerated and covered by a fibrino-purulent membrane. One of the most impressive features of the section is the dilated, empty condition of many infundibula which stand widely open in the midst of alveoli filled with exudate. At times they are filled with coagulable fluid. In sections from such acutely inflamed lungs there may be no < demonstrable organisms either within the exudate of smaller bronchi 186 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. or alveoli, although pure cultures of influenza bacilli -were isolated i from them. In somewhat later stages with similar injury and exu- J date, these organisms have been demonstrated in great numbers both intra- and extra-cellularly. They are ingested both by poly morphonuclear and mononuclear phagocytes. Within the latter they may be aggregated in minute spherical groups. Within the alveoli they stimulate an immigration of leucocytes. The nature of the above-described lesions and their presence in three very early cases in which micro-organisms were not demon strable in sections, and in one case with sterile cultures, indicate that the extensive injury may be brought about by an extremely toxic substance elaborated within and disseminated through the larger air passages to the more delicate structures of the lung. This hypo thetical toxic agent has little chemiotactic action toward leucocytes, but rapidly attacks the alveolar walls and their capillary bed, injur ing them to the point of rupture, and stimulating a fluid exudate in great quantity. The product of this preliminary reaction forms a favorable medium for whatever pathogenic organisms are at hand. Influenza bacilli enter through the bronchi, alone or together with pneumococci, streptococci, or staphylococci. These secondary in vaders, multiplying with great rapidity, give rise to further injury and inflammatory reaction more or less characteristic for the type of organism concerned. The recognition that there is a primary diffuse and extremely severe toxic type of injury to the lung in influenza affords a rational basis of explanation for the varied bacteriological and pathological results which have been so confusing, and at the same time establishes a pathological process which may be considered peculiar to this form of the disease. Following this initial injury the influenza bacillus may invade the alveoli over wide areas. Here they stimulate an immigration of polymorphonuclear leucocytes which rapidly ingest them. They are also actively phagocyted by large mononuclear cells. We have seen two cases in which these organisms were demonstrated in sections within the alveoli in large areas of consolidation. The exudate in these is predominantly cellular, with some serum and erythrocytes and little fibrin. But there is usually only a local invasion by these organisms within a group of alveoli about terminal bronchi. The localization of the infection begins four or five days after the initial injury. This is first evident in gross in the firmer, usually centrally situated areas of consolidation, which represent the earliest regions of involvement. A thin gray or yellowish gray zone appears about the bronchioles and infundibula, the width of each focus measuring 1 mm. or less, three or four of which are present in each lobule. No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 187 The intervening tissue is still purple, hemorrhagic, smooth, and firm. Later similar foci appear farther out toward the surface and within lobules which are not so firm, more edematous and less hemorrhagic. In contrast to the diffuse serous, hemorrhagic, fibrinous, and cellu lar exudate, these secondary foci are composed almost entirely of cells, polymorphonuclear and mononuclear, which fill the bronchi oles and several adjacent alveoli. If fibrin previously was present it is dissolved by the leucocytes. Influenza bacilli have been demon strated in such areas in great numbers within both bronchi and al veoli. As the foci increase in size, fluid exudate is absorbed and or ganization begins in the alveoli between them and within the exu date of bronchi where micro-organisms are less numerous. At the end of two weeks the most prominent feature of the fresh section of lung is the presence of numbers of these now yellow or grayish- yellow foci measuring 3 or more millimeters in diameter. In many of them a yellow opaque center with peripheral gray semitrans- lucent zone can be detected, representing organization about small abscess cavities. The fluid of the initial edema is absorbed so that at this time the surface is fairly dry. The surrounding alveolar tissue has a bright red color, from the reestablishment of circulation and the formation of new capillary channels within organizing exu date. One may find also bright red hemorrhages where blood has escaped into healing alveoli. In areas where the injury has been more severe an entire lobule or groups of lobules may appear yel low or grayish yellow, smooth, and firm. The yellow color is par tially due to large mononuclear cells within healing alveoli, the cyto plasm of which is filled with fat droplets. Two cases with pneumonia of 15 and 16 days' duration, the lungs of which yielded pure cultures of the influenza bacillus, have been observed in this series. The pathology in the lungs of each was es sentially the same. The following protocol is illustrative of this stage. Duration of pneumonia, 16 days. No excess of fluid in left pleural cavity; about 50 c. c. in right. Lungs are voluminous and pale pink anteriorly ; emphysematous between patches of consolidation. Inter lobular veins injected bright red. Left lung.—There is a thin fibrino-purulent exudate over anterior and lateral surfaces and between the lobes. Posterior half of lower lobe almost completely consolidated, light purple in color. Sub- pleural hemorrhages posteriorly over upper lobe. There is no edema. Section through posterior portion of lower lobe shows dif fuse broncho-pneumonia, characterized by the presence of multiple, •elevated, grayish and yellow foci of consolidation about terminal 103396—19 2 188 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. bronchi, measuring 2 to 5 mm. The bronchi are moderately dilated, and their mucosa appears edematous and thickened. Thick yellow pus can be expressed from them. Intervening alveolar tissue is red or purple in color with a fine grayish or yellow stippling partially outlining alveoli. This tissue is elastic, moist, semitranslucent, and is devoid of air. There is no evident pleural inflammation over these areas. The surface is smooth, glistening, mottled purple and pink, corresponding to consolidated and air-containing tissue. Mucosa of larger bronchi only slightly injected. Anteriorly in the lower lobe are patches of consolidation, bronchial in distribution, measuring 2 by 3 cm.; some of these are quite hemorrhagic in appearance, that is to say, the alveolar tissue between yellow foci has a dark purple color. Over this region is a thin fibrino-purulent pleuritis. In the anterior half of the upper lobe the lung tissue on cut surface is very pale and grayish yellow in color. Here there are innumerable firm, yellow peribronchial areas of consolidation, which are larger and more diffuse than in lower lobe. Near the hilum is a patch of uniform, smooth, moist, gray consolidation. Right lung.—Lower lobe completely and firmly consolidated: posterior halves of middle and upper lobes completely consolidated but nodular. Anterior halves of these lobes almost entirely consoli dated, but mottled with groups of lobules which are pink, em physematous and air-containing. The cut surface of these lobes presents changes which are quite similar to those on the left side. The lungs in general resemble those of an extensive tuberculous broncho-pneumonia. Corresponding to the widespread injury and destruction noted in the early stages of the disease, one finds in these two cases of longer duration extensive organization and fibrosis of the lung. The fibrinous exudate in alveoli has been invaded and absorbed by fibroblasts and capillaries from adjacent alveolar walls. In many- places the architecture of the lung is completely obliterated, and there remains only a young vascularized fibrous tissue including particles of incompletely absorbed fibrin. Small areas of hemor rhage are present, and occasional contracted alveoli lined by vacuo lated cuboidal epithelium. Polymorphonuclear leucocytes are rela tively few, but numbers of lymphocytes and plasma cells have ap peared. They are numerous within the organizing tissue, about blood vessels and within bronchial walls. Organization is proceed ing also within the exudate of certain bronchioles and infundibula forming branching plugs of young fibrous tissue completely occlud ing these passages and extending out into neighboring alveoli. Alveoli about many terminal bronchi are filled with polymor phonuclear and mononuclear leucocytes containing numbers of in- PLATE III. PLATE IV. 7, Acute inflammation of lung —varied exudate; 8, catarrhal exudate In alveolus from broncho- pneumonic patch showing numerous influenza bacilli ; 9, necrosis of alveolar walls. No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 189 fluenza bacilli. The yellow opaque foci noted in gross represent small abscesses or dilated bronchi filled with purulent exudate con taining influenza bacilli. . Many dilated bronchi are surrounded by a zone of alveoli which are plugged with masses of fibrin. About others these masses of fibrin have been organized and absorbed by fibroblasts or replaced by fused epithelial cells. This reaction about dilated bronchi will be described more fully in considering bronchiectasis. These two cases present clearly the progress toward healing of an influenza pneumonia unaccompanied by other organisms, and they demonstrate in an illuminating manner the fact that the pul monary injury in the initial stages is of utmost severity, and the process of healing and repair one of organization of large areas which could never be of more than very limited functional value. Resolution as it usually occurs in croupous pneumonia is not observed. Although the most extensive injury takes place during the early stages, the inflammation is progressive, and there is continuous de struction of tissue locally about many bronchi with the resulting formation of more or less chronic abscesses and bronchiectatic cavi ties which harbor masses of influenza bacilli. This fact is of especial interest in view of the observations of Boggs and of Lord on chronic bronchiectacis associated with this organism, and is evidence for the assertion that many cases in this epidemic pursued a similar chronic course with intermittent recurrences. A mechanical lesion of interest which appears to be distinct from the immediate inflammatory process, is rupture of alveoli and inter stitial emphysema in unconsolidated emphysematous pulmonary tis sue. Three cases with this condition were found in this series, all of them early. In one of these there was subcutaneous emphysema extending from the superior mediastinum into the neck. The neck anteriorly and laterally from the angles of the jaw on each side to the second intercostal space over the clavicles, was greatly distended with air, crepitating and pitting on pressure. In other instances seen clinically, the subcutaneous tissue over a considerable portion of the trunk has been similarly affected. On removing the sternum of the above case the mediastinal fatty and connective tissue was found distended with air. Following rupture of alveoli, air escapes into the interlobular tissues and eventually finds it way to the hilum whence it enters the mediastinum. Sections of the lung show large air blebs especially numerous in the interlobular and subpleural tis sue, though large cavities up to 1 cm. may be present within the lobule, the surrounding alveoli being atelectatic. Hemorrhages are associated with these lesions. 190 GOODPASTURE AND BURNETT PNEUMONIA. Vol. XIII. INFLUENZA PNEUMONIA COMPLICATED BY SECONDARY INVADERS WHICH MODIFY THE PATHOLOGY. Given the primary acute toxic injury to the lung substance which appears to be the essential lesion in the early stage of influenza pneumonia of the present epidemic, any pathogenic micro-organism harbored by the air passages has a fertile field upon which to become implanted, and to multiply, producing injury and reaction more or less characteristic for the organism concerned. Since an acute in- Jflammation of the air passages always precedes the extension into the alveolar tissue, there are in most cases pathogenic organisms, other than the influenza bacillus, present in the injured bronchi ready for invasion. Consequently, in .a majority of instances mixed in fection is present in the lungs, and the older the pneumonia the greater the probability of secondary invasion. Most common of these invaders in order of frequency have been the various types of pneumococci, streptococci, staphylococci, and micrococcus catarrhalis. Pneumococci have been cultivated from the lungs together with influenza bacilli in 14 cases, and. once alone. In three instances the secondary infection was apparently of such short duration that they had not modified appreciably the gross or microscopic appear ances of the lungs. The pleurae were smooth, the lungs edematous, hemorrhagic, and partially or completely consolidated with acute exudate. In one case numerous pneumococci were found within the alveolar exudate, and in the other two in a narrow zone beneath and within the pleura, but not more deeply within the inflamed lung. In 11 cases the sec ondary infection had been of sufficient duration and extent to bring about a more or less characteristic reaction to their presence. The pathology in these is exceedingly complex ; for the lungs of a single individual show in different parts various stages and degrees of injury and intensity of secondary infection. In each of these 11 cases there was a fibrinous or fibrino-purulent membrane over the affected pleura, often with a sero-fibrinous effu sion on the side most involved, amounting at times to 500 to 1,000 cubic centimeters. Grossly, the lungs presented in a portion of one or more lobes the typical dry, gray, granular surface characteristic of croupous exudate. These areas contrast sharply with the accom panying lesions of influenza pneumonia which are always recogniz able in the same or other lobes. The areas of croupous pneumonia are more voluminous, dry, granular, and friable. Their color is more uniformly gray and opaque. The surface of adjacent areas of in fluenza pneumonia is smooth, moist, elastic, with a variety in colors and irregularity in density. No. 2. GOODPASTURE AND BURNETT- —PNEUMONIA. 191 Smaller foci of broncho-pneumonia in which pneumococci pre dominate are not distinguishable from similar patches in which influenza bacilli only are present. Such focal areas are not infre quent in these cases, the initial bronchitis and alveolar injury seem ing to predispose to a broncho-pneumonic type of inflammation whatever organism may be invading. Microscopically, croupous pneumonia is quite as distinctive as in gross. The alveoli, distended uniformly with dense plugs of leuco cytes and fibrin, contrast with those of influenza pneumonia, in which there is such an irregular distribution of the various inflam matory elements. One notices, however, a greater degree of injury to alveolar walls, in the form of thrombosis of capillaries and focal necrosis, than is usual with simple croupous inflammation. In two cases there was a healing influenza pneumonia in the lung on one side and an outspoken croupous pneumonia on the other. In the healing lung no organisms were found. Early organization and fibrosis were present, and numbers of plasma cells and lymphocytes. Another lung presented large regions of croupous exudate in the left lower lobe, while in the right lower multiple small abscesses and dilated bronchi were abundant. INFLUENZA PNEUMONIA COMPLICATED BY STREPTOCOCCUS INFEC TION. In five cases hemolytic streptococci were cultured from the lungs. In three of these multiple abscesses were present, measuring up to 2 centimeters. Streptococci and influenza bacilli were associated in the other two cases in the production of widespread bronchiectatic abscesses and bronchitis with ulceration. In the lungs of the first three cases there were large and small masses of lobular pneumonia, in the centers of which were yellow, opaque, soft areas of necrosis or excavation. Microscopically, the alveoli contain leucocytes and fibrin, with extensive necrosis in places of both exudate and alveolar walls. Here streptococci in short chains are present in enormous numbers.- A fibrino-purulent exudate con taining streptococci was present over the lungs, and in one case there was a left sero-purulent effusion of 2,500 cubic centimeters. ACUTE BRONCHIECTASIS. Even in the earliest stages of influenza pneumonia, that is from two to four days' duration, one of the most striking appearances is the gaping, dilated condition of infundibula and the general emphy sema in unconsolidated portions. In three cases rupture of alveoli had taken place with subsequent interstitial emphysema. This ten dency to dilatation of the air passages has manifested itself as actual 192 GOODPASTURE AND BURNETT—PNEUMONIA. Vol. XIII. bronchiectasis in four cases. Two of these were associated with pure cultures of influenza bacilli and have been described with the other cases showing this organism alone. In the other two bronchi ectasis was extensive, with abscesses and ulceration of many bronchi. The bronchiectasis in one instance was confined to the right side, the site of the older pneumonic process, the left lower lobe being firmly and almost completely consolidated in a state of gray hepatization with pneumococcus infection. In the remaining case bronchiectasis was extensive in each lobe on both sides. Cultures from this and the previous case demonstrated both influenza bacilli and hemolytic streptococci. The association of influenza bacilli with chronic bronchiectatic changes in the lung is well known, especially through the publications of Boggs and of Lord. It is of exceptional interest that dilatation of bronchi and the permanent changes incident to ulceration and abscess formation can proceed so rapidly as is evident in our cases. The following protocol describes the gross appearances of the lungs in the case which presented the most advanced lesions and in both lungs. The clinical evidences of pneumonia were of 10 days' dura tion. No excess of fluid in either pleural cavity, only a few cubic centi meters of thick yellow pus. Left lung.—There is an injection of the pleural vessels, especially between the lobules, so that they appear bright red and prominent. A thin slightly sticky exudate is over the pleural surfaces, and the lobes are adherent by a fairly firm fibrino-purulent exudate, scant in amount. Both lobes are almost completely consolidated by numerous small areas of consolidation which give the surface of the lung a coarse nodular feel. On cut section the larger and smaller bronchi are found to be very widely dilated giving to the surface a worm- eaten appearance. There are numerous fairly uniformly distributed nodular grayish -yellow areas of consolidation associated with the bronchi which are elevated above the surface. The intervening alveolar tissue is grayish-purple jn color containing some air and fluid which can be expressed easily. The bronchi are filled with a thick semifluid yellow pus. In the upper lobe there is a patch measur ing 1£ cm. in diameter in which is a widely dilated terminal bronchus surrounded by a rosette of gray elevated areas of consolidation. The dilated bronchus measures 3 mm. when opened; the areas of consoli dation 4 to 5 mm. Right lung.—Presents a similar appearance to the left on the surface. It is heavier and the consolidation is more extensive and diffuse. The cut surface on this side presents a similar but more advanced degree of the same changes noted on the left. The ter minal bronchi measure 2 to 3 mm. in diameter in cross sections. The PLATE V. 10, Healing bronchiole —epithlelial plugs in surrounding alveoli : 11, high magnification of epithlelial cells within alveolus from 10; 12. organizing bronchiole causing obliteration of lumen; 13, wall of dilated bronchus, showing surrounding alveoli, collapsed or filled with dense fibrin; 14. wall of small abscess in bronchiole. Surrounding alveoli tilled with fibrin. PLATE VI. 15, Organizing alveolar exudate; 16. hyal'ne necrosis and repair of rectus abdominis muscle; 17. focal necrosis of adrenal cortex with some polymorphonuclear exudate. No. 2. GOODPASTURE AND BURNETT—PNEUMONIA. 193 middle lobe shows early stages of bronchiectasis and broncho-pneu monia. With little consolidation there is noticeable dilatation of larger and small bronchi surrounded by a zone of dark purple, slightly elevated tissue. The mucosa of smaller bronchi is pale; of larger ones it is hemorrhagic. Microscopically the pneumonia in most places is evidently peri bronchial and lobular in distribution. Bronchioles and adjacent alveoli are filled with a leucocytic exudate and practically no fibrin. Peripheral alveoli contain increasing numbers of mononuclear leuco cytes. Both polymorphs, and mononuclears contain numerous influ enza bacilli. The smaller bronchi are dilated to 3 mm. The mucosa is totally or in part ulcerated and covered with a fibrino-purulent membrane. A wide zone of alveoli surrounding bronchi are filled with dense plugs of fibrin in which are a few mononuclear cells. Others of these alveoli are partially or completely collapsed. There is a beginning immigration of mononuclear wandering cells, which are more numerous about blood vessels and within bronchial walls. Many of them appear to be plasma cells. Within the exudate in the lumens of ulcerated bronchi and in the fibrino-purulent membrane are found many streptococci in short chains. Whereas within the alveolar exudate the prevailing organ ism is the influenza bacillus. In larger areas of consolidation there are in the exudate, in addition to leucocytes containing influenza bacilli, a good deal of fibrin and red blood cells and considerable destruction of alveolar walls. The presence of fibrinous plugs within alveoli adjacent to the bron chus seems to be a constant accompaniment of excessive dilatation. Just how this is brought about is not clear, though it seems likely that intermittent lateral pressure mechanically further injures the already weakened alveolar tissues. It does not appear to be due to direct injury from the absorption of toxic substances from the lumina, for it may be seen around fairly large bronchi whose epithelial walls are intact and in which no organisms or cellular exudate are demon strable. The presence of the fibrin tends to make the air tube more rigid and assists mechanically in limiting the infection in terminal portions where the bronchial walls may be partially or completely necrosed. The process of healing probably renders the dilatation per manent, if it does not actually accentuate it, for the fibrin about larger bronchi becomes organized and eventually converted into dense fibrous tissue, while about smaller bronchi it is replaced by masses of closely approximated or fused epithelial cells, which are sur rounded by thickened fibrous walls. The more or less extensive organization and subsequent contraction of intervening alveolar tissue will also dispose to fix the dilated state. 194 GOODPASTURE AND BUBNETT—PNEUMONIA. Vol. XIII. The importance of a secondary streptococcus infection in produce ing extensive ulceration and bronchiectatic cavities in the acute stages is to be emphasized. These organisms especially produce local necrosis, and in this way extend the margins of infection. The influ enza bacillus probably persisting much longer, may perpetuate the inflammation in a chronic state. CHANGES IN OTHER ORGANS. In the cases dying within four or five days after the onset of pneu monia, congestion and edema of the liver, kidneys, and adrenal glands are quite evident. The adrenals in a majority of instances contain focal hyaline necroses, usually quite small and situated either in the glomerular zone or the adjacent part of the fascicular zone. Rarely there is a narrow strip of necrosis extending parallel to the surface through many columns of cells. Occasionally a few polymor phonuclear leucocytes infiltrate the necrotic foci. In one instance in which the pneumonia was of longer duration and complicated by streptococcus infection, the focal necroses were accompanied by hem orrhage and fibrinous exudate* and a few streptococci were found within the lesions. The spleen in uncomplicated cases is not appreciably enlarged, though often congested. Where secondary infection with pyogenic organisms is present there is enlargement, with the usual swollen, gray appearance and soft consistency of acute splenic tumor. In one case an influenza pneumonia was coincident with a purulent cerebro-spinal meningitis, due to micrococcus catarrhalis. Five cases, only one of which was associated with a pure culture o f influenza bacillus in the lungs, showed extensive hyaline degenera tion, necrosis, rupture, and hemorrhage in one or both abdominal rectus muscles. In its inception this lesion is probably a result of extreme intoxication, but later the degenerative necrotic areas may be invaded by secondary micro-organisms. In one case pneumococci were found within the lesions, in another streptococci, but in neither were they in considerable numbers and there is practically no cellular reaction. Acute arteritis and phlebitis were seen within the injured areas. Repair by fibrosis is rapid. RESUME. The difficulties of analyzing the pulmonary lesions in any group of influenza pneumonias, as they have appeared in this epidemic, are very apparent to anyone who has had an opportunity to observe the bacteriology and pathology of this accompaniment of the dis ease. The uncertainty as to the nature of the infection, the varied character of the primary injury and reaction, the multiplicity of Ho. 2. GOODPASTURE AND BUBNETT—PNEUMONIA. 195 complicating micro-organisms, and the modifications presented at different stages of the lesions preclude a clear-cut picture of all the interrelated and consecutive changes. We have attempted, how ever, to present as clearly as they have appeared to us certain distinctive features of the disease, and to separate from them coincident changes obviously of a secondary nature. Careful bac teriological data have been essential because of the high frequency of these secondary micro-organisms. The very fact that so many complicating infections and their resul tant pathological changes occur in influenza pneumonia is a distinctive </ feature in itself ; for, probably in no other acute pulmonary disease are they so varied and frequent. In explanation of this it must be remembered that for several days before the onset of pneumonia there is a severe acute respiratory inflammation and general intoxication, lowering resistance and paving the way for the entrance into the lung of pathogenic organisms harbored there. Suddenly there comes an injury to the lung tissue in one or more areas, bronchial in distribu tion. The nature of this injury is such that there is an acute outflow of the fluid elements of the blood especially, and of hemorrhage. The alveoli in lobular areas, not infrequently in an entire lobe, become filled with this exudate, which, apparently, constitutes under these cir cumstances an excellent medium for the growth of pathogenic micro organisms. < The pulmonary injury and reaction being so acute and often wide spread, and the fact that in certain very early cases demonstrable bac- v teria of any kind are scarce or not found at all, make us feel, notwith standing the demonstration of influenza bacilli in pure culture in the lungjnjdliuU^jm^instance, that at this stage organisms are compara tively few within alveoli, and the primary injury is due to a very potent toxic agent elaborated in and disseminated through larger air passages. That there is such a toxic substance in influenza is evi dent from the sudden, severe general reaction from the beginning. Primary toxic injury to the pulmonary tissue is a constant feature in the early stages of the pneumonia, and presents a fairly charac teristic picture. Alveolar walls are injured, capillaries ruptured and in places necrosed; there is an exudation of all the elements of the blood, and larger or smaller areas of hemorrhage. Leucocytes are not especially prominent at this time, and many of them are of the large mononuclear variety. This primary lesion may rapidly increase in extent until an entire lobe is affected, or may remain in larger or smaller patches within several lobes. Apparently, such a focus may rapidly begin to heal by organization before any organisms in demon strable numbers gain entrance, but as a rule, after the acute condition has persisted three or four days, we begin to find micro-organisms of various kinds in different cases, even in the same case, within the 196 GOODPASTURE AND BURNETT —PNEUMONIA. Vol. XIII. pulmonary exudate. Influenza bacilli appear alone in certain cases. They are rapidly ingested and their further injurious effects upon the tissue is local about bronchial terminations. Small abscesses may form, in which these organisms are demonstrable in great numbers. When they are most numerous the exudate in neighboring alveoli is composed of leucocytes, with little or no fibrin. In larger areas of inflammation, lobular or lobar in extent, the infection gradually focalizes about smaller bronchi where the bacilli persist longest. At the same time absorption of fluid, organization, and repair proceed in the intervening tissue. Associated with the localization of infection are bronchiectasis and abscess formation. In some cases bronchiectasis is extensive. An exudate of fibrin ap pears within alveoli in a zone about the dilated tubes, and the sub sequent organization of it tends to make the change a permanent one. Healing in all the different forms of inflammation associated with the influenza bacillus alone is by organization of the exudate and fibrous induration of injured structures. Influenza pneumonia as described by Pfeiffer corresponds fairly well to the stage of the process as we have seen it after a duration of two weeks, excepting that the injury of alveolar tissue was apparently much more extensive in our cases. In addition to the cases from which pure cultures of the influenza bacillus were recovered, there is a large percentage in which is present an additional infection with one or more organisms, par ticularly pneumococci or streptococci. Multiple areas of bronchial and lobular pneumonia in which one of these types of organisms predominate are to be found. In cases complicated by a secondary pneumococcus infection one usually finds extensive areas or an entire lobe consolidated by a typical fibrino-purulent or " croupous " exu date, characteristic of the reaction to these organisms. In mixed infections with streptococci a purulent exudate with large areas of necrosis and abscess formation is the usual result. There are also numerous lesions due to various combinations of organisms, such as multiple focal areas of broncho-pneumonia with abscesses and bronchiectasis due to a mixed infection with influenza bacilli and hemolytic streptococci. In conclusion, influenza pneumonia as we have seen it, in cases from which only pure cultures of influenza bacilli were obtained from the lungs, consists primarily in a severe toxic injury to the lungs in areas which are peribronchial, lobular, or lobar in dis tribution. In later stages, or from the beginning if the injury be slight, the infection focalizes about bronchi and their terminations, so that the bronchial and lobular distribution becomes very conspicuous. Mili ary abscess and bronchiectasis are the usual accompaniment of this No. 2. 197 GOODPASTURE AND BURNETT—PNEUMONIA. phase. Finally healing and repair take place by organization and induration with extensive permanent distortions and impairment of the pulmonary tissues. TECHNIQUE. For microscopic study pieces of organs were fixed in Zenker's fluid and paraffin sections stained by the eosinmethlyene blue method. This stain was found fairly satisfactory for demonstrating the in fluenza bacillus and especially other organisms in the tissues. Much more sharply defined staining of the influenza bacilli was obtained, however, by the use of the following method which was devised for this purpose : 1. Tissues fixed thoroughly in Zenker's fluid. 2. Steam thin paraffin sections for five minutes in a few drops of the following solution poured over the section fixed to the slide : Basic fuchsin 0. 5 gram. Carbolic acid (crystalized ) 1.0 cc. Anilin oil 0. 5 cc. Alcohol, 30 per cent 100. 0 cc. Dissolve fuchsin in the dilute alcohol and add the other reagents. 3. Wash off excess of stain rapidly in tap water. 4. Differentiate and decolorize with 40 per cent formalin, poured over section a few drops at a time until no more color is discharged. 5. Rinse in water and counterstain for one minute in a saturated aqueous solution of picric acid. 6. Dehydrate quickly In 95 per cent and absolute alcohol ; xylol ; balsam. This staining method is easily applied and has in our hands given in most instances satisfactory results. In properly stained prepara tions the influenza baccilli are stained sharply a dark purple, almost black color, with a lemon-yellow clear background. The details of their morphology are quite distinctly brought out.1 REFERENCES. Keegan, J. J. Jour. Am. Med. Assn. Sept. 28, 1918, vol. 71, p. 1051. Mason: Influenza in Boston. Boston Med. Jour. Feb. 1890, p. 145. yveichsellaum: Wiener klin. Wchnschr. 1S92, 32. Ribbert: Deutsche med. Wchnschr. No. 4, 1890. Finkler: Deutsche med. Wchnschr. No. 5. , Leichtenstern: Specialle Path. w. Ther. Nothnagel, IV. Bd. I p. S3. Pfeifler: Leitsch. f. Hygiene w. Infections krankheitens, Bd. XIII, 3, 1893. Beck: Handbuch d. path, mikroorganismen. Kolle w. Wassermann. 1903, p. 382. Boggs: Bull. Johns Hopkins Hosp. 1905, 1G, p. 288. Lord: Boston Med. and Surg. Jour. 1905, cl. 11, 537. 1 We wish to express our Indebtedness for the privilege and opportunity of making this study to Captain J. N. Blackwood, Medical Corps, U. S. N. ; Commander J. M. Blister, Medical Corps, U. S. N. ; and Lieutenant Commander M. J. Rosenau, Medical Corps, U. S. N. R. F., director of the laboratory ; and to Lieutenant J. Keegan, Medi cal Corps, U. S. N. R. F., tor hla bacteriological data. 198 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. Vol. XIII. A ROUTINE METHOD OF MENTAL EXAMINATIONS FOR NAVAL RECRUITS. By L. E. Bisch, Lieutenant, .Medical Corps, United States Naval Reserve Force. The system of psychiatric examinations which forms the subject matter of this paper is that which has been devised and applied at the Naval Operating Base, Hampton Eoads, Va. Considerable ex perimental work had to be carried on and numerous tests and schemes were devised, later rearranged or discarded, until the present plan was perfected. It is not claimed that any of the methods or procedures are infallible, but it is believed that since they have proved them selves to be a strongly suggestive and fairly dependable method at one station that possibly some of the methods at least may prove of value at other training centers. This paper is to deal primarily with the problem of testing the raw naval recruit as to his fitness for service from mental and neuro logical points of view. For purposes of completeness, however, a cursory summary of the other activities of the Psychiatric Division are touched upon. GENERAL SCHEME OF EXAMINATIONS. The "schema of examinations," which appears in diagrammatic form gives a general idea of the sources of supply of cases, the methods used in classifying them, and their final disposition. The cases with which the division is concerned are classified according to sources of supply, as follows: (I) Recruits, (II) training station, (III) air station, (IV) base hospital. On the schema referred to, these are the sources of supply for the intensive examination which is Indicated by the large square marked " Intensive psy chiatric examination." This examination is the major examination given by the division, and, in addition to a complete medical history, includes all de tailed psychiatric and psychological procedures. (I) The recruits with which the division is concerned at Hampton Roads may be classified into " superiors," " average," " inferiors," and " illiterates." They are classified In the detention unit at the time of their entrance Into the service by the preliminary psychological examination, as Is indicated on the chart. They receive in addition an examination to determine their neurological status. Then, if they are " superiors," they are regarded as petty officer material, and candidates for the specialized entrance examination to the petty officer schools ; if " average " they proceed in the regular manner through the detention period into the training station ; if " inferior " they are held over In the detention unit before being outfitted and are candidates for the Intensive psychiatric examination mentioned above; If "illiterates" but mentally com petent they are candidates for the Y. M. C. A. school for Illiterates at the end of their detention period. On the chart these types of cases and procedures are Indicated by characteristic dotted lines. Strictly speaking, the division is concerned only with two types of cases — the "superior" and the "inferior." The former proceed through their deten tion period and are candidates for the preliminary intensive examination for the petty officer schools, as well as for the specialized entrance examination Li k| •* Kf^m ^^? 1 •** iRHpl Recruits taking preliminary psychological examination at tables. No. 2. 19 BISCH —MENTAL, EXAMINATIONS FOE BECKUITS. given candidates for each school. Failure in either of these examinations ri turns the man to the training station. The " inferiors " are held over as cai didates for the intensive psychiatric examination in order to Anally and acci rately determine their status, and, in addition, where It is necessary, they ar given clinical pathological tests, consisting of serological and parasitical ei Mutilations, urinalysis, etc. 200 BISCH MENTAL, EXAMINATIONS FOR RECRUITS. Vol. XIII. The Intensive examination may result in (1) the man being returned to the detention unit to be outfitted and to proceed into the training station, (2) retention in the psychiatric observation ward for further observation and dis position, (3) medical survey. (II) The training station furnishes another large and Important supply of cases. In addition to recruits, the station includes thousands of men en route to and from the fleet who are on the station for varying periods of time—from a day to three months. The following types of cases are received from this source: (a) Brig and "mast," (6) cases referred by regimental surgeons, (c) cases referred by com pany commanders. A member of the division attends the daily " mast," and the division examines all general court-martial prisoners in the brig to deter mine their mental responsibility. The regimental surgeons refer all cases to the division involving mental status for diagnosis and disposition. A printed sheet is distributed to all company commanders with instructions that they are to report to the psychiatric division all cases showing any one or more of the following hehavior characteristics: L Resentfulness to discipline or inability to be disciplined. 2. Unusual stupidity or awkwardness in drills or exercises. 3. Inability to transmit orders correctly. 4. Personal uncleanllness. 5. Criminal tendencies. 6. Abnormal sex practices and tendencies, including masturbation. 7. Filthy language and defacement of property. 8. Distinct feminine types. 9. "Bed wetters." 10. Subjects of continual teasing or ridicule. 11. Queer, peculiar behavior. 12. All recruits who persistently show the following characteristics : Tear fulness, Irritability, seclusiveness, sulkiness, depression, shyness, timidity, antisocial attitude, overboisterousness, suspicion, dullness, sleeplessness, sleepwalking. 13. Chronic homesickness. All cases referred from training station sources are given the intensive psy chiatric examination as indicated on the chart and are disposed of in the same manner as cases In the detention unit. (III) (IV) The two last sources of supply of cases for the psychiatric divi sion, the air station, and the base hospital furnish a smaller percentage of cases than the other two sources mentioned. These cases are given the intensive ex amination and disposition Is the same as in the cases from the training station and detention unit (As a preliminary intensive examination for the petty officer schools, the so- called 16-year-old or average adult test of the Stanford revision of the Binet- Simon test is tentatively being used. So far as the specialized entrance ex aminations for the various schools Is concerned, considerable experimental work Is underway.) THE PROBLEM. Roughly speaking, one may divide the types of cases to be weeded out of the service into three great classes—namely, (1) the feeble minded, including constitutional inferiors; (2) psychoses, actual and potential; (3) functional and organic nervous diseases. In other words, the cases to be looked for comprise not only defective intel No. 2. 201 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. Jectual processes existing from birth or from an early age, but also cases of disordered thinking coexistent with the mature intellect, such as the insanities and the functional types, as well as cases of organic lesions of the central nervous system. Obviously, the matter of weeding out such unfit subjects can not be left to methods of casual observation and personal judgment. Naturally, a frank case of insanity, for example, would not require specialized methods to detect it. But the cases which present them selves at a training station are, as a rule, border-line types of all kinds and only careful and detailed examinations will bring their defects to light. Perhaps the greatest difficulty lies in discovering the higher types of feeblemindedness, such as morons and high-grade imbeciles. These can not be identified by inspection. Many of them have a fluent command of language and possess a passable fund of general information. They talk to the examiner readily and plausibly, and tend to make a good impression. Yet, it is precisely such cases that present the greatest menace to the service. So far as neurological and purely psychiatrical examinations were concerned, recognized and unfailing methods were already at hand. When it came to the question of testing for mental inferiority, how ever, the problem at once became exceedingly complex because of the multitudinous number of psychological tests already in use, the fact that but few were standardized and therefore not of proved value, and the fact that none of them by themselves seemed to constitute a satisfactory method so far as the problem of the naval recruit was concerned. It was therefore necessary either to devise new tests or to modify already existing standards. As noted above, both methods were tried and finally a system was adopted which is de scribed further on. In adopting the tests which were to compose the preliminary examination two factors were considered of prime importance: (1) Reliability of the tests selected; (2) time consumed in giving the tests. It was deemed essential that recruits be examined before they had received their naval uniforms and while they were still in civilian clothes in order that the Government might be saved the cost of out fitting candidates for prospective medical survey. Hence it was necessary to devise preliminary tests whereby the routine physical and dental examinations, etc., incident to arrival of the recruit at the receiving building would not be unduly delayed by the psychological testing. On the other hand, the tests selected had to be of such a nature as to accurately identify for further examination the group with which the division was concerned. 202 BISCH—MENTAL EXAMINATIONS FOB BECBUITS. VoL XIII. GROUP VS. INDIVIDUAL METHODS. The group method is the one usually employed in giving mental tests to large numbers of men. Because of lack of time it is often impossible to examine each man individually. An alternative has seemed to be that of addressing the tests to a group of men who could make the responses in writing. To this end various so-called " mass tests" have been devised and used. In this way groups of from 10 to 200 men may be treated at once. The method, however, is open to some criticism. (1) Test scores depend exclusively on the time ele ment. We have no psychological grounds for believing that a mental process should occupy a given amount of time. (2) The group method leaves no opportunity for the adaptation by the examiner to the individualities of the subject. (3) Failure in performance of tests given bj- the group method, in the absence of the individual ob servation of that performance on the part of the examiner, is not reliable evidence that a failure was due to low mentality. (4) The group tests are of necessity dependent upon written responses, and the act of writing adds a complication which it is difficult to evaluate and separate from pure intelligence factors in scoring. Hence it was felt that some modification of the individual method of giving tests to meet the necessity of limiting the amount of time consumed should be the method finally adopted for naval recruits. TESTS AND METHODS ADOPTED. The selection of tests to compose the preliminary psychological examination was governed, so far as possible, by the principle that they should not be tests dependent largely upon school knowledge, but that they should be tests involving manipulation ; in other words, " performance " tests. In such tests the emphasis is placed upon manual performance rather than upon language ability. Various " form-board " tests, picture-puzzle tests, and puzzle-box tests come under this head. In these tests an objective situation is presented to the subject by means of physical apparatus or objects in as few words as possible, and his reactions are not dependent upon language but upon per formance. In such tests the mental processes of the subject are more apparent, inasmuch as his mental reactions may be observed during his performance of the tests and the examiner is not dependent upon a verbal response alone. To this end the numerous performance tests were reviewed and selections made. Many of the tests had to be rejected because of the fact that a greater amount of time was consumed by them than could No. 2. 203 BISCH —MENTAL EXAMINATIONS FOB BECRXJITS. be allowed in the detention situation. Finally the following tests were adopted : 1. Knox cube.1 2. Digits backwards.2 3. Healy "A" form board.' 4. Comprehensive tests (four degrees).4 It was necessary in every case to modify the author's method of giving the above tests. In some cases the method of scoring was not suitable to our needs, and in other cases it was necessary to change the instructions accompanying the tests. In succeeding sections a detailed discussion of the tests will be given. Acknowledgments are hereby made to the various authors for the use of their tests. It is not likely that the four tests that have been adopted ade quately or completely analyze all the mental processes, or that they present a complete view of the individual's intelligence. It is be lieved, however, that the essential processes are examined and that a satisfactory percentage of the imbeciles and morons are identified before they proceed into general naval service. METHOD OF GIVING TESTS. As has been previously stated the individual method of giving the tests was considered superior to the so-called " group " methods. The only criticism of the former method lay in the fact that a large amount of time was necessary in presentation of the tests. At first it seemed that this difficulty could not be overcome, but later the following method was devised which overcame this difficulty. A yeoman assistant was assigned for each of the four tests to be given. These four assistants, who were called "psychological testers," were installed at separate tables. A fifth assistant who sat at the first table took the recruit's name and rate on the " Prelimi nary psychological examination" sheet (Form II) and also made out a card (Form I) which contained a brief history of the recruit's education, occupation, diseases, and institutional history. The re cruit then carried the preliminary test sheet and card in his hands and progressed from table to table, receiving one of the tests at each table. Each tester scored the performance of his particular test and the last tester totaled the individual scores and from the total score determined whether or not the man should be held over for an inten- 1 Knox, Howard : A Scale for Estimating Mental Defect. Jour. Am. Med. Assn., March 9, 1914, p. 741 ; Journal of Heredity, March, 1914, p. 122. • Terman, Lewis M. : The Measurement of Intelligence, p. 207, ff. •Healy, William A., and Fernald, Grace M. : Tests for Practical Mental Classification. Psychological Monograph No. 54, March, 1911. Psychological Review Publishing Co.,. Princeton University. •Terman, Lewis M. : The Measurement of Intelligence, pp. 157, 181, 216, 268. 103396—10 3 204 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. Vol. XIII. sive examination. (A discussion of the scores and the method of arriving at them will be taken up in a later section.) Form I. No Name Rate Date Birthplace Race Married Children, m f Education: No. yrs City Country Grade Prep Col Occupation Avg. weekly wage Disease history Venereal Institution record Ale. and Dr Physical defects Stigmata Neurological defects Amentia Inferiority Crass ignorance Illiteracy Psychopathy Psychiatry Family history Summary . Disposition Form I. (Reverse side.) Special abilities. Date of birth Chronological age_ Score Test Date Exr. Summary Years Months Preliminary test Stanford revision Binet-Simon 3 4 MA IQ MA MC 5 6 7 8 9 Special tests: 10 12 14 16 18 Reactions during examination: Total: Comments: On the back of the "Preliminary test sheet" (Form II, reverse side) which the recruit carried with him are listed a number of " character descriptives." Each tester checked one or more of these characteristics, basing his judgment on the recruit's performance of the particular test. The tests were so timed that the instruction for and the performance of any test did not take more than three minutes. It was thus possible to complete the testing of a recruit every three minutes, and at the same time give each recruit an individual test. No. 2. BISCH —MENTAL EXAMINATIONS FOR RECRUITS. 205 No. Form II. PSYCHIATRIC DIVISION. Preliminary examination. Detention Unit. Name Rate 1. Knox cube: (a) 1234 (e) 13243. (6) 1324 (a) 13124. (d) 1423 (A) 143124. Date. Comment. Score: 2. Numbers (backwards): (3) (3) (4) (4) (0) (6) 9182736453 7353281964 3915846273 4691823574 3546372819 Score: Comment. . . 3. Healey "A": Time. No. of moves. No of false moves reported. First trial: Second trial: Planfulness Learning capacity. Score: 4. Comprehension: First degree (sleepy) Second degree (fire) Third degree (unintentional injury). Fourth degree (actions v. words) Score: Held over. . Binet Disposition . Total score: 206 BISCH MENTAL EXAMINATIONS FOR RECRUITS. Vol. XIII. Form II. (Reverse side.) REACTIONS DURING PRELIMINARY EXAMINATIONS. + — + - + + Composed Childish Irritable Restive Willing Oafish Resentful Nervous Cooperative Stolid Resistive Variable Interested Timid Defiant Suggestable Attentive Bashful Sulky Distracted Cheerful Sensitive Shut-in Anxious Stable Reserved Moody Afraid Careful Modest Depressed Fearful Deliberate Frank Jovial Suspicious Forward Overconfident Despondent Tearful Assured Effeminate Nostalgia Apt Energetic Untidy Uncleanly Rapid Self-conscious Systematic Conceited Thorough Scornful Self-depreciative Efficient Intelligent Boastful Boisterous Sympathy-seekin .y Profound Euphoric Abnormalities Specia Confidence gained quickly Plea of unfamilia dty No. 2. BISGH —MENTAL EXAMINATIONS FOR RECRUITS. 207 Fobm III. PSYCHIATRIC DIVISION. Detention Unit. Neurological status. Nnme Rate Age Examiner r Date , 191-. Syphilis Chancroids Gonorrhea Enuresis, D-N Alocohol Drug addition Convulsions , Fainting or dizziness Seusory disturbances Subjective symptoms Institution history Neurotic history - Test words: Slurring , Ataxia- , Transposition , Elision Speech defect : Stuttering , Lisping , Faulty articulation Paralysis , Atrophy , Asymmetry , Spasms Pupils: Right.., Left—; Irregular.., Unequal.., Reaction to light sluggish- Absent , Nystagmus Strabismus Hyperthyroidism: Enlarged thyroid.-. Persistent tachycardia Exophthalmos General nervousness Tremor: Coarse Fine , Face , Tongue Hands , Muscles , Intention Patellar reflexes: Right , Left , Normal , Absent Diminished , Exaggerated Babinskl Clonus , Romberg Gait " Stigmata of degeneracy " Wassermann: (1st) Date , Result (2d) Date , Result- Disposition The advantages of this method are : ( 1 ) Each recruit received an individual examination from each of the four men; (2) the total score represents the judgment of four different examiners and is likely to be free from individual bias; (3) while each recruit receives a personal examination, lasting some 15 minutes, it is possible to complete an examination every three minutes; (4) the fact that the recruit moves from table to table and is compelled to face a new situation each time is in itself a test of intelligence; (5) the scoring is complete at the end of the examination, and it is not necessary to score large numbers of examination sheets, as would be the case if the " group " methods of giving the tests were used. 208 BISCH—MENTAL EXAMINATIONS FOE EECBUITS. Vol. XIII. NEUROLOGICAL STATUS. After the recruit has taken the preliminary psychological tests, he passes into another room, where a neurologist examines him for any neurological signs or symptoms of organic disease. These are noted down on Form III. It may be noted that in case the patient showed signs of syphilis of the nervous system, which was later verified by positive Wasser- mann findings, the man was immediately brought before a board of medical survey without any further procedures being carried out in his case. Where the man gave a history of venereal infection his name was sent to the genito-urinary department, where laboratory tests were performed and the man later given treatment if necessary. DESCRIPTION OF TESTS. (I) THE KNOX CUBE TEST. Apparatus. —The apparatus1 for this test consists of a strip of wood, about 22 inches long by \% inches wide, divided into four equal sections. The sections are painted red, blue, green, and yellow, respectively. In the center of each section is placed a cube about three-quarters of an inch square of the corresponding color. In addition there is a detached cube about one-half inch square painted black. Object of test.—The colored cubes are tapped in certain sequences by the detached black cube in view of the subject, and it is the pur pose of the test to have the subject tap them in exactly the same order. No language is involved other than brief preliminary in structions. The test involves the psychological capacities of attention, ability to carry out instructions, and visual memory. The sequences are arranged in ascending grades of difficulty. The following sequences were used : 1—2—3—4, 1— 3—2—4, 1—4—2—3, 1—3—2— 4—3, 1—3—1—2—4, 1—4—3—1—2—4. Instructions to subject. —The cubes are placed before the subject and are tapped in the order given, beginning with the red section. The only instructions given the subject are as follows: "I am going to tap these cubes in a certain order with this block I have in my hand. Watch me carefully, and when I get through I want you to tap the blocks in exactly the same order in which I do." The numbers on the preliminary test sheet represent the successive colored sections of the wooden strip, No. 1 being red, No. 2 being blue, No. 3 being green, No. 4 being yellow. The blocks were only 1 The material for this (est and the other tests described In this paper may be obtained from the C. H. Stoeltlng Co., 3037-3047 Carroll Ave., Chicago, 111. No. ^. BISCH —MENTAL EXAMINATIONS FOB BECBUITS. 209 tapped once by the examiner for each trial. If the subject did not seem to understand he was cautioned as follows : " Now watch me carefully and tap them just as I do." The blocks were tapped in exactly even intervals of time, i. e., there was absolutely no rhythm. The blocks were tapped at the rate of one per second. (II) DIGITS BACKWARD. No apparatus is necessary for this test other than the block of numbers printed on the preliminary examination sheet. These numbers are printed for the purpose of serving as a guide for the examiner in order that he may thus avoid using the same set of numbers twice. Object of test.—The digits are pronounced to the subject, and he is required to say them to the examiner in the reverse order. Two sets of three digits each, two sets of four digits each, two sets of five digits each, and two sets of six digits each are read. Any group of digits may be given provided there are no sequences either in de scending or ascending order. It is essential that the examiner read the digits with absolutely no rhythm and at the rate of about one per second. This test involves: (1) Ability to carry out instructions, (2) auditory memory, (3) manipulation of imagery, (4) attention. The heaviest demand is made upon the capacity of attention. The digits must be retained in consciousness by means of mental imagery. Terman 1 emphasizes the dependence of the test on the manipulation of imagery. In the Stanford revision of the Binet-Simon tests Ter man places the digits-backward test as follows: Three digits re versed as an alternative test in year VII, four digits reversed in year IX, five digits reversed in year XII, six digits reversed in year XVI (average adult), seven digits reversed in year XVIII (superior adult). The criterion of success in the Stanford revision is the cor rect performance of one group of digits out of three for each mental level. Instructions to subject. —The following instructions are given the subject for this test: "I am going to say some numbers, and when I get through I want you to say them backward ; that is, I want you to say them in the opposite order to which I give them. For instance, if I should say 8— 1, 1 would want you to say 1—8. Do you under stand? Now listen carefully and say them backward." It is permissible, in case the subject does not understand, to repeat the instructions, emphasizing that the numbers are to be given back ward. Not more than one repetition is allowed. lCt. Terman, pp. 208-200. 210 BISCH —MENTAL, EXAMINATIONS FOR RECRUITS. Vol. XIII. (Ill) HEALY "A" FORM BOABD. Apparatus. —This test was standardized by Healy,1 and the appa ratus consists of a square wooden frame, in which are fitted evenly five wooden blocks. Object of test. —The empty frame and blocks are placed before the subject and he is instructed to put them into the frame evenly in the shortest possible time. This is the only test of the four in which the time element is important. If the blocks are not fitted in correctly at the end of one minute, they are correctly placed by the examiner in full view of the subject, removed from the frame by the examiner, and the subject is required to replace them correctly within 20 seconds. In case the blocks are placed correctly the first time before the end of one minute, the time is taken by stop-watch and noted on the preliminary test sheet. In all cases a second trial is given in which the maximum time allowed is 20 seconds. The method outlined here is a modification of the method used by Healy. The test was devised by Prof. Freeman, and adapted and standard ized by Healy and Fernald, Kuhlmann, and Miss Gertrude Hall. Terman * places it as an alternative test in year X in the Stanford revision of the Binet-Simon intelligence test. The method used by the subject in the performance of the test is important and should be noted by the examiner on the preliminary test sheet. The examiner should look for the repetition of absurd mistakes, and note whether the subject profits by experience. The test is especially valuable, inasmuch as language ability is not essen tial. Psychologically, the test involves ability to profit by error and mechanical ingenuity. Instructions to subject. —When the empty frame and blocks are placed before the subject, the following instructions are given: " These blocks fit into this frame without any space left over —they fit in evenly. I want you to fit them into the frame just as quickly as you can. Go ahead." It is permissible to repeat the instructions once. The stop-watch is started at the signal " Go ahead." At the end of 1 minute, if the blocks are not correctly placed, the examiner should place them correctly and expose the completed board to the subject. The ex aminer should then empty the frame and say : " Now, try it again." On the second trial the blocks should be placed within 20 seconds. (IV) COMPREHENSION. No apparatus is necessary for this test. The following " degrees " were selected from the comprehension tests used by Terman in the Stanford revision of the Binet-Simon tests: First degree (Stanford 1 Cf. footnote, p. 203. ! Cf. Terman, p. 280 No. 2. BISCH —MENTAL EXAMINATIONS FOR BECRUITS. 211 revision, year IV), "What must you do when you are sleepy?" Second degree (Stanford revision, year VI), " What's the thing to do when you find that your house is on fire?" Third degree (Stan ford revision, year VIII), "What's the thing to do if a man hits you without meaning to do it?" Fourth degree (Stanford revision, year X), " Why should we judge a person more by his actions than by his words?" 1 Object of teat.—Any normal reaction to the situation described in the questions is scored plus. Bizarre and irrelevant responses should be noted, and are scored minus. Responses to the first question should embody the idea of going to sleep, going to bed, etc. Re sponses to the second question should suggest measures of extinguish ing a fire or escaping from it. Responses to the third question should suggest the idea of overlooking the unintentional injury. If in re sponding to this question the subject indicates a desire to retaliate or demand an apology, the response is scored minus. Responses to the fourth question are satisfactory if it is indicated that deeds are more reliable than words, i. e., a man may conceal his true intent by words. At best, these questions only feebly reproduce true situations, and it is possible if the situation described were actual, that the subject might react normally. In connection with these tests, Terman * points out that it is likely that it requires a higher degree of intelli gence to tell what one would do in a given situation than to act iii an actual situation. Instructions to subject. —No other instructions than the questions themselves as indicated above are given. In case the subject does not understand the instructions, it is permissible to repeat them once. SCORING AND NORMS. Necessity for scores.—A detailed description of four tests and the method of using them has been outlined. To make effective use of these tests it was necessary to adopt some system of scoring. The tests were in the hands of examiners with but a small amount of phychological training, who, on a basis of mere success or failure in a given test, could not with accuracy determine whether a recruit was a candidate for the intensive examination. The adoption of a method of numerically weighing the various tests composing the preliminary psychological examination makes it possible to arrive at a total score, also a numerical value, which has a defienite statisti cal meaning. On the basis of experimental norms, this total score may come to be the basis of a rough preliminary estimate of the ' Cf. Terman. pp. 157 ff, 181 IT. 215 IT. 2«8 B. 'Ct. Terman. p. 159. 212 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. Vol. XIII. recruit's mental fitness for the service, and hence the basis for de termining whether or not the recruit is a candidate for the intensive examination, the latter to establish exactly his mental status. Such a score also would be a part of the " clinical picture " if the recruit were retained for further examination or a part of his psychiatric record for the purpose of future reference. This is exactly the pur pose of our preliminary psychological examination. The scores adopted were, to a certain extent, arbitrary, arid the total score conies to have meaning as an increasing amount of data is accumulated. To finally establish such a total score it would be necessary to correlate it with other intelligence scales, school grades, etc. Certain of these procedures have already been followed out, and it will be the purpose of the following sections to describe them. It is desirable, however, that further data be obtained in order to conclusively establish the scores, and later on more complete data may make a revision neces sary. The exigencies of the situation in the detention unit at Hamp ton Roads demanded a system of scoring for immediate use. It is the purpose of this paper to describe this system. SCORES EXPERIMENTALLY ADOPTED. The first step in the adoption of scores was an inspection of a record of the successes and failures on each of the four tests. These were merely records of raw performance to which no numerical weight had been given. (I) The Knox cube test. In this test there are seven possibilities of performance: (1) Complete failure in all sequences, (2) success ful performance in one sequence, (3) successful performance of two sequences, (4) of three, (5) of four, (6) of five, (7) of six sequences. The following table summarizes the performance by sequences in a thousand cases:1 Successful performances ending with— Complete failure. First sequence. Second sequence. Third sequence. Fourth sequence. Fifth sequence. Sixth sequence. 4 38 152 325 298 160 23 The above table indicates that the first three sequences were per formed successfully by more than 50 per cent of the entire number i Table 1 (a). —Performance of Knox cube test, tabulated with reference to success by sequence. 1 The thousand cases from which the data for this table and the following tables was obtained are unselected, 1. e., beginning at a certain date all cases were used In the order of the appearance at the detention unit of recruits until a thousand had been obtained. • No. 2. BISCH— MENTAL, EXAMINATIONS FOE RECRUITS. 213 of cases. Only 38 cases out of a thousand were unable to progress further than the first sequence, 152 failed after the second sequence, and only 28 were unable to perform all six sequences. Table 1 (6).—Performance of Knox cube test, tabulated with reference to total successes. Total successes bv sequences. First sequence. Second sequence. Third sequence. Fourth sequence. Fifth sequence. Sixth sequence. 996 958 806 481 183 23 Table 1 (6) states positively what the previous table stated nega tively. It will be noted that the greatest discrepancy occurs be tween the third and fourth sequences. Reference to the description of the Knox cube test will indicate the reason for this. The first three sequences, while of increasing complexity, only involve four blocks. The fourth sequence involves five blocks. A score of four was experimentally adopted for each of the six sequences. If the subject performed the first sequence, he was given a score of 4; if he performed the first two sequences, he was given a score of 8 ; a successful performance of all six sequences scored the subject 24 for the test. Inasmuch as more than 50 per cent of the cases were able to successfully perform the first three sequences, we may call the successful performance of the first three sequences an average performance. On this basis, then, we may say a score of 12 should be expected from the average in our group. (II) Digits backwards: In this test there are eight possibilities of performance: (1) Two sets of three digits each, (2) two sets of four digits each, (3) two sets of five digits each, (4) two sets of six digits each. The following table summarizes the performance by group of digits in 580 unselected cases. (Owing to the fact that the method of giving this test was slightly altered for experimental purposes, only 580 cases could be used under the method described in the pres ent paper.) Table 2 (a). —Performance of the digits-backwards test tabulated with reference to success by digit groups. Successful performances ending with— Complete failure. Three digits. Three digits. Four digits. Four digits. Five digits. Fivo digits. Six digits. Six digits. 4 24 108 113 153 95 47 25 11 214 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. Vol. XIII. It will be noted that a performance through and including the second group of four digits includes more than 50 per cent of our cases. The following table will emphasize this fact : Table 2 (b). — Performance of digits-backwards test tabulated with reference to total successes. Total successes by digit groups. Three digits. Throe digits. Four digits. Four digits. Five Five digits. Six Six digits. digits. digits. 576 552 444 33! 178 83 36 11 It would seem that the successful performance for each pair would be approximately the same— that is, the same group of individuals should be able to do the second group of three digits backward as were able to do the first group of three digits backward. This, however, is not the case, and is very likely due to various factors, such as inattention, failure to hear the digits as pronounced by the examiner, fatigue, etc. From the above table we may say that the average individual of our group should be able to give four digits backward twice in succession. A score of three from each group of digits correctly given backward was experimentally adopted for this test. If all the groups were successfully given backward the perfect score for this test would be 24. (Ill) Healy "A" form board : According to our method of giving the test these are six possibilities of performance which are outlined in the following table. : Table 3 (a). —Healy "A" performance possibilities. Possibilities. First trial. 1 i 35 seconds or less 2 ! Between 35 seconds and 1 minute. , 3 Shown after 1 minute 4 35 seconds or less Between 35 seconds and 1 minute. Shown after 1 minute Second trial. 20 seconds or less. Do. Do. Over 20 seconds. Do. Do. According to our standard for this test as given in the description of it on page 210, possibility 1 would be a complete success and possi bility 6 would be a complete failure. Failures on the first trial are indicated in possibilities 3 and 6; possibilities 4, 5, and 6 indicate failures on second trial. On the basis of other experimental data it was found that out of 1,000 cases only 225 were unable to place the blocks correctly before the end of one minute at the first trial. This, then, may be considered a normal performance of the test on No. 2. 215 BISCH —MENTAL EXAMINATIONS FOB BECBUITS. the first trial. The following weights were given the various possi bilities of this test : Table 3 (6).—Healy "A" score possibilities. Possibilities. First trial. Second trial. Total score. 1 2 3 4 5 35 seconds or less (score 15) Between 35 seconds and 1 minute (score 10). Shown after 1 minute (score 0) . 35 seconds or less (score 15) Between 35 seconds and 1 minute (score 10). Shown after 1 minute (score 0). 20 seconds or less (score +5). 20 seconds or less (score +5). 20 seconds or less (score +5) . Over 20 seconds (score —5).. Over 20 seconds (score —5).. 20 15 6 10 6 Over 20 seconds (score 0). It will be noted from the above table that the subject is penalized five points for failure to perform the test within 20 seconds or less on the second trial. It is possible that this scoring may be criticized because of the fact that more weight is not given to the failure or suc cess of the second performance. The two factors in the test, the ability to profit by experience, which is shown by the failure or suc cess of the second trial, and the factor of ingenuity and planf ulness, as shown by the performance on the first trial, have unequal weight in our scoring. It was felt that the performance of the first trial should have the greater weight, inasmuch as the essential reactions are found in it. The distribution of the 1,000 cases, according to the above method of scoring, is as follows : Table 3 (c).—Scores of 1,000 cases of Healy "A" form board. Scores. Zero. Five. Ten. Fifteen. Twenty. 64 191 55 140 550 (IV) Comprehension test: The standards of success and failure in the responses to the questions in this test have been outlined in the section in which the test was described. The following tabulates the raw performances on the test: Table 4 (a). —Performance on comprehension test tabulated with reference to successes by "degrees." Performances ending with— Complete failure. First degree. Second degree. Third degree. Fourth degree. 1 4 71 635 289 216 BISCH MENTAL EXAMINATIONS TOR RECRUITS. Vol. XIII. It will be noted from the above table that complete failure on this test is an exceedingly rare performance. The greater number are able to give correct responses up to and including the third question, when there is a sharp decline and only 289 were able to complete the four questions entirely. These facts are more clearly shown by the following table compiled from the same data as the preceding table: Table 4 (6). — Number of successes. First degree. Second degree. Third degree. Fourth degree. 999 995 924 289 Because of the language involved and because of its rather arti ficial nature this test was given the least weight of the four tests. A score of 4 was given for a correct response to each of the four questions —that is, the subject was scored 4 if the first response was correct, 8 if the first and second were correct, 12 if the first, second, and third were correct, and 16 for the correct response to all four of the questions. (V) Summary : Summarizing the total score for each of the four tests we have the following : Table 5 (a). —Test scores. Test: Total score. Knox cube 24 Digits backwards 24 Healy "A" 20 Comprehension 16 Perfect score 84 The perfect score of 84 to have meaning must be evaluated on the basis of the distribution by scores of a large group of cases. It will be the purpose of the following section to discuss such distributions. (VI) Total scores: One thousand unselected cases1 scored by the method just outlined distribute themselves as follows: 1 The cases composing this thousand and the cases composing- the thousand in Table 6(6) are from the detention unit and are the total scores of 2,000 recruits taken In the order of their appearance during the months August, September, and October, 1918. No. 2. BISCH —MENTAL EXAMINATIONS FOR RECRUITS. 217 Table 6 (a). —Distribution of the first thousand cases by scores. Number o( 1. 1. 6. 1. 9. 3. 12 12 1. 1. 23 22 5. S. 17 SI 11 6. Score. 12 20 22 24 25 28 20 30 31 32 33 34 35 36 37 38 39 Number of 12. 38. 14. 9.. 40. 19. 10. 25. 43. 14. 13. 19. 98. 12. 5. . 24. 115 Score. 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 50 Number of men. 6.. 10. 19. 113 3. . 7.. 4. . 73. 5.. 3.. 46. 5.. 2.. 15. 1. . 10. 3.. Score. 57 58 59 00 01 02 03 04 00 07 08 70 71 72 75 76 80 Mean=51.41.' A second thousand cases from the same source distribute them selves as follows : Table 6 (6).—Distribution of the second thousand cases by scores. Number of men. 1. 1. 1. 1. 2. 5. 1. 2. 7. 12 7. 10 15 5. 12 13 1!) 10 0. 8. Score. Number of men. 16 15 18 1 10 20 13 21 21 23 31 24 26 20 23 28 33 29 44 30 23 31 25 32 44 33 26 34 19 35 18 30 37 32 38 20 39 27 40 63 Score. 41 42 43 44 45 40 47 48 49 50 51 52 53 54 55 50 57 58 59 00 Number of men. 13 11 32 67 12 12 17 40 7. 8. 0. IS 9. 6. 1. 12. 1. 12. 3.. Score. 61 02 03 04 05 00 07 08 09 70 71 72 73 74 75 70 77 80 84 Mean=53.137. 1 Whipple, G. M. : Manual of Mental and Physical Tests, Warwick & York, 1914, Part 1, p. 21 ff. 218 BISCH —MENTAL EXAMINATIONS FOR BECHUIT8. Vol. XIII. The above distribution is represented graphically in charts "A," " F," " G." An inspection of the tables and charts reveals the fact that the upper limits of the curve are somewhat heavier than the lower limits, indicating that the greater number of cases fall above the mean. In general the distribution is a typical curve of error. The mode and the mean very nearly coincide. Charts " C," " E " indicate that our lower limit of normality lies between 30 and 40 and the upper limit between 50 and 60. Our exact limits of normality, i. e., the limits within which lie more than 50 per cent of all the cases, are between 34 and 68. These are broad limits. The more exact limits may be placed at a score of 51 and 68. Between scores 34 and 51 undoubtedly are included some low-grade cases, but they do not present a sufficient degree of defectiveness to be held over for an intensive examination. LOWER LIMIT OF NORMALITY. It was necessary to find the score in our scale below which a re cruit could not fall without being retained for the intensive examina tion. This point is, of course, an arbitrary one. The limit which it defined must be placed high enough to include all cases of suspected mentality, but not so high as to include too large a number of men. The men which it was the purpose of the examinations to eliminate from the service were only those that deviate to a marked degree below normal. A score of 30 or below was adopted as the score below which a recruit could not fall without being held over for further examination. This limit has proved satisfactory. The thousand cases repre sented in the distribution in Table 6 (b) indicate that 21 cases re ceived a score of below 30. These cases were intensively examined with the following results: Table 7 (a).— Cases surveyed in first thousand cases. N'umlier Riven Stanford re vision of the Binet-Simon test. Numl er sur veyed from service. Number re turned to duty. 9 12 11 No. 2. 2 IP BISCH —MENTAL EXAMINATIONS FOR RECRUITS. 035 •I11XI0A •SIIAHOaH HOJ SKOIXVKlWVXa TVXN3K — HOSTS No. 2. BISCH —MENTAL, EXAMINATIONS FOE RECRUITS. 221 The intelligence quotient and mental age values in the 11 cases given the Stanford revision range as follows: Table 7 (6). Case L Case 2. Case 3. Case 4. Case 5. Case 6. Case 7. Cases. Case 9. Case 10. Case 11. I. Q.'.. M. A.2. 42 6-9 55 8-10 53 8-6 56 7-9 48 7-9 51 8-2 59 9-5 57 9-1 81.5 13-10. 5 58 9-7 52 8-i 1Intelligence quotient. 1 Mental age. The diagnoses of the nine surveyed cases are : Table 7 (c).—Diagnoses. Imbecility. Constitutional inferiority. Constitutional psychopathic state. 5 3 1 It will be noted that there is a markedly small number of surveys because of imbecility in a group of 1,000 cases. Studies of feeble mindedness that have been made from time to time by psychiatrists Recruit Group : Second thousand. and psychologists have brought out larger percentages than were obtained in our study. This is due, in part, to the type that compose our group, and, in part, to the peculiar service situation under which surveys were made. The men who volunteer for naval service have 222 BISCH —MENTAL, EXAMINATIONS FOB BECBUITS. Vol. XIII. indicated a higher mental status by the fact that they have taken the initiative themselves. The act of volunteering has indicated an inherent planfulness, an interest in their own affairs and in the Recruit Group : First thousand. future that is not typical of even the high-grade feeble-minded per son. From such a group, then, we may expect a rather higher type Recruit Group : Second thousand. of individual than is usually found in unselected groups of this size. Again, the small percentage of feeble-minded in our group may be No. 2. 223 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. explained because of the service conditions under which surveys had to be made. At the time the scores were made on the group described the war situation was such that it was necessary to conserve the man-power to the greatest extent possible consistent with an efficient fighting force in the Navy. Some very high-grade cases were therefore retained and given a type of duty commensurate with their intelligence. THE ARMED GUARD GROUP. At the St. Helena Training Station, where the tests were given to the armed guard, a thousand unselected cases were tabulated. We should expect in this group a rather higher intelligence level than in the recruit group. These men had already stood the test of service adjustments. The mentally unfit had been weeded out by the stress and strain of naval life. In addition, they were a specially selected group for a special service. Our scores from this group bear out these facts. The following table will indicate that the greater number of performances fall on the higher scores. Table 8 (a). —One thousand cases, armed-guard group. Number of men. Score. Number of men. Score. 17 15 45 20 4 46 24 9 47 25 22 48 2S 28.-. 49 30 10 50 32 51 33 62 52 34 18 53 36 7 54 37 19 55 38 96 56 39 13 57 40 2 58 41 22 59 42 107 60 43 8 61 44 8 62 Number of men. Score. 1. 1. 2. 1. 1. 2. 4. 6. 7. 9. 16 4. 5. 17 17 8. 8. 12. 102 1.. 1.. 11. no 2.. 7.. 74. 2.. 1.. 45. 1.. 2.. 21. 11. 64 65 66 67 68 70 71 72 74 75. 78 77 78 80 84 Mean=58.71. The mean in this group is markedly higher than in the previous groups. The general tendency of the scores to overweight the upper end of the scale may be due in part to the peculiar conditions under which the tests were given. The men in this group were examined by companies and the examinations extended over a period of weeks. This made it possible for coaching to be a factor in the scores. A man would have the opportunity to tell his mates about the tests and there is no doubt but what they were much discussed by the men of this group during the time the tests were being given. With our re. ruit group this is not possible, as the men are brought in from 224 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. Vol. XIII. civil life and have no opportunity of discussing any of the examina tions previous to the time they take the tests. Chart " I " represents the relation of the armed-guard group to the recruit group; characteristic shading indicating the relatively higher scores received by the former group. Chart " J " shows the Armed Guard Group. distribution of the thousand cases of the armed guard. Due to the source of error just mentioned, too much reliance can not be at tached to these scores. No. 2. 225 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. CORRELATIONS. Data was collected on a thousand cases 1 for the purpose of making a correlation between school grade and scores received in the pre liminary psychological tests. The educational data was obtained from the card made out for each recruit at the time of his entrance in the detention unit by the psychiatric division. On the appended chart (Table 9) will be found a table showing the distribution of school grades by scores received in the preliminary psychological examinations. A visual inspection of this table reveals a marked degree of correlation. It will be noted that but few of the higher school years are indicated as belonging to men receiving low scores. On the other hand it will be noted that few of the cases in the lower school grades received high scores in the preliminary examinations. The index of correlations was precisely computed by the " Product- Moments " method of Pearson.2 This proved to be +0.35. Table 9. —Education-scare distribution. School year. 1 0 1 ii 1 1 0 2 5 0 1 ii 2 7 12 7 !il 15 5 12 13 19 L6 6 a 15. 10 13. 21 31 26; 'The thousand cases discussed In this section from which correlations were made are- the same thousand on which scores were tabulated In Table 6 (b). » Cf. Whipple, p. 38 IT., and Davenport, C. B. : Statistical Methods, John Wiley & Sons. (Inc.), New York, 1014, p. 14 It. Scores. 1 3 4 3 8 7 8 9 10 11 12 13 14 IS IS 16 1 17 18 1 19 20 1 21 1 23::::::::.. 1 1 24 1 2 1 1 26 1 27 28 2 29 1 1 2 1 1 1 30 1 2 3 1 2 2 1 32:"::::::.. 1 1 2 2 1 1 T 3 3 1 2 3 1 4 2 1 1 1 1 34 2 1 1 1 35 1 1 2 3 1 2 1 1 1 2 4 3 2 1 37 1 1 4 2 1 4 2 1 1 2 38 2 1 3 3 3 2 1 1 39 1 2 1 1 1 1 1 1 1 2 "i 2 41 2 3 5 3 1 1 42 2. 1 2 2 1 1 3 2 2 5 1 1 3 2 2 3 3 2 3 1 1 1 ::: 2 2 3 6 5 4 4 2 2 1 2 6 5 5 3 1 1 Fre quen cies. 226 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. Vol. XIII. Table 9. — Education-score distribution — Continued. School year. Score. 12 3 415 6 7 47.. 48.. 4!).. 50.. 51.. 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. S4. Total. 0 25 I 0 41 56 68 119 10 11 I 12 13 14 i5 16 148 137 113 3 1 1 3 3 6 13 2 2 4 3 1 2 2 1 I 1 ... 1 1 ... 1 .. |86 111 41 34 13 Fre quen cies. 23 33 44 23 25 44 26 19 18 60 32 20 27 63 13 11 32 67 12 12 17 40 7 8 6 18 5 6 1 12 0 1 i) 12 0 0 0 3 1, 000 It would seem that a correlation of +0.35 is not as large as we should expect from our data. The educational data, however, is not entirely reliable. The data was taken from the recruit without possibility of verification, and it is possible that the school grades which the recruit gave do not represent his educational status. Among the older men it is possible that the question regarding edu cation could not be accurately answered because of poor memory. Again, the idea is not entirely reliable, due to a misunderstanding of the instruction as to how the questions regarding educational status were to be put. In some cases the question was : " How many years of schooling have you had?" In other cases the question No. 2. 227 BISCH— MENTAL, EXAMINATIONS FOR RECRUITS. was put as follows: "What grade did you reach in school?" The most important source of error lies in the various systems of school classification represented in the answers to either of these questions. The recruits are very largely from the Southern States. In these States the system of grading varies; some of the school systems are ungraded ; in some of them the term " high school " applies to the last four years of grammar school. This lack of standardization was a source of discrepancy which it was impossible to eliminate from our data. Three thousand cases. INTENSIVE EXAMINATION. The intensive psychiatric examination which always followed the preliminary psychological examinations and " neurological status " in the case of hold-overs, consisted of the performance of such stand ards as the Stanford revision of the Binet-Simon intelligence test in the case of suspected aments, or the giving of a complete mental examination such as that used by the New York State Hospitals for the Insane. In addition, in each such case, a complete record was made and kept on file, which included the following : ' 1. Chief complaint. 2. Referred by whom. 3. Family history. 4. Personal history. 5. Present condition. 6. Physical and neurological examinations. 7. Verbatim report of conversation with patient, aimed to elicit mental abnormalities. 8. Report of psychological tests. 228 BISCH —MENTAL EXAMINATIONS FOR RECRUITS. Vol. XIII. 9. Summary of findings. 10. Diagnosis. 11. Prognosis. 12. Recommendations. 13. Copies of report of recommendations made to commanding officer or senior medical officer referring the case, if any. 14. Pinal disposition. The reverse side of Form I was used as a summary of the various examinations given. CONCLUSION. The material presented in this paper is merely a record of per formance. • The psychological and statistical analysis of tests and data is by no means exhaustive, and the methods used and the con clusions derived are tentative and provisional. A certain situation was presented in connection with the mental examination and classifi cation of naval recruits which had to be met by more or less rough- and-ready methods. This situation was such as to preclude any extended psychological research. The tests and methods presented, however, have given a considerable degree of satisfaction, and it is believed they contain certain features that may prove of permanent value. The features that seem to be of especial value are: (1) The indi vidual method of giving tests; (2) the methods of scoring the indi vidual tests; (3) the use of the Knox Cube test, Digits-backwards test, and Healy "A" Form Board tests as preliminary tests. Further data and a more detailed statistical analysis is necessary before the system of scoring may be presented as final. In its entirety the fore going results are derived from 3,000 analyzed cases. The use of the foregoing psychological methods by persons without any scientific training along these lines is to be deprecated. No subject should be diagnosed on tests alone, and for all cases a neuro logical status, a physical examination, and a complete medical history should be included. Tests which do not depend upon school knowl edge or training should be stressed as much as possible. Great care should be exercised to avoid confusing ignorance with feeble-minded- ness. The nervous factors involved in examining a man in a new and unusual environment for him, frequently after a long and tedious journey from home, should always be given consideration. The psychological tests presented in this paper are only intended to be a means of rapidly classifying the recruits upon their induction into the service for the purposes of further examinations and classifi cation. (Sincere indebtedness is hereby expressed to Chief Yeoman F. S. Fearing, who, in the capacity of a trained psychologist, has rendered most valuable assistance in the compilation of the statistical analyses presented herewith.) No. 2. JACOBY—TREATMENT OF MILITARY OFFENDERS. 229 THE TREATMENT OF MILITARY OFFENDERS. By A. L. Jacobt, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. The trend of modern medicine, both in and out of the military services, is, primarily, toward the prevention of the loss of useful function, and, secondarily, toward the restoration of that function, if it is lost. Formerly, the physician concerned himself only with treat ing derangements of a given organ or group of organs. A little later he began giving attention to preventing these same derange ments from occurring in healthy individuals, and now the idea of prevention is being carried still further in what is called social medicine, which deals with prevention of the loss of function of the individual as a whole, and not this or that organ of the individual. Just as we are in the habit of studying disease processes in the living patient by the symptoms which the patient presents, so we may study the individual as a whole by his behavior. The behavior of an individual, then, becomes the symptom-complex of what we call his mind, the part of him which "thinks, feels, and acts." If his ability to "think, feel, and act" in harmony with other minds is impaired or lost, his usefulness is impaired or lost, just as the heart's usefulness is impaired if it fails to function in harmony with the other organs of the body. The failure to function in har mony with the other members of society often makes it necessary for society to remove the individual, and he is placed in an institu tion of some sort or other, where his functioning is done for him to a greater or less degree. Sometimes it is the prison to which he is sent, other times the insane hospital or institution for the feeble minded, or it may be the poorhouse. To which of these places he may go is often a matter of the purest accident, depending only upon how attention may have been called to him, and it frequently hap pens that the same individual is sent to one place upon one occasion and to an entirely different sort of institution on another exactly similar occasion. The fact that very little attention is paid to the kind of man under consideration before it is decided to which insti tution he shall go, or how long he shall stay there, leads often to a great and unnecessary loss of human function, and very often in duces great harm to the individual himself and to the society to which he will have to return sooner or later. At the U. S. Naval Prison, Portsmouth, N. H., there are now over 2,000 general court-martial prisoners. Each man is in the prison be cause he failed to adjust himself to his environment, the Navy, and the Navy has determined that he must not be allowed to function in society for a given period of time. The duration of this depriva 230 JACOBY—TREATMENT OF MILITARY OFFENDERS. Vol. XIII. tion of function is, in every case, largely determined by the serious ness of the specific act of conduct which is accepted as evidence that he was not fit for the Navy. The " Naval Courts and Boards, 1917." contains instructions, in the form of a table of sentences to be admin istered for each of numerous offenses, and it even subdivides a single offense according to the degree of damage done by the offender, with gradations of punishment accordingly. For example, the theft of less than $50 is to be punished by confinement for two years, and dishonorable discharge ; if the amount stolen is between $50 and $100, the confinement shall be three years ; and for the theft of over $200, confinement for four years is suggested. It is as if we were taught to administer 2 grains of phenacetin for all fevers under 100; 3 grains for fevers ranging from 100 to 102 ; and 4 grains for every fever above 102. We know that the fever is merely a symptom of a disorder of function in the organism, and that the degree of fever does not necessarily indicate the severity of the disorder. Just as we make an attempt to find and correct the disorder causing the fever, so we should study the offender against society, with a view to determining what is wrong with him and correct it, if possible. The duration of the deprivation of his liberty should not depend alone upon the offense any more than medication depends upon the amount of fever, but it should depend upon the kind of man he is. It is very commonly observed that men of the worst type, so far as usefulness is concerned, are sent to the Naval Prison for relatively minor offenses, as absence over leave, with short sentences, and are eligible for return to duty in the Navy. At the same time youths of great potential possibilities of usefulness in the Navy are sent to the prison for desertion with longer sentences and are not eligible for return to duty. It is true that desertion in war time is much more serious than absence over leave, just as a fever of 104 is more serious than a fever of 102, but it does not follow that the man who commits absence over leave should receive less treatment than the deserter, any more than that the patient whose fever is 102 neces sarily receives less treatment than one whose temperature is 104. In the cases with fever other symptoms are sought and considered before treatment is instituted. In the same way other symptoms should be sought and considered before treatment is administered to offenders. A careful study has been made by examination and observation in 566 general court-martial prisoners and the conditions enumerated in table I have been noted. No. 2. 231 JACOBY —TREATMEKT OF MILITARY OFFENDERS. Table I. Subnormal Hysteria Dementia precox Manic depressive insanity Anxiety neurosis Epilepsy Paranoid state Depression (undifferentiated) Drug addiction Chronic alcoholism Traumatic neurosis : Organic brain disease (undifferentiated) Symptomatic mental state Cerebro-spinal syphilis Psychopathic personality Constitutional inferiority Cerebral arteriosclerosis, Congenital syphilis ' Unclassified mental disorders Neurological conditions: Sydenham's chorea Toxic neuritis Trifacial neuralgia Hyperthyroidism Multiplesclerosis : Tabes dorsalis Nerve injury Migraine ; Foreign body in the cranial cavity Fracture of spine with resulting nerve pressr.re Examination negative Per cent. 142 23.3 57 10.0 23 4.0 8 1.4 14 2.2 16 2.8 1 . 1 1 . 1 3 . 5 34 6.0 1 .1 4 . 7 I . 1 13 2.3 43 7.6 44 7.7 1 . 1 1 . 1 11 1. 9 1 . 1 2 .3 1 . 1 2 . 3 1 . 1 2 .3 1 .1 1 .1 1 . 1 1 .1 13-1 23.6 It is not my intention to attempt to prove in each case enumerated above, that the offense is a symptom of the existing disorder at the central nervous system level, although that is often the case. More frequently, however, the offense for which the man is in prison, bears no direct relation to his nervous or mental disorder. Even a casual glance at the above table, however, will show that the majority of the disorders enumerated are of such a nature that they must have existed before the man was admitted to the prison, and even before he enlisted. When those 566 cases are classified with reference to the length of their service, that is, the time elapsed between the date of enlistment and the date of arrival at the prison, which is very often several months after the commitment of the offense, it is found that 122 of them served less than six months; 241 between six months and a year ; and 203 served more than a year. In nearly two-thirds of them, then, or to be exact 64.1 per cent, less than a year had elapsed from the time of their enlistment until they were actually in the prison. Certainly such conditions as a subnormality, constitutional inferiority, and the constitutional psychopathic states may logically be said to have existed when the patient was enlisted. Such defects 232 JACOBY—TREATMENT OF MILITARY OFFENDERS. Vol. XIII. can not be said to have been acquired as a result of service conditions. It is very often the case, however, that the Navy environment im poses requirements of adjustment upon certain defective individuals which are more difficult than have ever been required of them before, with the direct result that these individuals " break " under the added requirements, and find their way to prison. If we study the previous histories of this series of 566 prisoners, it is found that 236 of them have a record of at least one residence in a penal institution or in a hospital for the insane before enlistment, and there are 11 instances in which the individual had been committed to both penal and insane institutions before enlistment. This data is shown in Table II. Table II. Commitments to penal Institutions : Times committed — • Number. 1 102 2 31 3 16 4 10 5 , 6 More than 5 1 55 Total 220 Commitments to Insane Institutions: Times committed — 1 ^ 10 2 2 3 2 More than 3 2 Total 16 No previous residence in penal or Insane institutions 113 No record or record unconfirmed 228 It will be seen from this table that in those cases in which accurate data was obtainable about two-thirds of them had experienced life in a penal or insane institution before they enlisted. It is along the lines suggested by these data that the greatest possibility lies for the ex clusion of the misfits in the recruiting office. The failure of a man to adjust himself to his environment should always be a matter for con sideration by the medical officer, whether that failure to adjust arises through an attack of pneumonia or through delinquency. In either case the individual is lost as a useful member of society. The medical officer on recruiting duty should have impressed upon him just as great responsibility in regard to the enlistment of repeated offenders as he has in enlisting blind or deaf men. In either case the man en listed is almost sure to become an expense to the Navy rather than a useful member. It is hardly within reason to suppose that a man No. 2. JACOBY —TREATMENT OF MILITARY OFFENDERS. 233 who has been committed to penal institutions in civil life over and over again for drunkenness, disorderly conduct, or what not, is going to be a profitable addition to the Navy. In spite of this we not inf re- quenty see repeated offenders " sentenced " to an enlistment in the Navy by civil authorities. The importance of taking a short previous history of the applicant for enlistment has been well set forth by Stearns.1 In Volume XII, No. 4, of the United States Naval Medical Bulletin, October, 1918, there appears an editorial, "Where the Psychiatrist Fails," in which the writer asks for a brief, comprehensive method of procedure, capa ble of being used by every medical officer for detecting defectives, and he refers to the need of a proper routine method of testing. A routine set of questions now exists on the application form for en listment and it was apparently intended, from the nature of these questions, that they should exclude undesirable types. These ques tions make inquiry as to the habits of the individual, his previous commitments to penal institutions, etc. They are excellent questions, and, if they were answered truthfully by the applicant for enlist ment, would serve to exclude, very satisfactorily, a large majority of delinquents, but it is not to be expected that the applicant will answer these questions truthfully, when they are put to him in so perfunctory a manner. If these same questions were removed from the application form and put to the applicant orally by the medical officer himself, and in private, they would be of vastly greater value. I have been told over and over by general court-martial prisoners that a " doctor never saw me when I shipped," and some men of the most undesirable types have described to me the testing of their vision by an enlisted man as the only physical examination received by them for enlistment. This condition, we may say, is, in a measure, excusable in the stress of war-time recruiting, but all will agree that it should not be. It is impossible for the medical officer on recruiting duty to be highly specialized in all branches of medical science, but he is usually well enough versed in each of them for practical purposes if he uses the training which he has had. There is no more important duty that the medical officer is called upon to perform than that of recruit ing, and if he is made to feel the same responsibility for enlisting habitual delinquents as he feels about enlisting a man blind in one eye, a great step in advance will be made. Some psychiatrists have attempted with elaborate and more or less mysterious tests to accom plish the elimination of the mentally unfit from our service, with the result that they have often overstepped, as it were. They remind "Steams. A. W. : " The History as a Means of Detecting Undesirable Candidates for Enlistment with Special Reference to Military Delinquents," Naval Medical Bulletin, Volume XII, No. 3, July, 1918. 234 JACOBY—TREATMENT OF MILITARY OFFENDERS. Vol. Xtll. one of the celebrated internist who was examining an applicant for the position of intern. He produced a very difficult case and told the applicant to " give the diagnosis of that case." The applicant im mediately asked the patient what the matter was with him, and when the patient replied that he had syphilis, the would-be intern turned in that diagnosis, which was the correct one, without examining the patient. There is nothing weird or mysterious about practical psy chiatry. In fact, it has been defined as applied common sense. If the medical officer on recruiting duty will have a private interview with each applicant, directing his questions toward finding out what schooling the applicant has had, his occupations, the maximum wage he has earned, why he wants to enlist—in short, what he has done with his life—he will form an excellent idea of the applicant's fitness or unfitness. This interview must not take on the character of a per functory state meeting, but it must be done in such a way that the applicant feels that the doctor has a real personal interest in him. A very few minutes, probably not more than five in most cases, is all the time which needs to be consumed in this way. It is to be ex pected that some men will lie, but the medical officer will find that he is able to detect nearly all the liars, if he is face to face with the applicants. A procedure such as outlined above will serve not only to keep out of the service most of the recidivist type but it will stim ulate the medical officer to meet the responsibility which the corps as a whole should bear to the problem of discipline. At the training stations the psychiatric problems should be and are in the hands of men with special training, and at this point in the recruit's career his service record and health record should be a mat ter of careful consideration, as well as physical and psychiatric exami nation, before he is permitted to go into the service proper. The way a recruit adjusts himself to his environment is of far greater impor tance to the service than they way he may perform psychological tests of one kind or another. It is expected that at the training stations neuroses and the milder degrees of constitutional defect will be de tected. The various psychological tests are valuable aids to be used in reaching our conclusions, particularly at the training station, but they are of limited value if used alone, just as the Wassermann is of limited value in determining a man's general state of health. The Wasserman does not give evidence of flat feet, for example, and the intelligence tests will not give evidence of bed wetting. At the train ing station as well as throughout the service the relationship between the medical corps and the line can not be too close in reference to the problem of discipline. The exclusion at the recruiting office or the elimination at the training station of undesirables by the medical officer is only a small portion of his function in this matter of discipline. Aboard ship. No. a. JACOBY— TREATMENT OF MILITAEY OFFENDERS. 235 every time a court-martial is ordered the doctor should feel that here rests an opportunity for usefulness. The general court-martial, with its double function —first, the determination of the guilt or innocence of the accused, and, secondly, the determination of what shall be done with him if found guilty—frequently errs in its second function, particularly because it has insufficient information upon which to draw its conclusions. The medical corps should be the means of furnishing to the general court-martial information of immense value to help it determine the best course in a given case. As a result of the court's lack of information about the accused, particularly if he happens to plead guilty, there is an enormous loss to the service of useful men, not to mention the financial loss and the actual harm done to men by confinement, which is not necessary, and the harm done society or the Navy in particular by releasing men from confinement prematurely. Punishment can no longer be considered as the last word in any case, and it should only be considered as a means toward a definite end, the end being the accomplishment of a harmonious adjustment of the individual to society. If it does not do that, it fails as a method of treatment. If sentences were only imposed after the con sideration of all the available data concerning the accused, such as his family history, his previous medical and social history, mental and physical examinations, and a period of observation by medical offi cers especially trained, together with line officers versed in matters of discipline, as well as the consideration of the facts directly related to the offense, a minimum loss of function would occur. It is impos sible for the general court-martial to obtain all this information with the time and means at its disposal. Therefore it is believed that the general court-martial, as now constituted, should limit its function to the determination of the guilt or innocence of the accused, and give no consideration to the character or amount of punishment to be ad ministered. If the accused is found to have committed the offense charged, he should then be deprived of his liberty for a period of from two to three months, during which time he should be placed under observation at the Naval Prison or other suitable place. At this place of detention for observation there should be officers with special training in the matters of human conduct. A copy of the proceedings of the trial of the accused should accompany him to this observation hospital, and here all examinations should be con ducted and complete data concerning his family and personal his tory should be obtained by correspondence or otherwise. At the expiration of this period of observation, of from two to three months, the offender should come before a second court or board, together with all the information concerning him and his offense, for recom- 103396—19 6 236 JACOBY—TREATMENT OF MILITARY OFFENDERS. Vol. XIII. mendation as to disposition. This board might recommend restora tion to duty, discharge from the service, transfer to a hospital, con finement at hard labor, or such other disposition of the case as may be deemed necessary to best meet the needs of the service for useful men, and of the particular man under consideration. This board should be very carefully selected, and it should contain men capable of interpreting and correlating data received from the great variety of sources that its information would necessarily come. In addi tion, its members should be men thoroughly acquainted with Navy life in all its phases. This second court or board would also serve the function of a court of appeals, and would consider any new evi dence relating to the offense which may have come to light since the trial. Such procedure, it is true, would be a great departure from estab lished precedent, but the period of history through which we are now passing is characterized by the breaking of precedents. In an urticle of this length no attempt can be made at the full consideration of the detailed application of such a system, and it is only intended to offer a suggestion of a plan designed to prevent, so far as is possible, in our present state of knowledge, the loss of useful men to the service and the elimination as early as possible in their careers of men who are never going to be useful in the service. CONCLUSIONS. 1. The problem of military delinquency is essentially one for the consideration of the medical corps. 2. The use of a few minutes by the recruiting medical officer in a man-to-man conversation with the applicant for enlistment will serve much better than the psychological tests for the exclusion of delinquents and psychotics. 3. The observation by trained men at the training station, with consideration of the recruit's method of meeting and adjusting him self to his new environment, will serve to eliminate very largely the neuroses and the milder degrees of constitutional defect. 4. The general court-martial as now constituted should determine only the guilt or innocence of the accused. 5. If found guilty the accused should then be placed under obser vation for from two to three months, and all possible information obtained about him and the stock from which he comes. 6. A second court or board should determine the disposition of each case which will best meet the needs of the service and of the accused after the consideration of all the data collected during the observation period and any new evidence in connection with the offense. No. 2. 237 ROBIN —EXTRACTION OF METALLIC BODIES. EXTRACTION OF METALLIC FOREIGN BODIES WITH FORCEPS UNDER DIRECT X-RAY CONTROL. By E. Robin, MGdecin de I ere Classe, Chef du Service Chirurgicale, HOpltal de la Marine, Brest. Dr. le Coniac, during the first three years of the war, and for the past year Dr. Corolleur, have been in charge of the department of skiagraphy at the Hopital Principal de la Marine, of Brest. Both of these radiographers, being familiar with the localization of for eign bodies, have developed while working in intimate collaboration; with surgeons, a method of extracting foreign bodies with forceps under the direct control of the fluroscopic screen. This method, in the hands of one with a little training, is most rapid, accurate, and harmless. The surgeon after a time may become so trained in radiosurgery that he is able to localize and extract foreign bodies without the direction of the radiographist, but until he has acquired what may be called "the radioscopic eye" he should be guided by a skillful radiographer. The method which forms the subject of this paper is so simple as to be applicable to most cases. The following principles, however, should be kept in mind : 1. All the wounded passing through a hospital, whether their lesions be recent or old, should be examined from head to foot by radioscopy in order to deter mine the presence or absence of foreign bodies. It often happens that men keep silent about foreign bodies, especially if their papers state that the missile has been extracted. 2. Any foreign body of the soft parts, no matter how small, should be removed for two reasons: (a) It may be the seat of latent infection or the source of acute developments in the future. (6) Even if the foreign body be well tolerated, the patient may make it a pretext for exemption from work or duty, or even for pension or passage to an auxiliary service. Every foreign body, then, even if it be no larger than a plnhead, should be removed. Localization. —Such systematic extraction would be impossible were the radiographer obliged to make plates, measurements, and calcu lations for each patient, as is the case when one uses a localizing apparatus. Thousands of foreign bodies have been removed in the radio-operating room at Brest without the use of localizing instru ments. The only practical localization is anatomical localization. The application of compasses takes a long time and does not give, for instance, the exact relation of a piece of shell to the different parts of the body around it. It is not of first importance for the surgeon to> know that a foreign body is 8 or 10 centimeters deep in the gluteal region ; but it is important for him to know its relationship to thu- iliac bone or the sciatic nerve or other anatomic structure ; informa tion that the compasses can not give. 238 ROBIN EXTRACTION OF METALLIC BODIES. Vol. XIII. Both radiographer and surgeon must know their anatomical topog raphy. The anatomical localization is obtained by studying the re spective displacements of the foreign body on the one part and of the organs of the neighborhood, chiefly bones, on the other part, while the body is being rotated from one side to the other. The shadow of a foreign body situated in front of the general axis of rota tion will displace in the same direction as the part of the body which Is next to the screen and in an Inverse direction than the part of the body nearer the screen. If the foreign body is behind the axis, the contrary will take place. Besides, it is evident that the displacement of the shadow is more rapid when the foreign body Is more distant from the axis of rotation. During the rotation, the shadows of the skeleton move also. The relative dis placement of the shadow of a bone and the image of the foreign body is con siderable when they are widely separated ; If during the rotation, bone and foreign bodies keep at the same distance and move in the same direction, one may say that they are near each other. The displacements of the foreign body during spontaneous, induced, or psyslologic movements give very useful In formation. As an example, we may suppose the piece of a shell In the fleshy part of the limb ; if the radiologist moves it through the skin, these movements may be seen on the screen, and the propulsion will reach its maximum when the finger is as near as possible to the foreign body. The shadow of a bullet in the scapular region will displace on the ribs during the raising up of the arm, and this simple test will show that it is not Intra thoracic. A lot of information may be obtained by comparing the displace ments of the foreign body with the physiologic movements of the thorax. Every body knows that during inspiration the diaphragm goes down and the ribs go up. Hence If an Intrathoracic foreign body follows exactly the movements of the diaphragm, but at a distance from It, one can be sure that it Is intra- pulmonary- If. on the contrary, it goes up and down with. the ribs, it is depend ing on the ribs. Then we use the method of rotation to find out if it is extra or intrathoracic; in the latter case, it is either pleural or cortico-pleural with pleural adhesions. Foreign bodies near the mediastinum are not very mobile, but by rotation we can see at once what their position is Inside the thorax. Foreign bodies near the heart are the seat of transmitted beatings from the heart ; rotation will allow us to see if they are near, on, or in the pericardium. On the whole, the method of rotation associated with ordinary methods of common sense enables the radiologist and the surgeon to localize the exact position of the foreign body, and the surgeon has anatomical and clinical means of selecting his avenue of approach to It.—These de Gourion, Bordeaux, 1917. SURGICAL INDICATIONS FOR THE EXTRACTION OF FOREIGN BODIES WITH FORCEPS UNDER DIRECT CONTROL OF RADIOSCOPY. (a) In the ambulances, " auto-chirs," or hospitals at the front, the •extraction of foreign bodies is only a part of the general treatment of war wounds (large incisions, extraction of foreign bodies and pieces of clothing with primary suture, if possible). Under these conditions, if the foreign body is rather deep in the muscles, the X-ray is most useful in reaching it. No. 239 ROBIN—EXTRACTION OF METALLIC BODIES. (b) In very many cases, owing to overcrowding, the wounded are evacuated from the front to the hospitals at the rear with foreign bodies still in situ. These foreign bodies may develop infection and abscess around them, but, on the other hand, are often well tolerated and become surrounded more or less rapidly by an envelope of fibrous tissue. Should these cases come to the knowledge of the radiographer F.B.- jP\BLE TUBE FORCEPS TUBE, SHADOW OF F.B. AND TIP OF FORCEPS ON SAME VERTICAL LINE FORCEPS MORE SUPERFICIAL RAPIDLY PASSES OVER. THE SHADOW OF F.B. F.B. MORE SUPERFICIAL 3EPARATE3 FBOM THE TIP OF FORCEPS or the surgeon, they should be operated on for the reasons indicated above. The systematic extraction of foreign bodies would not be pos sible, if each one had to be reached by a large incision which opened widely plane after plane of fascia and muscle. Even with an experi enced surgeon, possessing full knowledge of the anatomical planes, 240 ROBIN —EXTRACTION OF METALLIC BODIES. Vol. XIII. the inconvenience resulting from such an open method of interfer ence, as far as small and deeply situated foreign bodies are con cerned, outweighs the disadvantages of leaving these missiles in place. Extraction under the direct control of the X-ray, with forceps passed through a small button hole in the skin, is most rapid, practical, and safe. The criticism that it is a blind method does not hold good and is only raised by those who do not know this method, or have failed in its application. Eight or ten foreign bodies of the extremities at different depths can be removed in a half hour; this time including sterilization of the skin in different areas. Usually 5 cubic centimeters of ethyl- chloride will provide sufficient anesthesia for the removal of a foreign body from a thigh or from a leg at any depth. This method is undoubtedly safe; I have removed more than 1,000 foreign bodies and I have never damaged a nerve or a blood vessel of importance. The surgeon must choose his route of access so as not to endanger important structures, such as blood vessels or nerves and to avoid obstacles such as bones and thick tendons. For instance, a foreign body in the thigh, in front of the obturator foramen, should not be attacked through Scarpa's triangle; but the introduction of a long forceps into the inner aspect of the thigh through the adductor muscles will be perfectly safe. When the surgeon appreciates that a foreign body is in the im mediate vicinity of a dangerous organ he will modify his technique accordingly. In certain cases he will operate through an open wound in order to secure direct vision, using the rays to direct the incision and thus save time. The principles on which this method of extraction is based are: (a) Penetration through the tissues by an aseptic blunt instrument (for instance, an ordinary artery forceps with closed blades) is per fectly harmless. It breaks nothing, it only displaces the cellular tissue or the muscular fibers through which it is introduced; and these tissues resume their place after the instrument has been re moved, leaving but a simple puncture, (h) At all times the radi ographer must be able to tell the surgeon whether or not his forceps is moving in the direction of the foreign body, guiding him until he touches it. This information is obtained by observing the displace ment of the shadows, using the method of rotation described above. OUTFIT NECESSARY FOR THIS METHOD OF EXTRACTION. Room and lights. —A radio-operating room with red light or feeble white light ; alternating with full light, artificial or natural. Instruments.— Knife and artery forceps or foreign-body forceps of different sizes. No. 2. 241 ROBIN—EXTRACTION OF METALLIC BODIES. Radio-operating table.—We use the table of le Coniac which con sists essentially of a plane revolving around its long axis. The pa tient is firmly fastened to the rotatory table, so that he may be turned from right to left and inversely around its axis without fall ing off. Our radiographers use Piloris tubes ; a Coolidge tube would be better. The tube can be moved in an horizontal plane beneath the rotatory table. Diaphragming is rapid and easy. STEPS IN THE OPERATION. 1. The position of the foreign body is ascertained. 2. The patient is placed on the movable table in the best possible position for the operation. 3. The inhalation of ethyl chloride will furnish sufficient anesthesia for a short, easy extraction. If the operation is liable to be long, if there are several missiles to be removed from the same patient, or if complete immobility is necessary, chloroform or ether may follow. It has been our practice to use chloroform with the Kichard appa ratus. In radio-surgery the Richard apparatus has two advantages : (a) Its long connecting tube makes it easier for the anesthetist to work while the table is being rotated; (&) the noise of its valves during inspiration and expiration enables one to hear the respira tion of the patient. Let me state here that anesthesia is always begun when the lights are on and should never be administered in the dark except by a skilled anesthetist. I have never seen any fatal accidents due to it. 4. The skin is antisepticized with tincture of iodine and sterile towels are put in place. 5. The surgeon, when his eyes have become accommodated to the dark, asks for the rays. The radiographer centers the tube and the diaphragms. Both look through the screen. The surgeon, placing the point of his knife on the shadow of the foreign body, asks for red light or feeble white light. Then, using his anatomical knowl edge, he chooses his avenue of approach, and, as a rule, makes his puncture a trifle to the right of the foreign bodies, that he may use his right hand to better advantage in manipulating the forceps. 6. The puncture is made. This is a small, buttonhole incision, not more than half a centimeter in length, and divides skin, subcutaneous tissue, and fascia. The forceps is now introduced through the punc ture in the direction of the foreign body. As a rule, an artery forceps is used. Kocher's forceps may be used in some cases, but the teeth are liable to catch in the tissues. Some deep foreign bodies require long bullet forceps. 7. The surgeon asks for the rays as soon as the forceps is in the incision, and through the screen he watches it as it penetrates the tissues and he advances it gently but firmly. When the tip of the 242 ROBIN —EXTRACTION OF METALLIC BODIES. Vol. XIII. forceps reaches the shadow of the foreign body, if the surgeon does not feel or does not see the contact with it, a localizing test must be made to learn whether the tip of the instrument is too deep or too superficial. 8. The surgeon immobilizes his hand on the skin and his forceps in the patient's tissues so that each displacement of the table will be transmitted completely to everything lying over it. The radi ographer now indicates the direction in which the surgeon is to move, while both of them watch the respective displacements of the shadows. When the tip of the forceps and the foreign body are on the same vertical line, if the table be made to rotate, that shadow which moves more rapidly in the direction of the rotation is the more superficial. (See figures.) By one or two rotary movements the surgeon ascer tains whether his forceps is too superficial (between the foreign body and the skin) or too deep (between the foreign body and the table). 9. When once the surgeon's forceps has reached the foreign body he will use it as a grooved stylet with which to separate the foreign body from the surrounding tissues. After months have elapsed a foreign body is included in a mass of fibrous tissue. As a rule, this decortication is easily made. 10. When the surgeon has achieved the "metallic contact" and the foreign body is free, he fixes it by pressing it against sound tissue, and, opening the blades of his forceps, he catches it. 11. As a rule, the foreign body is withdrawn with ease, but occa sionally a slight twist is necessary in order to break its last connec tions with the surrounding tissues. 12. No suture is used, merely a dry dressing, which is removed in three days. This method of extraction is simple and very rapid when the sur geon has acquired a little experience. In the soft parts it may be undertaken with safety by any surgeon knowing anatomy. Slight modification of technique permits the surgeon to remove foreign bodies from bones (with curettes after trephining the bone) ; from the brain (after craniotomy and opening of the meninges). EXTRACTION OF FOREIGN BODIES FROM THE LUNGS. Since the first extraction from the lungs made by Petit de la Villeon, with Dr. le Coniac as radiographer, in 1915, more than 200 foreign bodies have been removed at Brest. The method of extrac tion from the lungs is the same as for all foreign bodies, with some modifications in technique; it is only a special application of the general method. No. 2. 243 KOBIN —EXTRACTION OF METALLIC BODIES. Without entering into the details we may say that— 1. A very accurate localization must be made (vide supra). 2. Skin and intercostal space are cut by an incision not longer than a small buttonhole. 3. A long forceps (ordinary bullet forceps or, better, forceps with crocodile jaws) is introduced and, under the control of the X-ray, passes through the two leaves of the pleura without causing pneu mothorax, and enters lung tissue. The penetration of a blunt instru ment through lung tissue does not cause hemorrhage. 4. By rotary movements of the table the progression of the for ceps to the foreign body is made in one-half inch steps. The radi ographer and surgeon are able to appreciate the direction by the dis placement of the shadows as described above. 5. The foreign body is caught and taken out slowly to avoid cut ting the lung by the sharp edges of the fragment. 6. The passage through the skin, if the foreign body be big, neces sitates at times enlargement of the incision. 7. A silk-worm suture closes the small wound. Usually we give a little morphia. With very few exceptions there is no hemoptysis or hemothorax. In some cases, when the operation has been done rap idly, we may notice a little bloody sputum for two or three days after the extraction. There is, however, no rise in temperature, and, as a rule, the patient is out of his bed in less than a week. After a careful radioscopic examination of his chest, to make sure that lungs and pleura have resumed their normal condition, the patient goes back to his work. This method of extraction of foreign bodies from the lungs must appeal to every surgeon because it is simple, rapid, and safe. M6de- cin General Duval, directeur du service de sant£ de Brest, has given his support to this method which was originated in Brest, and we have had the opportunity of operating upon many cases before Amer ican and French surgeons. All agreed with us that it is the method of election, infinitely preferable to extractions after pleurotomies with or without rib resection. It is to be borne in mind (a) that the region of the hilus should not be operated on by this method ; but all other parts of the lungs are accessible; (&) that before operating upon a lung the surgeon must be trained to remove foreign bodies from the soft parts of limbs. I have personally extracted 50 foreign bodies from the % thorax with perfect results and no deaths. An objection may be made that the hands and face of the surgeon may suffer from exposure to the rays. In answer to this it may be stated (a) The eyes are protected by lead glasses ; and besides there is no necessity for the eyes to be directly over the screen, (b) As for the hands, the radiographer uses the diaphragm as much as possible 244 LeCONTE AMPUTATIONS AND PROSTHESIS. Vol. XIII. and, as a rule, the forceps only is in the rays. Besides, we wear heavy, thick rubber gloves (Chaput's gloves). The operator may use Manclair's gloves with lead in them. We may add that after two years of intensive radio-surgery the skin of the author's hands is perfectly normal. NEW WAR METHODS IN AMPUTATIONS, STUMPS, AND PROSTHESIS OF THE LOWER LIMES. By R. O. LhConte, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. One of the cruel results of the present war is the enormous number of mutilated men it has produced. The treatment of the amputated has changed but little in a century, except for the perfecting of me chanical devices by ingenious mechanics who lack surgical knowledge and education. The comfort and usefulness of a man without a leg was left to the artificial-limb maker, for the surgeon's interest ceased often before the wound was fully healed, and the orthopedist's in terest was not awakened or limited to the recommendation of a maker of limbs. By the time the unfortunate's wound was healed prac tically all scientific surgical supervision of him ceased. To Dr. F. Martin, of La Panne, Belgium, was given the inspiration to study the results obtained by such a system of treatment, and after more than a year of intensive work he has written a new chapter in pros thesis, placing this long-neglected subject on as firm a scientific surgical basis as the correction of refractive errors of the eye. I use this simile advisedly, for our treatment of the amputated has been about as logical and scientific as the giving of the address of an optician to a patient requiring glasses. Dr. Martin starts with the proposition that all legs differ in shape as much as the features of the face; that a man's walk is as char acteristic of an individual as his voice; and that this character is largely due to the shape of his legs. Therefore to reproduce sta bility and comfort in walking, the exact counterpart of the limb lost must be reproduced in the artificial member. The treatment of the stump, which eventually will actuate the artificial limb, is as important as the limb itself. The development of the muscles that control the joint above must be constant from the moment the wound is healed. This develop ment is best attained by making the patient walk with a temporary apparatus. Crutches will speedily develop a lateral curvature of the spine in a uniped. Martin has therefore discarded them. This lateral curve is an effort of nature to produce stability while standing on one leg. The lumbar spine bows toward the sound side. The curvature is No. 2. LeCONTE—AMPUTATIONS AND PROSTHESIS. 245 quite apparent in two months and steadily increases with the. use of crutches. For the correction of lateral curvature in childhood and youth, exercises with crutches walking on one leg are strongly recommended. The immediate treatment of the psychic condition, always present in the mutilated, is of primary importance to the patient's future social value. For the patient then the best ultimate result will be obtained only through a close liaison of the surgeon amputating and the orthoped ist, for to the latter is delegated the treatment of the stump, its de velopment, its temporary walking apparatus, its final fitting with the artificial limb, and above all the treatment of the psychic condition and professional reeducation of the patient. When such a correla tion is brought about, the beggary of maimed men following a war will cease. AMPUTATIONS. Amputations in war surgery are desirable when the loss of the limb is certain, or the attempted preservation would result in death. These two indications are due to traumatism (mortality 6 per cent) and infections (mortality 28 per cent). Before this war the tech nique of an amputation was taught empirically, and three funda mental ideas govern this classical procedure : 1. The amputation must be done in healthy tissue. 2. The shape of the flaps is prescribed (circular, oval, or of un equal length). 3. The stump must be well padded with soft tissues. These classical ideas must now be forgotten, for they no longer exist in war surgery. Amputation of the lower limb in healthy tissue is practically never done except when the entire foot has to be sacrificed. There is an optimum length of stump for the leg; otherwise, every bit of bone that can be saved is left. The infected soft tissues are cut on a level with the bone (chop amputation) without any attempt at flap for mation unless the wound lends itself to short flaps. The position of the wound and the seat of fracture will determine the point of ampu tation, and not the splintering of the bone above the fracture. The disinfection of the wound is at once started, and it is left wide open until the infection is controlled, when the wound may be closed by a late primary or secondary suture, the tension on the flaps being re lieved by traction on the skin by adhesive tapes. When revision of an amputation is necessary it will be done when disinfection is com plete and the soft parts have been given all the elongation possible. The usefulness of the stump depends on the length of the bony lever and the muscular attachments which control the joint above. Disar 246 LeCONTE —AMPUTATIONS AND PROSTHESIS. Vol. XIII. ticulation of the hip and knee should not be done unless the joint is invaded and infected, and then an amputation at the lower third of the thigh is preferable to the knee joint for the fitting of an artificial limb. One inch of femur, if it contains the muscular attachments to the trochanters, is invaluable to an artificial limb, and the same is true of the tibia if the extensor and hamstring attachments can be re tained. Should one or the other of these be stripped from the bone, their reattachment should be made when possible. The relation of the length of the stump to the prosthetic apparatus may be stated as follows: The length of the stump increases by arithmetical pro gression, while its action on the artificial limb increases by geomet rical progression. As none of the body weight is borne by the end of the stump, the padding of this with soft tissues is no longer con sidered. The surgeon's considerations in amputations are, therefore, first, to save life; second, to save all tissue that will aid in actuating the arti ficial limb; and, third, healing of the wound in the shortest possible time. The rapid healing of the wound is important for the exercis ing of the joint above and the muscles controlling it. To preserve the functions of this joint, passive motion should be made at each dressing and the joint kept in extension and not propped with pillows in a semiflexed position. If the stump needs support, pillows may be placed laterally, but not underneath. The muscles that actuate the joint should be exercised and massaged to keep them in their most efficient state. When adhesive tapes are employed to draw down the flaps, the muscles may be exercised against the weights making this extension. The length of the stump is determined by the operation, but its power and mobility depend largely on .the treatment. The wound should be healed in two weeks or not more than four weeks and the patient turned over to the care of the orthopedist. The orthopedist's first duty will be to fit a temporary apparatus and have his patient out of bed and walking on two legs. To walk with one leg and crutches ruins the static equilibrium of the am putated, for the center of gravity of the body must pass through the supporting foot. The body in attempting to compensate for this will develop a scoliosis of the lumbar spine, and as these war vic tims are young this will be apparent in a few weeks. It is therefore preferable to confine a patient to bed or a chair rather than allow walking with one leg. The provisional apparatus permits of imme diate walking; it replaces the mechanical or manual mobilization of the stump and massage of the muscles by natural and agreeable ex ercise; it has a profound influence on the mental attitude of the patient to his mutilation; it improves his general health; it per mits of an early reeducation ; and it exerts on the stump the necessary and beneficial action of supporting weight, hastening its shrinkage, No. 2. LeCONTE AMPUTATIONS AND PROSTHESIS. 247 and thereby shortening the time for the fitting of the artificial limb. For these reasons the temporary apparatus is an indispensable ele ment in the treatment and should not be considered as a makeshift of no special importance. PROVISIONAL APPARATUS. The provisional apparatus applied to an always sensitive, often painful, stump must be carefully molded to properly support the weight of the body. There must be no pressure on the lower portion and end of the stump, no friction and no pull on the skin that would tend to reopen the wound. It must permit of free movement of the articulation above. It must be applicable to double amputations as well as to single ones. It must be readily changeable to conform to the constantly changing stump. It should be light in weight, in expensive, and easily and rapidly made. The following description is for a midthigh amputation, and is given as an illustration of what can be done cheaply and quickly. The apparatus costs prob ably less than a dollar ; its weight is about 2 pounds ; it will last five or six months, but, owing to the shrinkage in the stump, it will require two or three renewals of the plaster mold. The materials needed are plaster of Paris bandages, plaster cream, two pieces of wire netting the size of the palm of the hand, an iron hook fastened to a short piece of strap iron, and two pieces of wood similar to the lateral supports of a crutch. These pieces of wood are beveled at their upper portion and longitudinally grooved, the better to incorporate them in the plaster. The patient is placed on the table, lying on the sound side, with the limb straight and the stump following this alignment. The stump, buttocks, and lower abdomen are covered with a thin coating of vaseline. The stump is encircled with plaster bandages and the plaster is carried well up on the buttocks and over the crest of the illium and made partic ularly strong in the region of the ischium. The wire netting is in corporated in the plaster over the great trochanter and on the inner side of the thigh just below the ischium. The inner stick is placed about an inch below the ischium and incorporated in the plaster. The outer stick rises to the level of the great trochanter, and just in front of it on a level with the trochanter the iron hook is placed. While the cast is drying the lower end of the stump is freed from all pressure by cutting away the plaster, and the upper level of the cast is outlined with a pencil. This should follow the fold between the buttocks to the crest of the illium, pass a shade below Poupart's ligament and a little below the perineum. The cast is then removed and allowed to dry for 12 or 15 hours. The upper portion of the cast is pared to the pencil line, and the cut 248 lecontk— amputations and prosthesis. vol. xiii. edges are made smooth with molded plaster or adhesive tape. In this way an open cone is produced in which the two supporting sticks are incorporated. The apparatus is completed by joining the two crutch pieces of wood with a cross bar 3 or 4 inches below the end of the stump, and fitting the ends with a cylinder of wood to walk upon. The length of the apparatus should correspond to the length of the other leg without its shoe. When the stump is thick the internal wooden support should be placed a little anterior to the mid line, and the outer support a little posterior to the mid line, so that the bulk of the apparatus will not rub the inner side of the other leg. For high amputations of the thigh, the apparatus must be stiffened with iron. To the hook which holds the waist band a curved iron strap is attached, which will partially encircle the stump. On the anterior inner end of this strap a metal support or flange is riveted, which will rise to within an inch of the perineum. This is incorpo rated in the plaster, and if still more rigidity is required it can be riveted to the lateral wooden supports. For a disarticulation of the hip the apparatus is still further strengthened by riveting metal flanges to the upper end of the two lateral wooden supports before they are incorporated in the plaster. The apparatus is applied as follows: A stockinet cover is drawn over the stump with the end toward the foot left long. The stump is fitted into the plaster mold and the long end of stockinet drawn down and fastened to the crossbar. This downward traction on the skin relieves the wound and the end of the stump from all pressure. A suspender passes under the crossbar and over the opposite shoulder and a belt under the hook and across the crest of the illium on the other side. This fixes the stump in its mold. The patient is assisted in his first attempts at walking until he acquires a static position; then he walks with two canes, and very soon he will discard the use of even a single cane. In a couple of weeks he should be able to walk a mile or two without a stop. As the stump shrinks in size a new plaster mold is made. This change will be needed two or three times before the form of the stump is sufficiently permanent for the artificial leg. The two things which will do more to bring the patient out of the slough of despond that always follows mutilation are walking and work. The orthopedic treatment of the stump is helpful, for it shows the patient that you are personally occupied with his welfare. The object lesson of seeing other mutilated people happy and at work will give him the moral support needed to overcome this psychic depression —a feeling that life in the future will be vegeta tive instead of animal. Too much stress can not be laid on the No. 2. 249 LeCONTE —AMPUTATIONS AND PROSTHESIS. treatment directed toward the patient's regaining his moral tone, for on this depends the necessary stimulant to keep him from beggary. ARTIFICIAL LEG. The value of an artificial leg is confined to its static and dynamic functions, and it is good or bad, depending upon whether these func tions are good or bad. Every individual has his personal charac teristics in these two functions, depending upon the length and angle of the thigh, the length and curve of the leg, the relation of the axes of the knee and ankle, etc., and in no two individuals are all these measurements and angles the same. It follows, therefore, that if the artificial limb is to reproduce the functions of the lost limb, it must copy exactly the lines and measurements of the lost leg. Therefore any artificial limb which is designed for all men and adapted to the individual's use will fit no one. If the comfort of a man walking and working is to be compared with a man wearing glasses, the same precise surgical and mathematical skill must be displayed in obtain ing a perfect result. In either instance it is not a province that should be relegated to a skilled but ignorant workman, and belongs solelj7 to the orthopedist and eye surgeon, respectively. Up to the time that Dr. Martin made his intensive studies of the mutilated, the so-called American artificial leg was considered the best in Europe. It was designed on the following principles : 1. The axis of the knee and the axis of the ankle are supsrinpos- able in all points, since they are on the same frontal plane. 2. The axis of the knee and the axis of the ankle are parallel to each other and to the ground. 3. The longitudinal axis of the foot passing between the first and second toes passes through the middle of the axis of the ankle and, therefore, the knee. 4. The longitudinal axis of the whole limb passes through the mid dle of the thigh, the axis of the knee, and the axis of the ankle. 5. The plane of the longitudinal axis of the foot and of the limb forms with the midplane of the body an angle of 18J degrees, directed forward and outward. 6. The anterior border of the great trochanter, the external con dyle, and the external malleolus are all on the same vertical plane. These are contrary, almost in their entirety, to the anatomic prin ciples of the lower limb. They produce a straight leg devoid of normal angles, a foot externally rotated 18.5 degrees beyond the mid line of the body, which necessitates the mounting of the foot on the leg at an angle of 110 degrees instead of at a right angle, making a pes equinus (figs. 1, 2, 3. 4). The stump, on being applied to a straight leg, must be vertical, therefore in a position of abduction and external rotation, as the abductors are also external rotators. 250 LeCONTE —AMPUTATIONS AND PROSTHESIS. Vol. XIII. This faulty position at once vitiates the normal walking movement of the stump. It therefore requires a reeducation of these muscles, changing their normal walking movement to abnormal ones, with the consequent rapid exhaustion of the muscles. The patient, uncon scious of the anatomic defects, blames the weight of the artificial limb for his exhaustion, and consequently seeks a lighter apparatus, which again fails. There are few cases of mid-thigh amputation that do not prefer to walk with a peg leg, or, discarding all pros thetic support, use crutches. Practically none of these artificial limbs will stand alone, while an anatomically correct apparatus stands erect, as firm on the ground as a riding boot with its tree. DR. MARTIN'S PRINCIPLES. His principles are to reproduce in the artificial limb all the lines, curves, angles of deflection and joint axes of the individual limb lost, and he models the new limb on the measurements and projections of the leg remaining, reversing the projections to produce its counter part. The stump enters his apparatus in its normal obliquity, down ward and forward, and the muscles which control the movement of the stump will conform to their normal movements of walking in actuating the artificial leg. The scope of this article is only to call attention to the monumental and epoch-making studies of Dr. Martin, and is not a translation of his 107 -page monograph (La Prothese du Membre Inferieur, Masson et Cie., 120 Boulevard Saint-Germain, Paris, 1918) or his 44-page article which has not yet appeared in print. For a detailed descrip tion of his methods the reader is referred to these two articles, as an outline only follows: . . The Belgian artificial limb is made on a plaster mold of the leg, with thin ribbons of beachwood, overlaid in various directions, and cemented together with water-proof glue. It is about 7 mm. (^ths of an inch) thick. To make this mold the leg must be modeled in clay with its circumferences reduced to conform to the thickness of the artificial limb. Art and precision are required for this, and only an outline of the technique can be sketched here. A cast is made of the stump on which the position of the ischium, the anterior border of the great trochanter, and the oblique axis of the stump are marked. When these points are noted on the patient with an aniline pencil, the color will be transmitted to the mold and in turn to the cast. A frontal and lateral projection of the sound limb is made and reduced in its dimensions by three-fifths of an inch. The projections are re versed and mounted on an easel. The following measurements are taken with the patient standing on a specially devised stand, which assures a normal upright, erect position (fig. 5) : (1) Perineum to the No. 2. 251 LbGONTE —AMPUTATIONS AND PROSTHESIS. ground; (2) end of stump to the ground; (3) the most prominent point of the internal condyle to the ground ; (4)' summit of the in ternal malleolus to the ground; (5) length of the stump from the perineum. The measurements 2 and 5 when added must be the same as No. 1 (fig. 6). From the measurements taken from the sound limb, a knee and ankle are carved from a block of wood, and, as these are destined to take their place in the artificial limb, they are made with a slightly decreased circumference. The knee block is made hemispherical at its base to articulate with the leg piece. These two blocks of wood later contain the mechanism to control their re spective joints. The cast of the stump is suspended from a gallows on the easel in front of and touching the frontal projection so that its outline fol lows the outline of the projection and its axis the axis of the limb. (Fig. 7.) The position of the knee joint and ankle joint are care fully noted, and the wooden knee and ankle are fastened to each other and to the stump by a wooden prop or brace in their correct situation. (Fig. 8.) All measurements and axes are carefully veri fied. Modeling clay is used to complete the leg. (Fig. 9.) A thin coating of the clay is applied to the lower surface of the cast of the stump, to avoid all pressure from the artificial leg on this sensitive * region. If the stump has other sensitive points a little, clay on the cast will relieve them from pressure. From this model a plaster cast is made and divided into a thigh and leg piece. On these the rib bons of beechwood are molded, with a hot copper roller and water proof glue. The surface is smoothed and varnished and the leg is completed by articulating the foot, leg, and thigh pieces together. (Fig. 10.) The Belgian artificial leg is the only one that reproduces the natu ral static qualities of the lower limb, and in accomplishing this it reproduces the esthetic qualities also. It is waterproof and therefore easily cleaned. It can be made without seeing the patient, if the proper measurements and projections are taken, and a cast of the sound limb and stump accompany them. Its mode of construction, the materials used, and the articulations are all new and founded on scientific principles derived from a study of the anatomy and physi ology of the leg. Few skilled workmen are required to make the ap paratus, as a matjor part of the labor at La Panne is furnished by the mutilated themselves, and all of it was unskilled at the start. The cost of the limb at La Panne is well below the price of the American- made leg. The life of the apparatus is at present unknown, but there is every reason to believe that it will last for m*ny years. To Dr. Martin belongs the -credit ef being the <irst to place the rehabilitation of the mutilated on a sound scientific basis. He feels 103396—19 6 252 LeCONTE —AMPUTATIONS AND PROSTHESIS. Vol. XIII. Iff. rtf. r. Fief, s; Fig. 1.—Frontal projection of normal and American artificial leg. Angle of femur 12°, leg 2*. Vertical line near external malleolus. Fig. 2.—Lateral projection of normal and American artificial leg. Genu recur vation 5° above joint, 4° below joint. Fig. 3.—Horizontal projection of normal and American-made foot. 1. Axis of the knee. 2. Axis of the ankle. 3. Axis rotation of foot. a. Longitudinal axis of foot 6. Longitudinal axis of leg. c. Midline of body. Fig. 4.—Normal foot: American-made foot. Fig. 5.—Stand for taking measurements. SS2— 1 Fig. 6.—Scheme of measurements. a=angle of external deviation of foot. Fig. 7.—Frontal projection and cast of stump. Fig. 8.—Mounting of knee and aukle. Fig. 9.—Clay modeling of limb. Fig. 10.— Belgian artificial limb. 253—1 • ••• No. 2. 253 LkCONTE AMPUTATIONS AND PROSTHESIS. 254 PUGH—EDUCATION AND SANITATION. Vol. XIII. that he has only just touched the subject, and that very many prob lems are still to be worked out. The effort at present to solve these problems is not sufficient and lacks coordination. Collaboration is needed between the surgeon, the orthopedist, the manufacturer and the technician, and the research work should be centralized in one institution for the proper coordination of the efforts of these experts. This war has already produced scores of thousands of mutilated, and makes imperative our duty of rehabilitation for these unfortunates. Dr. Martin expresses the hope that some day, soon, he will see one of the great countries injured by this war, establish such an institu tion of prosthesis, which will rise under the aegis and protection of an enlightened philanthropy. To quote him, " it would be a work of true and sane philanthropy, a source of great happiness to the am putated, and of economy to the nations." EDUCATION AND SANITATION ABOARD SHIP. By W. S. Puqh, Commander, Medical Corps, United States Navy. Few enlisted men and a relatively small number of young officers have any conception of the necessity of preserving a good sanitary condition of the ship. The correction of erroneous ideas in this matter is to my mind one of the most important duties of the naval medical officer. He must also be able to demonstrate the necessity for new appliances, and the results to be obtained by them must be made quite clear. The seagoing man does not welcome innovations, particularly those which require the expenditure of a little effort. As an example we will cite the following: A new system of heating and ventilation, combined with a humidity control, was placed in operation on this ship. The response from everyone concerned was not, "Well, we will try and see how it works," but "That thing won't work; it might as well be taken out." When a fair trial was insisted on, and carried out, it worked very well indeed. In order to overcome the opposition of ignorance the medical of ficers of this vessel decided on a campaign of education. In the first place a chart of the ship, showing all the decks and billets, was pre pared from a blue print and kept in the medical officer's office. Be side each billet number there was a hole for a pin and the following colored pins were used : Common colds , Black Scarlet fever Scarlet Tonsilltls White Influenza Violet Measles Pink Meningitis Green Pneumonia Yellow No. 2. 255 PUGH—EDUCATION AND SANITATION. Of course, the most usual condition was that of common colds. These will invariably appear in groups, and when this occurs it is customary to call in the division officer and the petty officer of the compartment. The medical officer then informs them that the case has been investigated and certain things have been found wrong. When these have been corrected those concerned are shown that their pins have disappeared. Splendid results have been achieved in this respect not only with common colds, but with several other forms of transmissible disease. THE SCUTTLE BUTT. This appliance is one of the most important elements in the preser vation of health when properly used and one of the greatest factors of evil when incorrectly used. Conditions such as tonsillitis, pharyngitis, bronchitis, and other affections of the respiratory tract are at times directly traceable to the scuttle butt. To prevent these conditions the appliance must be kept thoroughly clean, and the following or similar regulations posted on it in a glass-covered frame : 1. Don't press lips to scuttle-butt terminals. 2. Don't spit in scuttle butt. 3. Attendant will flame terminals twice daily with blow torch. The second sketch on page 259 is attached to the above. If neces sary a sentry should be placed on scuttle butts. INFLUENZA. just before the epidemic of influenza struck the fleet the following sanitary bulletin was isued for the information of officers and men : U. S. S. " Mississippi," 15 September, 1918. Subject: (a) Sanitary Bulletin No. 6. (b) Influenza. 1. Influenza or " grippe " is more contagious than measles. Though it is common enough at all times, there have been several epidemics. In 1889-90 there was a world-wide epidemic In which three-fourths of our city popula tions were affected. It is caused by a germ—the bacillus of influenza. The infection is introduced through the nose and throat It spreads most rapidly where people are crowded, as on a ship, because the air becomes filled with germs from the coughing and sneezing of those who have the disease. It is like a " common cold," but Is of greater severity. 2. Symptoms: It may begin within a few hours after infection, or may not appear for several days. It begins suddenly with fever, headache, pains in back and shoulders, and feeling of weakness. Coughing and sneezing appear early in the attack. The cough is at first dry and hacking, and may be accompanied by the sensation of suffocation. There are many complications which occur. Pneumonia appears to be common in this epidemic. After recovery a feeling of depression is liable to last a long time. 256 Vol. MIX. PtTGH— EDUCATION AND SANITATION. top tie Dope Do Use. A, Hanky ft££P OUT oF CROW^ GeT u5p- offtp Aju Use toia own ToilIT tens J)wins 'fiwwate /Icap lb •fooT Import &T 5fd Bat ifSet «f> L 'C D (f £ L0/ JUAKL 1fe. a itomC.diP' No. 2. 257 PUGH— EDUCATION AND SANITATION. &XP05UR.E III Jiat is one war of tfettintf colds AND ftVOID GOLD5. J$L^_ • • • P HOPE It WAY WHEN MUNMIW AT THE KEEP YOUR II Rf OFF THE METAL PAR.T5. 258 PUGH—EDUCATION AND SANITATION. Vol. XIII. 3. Prevention : It Is a dangerous disease and will, if we should have many cases, make it difficult to " play the game." We have not a single case aboard. Help us to keep clear of It. When coughing or sneezing place a handkerchief In front of your face. Swing your hammock head to foot Keep out of crowds. Don't use anyone else's towel, handkerchief, or cup. Get lots of fresh air. Report at " sick call " If you have a " cold." If you rate a " 48," paste this In your hat : Avoid the hug, Avoid the lip, Escape the bug That gives the " grippe." Approved for publication. (Signed) B. F. Hutchison, Captain, V. 8. Navy, Commanding. The object of these bulletins, which are issued to officers and men, is to acquaint them with the facts so that they will be encouraged to report to the medical officers in the early stages of the disease, thus aiding us in obtaining early recoveries without complications. In the sanitary lectures given to officers much stress is placed upon communicable disease and its relation to sanitation. Officers are given instruction as to how this information may be imparted to the men without causing undue excitement. During the presence of the disease on board the moving-picture projection was utilized and between the reels points bearing on the situation were thrown on the screen. These were in the nature of advice and where possible were combined with cartoons. The lan guage used was that of the men—" real old United States "—so that there could never be any doubt as to its meaning. These or similar sketches were thrown on the screen every night and soon became a very interesting part of the show. A little later the following bulletin was issued: U. S. S. " Mississippi," 8 October, 1918. Subject: (a) Sanitary Bulletin No. 7. (b) Present Status of Influenza. 1. Influenza is with us, but It is mild. We have had very few cases, and the majority of these have not been severe. We have fared better than the other ships In the fleet. A number of deaths have been reported from other ships. We have not had a single death. Only three of our patients have been sick enough to necessitate transferring them to the hospital ship, and these are now on the road to recovery. We now have 15 cases, and 8 have been returned to duty. These fine results are not a matter of luck; they are due to the splendid cooperation of the officers and men of the Mississippi. Keep up the good work. 2. When coughing or sneezing place a handkerchief In front of your face. S. Swing your hammock head to foot Ji». 2. 259 PUGH—EDUCATION AND SANITATION. a Iceep t up beys. fbiLow w Doc torsJVC and THE WR0N6 WAY • THE COftfttU WAV 260 Vol. XIII. EUGH— EDUCATION AND SANITATION. MHTdPlTOH to <? ORjWJA)Df WILL GET YOU. Question-Id- Wff£Itf WILL 1 WhSti ? ePoHT K I Mil iS5lt No. 2. 261 PUGH —EDUCATION AND SANITATION. 4. Keep out of crowds. 5. Don't use anyone else's towel, handkerchief, or cup. 6. Get lots of fresh air. 7. Report at sick call If you have a " cold." 8. A clean ship is a healthy ship. CLEAN 'EM UP, " MISSISSIPPI." Approved : (Signed) B. F. Hutchison. Captain, United States Navy, Commanding. The anti-influenza campaign along the above lines was highly successful. Petty officers would bring in their men and other mem bers of the crew would report in and make the medical officer cogni zant of things that otherwise would have escaped his notice. CAMPAIGN AGAINST BOILS. My coworkers and I are strong believers in the dirt theory for the etiology of boils, so that on the appearance of a number of cases of boils the following sanitary bulletin was issued : U. S. S. "Mississippi," 21 October, 1918. Subject: (a) Sanitary Bulletin No. 8. (6) Boils. 1. Boils, in ordinary terms, signify poisoning of a part of the body. The poison is an easily recognized germ which enters around the skin pores. 2. How do these germs get there? They are planted by the dust and dirt that gathers on your body and is rubbed in thoroughly by your clothes. 3. Who are the most susceptible? (1) Those who are dirty and wear dirty clothes. (2) Mess cooks and those who work in offices or who have charge of compartments and never, or seldom, get Into the fresh air. 4. Why are these people attacked? Because they shun the fresh air and sun shine, nature's greatest aids in the preservation of health, thereby lowering their resistance. Bolls are very great factors tending toward inefficiency, and n person affected with them is as a rule totally or partly incapacitated for his duty. In times like the present, when all must be fit to fight, boils should be regarded as first aids to the Kaiser and the Clown Prince. 5. The pus Is highly infectious and readily transmitted to other persons. Do your duty —take a bath frequently and scrub thoroughly. Wear clean clothes. Get as much fresh air and sunshine as possible. CLEAN 'EM UP, " MISSIS SIPPI." Approved : B. F. Hutchison. Captain, United States Navy, Commanding. This was shortly followed by a routine order, which we prepared for the executive officer, as follows : V. 8. S. " MISSISSIPPI." Routine Order No. 7. Attention of all officers is Invited to the fact that filth Is the most important factor in the propagation of disease, and that cleanliness is the best weapon with which to combat it 262 Vol. XIII, PUGH—EDUCATION AND SANITATION. 5 WIN<j JIAMM0CH3 HEAD TO fOOT VntN ifou $n Tut (tynES JpONT TAKE 1»G IN J/OWL, JJOUTH-OAMCRE-OFLIP, Mo. 2. 263 PUGH —EDUCATION AND SANITATION. A marked relaxation in the matter of personal bodily cleanliness has been noted among the members of the crew, which, along with the tendency toward use of filthy underwear, undoubtedly accounts for the many cases of bolls and abscesses among the crew. Officers will Impress upon their men the great necessity for a general bodily bath at least twice a week, with a change of underwear at the same time. (Signed) O. C. Dowlinq, Commander, United States Navy, Executive Officer. In connection with the above, the accompanying representative cartoons were used on the projectograph. ANTIVENEREAL CAMPAIGN. Our venereal propaganda has been conducted along three lines : 1. Moral. —In this the services of Chaplain Frank Lash, a very active worker, were enlisted, as it seemed to me that this was dis tinctly within the scope of the duties of his office; hearty coopera tion was obtained, and I think considerable good accomplished. 2. Educational. —The stereomotorgraph was secured and the series of films worked up by the camp community committee were used in connection with a lecture to small groups until every man in the ship's company had heard the lecture and seen the pictures. Moving pictures were brought into play and Brieux's famous story, " Dam aged Goods," was secured. This is a very effective picture. The soldiers' film, " Fit to Fight," was also produced, and was found very good. It is most surprising how many men will report and request an examination following an exhibition of these pictures. The accompanying representative cartoons were then made and shown on the screen by means of the projector. 3. Venereal prophylaxis. —Every effort was made to have the men report for prophylaxis immediately on return from liberty or, if pos sible, at the Army station while on leave, the regulations of the de partment being shown for their benefit. The results of the campaign were more than satisfactory. Following our propaganda there has been a very marked lowering of the sick rate coincident with a marked improvement in the cleanliness of the ship. The cartoon No. 13 appeared after a campaign and illustrates the success of our educational campaigns. INSTRUCTION FOR LINE OFFICERS. In addition to the foregoing the following sets of lectures and prac tical demonstrations are given for the instruction of line officers. First-aid lectures will be given by the surgical officer and will cover the following : 1. Wounds by firearms and cold arms, particular attention being given to the application of shell-wound dressings and first-aid packets. 264 Vol. XIII. PUGH —EDUCATION AND SANITATION. You aw i NO MA/T5 LAND HAVEYOlffcftH JHER.E? Ttl£.H DCWT fOROET TO ... TAKE VMkEDL IMMEDIATELY UPON TOUR. No. 2. 265 PUGH—EDUCATION AND SANITATION. 1k WM m nf nor Su up in Reei WATCH 1fe jmjm JULLETI/Jf MD fOLOW otoiL^ iMDICftJt I) DIRTY JfllPy CLOT J>qil5 ci(ifpit GiroOff ^HMttT "fed £Y HAVfMG CLEMT iOPlp" AND ClEiA ClOTflgT. AX SvSv / 103396—19 7 266 PUGH—EDUCATION AND SANITATION. Vol. XIII. 2. Hemorrhage, including the application of the tourniquet, partic ular emphasis being placed on the adjustment of this appliance, its proper use as well as its dangers. 3. Emergency treatment of fractures and dislocations. 4. Drowing cases. 5. Effects of heat and cold. 6. Common poisons. 7. Transportation of injured. -Sanitation. —Lectures on this subject will be given by the sanitary officer. This course is given with the idea that many officers will be ordered to ships or small camps where the services of a medical officer are not available. It will also assist the medical officer in obtaining the cooperation of his brother officers of the line. Without this union of effort on a ship, be it large or small, the health of the crew will suffer. This course will be given by an officer particularly con versant with this line of work. It will largely consist of general principles of health and hygiene that anyone will be able to grasp. 1. Air aboard ship, heating and ventilation. 2. Berthing of the crew and its relation to disease transmission. 3. Water supply and its care —scuttle butts, lavatories, wash rooms, etc. 4. Toilets and their care; their relation to disease transmission. 5. Clothing and bedding of the crew. 6. Dangerous occupations. 7. Sanitary police. 8. Landing parties and camp sites. 9. Sanitary policing of camps. 10. Water supply. The disposal of refuse, garbage, etc. 11. Diseases of camp and their prevention. HISTORICAL. JEAN DOMINIQUE LARREY, 1766—1842. Jean Dominique Larrey was born in the village of Baudean in the department of Hautes- Pyrenees on July 8, 1766, and at the age of 13 went to Toulouse to complete his preliminary education and later take up the study of medicine in the professional schools where his father's brother was in high repute as a teacher. At 21 Larrey went to Paris where he came to the notice of the eminent Louis.1 After due competitive examination Larrey was appointed a surgeon in the vroyal navy of France and went for a cruise in North American waters on the Vigilante. The voyage over, the young doctor resigned his commission, went to Paris and re sumed his professional studies at the Hotel Dieu and the Invalides. Three years later we find him in the Army of the Rhine serving under Kellerman and winning favorable comment from his mili tary superiors just as he had from his commanding officers in the navy. After the action of July 22 he was mentioned in despatches by Beauharnais and officially commended in the " Moniteur." It was during the campaign of 1793 that Larrey, painfully im pressed by the utter lack of system in caring for the wounded, con ceived the idea of organised effort on military lines to give imme diate and adequate succor to the victims of battle. Usually, the wounded remained where they fell until the fighting was over, rarely receiving the surgeon's attentions until 24 hours had passed. In case of defeat they were abandoned. The mortality in the field was tremendous. Larrey decided that the surgeon ought to go to the wounded and that aid must be a matter of routine, adminis tered with the same system and on the same status as any other military measure, deeming the hospital provisions three miles in the rear, called for by army regulations, wholly inadequate. The nearest approach to first-aid treatment in our modern sense was furnished by the " wurz " of Percy 2 " a sort of long, narrow caisson containing instruments and dressings with a top, round as a pudding, astride of which perched the surgeons who could jump 1Pierre Charles Alexandre Louis, who named typhoid fever and Insisted on the im portance of carefully prepared statistics In estimating the value of a given therapeutic measure. ' Pierre Francois Percy, 1754-1825. 267 268 HISTORICAL. Vol. xm. down and as quickly resume their places. Each ' wurz ' was drawn by six horses and manned by eight surgeons and eight attendants, the latter seated on the chests at the front and rear or riding the horses that drew the vehicle. The whole affair carried the necessary supplies for 1,200 wounded. Under the driver's box were stretchers to carry from the field such patients as could not walk. The ' wurz ' could maneuver with the speed of field artillery and went on the firing line." * Larrey modified the Percy idea as to the transportation of the wounded, but went far beyond him in arranging for a systematized service of ambulances and movable hospitals or dressing stations as an integral part of the organization of the army as a whole. His flying hospital legion was placed under the control of the chief surgeon of the army. It consisted of various medical divisions, the division being a unit designed to meet the needs of a military division. These units could be multiplied as required if divisions were com bined to form army corps or subdivided to accompany brigades and smaller formations. In any event medical personnel and ma teriel was always available at short notice. The administrative work of a division was handled in two sec tions. One was composed of a commissary and various subordinates, 12 mounted and 25 unmounted sick attendants, all soldiers, and a drummer. The other section consisted of 12 light carriages and 4 heavy vehicles, each with a man in charge, and a driver, a horseshoer, and a bugler. The personnel of the medical division numbered 113 persons. The division was formed of a number of subdivisions each with a directing surgeon and 15 subordinate surgeons of various ranks. The light vehicles drawn by one horse, or two if the terrain was difficult, were on springs, " easy running, furnished with mat tresses, padded sides and pockets for supplies." They collected the wounded and evacuated them to the heavy wagons which bore them to the principal dressing station or hospital beyond the battle area. The serious cases were attended to where they fell, and emergency surgery was done under fire. Larrey's scheme was put to the test for the first time during the operations before Metz in 1793 and gave such general satisfaction that he was ordered to assemble the necessary ambulance units for 14 armies of the Kepublic. Larrey was now designated chief surgeon of the expedition or ganized to wrest Corsica from the British. The British blockade of Nice, where the force assembled, interfered with the execution of the program, and Larrey profited by the delay to hurry to Paris for his marriage with a daughter of Laville-Leroux, a former min ister of finance under Louis XVI. 1J. Ambert : Le Baron Larrey ; Cosse et J. Dumaloe, Paris, 1863. No. 2. 269 HISTORICAL. At Toulon, Larrey acted as instructor in surgery and anatomy in a school gotten up for the benefit of the younger medical officers of the land and sea forces until his labors were interrupted by orders to occupy a chair in the newly created military medical school at the Val-de-Grace. Scarcely had he assumed his new functions when he was summoned by Napoleon beyond the Alps to superintend the oper ations of the " flying ambulance " for the Army of Italy. Bernadotte wanted him. besides, to take measures against the epidemic which was killing off the cattle of Friuli. Napoleon witnessed in person the evolutions of Bernadotte's " ambulance volante " and at their con clusion said to Larrey : " Your work is one of the happiest conceptions of our time." Returning from Italy, Larrey went to work again at the Val-de- Grace, but he was not left undisturbed for long. The campaign in Egypt was about to begin and his presence with it was now considered indispensable to the army. Some of the incidents of his adventurous and varied life at this period are worth recalling. After the battle of Aboukir Bay, Larrey had to amputate the right arm of Gen. Figuiere, who declared that he would never be able to draw his sword again and therefore presented the magnificent damascened blade to Napoleon who had attended him during the ordeal of operation. The latter accepted the gift and presented it on the spot to Larry with the remark : " He saves your life." Larrey established military hospitals in Cairo and a school of medicine and surgery for the medical officers of the army. During the stay in Egypt he made a painstaking study of Egyptian ophthal mia (trachoma) which threatened to become epidemic among French troops. On the expedition into Syria Larrey realized that his ambu lance carriages would be insufficient and had constructed a hundred long, open paniers, for a single patient each, to be carried as stretchers or drawn by mules. Napoleon has been reproached for his desertion of Kleber, but we may remember in his favor how, when means of transportation failed for the 10,000 wounded that complicated the evacuation of Palestine and a march of 180 miles across the desert, he assigned all the horses belonging to the staff to the use of the medical department and set an example of generosity by himself leading the way on foot.1 An example of Larrey's sense of duty to his patients is furnished by the following episode, unpretentiously set forth in his "Memoires de Chirurgie militaire et Campagnes." " I had barely time to load the wounded man 2 on my shoulders and bear him back toward our army, which was beginning to retreat. A series of holes or caper- tree trenches that I had to traverse saved me, for the cavalry could ij. Ambert : Loc. clt. *Gen. Silly, wbose leg had been crushel by a cannon ball. 270 HISTORICAL. Vol. XIII. not follow a route so cut up, and I reached our rear guard ahead of the enemy's dragoons. At last I got to Alexandria with my worthy patient on my back and there succeeded in curing him." After the campaign in Egypt, Larrey was appointed surgeon to the consular guard, and later made inspector general of the health de partment of the French armies. Meanwhile he had been selected for membership in the recently organized Legion of Honor, receiving the decoration at the hands of Napoleon himself, who remarked : "A well-deserved honor." When the Emperor collected a vast array of stores and assembled a huge army at Boulogne for the invasion of England, Larrey was at hand with a fully prepared medical service. " You came near being ready before I was," said Napoleon drily, as he remarked his chief surgeon's ceaseless activity. Larrey participated in all the principal campaigns after the rupture of the treaty of Amiens. He was present at Austerlitz, Jena, Eylau, Friedland, and Wagram. On the field of Eylau, Napoleon made him commander of the Legion of Honor. At Friedland, as everywhere, Larrey lavished his professional attentions on friend and foe alike. A wounded Eussian officer has described how he had been left for dead on the battlefield and robbed by marauders of his very clothing, and when he was finally found and carried to the dressing station the great French surgeon not only dressed his wounds, but supplied his deficiency of attire from his own wardrobe. The medical school of Jena conferred on Larrey the degree of Doctor of Medicine in recognition of his high attainments and no bility of character. During the peninsular campaign Larrey con tracted typhus fever and narrowly escaped death. On convalescing he rejoined Napoleon in Austria in time to be present at the battle of Essling. It was on the island of Lobau that Larrey concocted his famous broth for the sick and wounded. There was a dearth of all supplies, but he ordered his own chargers killed to supply the meat. There were no cooking utensils so the helmets of the cuirassiers were requisitioned. Gunpowder was substituted for salt as a condiment. Gen. Massena drank the first bowl of this concoction without suspect ing the nature of its ingredients. While Larrey was teaching and practicing his art during the French occupation of Vienna Napoleon made him a baron of the empire, with an annuity of $1,000. The great heart, the intrepid soul, the redoubtable energy of Larrey never showed to greater advantage than during the ill-fated campaign of 1812. His generosity, patience, tender devotion, and self-sacrifice were seconded by his ingenuity and resourcefulness. At Smolensk no lint was to be had for surgical dressings. A sort of tow made from the shred of the birch was used instead. Paper dressings replaced those of linen, the source of supply being the No. 2. 271 HISTORICAL. archives of the city. At Moskowa Larrey remained behind for 72 hours and worked day and night to relieve the sufferings of the thousands of wounded French and Russian soldiers. Thiers says that on this occasion he was " the benefactor of all sufferers." Speak ing of the retreat from Moscow Thiers, in his "History of the Consulate and Empire," recalls that the momentous decision to at tempt it was opposed by Larrey, " one of the best informed witnesses of the situation who believed that there were in the city ample provisions for a six months' sojourn." " Unfortunately, no attention was paid to his opinion," says Ambert.1 " Surgeon Larrey," says Thiers, " through his inexhaustible kind ness, had gone ahead to help the wounded at Kolotskoi as far as the brief stop there permitted. He arranged for the removal of those able to travel and lavished on the others the highest resources of his art. When he discovered there certain Eussian officers who owed their lives to his services and were profuse in their acknowl edgements, he required them to pledge their word of honor that from the approaching moment of their liberation, when they would become masters of the fate of those whose plight they had recently shared, they would repay to them the good they had received at the hands of the head surgeon of the French." In the memorable retreat from Eussia Larrey marched on foot, surrounded by his assistants, in the center of the long column of starving, shivering soldiers, setting an example of fortitude and cheerfulness to all. He put his own canteen to the lips of the dying and shared his meager ration with the hungry; he encouraged the weary by every means in his power; as the men fell to the ground he picked them up and revived them. He was everywhere sustaining, helping, cheering ; urging on the stragglers ; changing the dressings of the wounded, inspiring the disheartened with fresh hope. At night he wandered about among the wounded seeking to relieve their pain, and to those who were past all hope from surgery he addressed words of spiritual consolation. The passage of the Beresina was in the nature of a stampede under the decimating fire of the Bussians. Larrey got across with the remnants of the imperial guard, but had scarcely reached the farther bank when he discovered that the boxes containing certain important surgical instruments had been left behind. In spite of the urgent appeals of his companions Larrey retraced his steps and forced his way to the other side. When he finally sought to rejoin the main body his retreat was cut off by the dense mass of soldiery fighting for a foothold on the shattered bridge which the sappers and miners had finally been able to make passable. He would have been trampled to death by the maddened host of fugitives if some of the common 1 Loc. clt. 272 HISTORICAL. Vol. XIU soldiers had not recognized him and taking him in their arms forced a passage for themselves and their precious burden. In the campaigns that closed Napoleon's meteoric career his armies were made up to a large extent of raw young conscripts. Many of these were found after an engagement with mutilated hands. It was represented that these wounds were self-inflicted, and the Emperor was first overwhelmed with mortification and then fired with wrath. He proposed to make severe examples of the guilty. Terror invaded the ranks and the report was current that 1 man in every 20 would be executed. Larrey, who had carefully examined many of these wounds, stoutly maintained that they were not self-inflicted. He went before the Emperor and demanded an official inquiry into the subject before punitive measures were instituted. Napoleon grudg ingly consented, and some 2,000 youths, all suffering from wounds of the hands, were lined up in the precincts of the customhouse just beyond Bautzen. A painstaking examination was conducted by five army surgeons, a high ranking officer of the line, and a captain of the gendarmerie chosen by the provost marshal. For each man a care fully prepared report was drawn up after Larrey himself had in spected their hands and satisfied himself that the wounds were due either to the fire of inexperienced comrades in arms drawn up behind them or to the enemy's fire when the conscripts attacked up an in cline carrying their pieces high in front of them, covering face and chest, instead of at the hip. Larry went in person to report the results of the investigation. " Well, sir," said Napoleon in a tone of irritation, " do you still per sist in your opinion '( " " I do more than that," said the intrepid doctor, " I come to prove it to your majesty." He detailed the minute inspection to which the cases had been subjected and assured the Emperor that brave and worthy men had been grossly misrepre sented. " Very well, sir," said Napoleon testily, " I will attend to the matter myself." When Napoleon had satisfied himself of the soundness of Larrey's judgment he appeared before him in a state of profound emotion and paced the floor for some time, Ms arms crossed, his head sunk on his chest. Suddenly he halted before the surgeon exclaiming, " Good bye, Mr. Larrey. A monarch is fortu nate indeed who has near him a man such as you are. You will re ceive my orders later—wait." The Emperor seized Larrey's hands in his, then threw his arms around him in a warm embrace. The next moment he hurried from the apartment. An hour later Larrey was informed that he had been pensioned by the State and presented by Napoleon with a miniature likeness of himself set in diamonds. When Napoleon was banished to Elba Larrey wanted to accom pany him but the great leader bade him remain, declaring that he belonged to the soldiers of France. No sooner had Napoleon effected No. 2. 273 HISTORICAL. his escape than he summoned Larry to the Tuileries and publicly expressed regret at not having done more to reward his meritorious services. In the retreat from Waterloo Larrey's horse was shot under him by pursuing Prussians and he himself received two saber wounds. Later he was taken prisoner and at first mistaken for the Corsican, as he was wearing at the time a gray cloak exactly like Napoleon's. When his captors discovered their error they remembered that he had fired on them in attempting to escape and in their irritation promptly stood him up before a firing squad. Fortunately the Prus sian surgeon who advanced, handkerchief in hand, to bandage his eyes recognized Larrey from having been one of his pupils in Berlin. By threats and prayers he secured a stay of execution —or murder— and had the prisoner taken before Gen. Bulow, who in turn referred the case to Bliicher himself. During the Austrian campaign Larrey had been instrumental in saving the Prussian marshall's life and the debt was now discharged. Larrey was set at liberty and escorted to safety by one of Bliicher's own aids. After a brief period of oblivion following Napoleon's fall Larrey was restored to favor under the reinstated Bourbon government. A unanimous vote of the chamber of deputies renewed his pension. Louis XVIII appointed him surgeon of the royal guard. Under the government of Louis Philippe, Larrey was appointed senior surgeon to the Hotel des Invalides. About this time he worked out the de tails for the organization of the medical corps of the Belgian Army. In 1834 he went to Italy for the express purpose of seeing Napoleon's mother and other members of the Bonaparte family whom he loved for the sake of the fallen leader. When in 1840 Napoleon's remains were brought from St. Helena for interment in the splendid mausoleum prepared for them on the banks of the Seine, Larrey, now 74 years old, followed the procession, bareheaded and on foot, all the way from the Arc de Triomphe, though it was bitterly cold, the coldest day of the j^ear. He was dressed in the uniform he had worn at Wagram. Tears streamed from his eyes. At 76 Larrey, who for some years had been forgotten and ignored by the public in spite of all he had accomplished for his country (he never uttered a word of complaint), was sent on a tour of in spection of the military hospitals in Algeria. He died in Lyons within a few days of landing in France after completing the duty assigned. While his son was ministering to his last needs on earth a letter from Paris announced the death of Madame Larrey. In 1850 a statue was set up to the memory of Baron Larrey in the grand courtyard of the Val-de-Grace. This ceremony was an occa sion of national importance, and eulogies of the great surgeon and 274 Vol. XIII. HISTORICAL. good man were pronounced by many eminent in science or high in army and Government circles. Among the speakers was Roux,1 representing the Academy of Sciences. His estimate of Larrey is in teresting. He calls him the hero of humanity, the idol of the French soldier, and in quoting the famous words of Napoleon's will—" Larrey is the most virtuous, the most upright man that I have ever known "—recalls the fact that Marcus Aurelius used almost identical language in regard to Galen, and Louis XIV in regard to Lamoignon when urging him to accept the presidency of the parliament of Paris. On the professional side he credits Larrey with great ability as a military medical officer, as an organizer, as a pioneer in the adequate and systematic relief of the wounded. He calls attention to Larrey 's use of debridement (a word heard often to-day) in gun shot wounds, to his fine work in the treatment of fractures by im mobilization, his belief in the prompt amputation of limbs where the destruction of tissue has been excessive, his studies of frostbite, his method of disarticulation at hip and shoulder, but condemns Larrey's disinclination for the primary suture of wounds. The favorable and unfavorable comment are alike a panegyric of a sur geon who had neither aseptic nor antiseptic methods, much less an ancillary bacteriological laboratory at his command, but whose patients got well. Larrey left an imperishable name. Other men have devised op erations, worked cures, contributed to the progress of science, but their names are known only to the student who disturbs the dust on the worm-eaten records of medical history. Larrey's fame is a living inspiration, because back of his native talent and the skill acquired through laborious effort there shines a character made beautiful by purity, unselfishness, and unassailable integrity. A single sentence from Napoleon's testimony to Larrey's virtue has been quoted a thousand times. The rest of what he said is not so well known. The omitted sentences are practical and specific. They contain a wonderful rebuke to the military surgeon who can always be found at headquarters, to the Navy doctor who attempts to administer the sick bay from the wardroom and wins a favorable report by playing a good hand of bridge in the cabin. " In the most inclement weather and at all times of the night or day Larrey was to be found among the wounded. He scarcely al lowed a moment's repose to his assistants and kept them eternally at their posts. He tormented the generals and disturbed them out of their beds at night whenever he wanted accommodations or assist ance for the wounded or sick. They were all afraid of him, as they knew he would instantly come and make a complaint to me. He paid court to none of them." 1 Phllibert-Joseph Roux, who succeeded Dupuytren at the Hotel Dleu of Paris and was a pioneer In operative gynecology. No. 2. 275 HISTORICAL. EXTRACT FROM A SURGICAL MEMOIR READ RY BARON IARREY BEFORE THE ROYAL ACADEMY OF FARIS, FEBRUARY 19, 1819.1 Translated by G. A. Lcnq, Captain, Medical Corps, United States Navy. The merit in this translation is its value as an Incident In medical history. The operations described were performed by one of, if not the most famous of military surgeons known. They are conspicuous in that they were undertaken at a time when few surgeons had the hardihood to undertake such tasks. Anesthetics were unknown. Hemorrhage during operation, suppuration, and secondary hemorrhage were always likely complications that deterred many surgeons from entering into fields where now they safely venture. At the time that Larrey performed these operations the armamentarium of the surgeon, except for certain elegancies and refinements, was much as it is to-day. Suppuration was regarded as inevitable and accepted as a matter of course. Where it did not occur In abundance and for a protracted period it evoked some surprise and a profound 'sense of satisfaction in the surgeon. Such a happy condition, when It happened, was probably due to some fortuitous act in the ordinary effort at cleanliness, or some fortunate action of the various substances that were applied In the dressings. Of course, too, It Is to be ob served that certain patients in combination with other favoring circumstances may have been spared infection through their own natural powers of resistance. Larrey's success in this respect may have been largely due to his use, for a period prior to operation, of tonics to build up the health of the patient and thus increase his resistance to suppuration and shock. It is also possible that his practice of using mercury locally for a period prior to operating may have had something to do with the rapid recovery from the immediate effects of the operation. The case of Nicholas Moret is interesting because the detail and exactness of the description of his case by Larrey makes It resemble the record of a hospital patient of yesterday. He calls the affection a tumor, but implies that it was a cancer that had not yet undergone " cancerous degeneration." From his very careful description of its appearance, location, size, structure, i'nd duration, it was in all probability a lympho-sarcoma. The points conspicuous in Moret's case are: The surgeon's great anxiety to control the hemorrhage; that the wound was cleaned and a styrax ointment was applied covering the entire area of the operation; that the patient bore the operation with great courage, and that he suffered a period of what is now termed surgical shock ; that the operation was accomplished in 50 minltes ; that the wound healed in 31 days. In the volume from which this translation was made there appears a wood cut depicting the appearance of the tumor before operation. The case of Madame de L. is even more interesting. Judging from the descrip tion of Its appearance it must have been a carcinoma. Larrey's method of extirpation of the cancer was essentially the same as the accepted one of this day and described In text books as the Halstead operation. It is amazing to think of one undertaking these operations without an anes thetic, and equally so to read how promptly the patient recovered. The case of Madame de L. was one of several Larrey operated on successfully. In the record of the Moret case he states that he had removed the breasts of 15 or more women afflicted with cancer, and that no recurrence manifested Itself in periods of from 3 to 10 years following. »From "Tralte de la Maladle Scrophuleuse," by C. C. Heufeland, Paris, 1821. 276 HISTORICAL. Vol. XIIL In this translation the writer makes no claim to being proficient in Uk» French language. It was literally dug out with the use of the dictionary and, on occa-' sions, with other help. It is offered as a small contribution to the study of medical history. I am not aware that It has been translated. DESCRIPTION OF AN UNUSUAL OPERATION, TOGETHER WITH SOME OBSERVATIONS ON THE NATURE OF THE DISEASE NECESSITAT ING THIS OPERATION. If the nations have experienced deep afflictions as the result of the last war, which extended its theater of operation throughout all of Europe and over a part of the New and Old Worlds, humanity has found in French surgery a real source of consolation. And during this memorable war this art has made such great progress, it has, per haps, attained its highest degree of perfection. The numerous and bloody conflicts which our armies endured in all countries have supplied military surgeons, guided by leaders full of years of devotion, with numerous opportunities for experiments, whose happy results have served to simplify many surgical problems hitherto considered insoluble. But in order to reach this much- desired goal, military medical officers have had to unite genius and intelligence to a firm and indomitable courage, by which they have braved dangers, surmounting all obstacles and opposed by prejudice and routine. If we may presume to mention ourselves among those gentlemen who have distinguished themselves in these matters, we shall remind the Academy of Science of those memoirs on the principal points of our art which we have had the honor to communicate to it at various times. May it permit us, however, to refer again to the subject of some of the most striking of these memoirs. Some had undergone, according to a method of our own, amputa tion of the arm at the shoulder, others that of the thigh at its upper joint, others, again, opening' of the chest with resection of a rib for the extraction of missiles lost in that cavity. In short, many others, not less remarkable, have specially attracted the attention of the commissaires receiving these memoirs. The skill we have acquired in the practice of these large and difficult operations has made us undertake, against the advice of several famous surgeons at this capital, the one that is the subject we are about to report, and the observations which accompany it. Nicholas Moret, aged 40, farmer, born and living in the country about Louviers, of a robust constitution but with scrofulous idio syncrasy, presented on the left side of the neck a tumor, lobular, slightly mobile, indolent, and without any change of color of the skin. It stretched from the mastoid process, along the jaw, filling No. 2 277 HISTORICAL. all iho deep hollow of the neck to the larynx, forming in front of the maxillary bone a projection about the size of two fists. This tumor had developed 10 years before. The patient, after submitting in vain to several treatments, went to Paris during July, 1818, to consult the best doctors. Their opinions, heard separately, were very different. Some advised extirpation of the tumor without manifesting any desire to operate. Others regarded an operation as highly dangerous. Others again were undecided as to what to do. His hopes dashed, Moret left Paris and returned to his home in Normandy deeply distressed at his condition. However, he fell in, by chance, with one of our own soldiers whose arm had been ampu tated at the shoulder, and who strongly advised him to return to Paris to see the surgeon who had operated on him. And Moret came to seek us toward the middle of November of the same year. After having examined the tumor with great care it was easy to determine its character and to foresee the serious consequences it would entail if not promptly removed. This indication seemed positive and what made its execution more urgent was the fact that the disease had arrived at the stage where cancerous degeneration usually sets in. We had already seen three different patients die from the same malady and in which its spread had been so rapid that the surgeons consulted, not daring to operate, remained simply spectators of the sufferings and the process of strangulation which soon ended the days of these three unfortunates. On the other hand we might well have been deterred by the tragic accidents that had happened to several of those who had removed tumors similar to this of our patient. But we overcame this obstacle by the certainty of controlling the hemorrhage by means of ligatures and compression. We were not deterred by the fear of meeting the criticism of those who were probably less skilled in the exercise of their art. Having thus carefully considered the possibilities of the opera tion and its results, the patient being perfectly in accord, we decided to operate as promptly as possible. To this end we consulted with those two enlightened physicians, Messrs. Chaussier and Ribes, who coincided with us in the urgent necessity for removal of this huge tumor already producing mechanical pressure on the principal ves sels of the head, the larynx, the tracheal arteries, putting the patient in the greatest danger. All being arranged we proceeded to operate November 16, 1918, assisted by one of the consultants, by M. de Lacaze, surgeon major of the 2d Regiment of the Swiss Guard, and Messrs. Grinelles and Desrulles, major assistant surgeons to the Hospital of the Royal Guard. 278 HISTORICAL. Vol. XIII. The patient being laid on a specially made bed, we traced in our minds the plan of the operation such as we shall describe, anticipat ing above all to take every precaution necessary to prevent hemor rhage of the many arteries to be cut, the only dangerous accident to be feared. However, the intelligence and skill of the assisting sur geons reassured us as to this danger, and moreover we said with Celsus, " Melius est anceps experiri remedium quam nullum." 1 By means of an incision paralleling the edge of the jaw we first cut the skin covering the surface of the tumor. Three other in cisions crossed it at right angles, one followed the anterior edge of the sternomastoid muscle to the clavicle, the second, the center of the tumor, and the third smaller one followed the immediate line of the larynx. The strips resulting from these incisions were promptly detached from the exposed surface of the hardened mass. Several arteries cut in these incisions were successively tied and we continued the dissection until the tumor was isolated for about three-fourths of its circumference. Deep cellular furrows divided it into several lobes of different sizes. These were like so many paths by which we arrived at the roots of the tumor. Carefully following the layers of these furrows, we detached these glandular bodies, the tissues being easily cut by means of a button bistoury. The largest and most prominent part was thus soon shelled out. Its pedicle being two large vessels we passed a ligature about it before cutting them. Removal of this glandular body involved the jaw, which we found necrosed to a depth of several lines, disclosed the other tumors, and facilitated the rest of the operation. One of the glands was embedded in the interval of the transverse apophysis of the second and third cervicle vertebrae and was removed with the same precautions. The second one, of an egg shape, and the size of an almond, was involved in the sheath of the common carotid artery. Nevertheless, it had to be removed like the others or else the malady would have reproduced itself. After having firmly compressed this artery below the gland, we cautiously cut its sheath. We detached it by means of the button bistoury. Its removal completely bared this main ves sel, but everything was prepared for its ligation in case of accident. The third gland, composed of several lobules, adhered to the left side of the larynx, the genio-glossal muscle, and the hyoid bone. Its extraction, though difficult, was equally successful. We can even feel sure that not a single glandular fragment re mained within the seat of the infection. We can venture to guaran tee that there will never be the least recurrence of trouble in all this region of the neck and head. 1 It is better to try a hazardous remedy than none. No. 2. 279 HISTOKICAL. More than 15 arterial vessels were tied. Among them we may mention the external maxillary or common labial, the submaxillary, the occipital and superior thyroid, and a number of others of some size developed by the malady. Several nerve fibers of the facial, vagus, lingual, and Willis's ac cessory on its way across the sterno-mastoid muscle were cut. The incision washed and cleansed, we approximated the edges, fastened it with a score of sutures, adhesive plaster, and fenestrated linen, covering with a styrax ointment which covered all the region upon which we had operated. We were careful to fasten the liga tures at the open angles of the incision. Lint and an appropriate bandage completed the dressing. The patient had borne the operation with the greatest courage, although it lasted 50 minutes in all, but some moments afterwards he was seized with a marked syncope followed by a chill of a febrile nervous character, a transitory but unavoidable accident. Perfect calm succeeded this storm, and for the first time for a long while this farmer enjoyed the benefit of peaceful sleep. The happy outcome of this extensive operation made us forecast favorable results, and, as it was, the patient grew better and better, and the first three days passed without the least drawback, except a slight temporary fever the night of the third day following the op eration. The first dressing was lifted on the fourth day. It was saturated with purulent matter and without one drop of blood, all the stitches taken in the wound being already reunited, and, with the exception of the opening we had left in which to place the ligatures and favor the draining of the fluids, all the incisions were almost entirely healed. The ligatures fell between the ninth and tenth days, and shortly afterwards the edges of the wound corresponding to the passage of the ligatures were themselves joined, so that the patient was cured on the thirty-first day from the operation and left for home on the forty-first with every sign of perfect health. We examined the glandular tumors with great care. All were enveloped in membranous tunics of a dense tissue, red in color. The deepest layer of these was furnished inside with very thin partitions like those observed in the lemon. The substance interposed between these gray and white layers can not be better compared in appearance and density than to the pulp of that fruit. It was firm, elastic, like half-cooked albumen, so that in cutting one of the glands across the fleshy tissues of each of them, it swelled and exuded by a sort of erectility. It was hard to tear the tissue. These membranous en velopes evidently received nerves and vessels, and they also ap peared to be endowed with vital properties in varying degrees, so that irritability of the blood vessels and lymphatics had been in creased in our farmer, which were produced in the glands of the 280 HISTORICAL,. Vol. XIII. neck by some predisposing local cause unknown to us; first inflam mation, then stagnation of the lymph occurred in the interior of this glandulous system, whence there resulted permanent engorgement and tumefaction. During the first period this was slow and gradual; later the progress was more marked. In other respects this disease presented the same phenomena in all subjects attacked by it, with the excep tion of some variations depending on age, sex, and temperament. In general this morbid condition, without being accompanied by local pains, attacks the integrity of the neutritive functions and one of its principal effects which has not been noticed by writers is the unnatural and asthenic dilatation of the arteries, especially those near the tumors.******* Mme. de L., of Rouen, 62 years old, went to Paris early in the spring of 1816 to consult the best doctors about an enormous cancer of the right breast that she had had for several years. The cele brated Laumonier, chief surgeon of the Hotel Dieu, at Rouen, twice operated upon this case, amputating first the scirrhous breast and then the tumor associated with it which this lady developed after the first operation, the latter reproducing itself just as the first was healed. When we saw this lady for the first time the cancerous tumor was about the size of a child's head. It was depressed in the center, caused by its adherence about the cicatrix, which had contracted at this point, while its circumference presented a series of vesicular tubercles of bluish color and of different sizes, separated one from another by fissures from which oozed a yellowish ichorous humor of an extremely fetid odor. The skin covering this tumor was mottled with numerous and very large varicose veins. The glands on the same side were engorged and one of them formed part of the tumor. The arm on the affected side was engorged and almost immovable, and the patient suffered lancinating pains, depriving her of sleep and keeping her in a state of constant anxiety. The majority of physicians consulted had judged a third opera tion impracticable and useless. Madame deL., in despair, wa? on the point of returning to Rouen when, by the advice of one of the ladies upon whom we had operated several years previously, she came to consult us. In spite of the gravity of the disease, of which we have described the principal symptoms, we entertained a hope for the success of a third operation if preceded by the treat ment before mentioned. The patient accepted our proposition with joy, and that very same day submitted to this treatment, which was continued for six weeks. It resulted in marked diminution of the No. 2. 281 HISTORICAL. lancinating pains and the resolution of the axillary glands, except those forming part of the tumor, which remained about the same size. After these preparations we called in consultation the physicians who had aided us by their knowledge in the Moret case, Messrs. Chaussier and Ribes. They approved the operation that we sug gested, and, although its success was very uncertain and its execu tion difficult and dangerous, they agreed that it was necessary and preferable to the caustics that some doctors advise. In short, we per formed the operation in the presence of the doctors consulted, assisted by one of our pupils, M. Desruelles. In amputating the tumor we preserved as many of its inclosing integuments as possible, but we had to remove a layer of the large pectoral muscle, to which the cancer adhered. We then prolonged the incision toward the armpit to extract the glands tainted with the cancer. After having extirpated the roots we proceeded to tie the vessels and draw together the edges of the wound, which had a truly frightful appearance. The cancerous mass we removed weighed 2 pounds 3 ounces. It was composed of ovoid fungous bodies of different sizes, scattered inside with cells filled with a blackish and oleaginous fluid. These cells were separated by fibrous membranes, thick and opalescent. In short, this cancerous mass presented a peculiar aspect not ordinarily observed in cancer of the breast. The wound ran its course without any accident and reached com plete cicatrization before the sixtieth day. We doubtless prevented any recurrence by the care taken in operating not to leave a particle of scirrhous tissue and by the treatment with which we followed it during the first years succeeding operation. This lady, who recently came to see us in Paris, enjoys perfect health. The scar is white, firm, and painless, although adherent to the ribs. We presume to think that these facts and the observations that accompany them may suffice to encourage young practitioners and prove to the public that there are very few diseases, at least those not in their last stages, that may not be attacked with advantage, pro vided, of course, that treatment be administered with discernment. 103396—19 8 Fracture of inter-condyloid spine of tibia. No. 2. ROSS FRACTURE OF PELVIS. 295 the block, being used to hoist the anchor, was under heavy tension and flew about 10 feet. After striking the patient, who was thrown 8 feet in the air, the block glanced off and struck a large galvanized- iron bucket filled with sand. The impact was so great as to flatten this bucket. The patient was wearing a pair of high hip boots folded down in such a manner that the part of the leg struck was covered by about four thicknesses of rubber. For a moment, the patient was un conscious. Then, there was a severe pain in the leg—pain increased by motion. There was marked swelling, ecchymosis and a large hem atoma of both thigh and leg. Hot applications gave no relief. The following morning the patient was removed to the French hospital at L . The leg was extended and placed in a wire splint. On the third day the hematoma was evacuated by a large trochar, a pint or so of thick, bloody fluid being withdrawn. An attempt to walk failed and he spent two weeks in bed. After hobbling about for another two weeks without improvement patient was conveyed to this hospital. On admission, the knee was found to be somewhat swollen and slightly flexed and there were varicosities of the super ficial veins on the posterior surface of the leg. X-ray examination showed a transverse fracture of the intercondylar spine of the left tibia in good position and with some excess of callus. Persistency in passive and active motion has resulted in complete restoration of flexion and almost complete extension of the leg on the thigh, although there is still a sense of grating in the joint on motion. A CASE OF FRACTURE OF PELVIS. By G. G. Rosa, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. E. E. W., boatswain's mate second class, age 28, was admitted to United States Naval Base Hospital No. 5 on April 4, 1918. We were indebted to the medical officer of the U. S. S. Panther for the fol lowing history of the accident. At 4.30 p. m., April 4, patient was in a motor boat alongside the U. S. S. Panther. He was helping to transfer heavy sheet steel. Three sheets (6 by 9 feet,) weighing about 3,000 pounds, were low ered by tackle and pulley from ship's deck to motor boat. Upon reaching the bow of the motor boat one end of the sheet-steel pieces (which were slung together) struck the boat, jarring all three pieces, then fell about 15 feet and struck the patient, with their entire weight, on his left hip. The patient was thrown against his left hip and the side of the boat against his right hip. The motor boat yielded to the impact and thereby lessened the severity of the injury. The patient did not become unconscious and was carried to sick bay 296 MICHELS CHRONIC ARTICULAR RHEUMATISM. Vol. XIII. immediately. He had difficulty in voiding urine which was some what bloody. The medical officer was able to elicit crepitus in the left hip joint on straightening out the leg. There was no shock. The patient was admitted to the hospital two hours after the accident. He was catheterized and no evidence of rupture of blad der or urethra was found. The urine was bloody, but the blood was not clotted and it was well mixed with urine. This blood might easily have come from the kidney or from the contused bladder. Urinalysis was negative except for blood. On examination the man complained of pain all over the pelvic region, most marked over the left hip, in the right groin, and in the small of the back. The application of inward pressure simultane ously to both hips brought on extreme pain. He was especially ten der in the right groin and also over the sacro-iliac regions. - X-ray examination showed the following, April 5, 1918. Frac ture of descending ramus of pubis on both sides. Dislocation of left sacro-iliac junction ; partial dislocation of right. Whole left side of pelvis is pushed upward and backward about 2 inches. Stellate fracture at bottom of right acetabulum. Head of femur driven into acetabulum making a central luxation of first degree. He was placed on Bradford frame and the pelvis incased in an adhesive plaster belt, extending from above the crests of the ilii to below the great trochanter and completely encircling the body. At the end of a week an abdominal pelvic appliance, made of canvas and laced in front, was substituted for the adhesive plaster. Great care was exercised in moving the patient, as a false move could have resulted in puncturing the bladder or in cutting the urethra. Four men on the same side of the bed, all lifting at the same time, were able to raise him in a perfectly horizontal plane, and without dis comfort. At the end of two weeks he was able to sit up in bed and to flex both thighs on the abdomen. CHRONIC ARTICULAR RHEUMATISM CURED BY REMOVAL OF DISEASED APPENDIX. By H. H. Michels, Lieutenant, Medical Corps, United States Naval Reserve Force. This case is interesting on account of the sudden and complete relief from prolonged and intense suffering due to chronic articulai rheumatism afforded by an appendectomy. Sergt. L. R. , United States Marine Corps, while on dut} at Guam, was admitted to the sick list during March, 1918, with a diagnosis of chronic articular rheumatism. The knees, ankles, phalangeal joints, and right shoulder were the principal parts af fected. March 30, 1918, he was transferred to the United States 206-1 290-2 No. 2. 297 RYAN — MYELOID LEUKEMIA. Naval Hospital, Mare Island, Cal. He obtained sick leave during May, and while visiting his relatives in Chicago I was called and treated him for a severe recurrence of rheumatism, and later he was transferred to the United States Naval Hospital, Great Lakes, 111. July 27, 1918, he was discharged to duty and was attached to this recruiting district. He worked in the office on light duty, but with frequent recurrences of rheumatism, until November 4, 1918, when his disability required transfer to the United States Naval Hospital, Great Lakes. I recommended an exploratory operation on account of a constant tender area in the region of McBurney's point. All other points of possible focal infection being negative, it appeared probable that his frequent recurrences of rheumatism were due to some infective focus in the region of the appendix. Appendectomy was performed on December 6, 1918, at the United States Naval Hospital, Great Lakes, 111., and I was informed that the appendix contained three concretions and was in bad condition. January 2, 1919, he was discharged to duty, well. From the beginning of the chronic articular rheumatism, which really began about three months before his first admission, until December 6, 1918, he had never been entirely free from pain for a day. The patient informs me that he went on the operating table with rheumatic pains and stiffness, especially in the shoulder joints, and that was the end of it. Since January 2 his duty at this recruit ing station has required him to be outdoors in all sorts of bad weather, without even a reminder of his former trouble. I believe he is permanently cured. A CASE 07 MYELOID LEUKEMIA. By E. R. Ryan, Lieutenant, Medical Corps, United States Navy. L. R. G., seaman, age 21, married, came to sick bay on board the U. S. S. Arkansas on October 8, 1918, complaining of " stomach trou ble " and constipation. Family history.—Father, age 49, living and well. Mother, age 47, living and well. One sister, the oldest child, was stillborn. He has five brothers, all living and in good health. No family history of epi lepsy, insanity, or tuberculosis. Past history.—Had whooping cough at age of 4, mumps at age of 8, measles at age of 9, and diphtheria at age of 11. All these dis eases were uncomplicated and patient had complete recovery. Had malarial fever at the age of 13, and another attack at the age of 19. Nervous system.—Has had occasional headaches for past four or five years. No dizziness or tremors. No history of epilepsy. Hear ing and eyesight have always been good. 103396—10 9 298 RYAN—MYELOID LEUKEMIA. Vol. XIII. Respiratory system. —Has had frequent attacks of influenza. No history of cough or expectoration. No night sweats. Has lost some weight, approximately 10 pounds, during the last year. Circulatory system. —Has dyspnea on slight exertion. No palpita tion, edema, or swelling of feet. Gastro-intestinal system. —Appetite has always been good. Bowels were always regular until the past four months, when he began to be troubled with persistent constipation. Never troubled with nausea or vomiting. Genito-urinary system. —No history of gonorrhea or syphilis. No skin disease or alopecia. Has had to get up at least once a night for the past four weeks to urinate. No frequency of urination during the day. Habits. —Up to about six months ago patient drank about four glasses of whisky and a glass or two of beer daily. Smoked and chewed tobacco moderately. Present complaint. —Patient complains of pain in the stomach, which is continual, dull, and gnawing in character and aggravated by eating. He has frequently been nauseated during the past four or five days, but has never vomited. He has been persistently consti pated during the past four months. He also complains of a mass on his left side, which he first noticed two months ago, and which is slowly becoming larger. His color has been poor of late and he com plains of general malaise and loss of energy. There has been annoy ing pruritus of the scrotum and anus during the past two weeks. Physical examination. —Patient is about 5 feet 6 inches tall ; weighs 125 pounds. His complexion is sallow or yellowish white. Body is well nourished. Head and neck. —Scalp is negative. He has a few small palpable glands on either side of the neck, just below the clavicles. Pupils are equal and react to light and accommodation. Ears and nose negative. Tonsils are visible and the pharynx greatly injected. Teeth good. Gums negative. Chest. —There is a slight bulging of the chest on the left side, be ginning at the seventh rib and extending downward. Dullness of the left chest, which starts at the sixth rib and tapers to absolute flatness at the costal border. Dull area extends from the midclavicular to the posterior axillary line. Percussion negative over rest of chest. Breath sounds were normal over entire chest, except over the dull area. The sounds over this area were distant and a coarse leathery friction rub was heard. Patient complains of no pain in this locality and deep breathing gave him no pain. The apex beat was in the fifth interspace about 9 centimeters from the midsternal line. There was no enlargement or displacement of EDITORIAL. THE I.XSSON OF JOB'S WAR HORSE. The trend of American writers on war neurosis has been toward emphasizing the importance, as a preventive measure, of greater care in the selection of recruits. That too much care can not be taken at the recruiting office is generally admitted. The weeding out at camps and training stations of the vagrant, the ne?er-do-weel, the potential criminal, the mentally unfit, is of incalculable advantage to the mili tary services, but it is not enough in respect to war neurosis since the approximately normal are subject to this affection. A broader conception of the whole subject is suggested by the able paper of W. H. E. Rivers, in Mental Hygiene, October, 1918, entitled "War Neurosis and Military Training," which is a report to the Medical Research Committee, London. It should be read by all those who are particularly interested in war neurosis or concerned in a gen eral way with military training. While Rivers does not specifically make the statement, it may be legitimately inferred from his arguments that military unprepared- ness and the hurried and intensive training necessary to atone for that unpreparedness are no small factors in the production of war neurosis. It is known, of course, that such cases developed in the sea soned regulars, as well as in the raw recruits of the British Army, but this does not invalidate the proposition just affirmed if what he has to say about esprit de corps, the value of discipline, the relation of officers to their men, the importance of athletics is true. In all these things the element of time is an important consideration. To really play the part of elder brother or father to his men an officer must have something more than good will and good intentions. If he has not the wide range of information about his profession which will inspire confidence, he must have had experience in leadership such as the upper-form boys, acquire in the public schools of England — Rugby, Winchester, Eton, Harrow, etc. —which correspond in no sense to what we call public schools but rather to the academies at Exeter and Andover, to Culver, Groton, the Virginia Military Insti tute, etc. The world knows now, and we have always known, that the Ameri can will fight and fight well but, alas, a good fighter may be a poor soldier. We may see many reasons for this or merely regret the fact, but at any rate the good fighter who is a poor soldier will have to pay 283 284 EDITORIAL. Vol. XIII. the penalty of brief superficial training and intensive hot-house methods and so will the Government and the Nation. The word repression looms large in what the psychiatrists have to tell us about war neurosis. Rivers brings out the point that repres sion is a significant feature of the training camp. " A person who is being drilled is taken from our highly individualistic community, in which spontaneity and independence are encouraged, and is sub jected to a course of training calculated to produce a state allied to that of existing communistic peoples or of animals which are accus tomed to act in herds. One result of such a training, if it be not indeed also its chief aim, is to enhance the responsiveness of each in dividual to the influence of his fellows and the form which is taken by military training is especially designed to enhance his responsive ness to those who are immediately above him in the military hier archy. * * * The other aim of military training which espec ially touches the liability to different forms of neurosis is to fit the soldier to withstand the trials and stresses of warfare. One of the chief instruments by which this aim is met is the one already con sidered which makes the individual soldier act as a member of the aggregate to which he belongs in a closer sense than holds good in civil life. This does away with or diminishes greatly the tendency of any one individual in the group to react to fear or other emotional state in a way which would interfere with his military competence. * * * Repression forms a necessary part of all education and adaptation to social life. Perhaps the most important feature of the repression of military training is the relatively late period of life at which it takes place. (Italics ours.) The older a person is the more difficult it becomes for him to give up habitual modes of thought and action. It is where repression is incomplete and is the source of persistent mental conflict that it becomes a factor in the production and maintenance of neurosis. (Italics ours.) If the repression which forms part of military training is complete it probably helps greatly toward the success of the repression which will become necessary when the soldier enters upon active service, but if it is incomplete, so that the soldier enters upon active service accompanied by the active conflicts so aroused, his success in the, necessary repres sion of warfare will be prejudiced. * * * When the soldier is brought into contact with actual warfare a new set of repressions come into action. * * * It seems clear that different batallions show the incidence of neurosis in very different degrees, and this is probably clue more than anything else to the nature of the relations between officers and men by which the private soldier acquires toward his officer sentiments of duty and trust, while the officer is actuated, it may be dominated, by interest which could not be greater if those under his command were his own children. * * * Any- No. 2. 285 EDITORIAL. one having much to do with those who have taken part in the fighting of the present war must have been struck by the extraordinary manner in which an officer, perhaps only just fresh from school, has come to stand in a relation to his men more nearly resembling that of father and son than any other kind of relationship." From all of the foregoing we deduce that, so long as the country is under the sway of pacifists who deny the possibility and probability of war and of those who in practice, if not in theory, agree with them and reject all effort to prevent war by preparing for it, we shall go into war whenever it comes with a maximum risk of war neurosis, because soldiers can not be trained overnight to shoot straight and live straight or to practice repression, whatever may be their spirit as fighters when they actually go over the top. The power of repression spoken of by the psychiatrist is nothing more than the inhibition of ordinary pedagogic language. The train ing for this must begin in infancy and be continued to adult life. Universal physical training, a maximum of military training for those of military age, participation by all the students in our colleges who are not actual cripples in athletic games of one kind or another instead of the exaggerated training of the few to perform in a gladia torial way under the eyes of the many —these are other features of a serious and determined effort to prevent neurosis in our next war. With a far larger Army, Navy, and Marine Corps as a nucleus it will not be so necessary to employ the hasty methods made imperative by our predicament in 1917 and the life in camp, the special training of officers and men, can be lengthened, amplified, and rounded out so that they will not have to be rushed to the front before they have thoroughly accommodated themselves to the novelty, the restrictions, the trials of the early stages, so that they will not be subjected to the difficult process of accommodating themselves to the environment of war before they are even inured to the life of the camp. The successful prophylaxis of war neurosis lies in the cultivation of inhibition or repression beginning in the nursery or kindergarten and continued through the period of military age; in the general development of physical prowess through participation of all youth in games and athletics which have a disciplinary and moral value; in such regular and prolonged military training as is calculated to make its details matters of habit and routine. Incidentally, of course, the defective, the degenerate, and the habitually vicious should be excluded. To use plain language, war neurosis is in part based on some form of fear. Fear is practically universal in war, but it is controlled and dominated so it is not a matter of reproach. We have learned rather generally to call that man truly brave who with a full realization of the magnitude of a given peril faces it through subordination of fear 286 Vol. XIII. EDITORIAL. to other emotions. The war neurosis developing in the private is commonly due to defective inhibition of the instinct of self-preserva tion. In the officer the fear, equally real and disturbing, which in duces neurosis is usually not so much of bodily harm as of failure to meet the responsibilities of his position. He is able to inhibit the fear of bodily harm in part through the previous circumstances of his life and in part through the nature of his position, but yields to an anxiety neurosis in regard to that very position. That form of epidemic or contagious fear which we call panic leads to the precipitate flight and rout of regiments, of armies, and may wreck a cause with little damage to the individual. There is no consequent war neurosis because the disintegrating effect of internal conflict is lacking. A wave of emotion, sudden and transitory, affects a multitude at once and passes over it without mental or physical after effects. Overwhelming odds unexpectedly developed, errors of tactics or strategy so colossal and conspicuous as to be appreciable to the mass and destroying confidence in leaders, make the attempt at inhibition useless or seem useless to the multitude and solidarity still remains ; the men act en masse rather than as individuals. A homely illustration of the power of inhibition developed by training may be found in the horse, timidest of all animals, yet capable of becoming a valuable coadjutor of man in war, racing to the charge with keener relish the higher his spirit and breeding, the greater his nervous energy. What lover of horses but thrills at the following beautiful description : Canst thou make him afraid as a grasshopper? The glory of his nostrils Is terrible. He paweth In the valley and rejolceth In his strength; he goeth on to meet the armed men. He mocketh at fear, and Is not affrighted ; neither turneth he back from the sword. The quiver rattleth against him, the glittering spear and the shield. He swalloweth the ground with fierceness and rage ; neither believeth he that it is the sound of the trumpet He salth among the trumpets, Ha, ha ; and he snielleth the battle afar off, the thunder of the captains, and the shouting. —Job xxxlx, 20-25. Similar conduct in a charger of to-day is the result of long training in habits of obedience to the rider's will, of unabuscd confidence in that rider's judgment, of such prolonged familiarity with sights and sounds like the flash of gunpowder and the roar of cannon that they no longer terrify. On the other hand, instinctive horror of a dead animal of his own kind, the fear provoked by the. smell of a fresh equine carcass, often renders the best steed unmanageable. This is probably the one experience of battle for which he has not been pre pared by military training in time' of peace, and it is too painful an experience to be covered by a limited, undeveloped repression. SUGGESTED DEVICES. SANITARY DRINKING FOUNTAIN. By D. S. II i i.i.i s . Lieutenant Commander, Medical Corps, Dnlted States Naval Reserve Force. The sanitary drinking fountain designed by Captain C. M. De Valin, Medical Corps, United States Navy, is in use at the United States Naval Training Station, Great Lakes, 111. This design seems to fulfill the requirements better than any fountain so far devised. The illustrations show the usual and proper method of use and the action of the ring in preventing direct contamination of the spout. CLINICAL CHART HADE BY A RUBBER STAMP. By J. J. Cancblmo, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. For the medical officer who wishes to give his brother officer a better idea of a case, a simple means of showing temperature, pulse, respiration, and number of stools should be of value. A rubber stamp may be made which will print a chart; such a stamp does not take up too much room; it is easily written up and tends to make the medical officer more careful. The stamp need not be used in all cases, but only when a patient is transferred because of some complication which would be better treated at a hospital. Thus in figure 1 there is a case of pneumonia as a complication of influenza. The little effort in writing up a chart does more to make clear the patient's condition than a lengthy written statement. This is because the chart is graphic. Too fre quently patients are sent to hospitals with little more than a diag nosis. The hospital medical officer is entitled to more than this. He should be given all the necessary clinical data that will make the patient's condition clear to him. The chart would be of more value at sea, for it could be used with all febrile cases that are transferred. It might be also used in cases in which a permanent record is desirable because of some pending legal action. 287 288 Vol. XIII. GROVE AND CROW CLINICAL RECORDS. The rubber stamp was ordered through the quartermaster in the usual way ; that is, by drawing the necessary lines and figures on an N. M. C.-G. M. Form 637. &T0CU 105 o •V- O ■v- 104 / 103 / 101 J 101 p// 100 o 11 N w o© oo eO CD o o OO CO CO POISE OO oo O >~0 O oo OO o I— oo o— HL a.. -C a— O- ■<C o- -c a- O- Q_ m r-J 12 r-O JYood 105 •V- o •V- 104 103 v\ I0Z / / \ \ / \ / L 101 11 18 RKP pose oo o— 3 ro go CO -x> CsJ c-l <c D_ -c o- <c -C «**> o— a- a— o— m r»- - o— <=> No. 2. 289 GROVE AND CROW CLINICAL RECORDS. medical history. Jan. 6, 1919. Name of patient: K. G. K. Place: U. S. S. Ohio, at sea. A Scarlet fever. Origin in line of duty. Not due to his own misconduct. Symptoms : Characteristic punctate rash on chest and face ; circumoral pal lor, etc.; headache, severe sore throat; tongue heavily coated. Treatment : Isolation, sodium citrate gr. x q. 1. d. and gargle. To be sent to hospital on arrival in port. 1-8-19 Considerable itching. Treated with carbolated vaseline. T 1-10-19 Transferred to naval hospital, Philadelphia, Pa. 4 medical histoby. Jan. 11, 1919. Name of patient: A. V. M. Place : Marine barracks, navy yard, Philadelphia, Pa. A Influenza (458). Origin in line of duty. Not due to his own misconduct Symptoms: Prostration, myalgia and painful cough. Chest examination negative. Treatment: Calomel, followed by mag. sulph., aspirin gr. x and cough sirup. 1-13-19 Cough continues; suggestive signs of consolidation in right base. Sputum rusty. C 1-14-19 Diagnosis changed to— 3 A Pneumonia, lobar (667). Origin in line of duty. Not due to his own misconduct. Consolidation found in right base. T Transferred to naval hospital, Philadelphia, Pa. O A SYSTEM OF CLINICAL RECORDS. By W. B. Grove, Captain, Medical Corps, United States' Navy, and G. B. Cnow, Lieu tenant, Medical Corps, United States Naval Reserve Force. The following system of clinical records has been in use at the United States Naval Hospital, Norfolk, Va., since April 1, 1918. Samples of these records, together with brief explanatory notes were sent to the Bureau during the summer. The plan is briefly this: The clinical record of every patient ad mitted to the hospital is kept on a 5 by 7f inch clinical card. Labo ratory reports, X-ray reports, and records of operations are all made on additional blanks of the same size as the clinical cards. These various report blanks are printed on various colored papers to facilitate ease of recognition of the blanks. All such reports on a given case are sent to the ward and filed in a 5 by 8-inch jacket envelope, open at one side, provided for the purpose. Temperature charts and clinical records kept by the nurse are also folded once and filed in this same jacket when the patient is discharged or is transferred to another ward. The present forms of such charts and 290 Vol. XIII. GROVE AND CROW CLINICAL RECORDS. records supplied by the Bureau are 8 by 10£ inches and therefore do not easily file in a 5 by 8 inch jacket. We therefore cut these charts to 7f by 10 inches so that when folded once they are the same size as clinical cards, laboratory report blanks, etc. In other words, all the data on the case are kept together on blanks of uniform size, and filed in the envelope. The following instructions explain the method of handling in detail : INSTRUCTIONS REGARDING RECORDS OF PATIENTS' HEALTH RECORDS, CLINICAL CARDS, AND FILING SAME. All Medical Officers, Hospital Corps, and Nurses: 1. On admission of a patient to the hospital the Health Records Office force will fill out first two lines on clinical cards, attach card to health record and send to medical officer In charge of case. 2. The medical officer in charge of case will make an abstract on clinical card of such data given in the health record as seems most important. 3. After making such notes as are deemed necessary on clinical card, the health record will be returned to the Health Record Office and clinical card sent to ward for file in card index-filing box. Clinical records shall be kept in the ward at all times except when temporarily removed for use of boards of survey, etc. 4. Medical officers will make such entries from time to time on clinical cards as are necessary to show condition and progress of case, e. g., history, symp toms, clinical findings, important treatment, etc. Records should be kept up to date, I. e., complications or new developments should be promptly noted. 5. All laboratory reports, X-ray reports, operation reports, etc., will be filed with clinical cards In each case in jacket envelope provided for that purpose. Surname of patient to be entered in upper left-hand corner of envelope. In cases covered by a single card and without laboratory or other reports the card need not be placed In envelope. 6. When a patient is transferred from one ward to another the medical officer will bring card up to date and sign it. In all cases of transfer the clinical record (card or envelope with all data, including temperature chart) will accompany the patient. When a case is transferred from one medical officer to another the medical officer making the transfer will bring both the health record and clinical card up to date and sign them, transferring both to the medical officer receiving the case, who will send clinical card to ward, and after reviewing health record will send it to the Health Record Office for file. 7. Change of diagnosis will be entered on card and change diagnosis slip sent to Health Record Office, as at present. 8. The nurse or senior hospital corpsman in charge of ward will be respon sible for the proper filing of and care of cards, laboratory, and other reports and for transfer of all clinical records with patient to another ward. No one except medical officers and nurse in charge shall have access to clinical cards. 9. On final disposition of case the medical officer will send patient's name to Health Record Office and health record will be sent to him. He also notifies nurse in charge of ward to send clinical record to his desk. From clinical record he makes a brief abstract of case in health record, paying particular attention to " In line of duty " and points that may have a future bearing on health of patient. Health record and clinical record are signed and returned No. 2. 291 BUNKER—A DRESSING FOB WOUNDS. to Health Record Office for file of clinical record and forwarding of health record. 10. Requests for laboratory and X-ray examinations will be made by medical officers on blanks provided for that purpose. The red request blanks should be used only for emergency examinations. The two most Important points in the use of these records are : (1) It affords an easy means of keeping together nil the data on the case and of keeping It In the ward and easily accessible at all times. (2) These records are kept on file In the hospital by a card-Index system and will be available for reference not only for statistical purposes, but for reply to Inquiries frequently made from various sources regarding cases after the patient has been discharged from the hospital. Before the use of this system the health records of all cases In the hospital were kept by the medical officers In charge of the cases in their desks in the medical office. This had two seriousness disadvantages: (1) Health records were frequently lost. (2) As the records were not kept in the wards (keeping them in the wards would Increase the chances of their being lost) such entries as were made by medical officers were apt to be delayed and made from very hazy recollection of the points observed at the time the patient was examined. Furthermore, in a number of cases there are a great many points that arise that have a bearing on the case during that particular illness and should be noted for statistical purposes, but need not necessarily be entered on the health record. Under this system the clinical cards and reports give a more detailed and accurate picture of the case than it is feasible to give in the health record. Entries on the health record, therefore, need not be made until the patient Is ready to leave the hospital, or passes from the care of one medical officer to another, and such entries may be made comparatively brief, covering more particularly the question of " line of duty " and points that may have a bearing on the future health of the patient. On first thought it might be concluded that this system added materially to the paper work required of the 'medical officer. As a matter of fact this system docs not add to the work of the medical officers. If the notes on the case are made promptly, while fresh in mind, and at the time of sick call, a few minutes each day will serve to keep up the records on the number of cases ordinarily assigned for an officer after the case has been originally written up. As the original of all laboratory and X-ray reports are filed with the clinical cord, the medical officer is not called upon to copy any of these records. A DRESSING FOR WOUNDS. By C. W. C. Bunker, Lieutenant Commander, Medical Corps, United States Navy. The formaldehyde-phenol in camphor paraffin combination de scribed by Connell (Connell, K., Surg., Gynec. & Obst., July, 1918) impels me to call attention to a somewhat similar combination that I have used since 1912 with the greatest satisfaction. It was origi nally recommended to me by Lieut. Commander E. E. Curtis, Medi cal Corps, United States Navy, and I know that it has been used by others. I now take phenol (liquefied by heat), 45 parts, and gum camphor, 55 parts by weight, and triturate these in a mortar. A clear, perfectly stable liquid results. No diluent or solvent is used. 292 BUNKER —A DRESSING FOR WOUNDS. Vol. XIII. I consider it an ideal dressing for fresh wounds, and have em ployed it in all varieties up to severe lacerations of the extremities. The suturing or adjustment of the parts is accomplished after the usual methods, and the area freed from aqueous solutions by dry sponging. The part is dressed dry, and the phenol-camphor combi nation poured freely onto the dressing. I have never had occasion to use it inside a wound. Used in this manner, I have never seen development of clinical pus, injury to tissues (even normal skin) nor other untoward results. Dressing is required only every three days to a week, and each time one finds a clean, dry, granulating, and rapidly healing wound — one might almost say by first intention. As a matter of fact, habits acquired by the use of the older disinfectant solutions lead one to change the dressing much oftener than is necessary. There is a marked local anesthetic effect. The combination can be recommended as a dressing for venereal ulcers in the form of a dusting powder (5 per cent with a talc base), or as a 5-10 per cent ointment. It is also of service as a local applica tion for the trichophytoses. CLINICAL NOTES. EXTENSIVE ABDOMINAL WOUNDS FROM A HAND GRENADE. By J. M. Emmbtt, Lieutenant, Medical Corps, United States Navy. The following is a case of a penetrating wound of the abdomen ■with perforations of the stomach and small and large intestines. It is primarily of interest because of the relatively short time the patient was incapacitated for duty. The extensive wound in the abdominal wall was not treated with any of the chlorine preparations because early excision of the de vitalized tissue and free drainage was possible. J. C. P., 76th Co., Sixth Regiment United States Marine Corps, 18 years of age, was admitted to sick quarters, marine barracks, Quan- tico, Va., at 3 p. m. August 24, 1917. Diagnosis: Hand-grenade wound of the abdomen. Family history unimportant. Previous history : Usual diseases of childhood. He had had athletic training. Present condition: Admitted at 3 p. m. with a hand-grenade wound of the abdomen about 3 inches in diameter over the area of the um bilicus. Through this wound protruded a segment of the transverse colon and omentum. There was a history of an accidentally ac quired wound one hour before by the unexpected explosion of a hand grenade. The patient was holding the grenade in his hand at the time of the discharge. Symptoms of shock, so frequently seen in such cases, were becoming very pronounced. His pulse was 130, the extremities were cold, and he was begging for water. Because of the evident intra-abdominal injury and probable hemorrhage it was thought advisable to operate even in the presence of the symptoms of shock. He was given morphine, one-fourth grain, and prepara tions were made for an exploratory laparotomy. Through a high left median incision the abdomen was opened and a quantity of free blood was found in the peritoneal cavity. An offensive odor directed immediate attention to two large perforations in the transverse colon. After the escaped contents had been re moved with bichloride sponges, both perforations were closed with linen sutures. A small leak was found in the second portion of the duodenum. An abrasion found in the lesser curvature of the stom ach which extended down through the mucous membrane was re paired. 293 294 EOSS—FRACTURE OF INTERCONDYLAR SPINE OF TIBIA. Vol. XIII. The gastrocolic omentum seemed completely avulsed from the anterior surface of the stomach. Hemorrhage was arrested and the detachment repaired with interrupted catgut sutures. Two large bleeding vessels were ligated in the greater omentum and an effort was made to sponge out the blood in the peritoneal cavity. During the course of the operation several pieces of steel were found free in the peritoneal cavity. One fragment was found em bedded in the posterior wall of the stomach. Examination of the abdominal wall showed much devitalized tissue. This was excised and an effort was made to fill in the wound by transplantation of rectus muscle and fascia. A cigarette drainage tube was placed near the site of the colon perforation, another in the pelvic cavity, and the third in the right kidney fossa, where much blood was found. All drains were brought out through the injured abdominal wall. The exploratory incision was closed in the usual way, layer by layer. The time of operation was 1 hour and 20 minutes. The patient was in fairly good condition when removed from the operating table ; pulse, 120. Subcutaneous saline injections were begun and morphine was given freely for the first 24 hours. Twelve hours after the op eration the temperature was 100, the pulse 108. The wound showed free drainage of pus and blood. Small quantities of water were given by mouth in 36 hours and liquid diet in 72 hours. From the fifth day until the end of the second week the patient was septic, the temperature rising to 101 or 102 in the afternoon. At the time of removal of the drainage tube on the twelfth day a small fecal fistula became evident. The drainage from this lasted less than a week. At the end of four weeks the patient was up and about in a rolling chair; the wound was nearly closed. At the end of five weeks the patient was free from all symptoms and the wound had healed. He was able to walk about. On October 9, 1917, he was transferred to the United States Naval Hospital, Washington, D. C, for further disposition. A letter from the patient's mother 10 months after the operation assures me that the boy is in excellent health. A CASE OF FRACTURE OF INTERCONDYLAR SPINE OF TIBIA. By G. G. Ross, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. E. W. H., Ensign, U. S. S. Douglas, age 30, was admitted March 25, 1918, complaining of a swollen and painful left knee joint. He gave a history of having been struck on the posterior surface of the left leg, just below the knee joint, by a snatch block weighing about 45 pounds. His boat was in the harbor preparing to put to sea and No. 2. 299 CRANDON—PERICARDIOTOMY. the heart. No thrill. A soft blowing systolic murmur was heard in the fifth interspace about 4 centimeters from the midsternal line. Abdomen.—There was marked bulging of the upper part of the abdomen and distention of the costal arch. The liver extended to the lower border of the ninth rib. The spleen could be distinctly palpated and extended to about 1 inch below the umbilicus and about one-half inch to the right of the median line. Tympany over the entire right side, flatness over the tumor mass on the left side. Abdomen otherwise negative. Genitals were negative except for pruritus of scrotum. Cremas teric reflex normal. Extremities were negative. Knee jerks normal. No Babinski or ankle-clonus. No pain over the long bones. LABORATORY FINDINGS. Hemoglobin, per cent White blood count Differential : Neutrophils, per cent Eosinophils, per cent Large lymphocytes, per cent 70 325,000 Small lymphocytes, per cent TransIOonals, per cent— Mast cells, per cent Myelocytes : Neutro, per cent Eosino, per cent. 8 T 8 3 Several nucleated red cells were also encountered. Polkilocytosls marked. Stool was odorless, gelatinous in appearance and consistency and contained numerous bright-red blood specks throughout. Micro scopic examination showed a large amount of mucus and epithelium and a considerable number of white and red blood cells. Urine. —Slight cloudiness with very few shreds. Specific gravity, 1.024. Negative for albumin and sugar. Reaction, acid to litmus. The patient was transferred to a United States naval base hospital on the day following his admission, thereby making further observa tions aboard ship impossible. PERICARDIOTOMY. By. L. R. G. Cbandon, Lieutenant Commander, Medical Corps, United States Naval Reserve Force. T. N. was admitted August, 1918, with endocarditis acute, with fever, following acute tonsillitis. Went on for two months, running practically the course of a malignant endocarditis, except that there were no emboli. Blood culture always negative. * In October symptoms of cardiac distress became worse. Extraor dinary ranges of temperature, sometimes to 105°. X-ray at this time showed a very broad triangular cardiac shadow, base down, con sistent with pericardial effusion. Pulse, 160; sounds barelv audible. 300 Vol. XIII. PERRET —KERATOSIS PLANTARIS. October 24. 1918, operation (one-half of 1 per cent cocain). Diag onal incision over left fifth costal cartilage 1\ inches long, beginning at the sternal edge. Cartilage nibbled away for about 1 inch with rongeur. At this point appears the only important matter of careful technic, namely, that the internal mammary artery runs 1 inch from the sternal edge and parallel to it, and it might be better to clearly reveal it at this stage than to puncture without seeing it, because if it were cut or torn it might retract under the closely adjoining car tilages and bleed to a perilous amount before it could be controlled. The pericardium was then lifted by forceps, external to the artery, incised, and a small piece of rubber dam drainage inserted. Practi cally no fluid escaped on the operating table, because, as it appeared later, the heart floated up in the wound like a ball valve and closed it. In the course of the next 12 hours in bed about \\ pints of clear sterile fluid escaped, with great relief to the patient. December 8, 1918, five days after a complete embolic hemiplegia, patient died of general failure of heart power. Necropsy showed acute and chronic vegetative endocarditis, with adhesive pericarditis ; heart about twice normal size. A CASE OF KERATOSIS PLANTARIS. By J. M. Perret, Lieutenant, Medical Corps, United States Navy. The feet are such important parts of the fighting man's make-up that anything unusual about them ought to be of particular interest to the military surgeon. Keratosis plantaris is, according to Stelwagon, a " somewhat un common malady." S. R. J., a white youth of 22 years, a native of Missouri, was ad mitted to the United States Naval Hospital, Pensacola, Fla., on July 8, 1918, with a diagnosis of influenza. While under treatment he complained of painful feet. The examination of these revealed the following interesting findings : The entire plantar surface, except that part forming the arch and therefore not touching the ground, was yellowish, painful, smooth, hard, and thickened (about \ inch). Near the outer edges of this hardened skin were vertical parallel fissures. The healthy skin just above formed a pinkish zone of about \ inch. The soles looked like enormous callosities. The patient said that his feet had always been like they were at present. He had frequently suffered from sore feet. He had been in the service for seven months and had had a great deal of trouble Keratosis plantaris. 300 No. 2. FOLKEN—INFLUENZA WITH COMPLICATIONS. 301 after marching. The skin of his hands and the rest of the body were normal. A Wassermann reaction was negative. The patient says that his father's feet are in a similar condition to his. As the patient was evidently unfit for the service he was given a. medical discharge and therefore nothing can be said as to the therapy of this interesting case. The accompanying photograph will give some idea of how the feet looked. BEFORT OF CASE OF INFLUENZA WITH UNUSUAL COMPLICATIONS. By F. Q. Folken, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. L. S. M. was admitted to the naval hospital on September 25, 1918. Prior to this he had been in a sick bay with the diagnosis of influenza. Upon questioning him it was found that he had had the usual symptoms of the disease and physical examination revealed nothing further, so the diagnosis was confirmed. The patient was at once put on the usual routine treatment for admission. On September 26, 1918, his general condition was fair, although the temperature still remained high. This continued with but one marked fall, to go down by lysis until October 1. On that date it was noted that the temperature dropped below normal, followed by a quick rise and there was a decrease in pulse rate accompanied by an increased respiratory rate. Physical examination of the chest brought out areas of dullness and bronchial breathing, particularly over the left lung. The patient was very restless, complained of difficult breathing, and became cyanotic later in the day. The diag nosis was then changed from influenza to broncho-pneumonia. From this date the temperature curve took a zigzag course. On October 2 the patient complained of violent sweating, which con tinued through the day. No blood cultures were made, but a general septicemia was believed to be present. • On October 3 the patient complained of severe pains in the right groin, but examination of the part was negative. Chest examination showed more extensive involvement of the left lung; the right lung was negative. A faint systolic murmur could be detected at the apex of the heart. It had not been heard at previous examinations. On the morning of October 4 the patient was found in a dull men tal state. Examination brought out a complete left-sided hemiplegia, 302 FOLKEN—INFLUENZA WITH COMPLICATIONS. Vol. XIII. which had come on during the night. Closer examination showed the deep reflexes exaggerated and superficial reflexes absent. Babin- ski's sign and ankylosis were present on the left side. The right side was normal, including reflexes. Pupils were unequal in size> the left being slightly larger and more active to light. There was also a nystagmus of the left eye toward the right ; however, this was •i • ..CLINICAL- CHAM- ■Hal] -l^A:J*i _2J_: J (NIMt) (kftTt) (AOL) (coloa.) ThativityT TbuiASiT *in" |mokth a i f c r 3 8 3 | § 8 8 | 8 * S •K.LIAKKK.S • 5 c p. 1 9 9 IS 24 94 24 V 4»M 97 2* i upm10414 6AMIOO24. ; WAHK>227 I / 'Ofeat i \ $PM 104IB ■ 1i I 9 27 2PMlOl 27 \ (.M 11121 / BAM11434 i —- i —-- 2PM92 24 —~ / 4.PMIOO21 / 9 2.S12pm00 24. lOt 32 ! \ »» 'O*»1 ! / IOOSI i \ 4.PM?* U — r \ f V IOO28 fcAMot 34, j / OAMK>4K ! I zpmIOO32 / 6 PMlOl 52 | \ B JO II PMIOO30 S &AM10432 f IOAM10232 V. 2 PMIOO32 1 tPM '9 34 IO l 12PM•9 J* *A« «A 38 I '\ IOAM90 40 v I.I. - o*. ZPMIOO3» : i bit. Mi >y [>..h2«jt« ».^utk nhrJv^i very uncertain, due to a depressed mental state. At this time there was no rigidity of the neck, and Kernig's sign was negative. Heart examination showed a more distinct systolic murmur at the apex. No loss of sphincter control. A diagnosis of endocarditis, acute, was made with an embolism lodging in the right brain. At 4 p. m. the findings were the same as in the morning, but in addition there was noted a depressed mental state and involuntary action of both sphinc No. 2. FOLKEN—INFLUENZA WITH COMPLICATIONS. 303 ters, indicating spinal irritation. There was no rigidity of the neck, and Kernig's sign was negative. On the morning of October 5 the patient was examined and found in the same mental state as the day before, with no change in reflexes or paralysis, but in addition there was a marked anesthesia on the left side, slight rigidity of the neck, and a positive Kernig's sign. A diagnosis of meningitis was made, a spinal puncture was per- •z- • CLINICAL- CHAM-- mi ) :kJLH: • A_3- 2.l_; J (KAMI) ~(».»Tt) (AOl) (COLOM s ; -* s c r E 3 2 8 | 2 2 8 2 8 * § l« (0 1 p I" —r i 1 • V • • • • • &f*rt11838 zpmin 32. I 1 90 H —r rtft <X,.It i zm 911 i ifm w« 32 t i IO i am 104fa, i frAM91 zo 11 KM*98 22 i 2PM 116It. 1 <,PMno » i i 10 4 am 101}° 1 4am'94 3* —r 1 ow no 3)8 *W 114?T i 4PM('« J* r i 10 am fl| tft | \ —r zo 40 i lit 34 i \ 2PM1702« ll 4 PMl« 34 . .j. u 4PM 1*9f° N 19 1" IZO40 i i -* fipmHP 40 i \ IO <, (Z?MIf* t i s ZAM|4g4f 1 / 1 ^AM\&A4' \ 5'" | 3A« 41 1 *\ 4AM14045 —t 1 r 13041 1/ 5AM118<>« "I \ 1.1. -5 1 formed at once, and a milky watery fluid obtained under slight pres sure. Laboratory examination showed a high cell count and numer ous pneumococci (Type I). At 2 p. m. another spinal puncture was made and 80 cubic centimeters of milky fluid was removed under high pressure, and 75 cubic centimeters of antipneumococcic serum (Type I) were injected. The temperature continued to rise until 11 p. m., when the curve showed a drop of 3 degrees, followed at once by a rise. 304 FOLKEN—INFLUENZA WITH COMPLICATIONS. Vol. XIII. On the morning of October 6 the patient was found unconscious. At 4 p. m., same date, a third spinal puncture was made and 50 cubic centimeters of Type I antipneumococcic serum were injected. At this time 50 cubic centimeters of serum were also injected intravenously, which was followed by a rise in temperature to 108° by rectum. At 4 a. m. October 7 a spinal puncture was made and 4 cubic centimeters rT • CLINICAL- CHAPJ-- t_J-M- A- S- Zij_ ~MifTvTTY) rn/rog *ar I1 n •* I KLHikKtf.1 ; i crU i £ ,0 JO 44 w 7AM lit QAM fcfc 7ft f ? xw 5fV \ 4ft* $o ■4- HP* T 4i> \ | K>PM 4f 7 If* 2AM so AAM 48 5*m. y •,«. i- s CAM 4? O CAM 4-4 OAM M >-* "o" MAM **(( z L N dI 11V A T ———————-.- I of fluid removed under low pressure, and 20 cubic centimeters serum injected. At 11.30 a. m. October 7 the patient died. Post mortem findings : 1. A thin layer of pus over surface of entire brain. 2. Abscess in the right ventricle of the brain, involving the right thalamus. 3. Left lung showed marked congestion and small areas of consoli dation about the bronchi. No. 2. FOLKEN —INFLUENZA WITH COMPLICATIONS. 305 4. Heart findings showed numerous pinhead vegetations on the mitral, aortic, and tricuspid valves, the greater involvement being on the mitral. 5. Laboratory findings from smears taken from the brain abscess, valvular vegetations, and cut surface of the lung showed pneumo- cocci. Summary : 1. A true influenza, followed by broncho-pneumonia. 2. A broncho-pneumonia complicated by (a) general septicemia; (b) endocarditis acute; (c) hemiplegia, left side ; (d) septic embolism of the brain, most probably from the valvular vegetations (this would also account for the ventricular abcess) ; (e) meningitis, cere brospinal, coming on after the brain-abscess formation. PROGRESS IN MEDICAL SCIENCES. REVIEWERS. Captain J. 8. Tatlob, Medical Corps, United States Navy. Commander G. B. Tbiblb, Medical Corps, United States Navy. Lieutenant Commander G. F. Clark, Medical Corps, United States Navy. GENERAL MEDICINE. Rivas, D. Diagnosis, treatment and prophylaxis of malaria In Brlonl. New Or leans Med. and Surg. Jour., January, 1919. The author, who was at one time assistant to the Koch Institute in Berlin, gives with interesting detail the sanitary history of Brioni, an island in the Adriatic Sea, a few miles from Pola, and bearing southeast from Venice and south from Trieste, in the Province of Istria. Brioni has quarries which in the past gave it an importance dis proportionate to its size, and supplied building material for many of the palaces and public works of Venice, Vienna, and Berlin. At different times while the island was the property of private in dividuals, both Italian and Portuguese, malaria so decimated the population that cultivation and tenure of the land became impossible and Brioni acquired the sobriquet of " Island of Death." Brioni became a part of Austrian territory in 1866 and shortly afterwards was acquired for a trifling sum by a Swiss who attempted to cultivate the island but had only a temporary success. Malaria killed off his laborers and the project was abandoned. In 1880 Brioni was purchased by an enterprising and capable individual of the name of Kuperweisser, who proceeded to administer quinine to the inhabitants and to institute drainage. He further appealed to the authorities in Vienna for a commission to conduct a campaign against malaria in the island. As a result of this petition Dr. Koch took charge of the undertaking. After one year's work devoted to making blood examinations of the inhabitants and active treatment of all in fected cases the malarial patients were reduced 50 per cent. In 1901 the author formed part of a second expedition to Brioni. The work was now expanded by the treatment of chronic carriers and their quarantine or elimination from the island. (Fine for Brioni but not so advantageous for the localities to which the " eliminated " 307 308 GENEBAL, MEDICINE. Vol. XIII. betook themselves.) The third expedition in 1902 undertook the de struction of larval and adult mosquitoes and the screening of doors and windows and the island was subsequently declared free from malaria and has so remained. Herr Kuperweisser paid $40,000 for Brioni. By 1902 its value was estimated at $1,000,000. It soon be came the garden spot of the Adriatic region and a summer resort patronized by the wealthy and fashionable, filled with luxurious private residences^ villas, and castles owned by the Austrian aris tocracy. Dr. Kivas recommends the sulphate of quinine dissolved in dilute muriatic acid for oral administration as a routine measure and pre fers the hypodermic to the intravenous method in special cases. Qui nine by mouth should be taken on an empty stomach four or five hours after a meal —in the evening or on rising in the morning. The minimum dose for an adult is 15 grains and for children at the rate of a grain for eaph year. Rivas considers the time at which the quinine is given one of the most important points in the treatment. Based on a study of the changes in the parasite incident to the various stages of the asexual cycle the patient's period of crisis following the febrile period is the one in which quinine should be given, because it represents the begin ning growth of the trophozoite. The very young parasite is pecu liarly susceptible to the action of the drug and easily destroyed by it and as its metabolic activity is now great it seems proper to assume that it will take more quinine than in a later quiescent period when as schizont it is like the gamete actually refractory to the drug. The author considers the artificial lowering of high body tempera ture in pernicious types with prolonged fever a procedure of doubt ful propriety because a high blood temperature is unfavorable to the growth and metabolic activity of the parasite as it enters the erythrocyte. The administration of quinine should be continued for a certain period of time. It is recommended that a 15-grain dose be given when the fever begins to fall and repeated at the same hour for three days in succession. After four days without quinine repeat the treatment for three successive days and again give a free interlude. This should be kept up for two or better three months and thereafter a 10-grain dose once a week to the end of the season suffices. (J. S. T.) Dragotti, G. Epidemic lethargic encephalitis. Policlinico, Rome, XXV, 40, October 6, 1918. During the war human pathology has exhibited a multiform activity. Known diseases have increased, new types have developed, and forms of morbidity which had only a historical interest for the No. 2. 309 GENERAL, MEDICINE. present generation have reappeared. Among the latter may be the so-called epidemic lethargic encephalitis, which so far has manifested itself principally in England and France. The cardinal clinical symptoms of this affection which may be re garded as an infective process, are somnolence, fever, and paralysis of some of the cranial nerves. The cases have not been very numerous. Up to the end of May, 1918, 105 had been verified in Great Britain and 71 in France, but it must not be forgotten that some cases were probably not reported through error in diagnosis. The malady is not a new one. In the spring of 1890 when the pandemic of influenza was beginning to waver there occurred in Italy, particularly in the district of Modena, a number of cases of a lethargic condition styled nona. Synchronously with them similar cases were observed in Hungary, Bulgaria, Denmark, Germany, Switzerland, England, and in the United States where Young gave to the syndrome the name " grippal catalepsy." Camerarius, in 1712, observed at Tubingen a disease which he called sleeping sickness. More recently in 1916 an epidemic prevailed having symptoms identi cal with those seen in France and England to-day. Von Wiesner, in 1917, claimed to have isolated the etiological factor in the shape of a coccus. The recent epidemic has been studied by Harris and Hall (Lancet, London, Apr. 20, 1918) and by Saint Martin and Lhermitte, who assigned the name primary polioencephatitis with narcolepsy, while the more commonly employed designation is that of Netter. The symptom complex of the encephalitis in question varies in severity, in the duration of individual symptoms and especially in the matter of cranial nerves involved. However, the disease both in its positive and negative aspects is a distinct entity. It often be gins with vague manifestations attracting attention to the mucous membranes of the respiratory and digestive tracts such as are common in influenza. The conspicuous feature, however, is the somnolence which is ushered in by headache and vomiting. The patient ex periences a sense of prostration, the eyelids grow heavy, his whole being is invaded by an irresistible torpor. At first he is able to answer questions, but falls asleep the moment he is let alone. Gradu ally all movement becomes impossible and he lies helpless in bed. At intervals of two or three days he rouses himself to partake of food, but it may be necessary to feed him through a tube while still asleep. The sleep may become an actual state of coma, lasting weeks or months, interrupted by delirium, convulsions, paralysis of the sphincters, and profound decubitus. Almost as constant as sleep is the paralysis of certain external muscles of the eye evidenced by bilateral or unilateral ptosis, stra bismus, diplopia, and immobility of the globe of the eye. The onh 310 GENERAL. MEDICINE. Vol. XIII. thalmoplegia is central in origin. Nystagmus is common, while in ternal paralysis is relatively rare. The paralysis may extend to the muscles supplied by the trifacial when the patient will have a char acteristic facies varying with the particular muscles involved. Pa ralysis of the joints is rare, a catatonia being more common and like wise tremors and incoordination. Aphasia and paralysis of the sphincters have occasionally been noted. Disturbances of sensation are rare. Fever is present in all cases, but may be brief, attending the initial stages only, or else high and persisting throughout the attack. Rigidity of the neck is slight or absent, and the same is true of Kernig's sign and bradycardia, which characterize meningeal affec tions. Lumbar puncture yields a clear fluid under normal tension with normal sugar and albumin content. There is practically no lympho cytosis. These features of the spinal fluid have important bearings on diagnosis. The features enumerated are not constant, the only essential ones being sleep and paralysis of the cranial nerves. Epileptiform and apoplectiform seizures may occur, completely disguising the picture unless an epidemic is present. The duration of the disease is subject to great variation. It may be for a day or two, ending in recovery or in death from bulbar paralysis. As a rule the disease drags on for weeks or even months. When a favorable crisis does take place it is very marked, though psychic and somatic disorders persist for a long time. The mortality is placed by various writers at from 25 to 55 per cent. The pathological lesions are: Congestion and punctiform hemor rhages and cellular infiltrations around the vessels especially in the gray matter near the third, fourth, and lateral ventricles, and accord ing to P. Marie, especially at the level of the locus niger. The en cephalitis is diffuse, interstitial, of unknown origin, attacking by preference the vascular system. The pathology has some analogy to that of rabies, poliomyelitis, and sleeping sickness. An attempt has been made to connect epidemic encephalitis with poliomyelitis. The hypothesis is invalidated by the marked prefer ence of the latter for young subjects, by its higher mortality, and the lesser tendency to atrophies. On the other hand, in poliomyelitis the morphology of the spinal fluid is more distinctly altered and this feature permits the differential diagnosis from cerebro-spinal menin gitis. An attempt has been made to connect epidemic lethargic en cephalitis with botulism, but the dryness of the mouth and throat and the extreme dilatation of the pupil are lacking in encephalitis, while, on the other hand, lethargy and coma are not characteristic of botu lism. Where botulism is present there is usually a history of the in No. 2. 311 GENERAL MEDICINE. gestion of some suspected article of food by a more or less varied group of persons while cases of encephalitis are usually in separate families. The possible relationship between influenza and epidemic enceph alitis should be considered in view of the striking fact that in 1889-90 and now the diseases have appeared concurrently. Royal Society of Medicine. Encephalitis lethargic*. The Lancet, London, October 26, 1918. At a general meeting of the Fellows of the Eoyal Society of Medicine on October 22, 1918, the subject of encephalitis lethargica was exhaustively discussed, and the following notes are from the report in the Lancet. When cases began to develop in Great Britain they were reported as " botulism," but the failure to find the bacillus botulinus and the discovery of areas of perivascular infiltration in the central nervous system lead to the assumption in many quarters that the disease was a form of acute poliomyelitis of cerebral type. Clinical observers soon noted, however, that the cases developed a symptomatology all their own and essentially different from poliomyelitis. The exten sive investigations since carried out established the disease as sui generis with a definite pathology and distinct epidemiological pe culiarities. The onset is frequently sudden but oftener preceded by a few days of lassitude, headache, and sometimes vomiting of cerebral type. The patient then becomes lethargic but can be roused and is conscious of what is going on around him. Nocturnal wakefulness is not uncom mon. Asthenia is general with definite local paralysis, particularly of the ocular muscles, muscles of the face, and less commonly of pharynx. This results in strabismus, nystagmus, dysphagia, a mask like expression, disarthria of speech. First one and then another group of muscles is involved. The course of the disease is variable. Death may take place within a few days from failure of respiration or there may be recovery after months of illness. The disease occurs at all ages. The seasonal influence shows in the maximum of cases developing in the spring of the year. (J- S. T.) Royal Society of Medicine. Enceptalitis lethargica. Brit. Med. Jour., Novem ber 2, 1918. In a report of the meeting of the Royal Society of Medicine, Octo ber 22, 1918, Lieut. Col. F. W. Mott, Royal Army Medical Corps, is quoted as citing two cases studied by M. Marinesco of the depart 312 GENERAL, MEDICINE. Vol. XIII. ment of neurology, Bucharest, from the standpoint of pathology. In these cases disseminated miliary or punctiform hemorrhages visible to the naked eye existed in the gray matter in the neighbor hood of the floor of the fourth ventricle, the aqueduct of Sylvius, and even the third ventricle and were also found in the posterior part of the pons and peduncles. The cerebral cortex was practically nega tive in the two cases. On the contrary the first segment of the spinal cord, the portion available for study, presented the same histological lesions as the pons, bulb, and peduncles. The spinal fluid might or might not show lymphocytosis and albumin. Dr. P. N. Panton reported a series of cases in which the spinal fluid was clear and held that the examination of this fluid was a valuable means of making a differential diagnosis. Dr. A. S. MacNalty grouped the symptoms in three types. 1. General disturbance of the functions of the central nervous sys tem without localizing signs. 2. Localizing signs manifested in (a) third pair of cranial nerves; (b) affections of the brain, stem and bulb with local lesions of other cranial nerves; (c) affections of the long tracts—pyramidal, pre- pyramidal and up-coming afferent tracts; (d) ataxic types (cerebel lar mechanism); (e) affections of the cerebral cortex; (/) spinal cord involvement; (g) polyneuritic type. 3. Mild or abortive type. The acute manifestations are slight early rise of temperature, marked asthenia, catalepsy, stupor, changes in speech, choreic move ments of face, trunk and limbs, muscular pains, hyperaesthesia, skin eruptions dysphagia, constipation. The rapid complete or partial clearing of the paralysis was the most remarkable feature of cases with nervous manifestations. (J. S. T.) Bbown, G. E. Syphilitic aortitis. Am. Jour. Med. Sc, January, 1919. The author, in a concise and convincing way, brings out three important points. The disease is common, is easily overlooked or confused with tuberculosis and other thoracic diseases and is amen able to treatment only in the early stages. The first anatomical studies on the subject were made in the 18th century by Morgagni. The disease occupies somewhat the same posi tion in medical literature that tuberculosis did 30 years ago in that only the full-blown cases are deemed worthy of note. The diagnosis in each condition must be made in the incipient stage if treatment is to be of value. There is little or nothing to be done for aortitis when gross changes have occurred in the vessel wall. No. 2. 313 GENERAL. MEDICINE. In the past diagnosis has been relatively rare, though post mortem findings amply demonstrate the frequency of the condition. This was due in part to the indifference of the profession or to ignorance, as the textbooks contain few allusions to the subject. Then it is often a late manifestation overshadowed by coexisting paresis, athe roma, tabes. In the early stages the signs and symptoms are often slight and misleading. Brown quotes from various writers to show the frequency of aortitis. Thus Gruber reports a series of 6,000 autopsies with 4 per cent showing aortitis. Out of 256 autopsies on luetics reported by Marchand 82 per cent had the disease. Obendorfer found that 7 per cent of 1,436 autopsies on adults showed aortitis. The author made an antemortem diagnosis in 5.1 per cent of 136 luetics in whom a pos itive Wassermann or luetin reaction had been obtained. Brown quotes Heller's affirmation that syphilis, as compared with atheroma, is an inflammation with reparative reaction. The gross lesions consist of irregular folds and roughenings of the intima — translucent and pearly plaques. These cushions or wheals may be yellow in color. Aortitis does not show the fatty and calcareous de posits characteristic of atheroma, but the two diseases may be con current. Syphilis usually attacks the aorta at the orifice, and when the process extends centripetally serious damage to valves and coronaries is to be expected. It is least harmful when traveling in the other direction. While all portions of the thoracic aorta are liable to in volvement, the abdominal segment usually escapes, and this has not been explained. Klots has shown that there is a rich lymphatic supply to the ascending and transverse portions of the arch which are in close relation to the mediastinal glands invariably affected by retrograde movements of the spirochete, but the abdominal aorta also has close relations with the glandular system. Syphilis of the aorta may be confined to the first portion, may at tack the valves, cause aneurysm or obliteration of the coronaries. Brown discusses only the symptomatology of the first-mentioned type. In this the cardinal symptom is pain located under the sternum at the junction of the manubrium and gladiolus. There may be moderate or very severe sensations of compression or constriction. Pain radiates along the brachial plexus in one or both arms, com monly in the left arm only. Mental and physical fatigue is com plained of, the patient lacks energy, has a tendency to neurasthenia, and suffers from headaches. The early weakness is like that of in cipient tuberculosis. Dyspnea is variable in degree, but nearly always present. Hoarseness and fever are less constant. A dry non productive cough occurs. Cyanosis is relatively rare. All these 103396—19 10 314 GENERAL MEDICINE. Vol. XIII. symptoms approximate closely to those of beginning tuberculosis and may be very misleading unless great care is observed. The physical signs furnish the basis for positive, constructive, and differential diagnosis. The chief reliance is to be placed on X-ray examination by plates and the fluoroscope to determine if enlarge ment of the aorta is present. Enlargement is always present in aortitis and it is in both diameters. This may often be demon strated by percussion. The blood pressure is generally not elevated, which is an important differential point. The Wassermann or luetin test is usually positive. The last diagnostic measure is the thera peutic employment of mercury and the iodides. (J. S. T.) MacCullum, W. G. The pathology of the streptococcal pneumonias of Army camps. Medical Clinics of North America, September, 1918. It is interesting to learn that beginning with the early part of the sixteenth century there were numerous epidemics of pneumonia spreading over Italy, Spain, France, Germany, and other countries involving numbers of people and having a high mortality. It is dif ficult to determine the precise type of pneumonia that existed, but empyema was a frequent complication and it was probably strepto coccal in origin. In America similar outbreaks are recorded from the eighteenth century. In 1812 the troops in New York State and the civilian population of New England and of the Southern States were simi larly affected. The epidemic dragged along for three years in the North and did not disappear in the South for 14 years. During the Civil War, as recorded by Woodward and others, measles was extremely prevalent and was commonly followed by a broncho-pneumonia with associated empyema. During the four years 61,000 cases of pneumonia were recorded and many of them were separated as in some way related to measles. MacCallum has studied pathological specimens preserved at the Army Medical Mu seum, Washington, and finds that they correspond closely to the pathological material obtained in the recent epidemic. Streptococci were recognized in typical chains in the bronchi and pleural exudate and the gross appearance was that of the streptococcal broncho pneumonia of to-day. (J- S. T.) Stokes, J. II. The venereal problem and the war. Internat. Assn. Med. Mu seums Bull. VII, May, 1918. The author of that valuable and timely book, the Third Great Plague, reviewed in a previous issue, begins his comparative survey of the attitude to the problem of veneral disease of the participants in No. 2. 315 GENERAL, MEDICINE. the war, with a reference to the pioneer legislation on sociological lines of Denmark, Norway, and Sweden. The measures employed or contemplated by the belligerents fall into two groups. Group 1 : ( 1 ) Provision of universally available, reliable means of early diagnosis by the State. (2) Provision of universally available and efficient free treatment by the State. (3) Limitation of treat ment to competent hands, suppression of quackery, drug-store pre scribing, advertising cures, and patent medicines. (4) Moral and educational prophylaxis. Group 2: (1) Suppression or regulation of prostitution. (2) Dis semination of knowledge concerning venereal prophylaxis, and sale of the agents employed for this purpose, to the public at large. (3) Compulsory measures and penalties making treatment obligatory on the patient until he is cured, with or without preservation of his secret. (4) Reporting of venereal disease in open or anonymous form to the health authorities. (5) Indirect legislation bearing on transmission of infection in or out of marriage, professional medical confidence, marriage laws, etc. British activities are along the lines of group 1. Enactments in West Australia include all of 1 and a good deal of 2. Very little is known of what the French have done in this problem during the war. The Italian civil program antedates the English, and began in a Scandinavian type of provision for public treatment without com pulsory treatment in August, 1907, dispensaries being organized by the several communes with the cooperation of the minister of the in terior. In general, sentiment in France and Italy permits more drastic methods than would be tolerated in Anglo-Saxon communi ties. Up to 1903 Italian armies had the highest morbidity figures in Europe. In the present war Italy has passed rapidly from group 1 to group 2. Prophylaxis is carried out in connection with the houses of prostitution legalized as army institutions, thus imitating Japan in the Eusso-Japanese War. Marked success is claimed for this measure and morbidity figures have been brought down to about those of the British. The author considers that the Huns have incorporated into their public policy during the war a greater number of radical features than any other country, carrying them out with the painstaking attention to detail peculiar to the tribe. For a number of years prior to the war their army figures for venereal disease were the lowest in the world but the prospect of an increase due to campaign ing led to lively discussion of the additional means to be employed. Neisser favored indiscriminate specific treatment for all women who had had relations with soldiers even if infection could not be proved. 316 GENERAL MEDICINE. VoLXIH. He recommended the free distribution of condoms to the soldiers. Von Hindenburg signed an order for internment in prison camps or jails of all infected women. A regulated prostitution was enforced during the war for military districts. Many advisory clinics have been established to which army cases could be referred and over 70 special clinics have been established in Prussia by life insurance companies. Plans are being made to provide at least three years of active treatment for every syphilitic, and lifetime observation if necessary. The position of the United States in the world-wide movement against venereal disease is in some respects not altogether an enviable one. Our pub lic campaign has scarcely developed beyond the point reached by that of Eng land In 1898. Stokes lays down two facts of outstanding importance in the his tory of venereal diseases in armies and navies. (1) Increased inci dence in war; (2) efficiency of modern prophylaxis. In the Franco- Prussian war the venereal incidence in the First Bavarian Army Corps rose from 10.2 to 77.7 per thousand from January to May. British army morbidity for venereal disease has been given as 48 per thousand in November, 1916, and 43.5 in February, 1917. The Italian figures up to December 31, 1915, were 90.5 per thousand. From January to June, 1916, they were 46.2 as a result of methods of regulation or prevention put in force. From French writers various ■estimates are reported. Thibiege estimates 4,000 to 5,000 cases of syphilitic infection per month, which in three years of war would mean 150,000 to 200,000 new syphilitics for that country alone. The cases of venereal disease acquired by the Hun soldiery in Belgium during the period of occupation is estimated at 30,000. Allowing to Hun armies a rate of 40 per thousand this would give about 280,000 fresh venereal cases annually, 60,000 of them syphilis. Our own best figures (prior to May, 1918) are nearly double those of the British or Italians and are greatly in excess of foreign fig ures for peace times. The author quotes the Lancet as authority for the statement that in British educational prophylaxis the dis tribution of pamphlets and leaflets has been disappointing. The presentation of a concrete case of bad venereal infection was a much better deterrent. Stokes describes the prophylaxis of our Army and Navy as puni tive, in that there is a loss of pay for days lost for venereal disease, in that a man must use prophylaxis if required and is punished for neglecting to do so. Great Britain has not formally adopted a policy, but her navy tolerates the prophylactic packet. Italy conducts pro phylaxis in connection with its official military houses of prostitu tion. The Australian medical service claims good results from the prophylactic tents set up at the entrance of every camp. Riggs is No. 2. 317 GENERAL MEDICINE. quoted as giving the percentage of failures of prophylaxis admin istered within eight hours as 1.5 per cent. Exner is quoted as giving 1.4 per cent for the failures in 10,000 treatments for one American regiment in two and one-half years. Our author says, " * * * though not infallible, especially under conditions of Army life, medical prophylaxis is an indispensable weapon, and the nearer its application can be brought to the time of exposure, the higher will be the efficiency of the Army employing it, from a military standpoint." Next comes a review of the various indirect and moral agencies in operation here and elsewhere in the interests of enlisted men. (The reviewer notes with regret that in a majority of instances in America these efforts began with the war; before that our people cared for none of these things.) Reference is made to the effect of utter destitution in ravished Poland on the morals of her women : to the closing of "Animierknei- pen " in Berlin by police order, which in 24 hours left 700 women without their usual means of livelihood. Industrial readjustments in many localities have " thrown the women into a camaraderie with men in the civil population, which in the general lowering of moral tone induced by the war, has led to alarming consequences." As a result of general conditions, both industrial and military, clandestine prostitution has increased enormously in all war zones, and repressive measures scarcely meet the indications of this feature of the situa tion. The Huns have required a special military pass into military districts for all women not duly inspected professional prostitutes, but neither this measure nor wholesale arrests, deportations, and im prisonments have yielded commensurate results. On the other hand, the repressive measures of the British war zones seem to have done good, judging by the official figures on incidence of venereal disease. The real danger lies not in the fighting zone but in the cities whither men resort on furlough, the former being the domain of the clandestine, the latter of the professional prostitute. The occasions fraught with the greatest possibilities for harm are : (1) During mobilization and training; (2) during delays in transit; (3) during furlough; (4) during period of billetting in private houses, in towns and villages; (5) during convalescence outside of military influence. It has been estimated that in the Austrian service 5 per cent of infections took place at the front, 20 per cent on lines of communi cation and 75 per cent outside of the sphere of the army. The question of pay has an important bearing on the problem'.. The low pay of English and French troops makes them less attrac tive to the harpy than the soldiers of Australia, Canada, or the- United States, (j. s. T.) 318 Vol. XIII. GENERAL MEDICINE. Dbagotti, G. The cocaine habit. Pollclinico, Rome, XXV, 31 ; August 4, 1018. The cocaine habit became very general in Italy during the war. Cases of acute poisoning have been of almost daily occurrence in Europe. The habit of taking cocaine dates back some 30 years, when it was commonly used as a substitute for morphine in treating vic tims of the latter drug. The habit to-day is generally acquired deliberately and the number of addicts who drifted into the abuse of cocaine through the use of a physician's prescription, as for chronic rhinitis or neuralgia, is relatively small. The cocaine addict is prone to recruit companions in vice. The seekers of new sensa tions, the weaklings, the moral shipwrecks, readily become votaries of the drug. The habit is very common among prostitutes. A neu rotic or hereditary taint predisposes to its use. Degenerates take to the drug very readily. The effects of the drug on the human body are exerted particularly on the cardiac, circulatory, respiratory, and nervous systems. Pal lor of the face and coldness of the extremities are usual in cocaine addicts. Praecordial pains analagous to angina pectoris, dyspnea and arrest of respiration occur. The nervous phenomena are the most characteristic. While under the influence of acute cocaine poisoning, cerebral excitation is evidenced by loquacity, agitation, anger, or distressing emotion leading to tears. Vertigo is common. There may be a condition of stupor. Incoordination of movement and of tactile sensation is not infrequent. Visual and tactile hallu cinations occur though less commonly than in the chronic form of intoxication. Convulsions and even true epilepsy have been ascribed to cocaine. To the above must be added digestive disturbances such as ptyal- ism (followed by excessive dryness of the mouth) and very occa sionally vomiting and diarrhea, and urinary abnormalities (oliguria or anuria). Death may occur promptly or recovery be preceded by collapse, coma, or syncope lasting several hours. For months after acute poisoning a tendency to syncope, vague feelings of depression, dizziness, difficulty of speech, and incapacity for mental application may be manifest. The fatal dose varies as in the case of most poisons when taken into the stomach. A dose of 10 centigrams is usually tolerated. Serious and possibly fatal effects on heart and respiration may be produced by 45 to 50 centigrams. The subcutaneous injection of 5 centigrams is reasonably safe for adults. Alarming symptoms may develop from the use of larger doses, and when 20 centigrams are exceeded death may occur. Submucous injections, as in dentistry, are peculiarly active and the dose should not exceed 2 centigrams. Chronic poison ing by cocaine has a symptomatology all its own. A few individuals experience no effect from the first adventure, but for the majority No. 2. 319 GENERAL, MEDICINE. the immediate sensations are most delectable, and the craving for the drug is quickly established. The desire for cocaine may not be so compelling as is that for morphine, but it develops sooner. The general sense of wellbeing, the joy of life, the intellectual vivacity, the increased muscular energy begotten by cocaine are so delightful that once tasted these joys are hard to renounce for the future. In chronic habitues the sensations of wellbeing which marked the early indulgences do not persist. On the contrary, there is a general weakening of psychic activity and a general bodily weariness. The memory is impaired, especially as regards dates, and hence there is a disorientation as to time. The cocaine addict is commonly without appetite, undecided, listless, incapable of exertion. The disposition changes. He becomes moody, irritable, and unresponsive. Periods of activity are brief. Gradually there is an undermining of the moral sense, the deterioration showing itself most conspicuously in those whose financial situation makes it hard for them to procure the drug. They stoop to any baseness or crime to get cocaine, life having no purpose or ambition except in that direction. Sleeplessness and hor rible dreams like those of the dipsomaniac; auditory, visual, gusta tory hallucinations, make the periods between indulgencies occasions of intense suffering. The addict has various paraesthesiae, among them the sensation of a moving foreign body under the skin or of hot or cold water applied to the body surfaces. Worms and insects are felt crawling over their persons. With time the victim accepts these things as realities. Delusions come on varying in type with the indi vidual temperament. Hypochondriacal ideas and delusions of perse cution are frequent. While a certain lucidity of thought survives in the cocaine habitue, excessive indulgence in the drug or other forms of excess, such as an overindulgence in alcohol, bring on a delirium not unlike that of the chronic alcoholic. It is during such crises that occur the dramatic scenes, the acts of violence, and uncontrolled agi tation in public places which sooner or later lead to arrest and re straint in an asylum. It is by no means uncommon for the users of cocaine to be the slaves of morphine or liquor as well. In appearance the cocaine addict is pale, thin, haggard, and hollow-eyed. Tremors of the extremities, twitching of the lips, disordered articulation, and an explosive type of speech are noted. There is a tendency to hyper- hidrosis. The pulse is rapid and irregular. The eroticism of the early stages is followed by loss of sexual power. Among habitues who employ the drug in nasal tampons perforation of the septum is a common event. The prognosis in cases of chronic cocaine poisoning is extremely grave, the majority of them eventually reaching the insane asylum. 320 SURGERY. Vol. XIII. Many end their lives by suicide. Others languish in a state of pro gressive mental, moral, and physical decay. They are ready victims to intercurrent infections. Withdrawal or voluntary abandonment of the drug does not always result in complete cure, the constitution having been so undermined that mental and physical disorders per sist and complete return to normal is rare. The offspring of the users of cocaine are physical and moral degenerates. In acute poisoning by cocaine the patient should be put in a recum bent position with the head low. Nitrite of amyl has a valuable countereffect upon the basoconstrictor action of cocaine, but in serious cases its employment is not advisable. In cases marked by convul sions chloral may be given, or inhalations of chloroform or etber. When cocaine has been swallowed give a solution of tannin. Hypo dermic injections of caffeine, camphorated oil, or ether are recom mended to counteract the depression. For chronic cases the essential step is to withdraw the drug abso lutely and immediately. This measure does not involve the painful sequelae attendant on the sudden deprivation of morphia. The patient is put to bed and watched, and mild disturbances are met by the occasional administration of a stimulant. Gradual deprivation is advisable, however, in the presence of marked cardiac or renal disorders or of advanced cachexia. The cocaine habit should be studied and handled from the political and sociological standpoint, since the victims are weaklings with organic defects of the central nervous system. The most important measures are those looking to the prevention' of the habit, since its diffusion threatens the integrity of the race. (.1. s. T.) SURGERY. Parin, M. Sterilization of wounds by eleotro-ions. Presse mM., November 14, 1918. All surgeons now agree on the value of wound suture for short ening the period of cicatrization or improving the functional re sult by shortening the period of immobilization. Some surgeons at the front obtain excellent results with primary suture after extirpa tion of suspected tissue. Sometimes, however, primary suture can not be employed because the patient's temperature or the appearance of the tissues and the results of the bacteriological examination make the procedure undesirable. Finally this technique has been found impossible when the number of wounded men requiring im mediate attention was very large. When the primary suture has not been employed the patient usually reaches the base hospital with wounds that have become secondarily infected even if they were No. 2. 321 SUBGERY. not primarily infected. Such an infection retards the possibility of secondary suture. Indeed with serious infections and wounds containing pure or mixed growths of streptococci the surgeons ab stain entirely from suturing until extensive disinfection has been made. The resulting delay is in marked contrast to the immediate sterilization of wounds which can be obtained by the use of electro- ions even where the streptococcus is present. Prof. Leduc, of Nantes, in 1900 gave the first positive demonstra tion of the possibility of utilizing electrolysis to transfer the ele ments of a saline solution from outside the body to intimate con tact with the internal tissues. Leduc studied the action of different ions but Dr. Parin discusses only the results obtained in connection with the use of zinc ions. A very simple and instructive experiment consists in fastening to the positive pole of the source of electricity anodes made of different metals bathed in an albuminous solution. It is thus possible to esti mate the action and the penetrative power of different ions. Thus the zinc rod will become surrounded by a compact and adherent collar of coagulated albumin, the albumin having appeared rapidly and uniformly around the pole, whereas the iron rod has caused no coagulation but led to the formation of an albuminate of iron pre cipitated at the bottom of the containing vessel. The platinum rod likewise gives rise to no coagulation but liberates oxygen. The size of the cylinder of coagulated albumin proves the facility with which the zinc ion travels through it. Now, the coagulated albuminoids and the penetration of antiseptics into the heart of a tissue represent the essential features of wound treatment, the attainment of the very object in view when wounds are cauterized, curetted or dressed. Chemical antiseptics actually interfere with the penetration of the tissues by the coagulation of the albumin but the zinc ion is not thus hindered. Its penetration can be controlled at will by the operator. Leduc was the first to use this method with success in the treatment of boils and of anthrax. He also employed the zinc ion to cauterize and sterilize the uterine mucosa and to arrest hemorrhage. The English physician, Dr. Friel, head of the nose and throat clinic of the Johannesburg Hospital in the Transvaal, who had be come familiar with the new therapy of the Nantes school, was able by the use of the zinc ion to clear up suppurations of the middle ear and of the frontal and maxillary sinuses at one sitting. When Dr. Friel entered the English Army he used the ion method of steriliza tion of war wounds and in his surgical service at Abbeville war wounds were prepared for suture and healed up after one treatment. Dr. Parin has employed this method for the wounded who come to him directly from the front. The source of the zinc ions was a 322 Vol. XIII. SURGERY. solution of zince sulphate but any salt of zinc in solution, the chloride for example, would answer as well. He begins by cleaning the surface of the wound to be disinfected with a gauze compress soaked in the solution of zinc to be employed for the electrolysis, rubbing the wound vigorously so as to remove the contaminations—all the dead tissue which might prevent intimate contact between the wound and the solution. This intimate contact and the removal of foreign particles is an essential step in the pro cedure. The wound is then covered with 10 or 12 thicknesses of compressed gauze saturated with the zinc solution. Upon this is placed the electrode fastened to the positive pole, the whole retained in position by a few snug turns of a bandage. The adjacent integu ment is protected by the introduction between the skin and the com presses of a sheet of rubber dam cut so as to follow exactly the con tour of the wound and resist the passage of the current through the undamaged skin. The negative electrode should have a wide area and may be applied to any part of the body. Sterilization is ob tained at a single sitting. This is a distinct and indispensable fea ture of the treatment and Parin proceeds immediately to suture the wound, both the muscular and superficial layers, after widely free ing the integuments so as to promote the most accurate coaptation. Parin uses local anesthesia, stovaine either subcutaneously or by spinal puncture. He claims that the passage of the electricity causes no pain provided the intensity of the current is increased at the start and diminished at the end very slowly. When the current is carefully regulated the patient can stand 100 milliamperes during the time necessary for treatment if the intensity of the current is changed very gradually. Sudden increase to 5 or 15 milliamperes occasions considerable pain. Parin reports 15 cases treated successfully by this method after bacteriological examination and culture had demonstrated the pres ence of streptococci and other pus germs in the wounds. He gives the details of several cases. V.—Wounded July 19, 1918, by the explosion of a shell came under his care July 21 with a long deep wound of the left buttock which was kept open by contraction of the muscular fibers. On July 26 he was given a treatment of 3 milliamperes for 30 minutes, after which the lips of the wound were brought together with Michel hooks. The patient left the hospital completely cured an August 5. Dr. Friel has introduced a new electric unit milliampere-minute- square-centimeter and called it the Leduc. The Leduc, therefore, is the quantity of electricity produced by the current of 1 milli- ampere acting for a minute on 1 square centimeter of surface. Dr. Friel considers that a thorough sterilization can be obtained by the employment of about 4 Leducs. Ku.2. STTRGEBY. 323 Another case entered Dr. Parin's service with four bullet wounds which had a combined area of 146 square centimeters. He was treated by the Leduc method on July 30 and cicatrization was com plete on August 14. Perhaps the most interesting feature of Dr. Parin's report is the failure of the zinc to accomplish complete sterilization in two cases where bacteriological examination showed that streptococci were present in unusually large numbers. Recalling the fact that salts of copper had proved particularly destructive to streptococci in skin infections he substituted the copper ion for the zinc ion and obtained immediate results in the two cases which had previously proved refractory. Parin does not claim that the zinc ion can be regarded as having universal bactericidal power. He considers it probable that each type of germ is peculiarly sensitive to some particular ion and sug gests the propriety of determining this by a series of experiments. He concludes his paper with the further suggestion that in order to employ primary suture to the best advantage ion sterilization of wounds be employed at the front, as the method is simple and would be available for a large number of wounded. (J- S. T.) Caliceti, P. Abscess of thyroid following septico-pyemia from otitis. Poli clinics Rome, XXV, 50, December 15, 1918. Writing from Field Hospital 204 Dr. Caliceti reports the unusual and interesting case of an infantry private of the Italian Army without history of previous illness who reported for treatment in March, 1918. Mild symptoms of aural disturbance covering several months had been disregarded, but the development of pain, the ap pearance of discharge from the ear and swelling of the mastoid brought the patient to sick call. March 21, 1918. No pus found in auditory canal. Tympanic membrane red and infiltrated; scars in forward lower quadrant; bulging of upper quadrants. Redness, edema and tenderness over mastoid. Patient thin and not over muscular. Abdominal and thoracic organs negative. Paracentesis gives exit to a few drops of pus mixed with blood. Active treatment failed to arrest mastoid symptoms and on March 30 the mastoid was operated on and cleaned out under general anes thetic. The curetting was carried well back to the wall of the lateral anus which was normal. The patient showed marked improvement after the operation but on April 4 there was an evening rise of temperature and complaint of pain in the front of the neck. The next day slight redness and 324 Vol. XIII. SURGERY. swelling of the front of the neck was observed and the patient be gan to complain of difficulty in respiration and deglutition. From day to day there was progressive increase of the following symptoms: Palpitation and tachycardia ; pain on movement of the larynx ; dif ficulty of respiration and deglutition; nausea and vomiting; tremor of the hands; marked psychic disturbances; nervous irritability; widening of the palpebral fissure; eyes glistening and moist; no exophthalmos; weakness of the internal recti with deficient con vergence ; daily evening rise of temperature ; cough ; increasing loss of flesh and general debility. No fluctuation but increasing enlarge ment, redness and tenderness over thyroid. Mastoid wound doing well. On April 11 under ethyl chloride anesthesia the thyroid was in cised and odorless pus evacuated containing a pure culture of strep tococci in short chains identical with that obtained from the mastoid. The opening of the thyroid abcess produced a general alleviation of symptoms but nervous excitability continued marked. Weakness extreme. Sweating. On April 18 severe pain in left loin developed with tenderness on pressure. No tumor. Lateral decubitus. Evening rise of tempera ture. Both wounds healthy. By April 22 all symptoms were aggra vated and a swelling in the loin was apparent. Urinalysis showed albumen, cylindroids, granular and epithelial casts, leucocytes. Un der general anesthetic an incision was made into the peri-renal fat and a large abscess evacuated. General improvement followed this intervention but on April 27 pain in the right buttock developed and there was limitation of movement in right hip. Ah incision over the point of greatest tenderness brought a few cubic centimeters of choco late colored pus. A deep incision over the right trochanter gave access to a large abscess. From now on slow but continuous improvement set in and by June 16 the patient was able to be transferred to a territorial hospital for convalescence. The elaborate and detailed report by Caliceti from which the above outline of this interesting case is derived is followed by a discussion of the etiology of the pyemia and the various theories to account for the metastasis. 1. Was the infection transmitted through small intraosseous venules ? 2. Did the infective agent travel by the blood direct from the capil laries of the mastoid or the tympanic membrane ? 3. Was a small thrombus present in one of the minute vessels of the temporal bone ? No. 2. 325 SURGERY. Mayo, W. J. Acute perforations of the abdominal viscera. Surg. Gynec. and Obst., January, 1919. Three important surgical conditions—the relation of appendicitis to general septic peritonitis, perforations of the pancreas from fat necrosis, infections and perforations of Meckel's diverticulum —were made known to us by the late Reginald Fitz of Boston. As his re searches were wholly by autopsy a somewhat exaggerated idea of the fatality of these conditions gained credence. The operating surgeon by the study of living tissues has developed a more hopeful view. The prognosis depends on the quantity and virulence of the extravasated material, the general resistance of the patient and the anatomical location of the perforation as it bears on the possibility of adhesions, walling off, etc. The progress in surgical treatment is shown by the present attitude as to time of interference. An operation done from three to six days after perforation is not for the perforation but for the generalized peritonitis consequent upon that disaster in the hope of removing a still active focus or secondary deposits and so limiting the spread of the disease. Acute perforations of the abdominal viscera may be considered in three stages: (1) Stage of contamination evidenced by shock, local pain and tenderness; (2) reaction, a stage in which apparent ameliora tion creates the delusive hope that intervention may not be needed; (3) general peritonitis. In appendicitis 70 per cent may indeed recover from perforation that is from the one attack, but 30 per cent of fatalities is very high. The suposed recoveries are temporary. Subsequent attacks are com mon and may prove fatal. Mayo comments on the occasional coincidence in time of acute per forations of appendix and gall bladder. In such cases a gall stone has usually been present and the flora of the two organs correspond. It is well to bear this in mind when operating for either single con dition, since a successful treatment of the appendix or gall bladder may be followed by death of the patient if a rupture of the other organ passed unnoticed. Early operations for perforations of the gall bladder are frequently declined by the patient because he does not recognize the increased gravity of this over previous incidents con nected with, chronic cholecystitis or calculus. It is the delay that is fatal in these cases and not the inherent gravity of the accident. The anatomical surroundings of the gall bladder are excellent from the standpoint of protection. There is a close association between diseases of the gall bladder and biliary tract and diseases of the pancreas. In Mayo's cases of 326 SURGJBBY. Vol. XIII. chronic pancreatic disease 90 per cent were associated with infected gall bladder usually containing calculi. The danger of acute pancreatic processes "which may be spoken of pictorially as acute perforations" depends on whether or not infection is present. The prognosis depends largely on the question of infection. Mayo inclines to conservatism in the surgical treatment of acute pancreatic disorders preferring an anterior approach looking to drainage when indicated to incising the organ for anticipated trouble. Duodenal perforations into the abdominal cavity are the com monest of acute perforations. Happily the fluid contents of the duo denum are more or less sterile and of small bulk. These cases are often operated on for acute appendicitis, recovery following though the true cause of the symptoms was not discovered. An incision to the right of the mid-line through the rectus muscle enables the sur geon to examine appendix, gall bladder, duodenum, and stomach and engage in the procedure indicated regardless of the preoperative diagnosis. Mayo notes a marked difference between results from intervention undertaken within 10 hours and those delayed from 10 to 30 hours. When the operation is performed within 10 hours the perforation will usually be found closed and contamination may be prevented. Perforations of the stomach are more serious owing to the larger capacity of that organ and the greater likelihood of spread of con tamination, especially if they occur in the anterior surface. Chronic conditions usually precede perforation and give warning of the ever- present possibility of sudden acute dangers, but this has not been so generally recognized for gall bladder as for appendix cases. (J. S. T.) Soresi, A. L. The use of paraffin for drainage in surgery. Pollcllnlco, Rome, XXV-G 12, December 15, 1918. While the absolute necessity of giving escape to pus wherever or however produced and accumulating in different parts of the body is universally recognized, the daily experience of surgeons demon strates the futility of the great majority of devices used for drainage and what is worse the frequent liability of these devices to be of positive harm. The following propositions regarding the essential features of any method of drainage will doubtless meet with general acceptance: (1) The method employed must actually facilitate the flow of pus or other liquid to the surface. (2) It must not be the immediate or remote cause of local or general disturbance either at the moment of employment or at any later period. (3) It must not interfere with the healing of the diseased part. No. 2. 327 SURGEKY. As it can easily be proved that none of the methods now employed for drainage fulfill the three requirements given above, the author feels justified in publishing an account of the method of drainage by means of paraffin which he has employed for over five years, three of which were devoted to the treatment of thousands of wounds handled in the present war. Before describing the procedure in detail Soresi adverts to the complicated character of the fluids of the human body, all of which have the common property of tending to adhere in a greater or less degree to the parts with which they come in contact and of deposit- 1 ing on these parts either their organic or inorganic content. He notes further the familiar fact that nature has provided the blood vessels, lymphatics, and mucous surfaces of hollow organs and canals with special types of cells to which the liquids they transmit or contain will not adhere. To obtain adequate drainage therefore we can not do better than to imitate the performance of nature by employing devices which will have a minimum of affinity for the fluids to be withdrawn. Paraffin meets this requirement inasmuch as it does not fasten itself to the tissues and organic liquids do not adhere to it. In this connection the reader is reminded that trans fusion as employed to-day relies largely on the fact that the coating of paraffin on tubes and containers permits the blood to flow without coagulating. In brief, the advantages of paraffin for drainage may be summar ized in the statement that it does not stick to the tissues with which it comes in contact nor with the secretions from them. It follows from this that between the paraffin drain and the cavity to be drained there will always without any exception be a free space along which secretions from the walls of the cavity to be drained will have outlet. The interval between the paraffin drain and the walls of the abscess cavity will in every case suffice for drainage no matter what quantity of pus or secretion is produced. While the application of the proposed principle varies with the different types of wound, it requires no difficult technique, but on the contrary is so simple and so independent of special apparatus that it is within the reach of the humblest practitioner. The paraffin available for this method of drainage is the ordinary paraffin of commerce —any paraffin will do splendidly. The par affin to be used is prepared in the following manner : Water is set to boil in a tray, such as photographers use for developing, placed over an alcohol lamp. In this place a second smaller tray, making a water bath for dissolving the paraffin. The water bath prevents the paraffin from reaching too high a temperature and burning the patient. By this method the temperature of the paraffin will not 328 SURGERY. Vol. XIII. exceed 100 C, which will usually drop to 70° or 80 C. by the time the local application is actually made. Take an ordinary muslin bandage, a strip of linen, or a piece of tape of the length and breadth required and holding it by the two ends pass it through the liquid paraffin by a series of up and down movements until the paraffin is equally distributed along the mate rial. If the meshes are large two thicknesses of bandage may be used. Repeat the immersion until the drain has taken up the amount of paraffin desired. Now hold the drain by one end and dip the other into the paraffin. Drains prepared in this way can be used immediately, or after cooling can be put away between two sterile towels or preserved in some antiseptic liquid such as alcohol, to which a little iodine, bichloride of mercury, etc., has been added. Another type of drain can be prepared by folding the edges of the strip of bandage on themselves and submitting the strip to a pre liminary paraffin bath; then roll it between the hands and coat it with more paraffin. The last step should be performed quickly to prevent the first and inner coating of paraffin from being dissolved. By going over these steps several times a small, smooth rod some thing like a candle is obtained. The last step, of course, consists, as before, in paraffining one end of the drain. As the rod is withdrawn for the last time the excess of paraffin runs off the lower end and leaves a nicely rounded extremity which can be introduced into the tissues without pain or inconvenience. For more minute drains strands of linen, silk, cotton, or metal can be prepared as described above. Another way of using paraffin for drainage is to pour or inject the liquid directly into the cavity. The liquid paraffin can be drawn up from the container by a syringe, ladled with a spoon, or allowed to drip from a piece of gauze. When the paraffin is injected with a syringe into a wound having an entrance and exit aperture the most dependent one or both openings may be temporarily closed by a bit of gauze until the paraffin solidifies. Paraffin employed in this way when solidified becomes a " block " of paraffin ramifying through all the sinuosities of the wound. No fear need be entertained lest the paraffin becomes embedded in the tissues. It is expelled little by little as the cavity fills in. This will take place with a rapidity which will surprise anyone employing the method for the first time. Soresi has largely abandoned the use of tubing for drainage ex cept in those cases where the material to be abstracted comes from a considerable depth and where it is undesirable for the intervening tissues to be bathed in it. Tubing coated with paraffin is employed to advantage in draining the gall bladder and biliary ducts. T bandages and many-tailed bandages treated with paraffin are of use in special cases, e. g., drainage of the prevesical space. No. 2. 329 SUBGEBY. The paraffin method can also be profitably employed to drain cavities which at the same time require to be packed. With a piece of paraffined gauze of suitable width line the walls of the cavity somewhat as a paper hanger puts on the wall paper. Then use or dinary gauze for packing. When there is occasion to remove the latter it can be done easily and painlessly. Special indication for the use of paraffin threads of cotton, linen, or silk has been found in the closure of the abdominal wall by layers. Between the layers put a thread or two, leading the lower ends to the surface through a small special incision. This prevents those annoying accumulations of serum and blood which tend to make dead spaces in the depths of a wound and interfere with prompt healing either by the mechanical separation of the layers or by furnishing a culture medium for bac teria. The threads are withdrawn a little each day and completely removed by the eighth or ninth day after the operation. In perforating wounds the " block " method may sometimes effect a removal of minute foreign bodies such as bits of dirt, shreds of clothing, etc. The wound of exit is occluded and slight pressure is maintained over the wound track while the cavity is being injected with paraffin. When the cavity is distended pressure on the lower opening is discontinued and more paraffin is forced in. The vis a tergo now causes the paraffin to exude from the distal opening bring ing with it small foreign bodies. While far from claiming that this simple treatment will remove all foreign bodies the author does assert that it will bring away a great many of them and so reduce the trauma of operative interference looking to that end. The paper concludes with a detailed description of drainage of empyema, of mastoid, of prevesical space, summarizing the arguments in favor of the method described, (j. s. T.) Elmer, W. G. Surgical technic In orthopedic surgery. Ann. Surg., December, 1918. The extensive and varied procedures of surgery often involve forcible manipulation and more or less trauma of the parts. Hence perfect asepsis is indispensable. The following points made by Elmer are of interest to the general surgeon. He considers the rubber glove as ordinarily sterilized a serious menace. To wrap this article in gauze often partially folded on itself and sometimes folded twice and boil it perhaps in the center of a pile of other gloves, for 10 minutes after a " clean " and 20 minutes after a " dirty " case is to fall far short of the requirements. While steam may reach all parts of the outer surface of a glove, the author believes that air pockets are to be found inside the fingers which the steam never reaches. Such parts are therefore subjected, on the in- 103396—19 11 330 SUBGERY. Vol. XIII. side, only to dry heat and for the destruction of all germs and their spores by dry heat a temperature of 350 F. for one hour is re quired whereas boiling water (212 F.) for five minutes answers the purpose if all parts are reached. The proper treatment consists of a thorough preliminary washing with soap and water inside and out. The glove is then filled with water to expell all air, immersed in boiling water and held down by a piece of wire gauze. After five minutes boiling and when the water has cooled the nurse, wearing sterile gloves, removes the glove with forceps, dries it with a sterile towel, powders it inside and out with sterile talcum powder and folds back the gauntlet. Into this is now to be tucked a small gauze pad covered with talcum for the surgeon to use on his hands. The glove, now folded, is covered with muslin and laid in a large glass jar. When wanted for use gloves prepared as above, still wrapped in gauze, are laid in loose rows and not packed together in the auto clave, and sterilized for 20 minutes. The head nurse should personally and directly supervise the work of her assistants and the directress of nurses is responsible for the head nurse. The directress should occasionally go unannounced into the operating room while an operation is in progress and re main throughout the seance watching with critical eye every de tail of the work of her subordinates. Silk to be permanently imbedded in tissues will defeat the pur poses of the operation unless perfectly sterile. It should be boiled for 10 minutes in a 1-1000 bichloride solution and then for 10 minutes in plain water. If boiled with instruments the soda will impair tensile strength. In opening a joint two knives should be used; one for the skin incision, and one for the deeper structures. Sand pillows and operat ing tables should have rubber covers sterilized with the same care bestowed on rubber gloves and then be covered with sterile cloths. Instruments should not be provided in any considerable excess of actual needs. This complicates their proper handling and increases the wear and tear on them. Knives are not to be boiled but im mersed for 20 minutes in 5 per cent carbolic and then transferred by sterile forceps to a tray containing 85 per cent alcohol. The glass tubes containing catgut are to be boiled and then placed in a tray of 5 per cent carbolic or 3 per cent formalin. Nurses should not put their fingers into a tray but remove needed articles with forceps. Talcum powder can not be sterilized in milk. (J. S. T.) No. 2. 331 PATHOLOGY, BACTERIOLOGY, PARASITOLOGY. PATHOLOGY, BACTERIOLOGY, AND ANIMAL PARASITOLOGY. The laboratory diagnosis of gonococcal infections. Methods for the detection of spirochaetes. Pamphlet published by His Majesty's Stationery Office, 1918, for the Medical Research Committee (National Health Insurance). METHODS FOR THE DETECTION OF SPIBOCHAETES. Collection of material.. —Fluid freshly expressed from the lesion, after cleansing with salt solution or water, is to be used. If possi ble, the material should be collected before the use of any antiseptics. Puncture of the nearest enlarged gland and collection by syringe may yield results. Salvarsan and like remedies should not be used before the examination. (a) For superficial lesions take up exuding serum in a capillary pipette. Avoid getting blood. (b) Lesions of mouth. Same as (a) but care must be taken to avoid getting saliva, as it may contain organisms difficult to dis tinguish from the specific organism. (c) Skin lesions. Scarify or scrape papule and obtain serum by cupping or squeezing. Macules may be blistered. Blister fluid is to be thrown away and fresh serum obtained. (d) Lymph glands. Inject about 5 minims of salt solution into gland. Massage gland and withdraw fluid. DEMONSTRATION* OF THE SPIBOCHAETES. TJie dark-ground condenser. —The use of the dark-ground con denser is considered the ideal method. A note is made that the first application of the principle of the dark-ground condenser was due to English scientists. There is a discussion of the principles of the dark-ground condenser and the technique of the examination. Plates showing the appearance of the specific organisms, in comparison with S. dentinum and another organism, are shown. The S. dentinum is stated to have coils somewhat more angular and its motion is stiffer. The other organism has five coils to the diameter of a red cell while the specific organism has seven. The motion of the other organism is more active than that of the specific organism. Stained films. —Prepare film and fix as soon as it is dry, by apply ing absolute alcohol, methyl alcohol, or osmic acid. Stain by Giemsa's method or by Leishman's or Wright's modifications. India ink may be mixed with an equal amount of secretion and smears made in the- usual manner. Permit ink and secretion to dry. Examine with oil- immersion lens. Two per cent Congo red solution can be used instead! of India ink. In the use of India ink or Congo red the organisms are distorted. If the film is thick, they appear as fine filaments ;. if 332 PATHOLOGY, BACTERIOLOGY, PARASITOLOGY. Vol. XIII. the film is thin they appear thick. Characteristic movement of or ganism can not be determined by any staining method. Silver method. —Thibondeau's modification of Fontana's method is the one chosen. Technique.—Prepare films and dry them in the air. Fix by formol- acetic acid solution (acetic acid, pure, 1 cc. ; commercial formalin, 40 per cent, 2 cc. ; distilled water 100 cc.) , for one to five minutes. Treat with mordant (tannin 1 gram dissolved in 20 cc. hot distilled water) and heat until vapor arises, then allow mordant to act 30 seconds. Wash with tap water for 30 seconds and with distilled water for 30 seconds. Treat with silver solution for a few seconds in cold silver nitrate 1 gram, cold distilled water 20 cc. When solution is complete add ammonia water drop by drop. A brownish precipitate is first formed. On further addition of ammonia the precipitate begins to dissolve. Stop addition of ammonia when solution is faintly opalescent. Pour off silver solution and flood with fresh silver solution. Heat until solution steams gently and allow to act for 15 seconds. Wash in distilled water. Soft chancre and balanitis. —The committee finds no sufficient evi dence that soft chancre is a disease induced by a single species of micro-organism. It recommends that clinical observation of cases of soft chancre be continued for 12 weeks to exclude syphillis. A sim ilar recommendation is made with respect to conditions of balanitis. GONOCOCCAL INFECTIONS. Introduction. —The venereal diseases act has caused an increase in laboratory diagnoses of gonococcal infections. To reduce incorrect diagnoses to the minimum the committee has recommended that cer tain methods be followed. It is thought that such methods will pre vent grave injustice to individuals whose cases might be wrongly diagnosed. Gonococcus infection and on the other hand will serve to protect the families of men having the disease but in whose cases the diagnosis of gonococcus infection was not made. Recognition of gonococci in films.—A positive diagnosis may be justified from microscopic examination of films alone 1. When the clinical history and appearances are those of an acute gonorrhea. 2. When the proper technique has been employed. 3. When the observer is so thoroughly familiar with the appear ance of the gonococcus in stained films as to be beyond the danger of confusing other micrococci with it. There is a discussion as to the regions involved in the male and female. A note is made that a smear from the vulva is of absolutely no value, except in vulvo-vaginitis in children. It is recommended No. 2. 333 PATHOLOGY, BACTERIOLOGY, PARASITOLOGY. that the smears be made from urethral discharge. Cultures are to be made after cleansing with alcohol. Staining of smears.—Gram's stain is recommended. The commit tee thought the best results could be obtained by staining thin,, evenly spread smears with 0.5 per cent solution of methyl violet; pouring off, and without washing, applying a strong iodine solution (iodine 1, potassium iodide 2, water 100), then washing with absolute- alcohol and applying a solution of neutral red (neutral red 1, dis tilled water 1,000; 1 per cent glacial acetic acid 2). Cultivation. —The media found most satisfactory were : 1. Thomson's human plasma glucose agar. 2. Cole's tryptic blood agar. 3. Gordon & Hine's trypsinised pea extract agar. As the materials for (1) are most easily obtained in the service it is chosen for this review. (a) Beef heart free of all fat, minced, and placed in an equal weight of distilled water. Heat to 40 C, stirring constantly. Maintain temperature at 40 C. for 20 minutes, raise to boiling point and boil for 10 minutes. Strain through four thicknesses of butter muslin. (b) Dissolve 10 grammes disodium hydrogen phosphate (Na2 HP04) in 1 liter of sterile distilled water. (<?) Measure equal parts of (a) and (&) into a sterile flask and add peptone to make 1 per cent solution. (Best to make a paste with peptone and a portion of fluid.) Steam in Arnold for 45 minutes. (d) Add sufficient agar to make 3 per cent agar jelly. Steam in Arnold until agar is dissolved (60-90 minutes). Filter. Titrate and make plus 6, Eyre scale (plus 0.6), using phenolphthalein as an indicator. Add to agar solution sufficient glucose powder to make 2.5 per cent solution of glucose. Steam for 20 minutes. Place about 4 cubic centimeters in each tube and store in ice chest. (e) Collect blood in sterile centrifuge tubes, each tube containing 2 cubic centimeters of 2 per cent sterile solution of sodium citrate for 8 cubic centimeters blood. Centrifuge and collect plasma. Melt agar tubes and cool to 60 C. Add to each tube from 0.5 to 1 cubic centimeter plasma and mix by rolling between the hands. Slant. Incubate 24 hours to insure sterility. Methods for production of a focal gonococcal reaction. —Vaccinat ing or inoculating with 50,000,000 to 100,000,000 autolysed organisms or 100,000,000 to 200,000,000 of suspension of the cocci killed by heat, may set up a focal reaction, frequently accompanied by active discharge containing gonococci. There is danger that such a pro cedure may light up a latent iritis or salpingitis. A 0.5 per cent 334 EYE, EAK, NOSE, AND THROAT. Vol. XIH. solution of silver nitrate introduced into the urethra may induce active discharge in case of doubtful urethritis. Complement -fixation test.—This has been little employed in Great Britain. Its disadvantages hitherto reported are: (1) It very fre quently fails in acute gonorrhea, (2) Even in chronic cases if narrowly localized it may fail. (3) The test can not be used in patients treated with vaccines. (4) Antibodies from vaccine treat ment may persist for months. (5) It may give nonspecific results. The committee does not recommend any one standard method of performing the test. (G. F. C.) EYE, EAR, NOSE, AND THROAT. Kerrison, P. D. Tests for malingering In defective hearing. Laryngoscope, vol. XXVIII, No. 9. Complete bilateral deafness is rarely claimed ; the cases presented are usually advanced unilateral deafness or absolute deafness. Tests used by the author are Weber's loud conversational voice test; the binaural stethoscope test, eliciting incongruous variations and re sponses; the noise-apparatus reading test (Lombard's test). The routine is as follows: Only one registrant at a time is admitted to a room and is questioned regarding his condition, but at no time being led to suspect that his statements are under suspicion. Weber's test is now made, and if he refers the sound to the supposedly deaf ear, his honesty is probable. If he refers it to his sound ear, the next test is proceeded with. Loud-voice test: Blindfolding the patient and requesting him to close his better ear, words and numbers are repeated to him, at first in a low voice and then louder. If, after reaching a sufficient degree of loudness to enable him to hear with the sound ear, even though tightly occluded, he still claims not to hear, he is an intentional malingerer. Stethoscope test: Using the ordinary clinical stethoscope with a funnel-shaped chest piece, one ear piece is closed off with wax, and the stethoscope adjusted with the occluded ear piece to the sup posedly deaf ear. Words in a low whisper are spoken into the chest piece, and should be heard perfectly. The stethoscope is re moved and later replaced with the occluded piece in the sound ear. If he hears as well as before, the deafness was either exaggerated or pure malingering. Tests eliciting contrary responses: The ordinary tests are gone through with while the patient's eyes are open and the amount of hearing is approximately determined. He is again blindfolded, and Mo. 2. 835 EYE, EAR, NOSE, AND THROAT. the same tests are repeated several times, in varying order, and the results compared. It is likely, if he is malingering, that there will be contradictory responses. Lombard's test is made with a Barany noise apparatus, and de pends upon the fact that the sound of the voice is necessary to proper regulation of tone and intensity. The apparatus is adjusted, and the machinery started, using the sound ear. The candidate is then given a book to read aloud, and told not to stop when the noise apparatus is set going. With a one-sided deafness, and the normal ear with a noise apparatus, the patient's voice rises, and may be almost a shout. A malingerer will continue to read with unchanged, or only slightly elevated, tone. (G. B. T.) Woods, A. C. Ocular anaphylaxis. Arch. Ophth., vol. XLII, No. 2. Producing a hypersensitiveness of an eye by means of an intra ocular injection of homologous uveal emulsion, then after two or three weeks an intraperitonial injection of uveal emulsion, it was found in this series of experiments with dogs that within two or three weeks after the intraocular injection the noninjected eye began to show irritation, a pericorneal congestion associated with photo phobia. After the intraperitonial injection the affected eye became more active, while the uninjected or sympathizing eye developed a ciliary irritation, photophobia, iris finally becoming immobile, vitre ous opacities developing and the globe showing lowered tension. It is believed the condition produced was sympathetic ophthalmia. (G. B. T.) Maclay, O. H. Bacteriology ot tonsil crypts. Laryngoscope, vol. XXVIII, No. 8. The cases presented the usual clinical symptoms; in children his tory of repeated attacks, while the cases showing systemic involve ment were adults. The removed tonsil was immediately placed in sterile gauze and not handled until taken to the laboratory. The surface of the tonsil was cauterized and a sterile sharp kinf e used to cut cleanly into the crypts. Smears and cultures were made from the crypts. Surface smears show many different organisms, but probably only represent the organisms present in the mouth, while those in the crypts are responsible for infection and may be entirely different. Staphylococci were found in 166 cases, streptococci in 133, pneumo- cocci in 121, streptococcus hemoliticus in 17, streptococcus viridens in 1, diplococci in 49, bacilli in 5, hay bacilli in 2, tubercle bacilli in 1. (G. B. T.) NOTES AND COMMENTS. The Third Resuscitation Commission has sent to the United States Naval Medical Bulletin and to many other periodicals a summary of the proceedings of the session held at the Rockefeller Institute, New York, on May 17, 1918, with the request that it be published in whole or in part, certain paragraphs being especially emphasized. The portion of this report which appeals most strongly to the editor of the Bulletin is its appendix, which is herewith reproduced in full. APPENDIX. The commission consists of 15 members. Fourteen approved the foregoing report without qualifications. The fifteenth member wishes to qualify his vote by the following statement : Dr. Yandell Henderson qualifies his support of the resolutions as follows : While I concur In a considerable part of the report of the Resuscitation Com mission, I dissent from the statement in resolution 8 recognizing " the great need of simple devices capable of performing artificial respiration reliably and efficiently." Devices which are excellent from the mechanical standpoint are now available and widely sold, but the evidence regarding them Indicates clearly, I believe, that even If these devices were on the spot where several gassings or electro cutions occurred, and If all the victims were treated with them, except one who was given manual (prone pressure) treatment, this one would have much the best chance of recovery. In actual practice the apparatus is seldom right on the spot, adjusted, and ready. Critical time is lost, and thus in the above supposititious cases, as they actually occur, the only victim with any .consider able chance of resuscitation (aside from those who recover spontaneously and are credited to the apparatus) is the one treated manually. Even more important is the fact, demonstrated now by universal experience, that when apparatus is known to be obtainable, It is sent for and the manual method neglected. Thus, to-day the apparatus in public use is, on the whole, contributing very materially to decrease the saving of life. This is certainly sound, common sense and a very proper amplifi cation of the second important fact emphasized by the commis sioners : " That reliance upon the use of special apparatus diminishes greatly the tendency to train persons in the manual methods and dis courages the prompt and perserving use of such methods." We believe that the fact that in most accident cases no apparatus is at hand for immediate use is a matter of congratulation rather than regret. 337 338 Vol. XIII. NOTES AND COMMENTS. The commission recommends the prone pressure or Schafer method of resuscitation, the use of this method on the spot without the delay incident to transfer to a hospital and the employment in addition, in cases of gas asphyxiation, of inhalations of oxygen. The neglect to give proper instruction in methods of resuscitation at hospitals and in medical schools is deplored, as well as the disposition of police officers and even physicians to urge removal of the patient from the scene of the accident before normal breathing has been restored. Lecture course at Great Lakes, III.—In a previous issue of the Bulletin several papers were published which had originally been prepared for one of the bimonthly occasions on which the medical officers serving at the navy yard and United States Naval Hospital, Mare Island, Cal., met to talk over topics of common interest and to report and discuss interesting cases which had come under their care. Some of our hospitals are too remote from large medical centers to make it feasible for the medical officers serving in them to take advantage of all the clinical and laboratory material and of the facil ities for professional improvement afforded by those centers. At the United States Naval Hospital, Great Lakes, 111., a series of lectures has been arranged by which the busy medical staff may come in contact with the leaders of the profession in Chicago, Omaha, Fort Wayne, Iowa City, Milwaukee, Pittsburgh, etc. The course of lectures began in October, 1918, and will continue till the summer. To have such men as Bevan, Zapffe, McArthur, Wyllys Andrews, the Becks, the Ochsners, Nagel, Lespinasse, Porter, Wayne, Lemon, and others equally well known speak at Great Lakes on subjects connected with the various fields in which they are su preme is sure to be of inestimable benefit to the Navy men there. Both the conference and the lecture scheme might well be inau gurated at all our establishments. A department of physical training. —Two years ago the University of Virginia inaugurated a department of physical training along the lines advocated in the Bulletin. Credit was given toward the bac calaureate degree for satisfactory work done under the supervision of this department in the same manner as has always been done in Greek and Latin. With the advent of the Beserve Officers' Corps and the Students' Army Training Corps the supervision of this undertaking had to be abandoned and turned over to the Army authorities. Beginning with January, 1919, the department of physical training resumed its work. There are at present at the University of Vir- No. 2. 339 NOTES AND COMMENTS. ginia over a hundred students who would have no chance whatever of holding positions on the athletic teams but are doing interesting and effective work in mass athletics, in competitive games, in hand- to-hand and eye-to-eye work. A program has been arranged by which men of less vigorous physique than football players, for example, will have opportunity to develop the endurance, the leadership, etc., which hitherto have been the reward only of those participating in the intercollegiate games. The Germans and the scientific workers of Lille. —Dr. Albert Cal- mette, director of the Pasteur Institute of Lille, in his own name and on behalf of MM. G. Laguesse, H. Parenty, Duret, and Aime Witz, representing virtually all the scientific workers detained in that city during the German occupation, has addressed to the Aca- demie de M^decine a protest on the ill treatment which they suffered at the hands of the invaders. Without the slightest regard for their scientific work or their families they were on several occasions sub jected to domiciliary visits of the most insulting nature. Even their scientific apparatus and instruments were not respected, and the members of the faculty of medicine were expelled from their labora tories. Among the " hostages " deported to Poland was Prof. Bui- sine, director of the Institute of Chemistry, aged 62, and suffering from long-standing intermittent action of the heart and stricture of the oesophagus. His wife called the attention of the German sur geon major, Dr. Krug, who was examining the prisoners, to her hus band's condition, and received the brutal reply, "Madame, that is not contagious for the German Army ! " M. Calmette speaks of the responsibility of the German people for the misdeeds of its army, and says that those who, like himself, have witnessed the eagerness, even zeal, with which men who are not professional soldiers—for in stance, doctors—did the most hateful things without a word of ex cuse, regret, or pity, are compelled to recognize that, as a general rule, to which there are but two rare exceptions, the German heart is in accessible to generous, or even simply human, feeling. Henceforth the German people, in spite of its laborious intellectual activity, can only excite disgust and horror at the crimes of which it has been guilty. For this reason M. Calmette and his colleagues state that they will not in future collaborate in any German publication or take part in any scientific meeting or international congress attended by any German workers who have not first expressed by a public declaration their disapproval of the antisocial acts of their Govern ment in the war. They call upon their colleagues of the Institute of France, the Academy of Medicine, and the Academy of Agriculture 340 NOTES AND COMMENTS. VoL XIII. to join them in this declaration and to invite the scientific societies of all civilized nations to associate themselves with their action. — (Extract from the British Medical Journal, Dec. 21, 1918.) Physical education. —Willard S. Small, of the United States Bu reau of Education, in an address before the American Public Health Association, Chicago, December 9-12, 1918,1 stated that 35 per cent of the men in the first draft were rejected as physically unfit. De ducting 5 per cent for rejections not due to any general unsoundness, but to special sensory defects and insufficient height, we have in the United States 2,500,000 men between the ages of 21 and 31 who are unfit in some measure for the fullest accomplishment of the best purposes of life. He pointed out further, that passing the physical examination for the draft wag in itself no demonstration of a man's ability, through muscular control and versatility, to endure the rigors of intensive military training. Approximately 1,000,000 young men reach the military age each year. There are approximately 25,000,000 school children between the ages of 6 and 18 in the United States. At least 50 per cent of them have defects and ailments that impede normal development in some degree. Economic disparities between States are marked. Mississippi has property to the value of $2,100 for each child. In California prop erty is estimated as worth $15,000 for each child in the population. The speaker advocated broad and liberal legislation for physical education, including medical supervision of schools, the dissemina tion of a knowledge of the laws of health, individual examination and record, provision being made for boys and girls alike between the ages of 6 and 18. Federal aid should be given the States in the training and remu neration of skilled teachers. Duplication of effort and conflict of interests must be avoided. Autonomy and initiative in the different States must not be interfered with nor the native genius and tradi tions of localities be hampered. The training provided for boys should not be a substitute for but only preliminary to military training, which should not begin for boys under 18 years of age. Such training should not be exclu sively with a view to subsequent military service. Corrective gymnastics, intensive physical training for the older boys, development of habits of health, and gradation of physical exercises are among the measures advocated. ■Interstate Med. Jour., December, 1918. KaJ. NOTES AND COMMENTS. 341 The National Committee on Physical Education has prepared for Congress the draft of a bill appropriating funds and making pro vision for cooperation between the United States Public Health Service and the Bureau of Education of the Department of the In terior in the development of a national system of physical training and education for the young of the country. Transportation of sick and wounded.—Lieut. Commander K. G. Davis, Medical Corps, United States Navy, in a report on a recent return voyage of the U. S. S. Northern Pacific carrying troops and Army sick and convalescents, says: A scheme of the ship's capacity was worked out and totals of each classifica tion of sick and well forwarded by radio before arrival In France, giving hos pitals and embarkation officers time to expedite our loading and departure. At least 500 well were requested for sentries, latrine orderlies, mess cooks, and cleaning detail. Six hundred and twenty well troops with their officers were embarked on December 23, 1918, and those needed for the various details selected and assigned. The following two days 1,763 patients were received on board by serial number and ushered to their respective compartments, according to the nature of their cases, where medical officers and hospital corpsmen assigned beds and arranged for Immediate feeding. When the last man was on board a complete classification had been effected and all were dressed and ready for the voyage. Three medical officers and 17 hospital corpsmen were received In Brest, France, for transportation to the United States, and their assistance proved a valuable addition to the medical division. All medical officers and hospital corpsmen were so assigned that all dressings and treatments were done dally, and two men made an hourly patrol through all compartments, maintaining a close supervision over the patients and keeping the senior medical officer cogni zant of any needs or complaints. The messing was carefully arranged by the commissary department, and well-cooked, appetizing food was served In cafeteria manner to those in all wards and " helpless " compartments. All other cases were fed in the main mess hall. It appears from observation of injuries weeks after their reception that the pendulum of splint enthusiasm has swung a little too far, and if always necessary to be applied splints are left In place longer than indicated, producing pressure sores and stiff joints. They are applied for wounds, deep or superficial, on any part of the limb, and some 15 cases of heel decubitus were noted on the present voyage. Dr. Davis, whose report bears an indorsement from his command ing officer commending him for his "zeal and efficiency," describes two interesting cases transferred to the Northern Pacific for passage to the United States. One of these came aboard with a temperature of 101, pulse 124, respirations 30, badly emaciated from lobar pneu monia contracted two months before, and having an empyema drain age tube in his right side. Myocarditis and marked prostration from toxemia were present. He died on the fifth day out. 342 Vol. XIII. NOTES AND COMMENTS. The other case had an abscess of the brain following shrapnel wound, with hernia cerebri. On the day after sailing complete left hemiplegia developed with symptoms of intracranial pressure. Death occurred within 27 hours of embarkation. These two patients were clearly not fit to be evacuated. Traumatic rupture of spleen. —The patient was on duty at the United States Naval Air Station at Rockaway Beach, N. Y., when, on September 22, 1918, he was pulled into the air by a rising balloon and fell a distance of about 40 feet. He suffered various contusions, but as there were also symptoms of internal hemorrhage a laparotomy was performed and a ruptured spleen discovered. The pedicle was ligated and the organ removed. He made a good recovery, but remains somewhat asthenic, anemic, and susceptible to cold. Dis charge from the service as unfit has been recommended. Officer Material School at Princeton, N. J.—Lieut. D. F. Luby, Medical Corps, United States Naval Reserve Force, reports success in preventing any extensive influenza epidemic and in controlling sporadic cases in the Officer Material School for the Pay Corps at Princeton, N. J. With 250 men arriving each month the danger of the influenza being introduced at the school was appreciated and appropriate measures were taken in advance. This course was made possible by cooperation on the part of the commanding officer of the school and others in authority at Princeton. The first step was the formation of a military health board, consisting of Dr. Luby, the Army medical officer, the Princeton University physician, and the Princeton health officer. A campaign of education was conducted by means of lectures, dissemination of literature, and daily inspections of the personnel. An isolation hospital was gotten ready in advance of the develop ment of any cases, a fumigation room was installed, and the students were prohibited from visiting certain portions of the town and vicinity. The military health board made a survey of the sanitary situation and took steps to correct any defects in sewerage, water supply, han dling and sale of food, etc., that might contribute to sickness. Moving-picture shows, churches, schools, and restaurants were im mediately closed on the appearance of the first case. The special dormitory regulations were as follows : Windows open day and night. Moist sweeping of rooms and corridors. Beds placed 5 feet apart. Bedding aired all morning. Crowding in rooms for bidden. Spitting on floors punished. No. 2. 343 NOTES AND COMMENTS. There were few oases of influenza in the school in spite of the general prevalence of the disease in the neighborhood and of the constant arrival of men from the infected districts. Wanted a diagnosis. —The following report from one of the vessels of the Naval Overseas Transportation Service offers scope for study. It is interesting because of the unusual character of the manifesta tions described. The writer of the report has done his best to record the facts and deserves credit for the picture presented in view of his not being a trained medical observer, and still more because he was himself the principal sufferer. The most accurate diagnostician would scarcely have done better under the circumstances. Still it is to be regretted that no details were given about the two patients who were involved in a minor degree and that the health of the crew was not referred to. The existence of a real paralysis is confirmed by the Chilean physician, though the statement that all muscles were paralyzed must be taken with extreme reserve. Again it should be noted that the symptoms began on or about September 26, while the patients were seen by him on October 16. It is perfectly possible that the reflexes were increased at first and later diminished. This happens. Neither the tentative diagnosis of myelitis nor the adopted diagnosis of beriberi seem tenable. The first step in analyzing the report is to reject summarily the suggestion of a definite vegetable or mineral poison or of some tainted article of food. There was in no case any pain or diarrhea. The persons affected, the captain, a fireman, and a denizen of the sick bay, were, in a sense, members of widely separated communities. Their habits of life, their associations, their food had nothing in common, or at least, nothing which .would not probably have involved others in the crew as well. It is impossible to believe that oxalic acid or a salt of copper, tin, or lead would have had such a marked selective action as to attack the Jupiter, Vulcan, and ^Esculapius of the ship, leaving other deities and their satellites untouched. The symptoms were somewhat vague and indefinite at first since they were recognized " on or about " a certain date. The initial ones suggest an acute bulbar paralysis, but the ocular phenomena in ad dition to the glosso-pharyngeal paralysis introduce the idea of an encephalitis—motor disturbance following on central or nuclear involvement. The weakness and prostration referred to probably included two distinct phases: That apparent from the beginning, the usual con comitant of a severe infective process; that which resulted from the progressive atrophy of muscular tissue due to impaired innervation. 344 NOTES AND COMMENTS. VoL JUIL With the typical bulbar paralysis or an encephalitis there might be associated involvement of spinal accessory and phrenic nerves and of branches of the brachial plexus, but the widespread paralysis suggests at once a polyneuritis, and if such was the case, what was its origin ? Our readers may choose between porencephalitis superior, asso ciated with an acute anterior poliomyelitis (an acute encephalitis following influenza would be a legitimate diagnosis had there been an antecedent grippe) , a polyneuritis similarly caused, or some more special manifestation. Now, there is a disease which appears coincidentally with or soon after an epidemic of influenza, but not necessarily in those who suffered from that disease. It remains, therefore, to consider the possible diagnosis of the entity known as epidemic lethargic encephalitis, though no lethargy is specifically referred to in the report. This disease is characterized by paralysis, which almost always affects the eye and may be ex tensively distributed throughout the limbs, by lethargy which varies in degree, and by asthenia. The disease as a rule is marked by some fever, at least in the beginning, and in cases where mental dullness is noticeable. While Dragotti emphasizes the lethargy and places it among the cardinal symptoms (p. 308), and A. J. Hall, professor of medicine, University of Sheffield, does the same (Brit. Med. Jour., Oct. 26, 1918) , the latter modifies this at once by saying that " one or even two of the three cardinal signs may be slight or absent," and mentions a case in his practice which had no lethargy. Another patient had been rather drowsy at first, but this passed off entirely, the salient feature becoming a " general asthenia," which " was so extreme that he gave a typical picture of immobility, and at the time reminded me of myasthenia gravis. The actual cranial palsies were slight and limited to a slight ophthalmoplegia. When watching me and answering questions the head was perfectly still. He could barely move his arms and legs from the bed. He could not turn over in bed." " Fever is noted in many cases. Possibly it was present in all, but of that there is no proof." Hall mentions a case whose tem perature "never rose above 99 F., and that only on the first and eighth days. Yet his attack was severe and prolonged." Speaking of the lethargy, he says, " Often the patient was surprisingly awake to what was going on." Three cases are mentioned in which after six months recovery was far from complete, the incapacity being due to trunk and limb muscles generally. Pending an answer from the clinicians and internists among the Bulletin's readers, it is sug gested that these might have been cases of epidemic lethargic en cephalitis, and attention is invited to the reviews of articles on this topic in another department. No. 2. NOTES AND COMMENTS. 345 BEPOBT 01 PECULIAR DISEASE ABOABD THE U. 8. 8. . On or about September 26, 1918, 'the following three men: L , Lieutenant Commander, United States Naval Reserve Force, commanding ; P , Pharma cist's Mate, first class, United States Navy ; M , Fireman, third class, United States Naval Reserve Force, began to show similar symptoms, viz, partial paralysis of throat and tongue, and weakness of the neck and shoulders, and loss of control of the eyes (seeing double, etc.). The ship was then four days out of Seattle, Wash., bound for Arica, Chile, with a cargo of coal. Slow poisoning was at first suspected, but there were no definite symptoms. Precau tions were taken against an infectious disease. No further cases developed. Lieut. Commander L was able to continue duties on bridge. The other patients were isolated In the sick bay of the ship. The following Is the case of P , Pharmacist's Mate, first class, United States Navy, who was unable after the first week to follow the other cases closely. The other cases were similar but not so severe, the commanding officer being the least affected. Beginning with the paralysis of the throat, the mouth became dry, but much frothy, slimy mucous began to form in the throat, which It was necessary to remove with a piece of gauze on the finger. The appetite remained good at first, but after a few days became indifferent and was accompanied by a disagree able brown coating on the tongue and a bad taste in the mouth. No diarrhea or other intestinal disturbance. The weakness, which was apparent from the first, became gradually worse until it was impossible at the end of the first week to stand erect or keep the head from falling to the chest. Deglutition became Impossible at the beginning of the second week. Water was taken by rectum. The paralysis extended to the shoulders and arms and finally, at the end of the second week, to the respiratory muscles. Breathing became very difficult and was barely perceptible; lips and extremities became cyanosed. The mind was clear at all times. Slight improvement noticed after two days. Conditions con tinued to improve. By the middle of the third week he was again able to take nourishment In liquid form. The whole course of the disease was characterized by lack of all pain or fever. The temperature remained normal at all times. Atrophy of oil muscles. Loss of weight, 30 pounds. Ship arrived at Arica, Chile, on October 16, 1918. Port doctor was consulted. He could throw no light on cases. Arrived at Mejillones, Chile, on October 19, 1918. Port doctor consulted. Cases puzzled him. On October 21, 1918, P and M were transferred to Dr. G 's hospital at , Chile. No marine or public-service hospital available. Dr. G 's report and diagnosis is as follows : "Appearance of typhoid (fades). Paresis of all muscles. Reflexes dimin ished in general, disappeared in triceps muscles. Sensibility diminished all over skin. Paresis of palate. Lungs, heart, liver, and kidneys normal. " Diagnosis : Beriberi in form of multiple neuritis of myelitis. I do not think it is myelitis on account of diminished reflexes. It is rather interesting how it has been a painless neuritis. "Treatment: Strychnin (hypo) twice dally. Sodium salicylate every four hours. " Diet : Raw fruit, raw milk, raw vegetables, eggs, and meat. " Prognosis : Phenomena diminished. I think case is benign." Returned to ship October 29. Condition of both patients slightly improved. Complication of pyorrhea and tonsillitis (chronic) retarding improvement of M . P able to resume partial duties. L . commanding officer Is greatly Improved. Condition is nearly normal. 103396—19 12 346 NOTES AND COMMENTS. Vol. XIII. In this connection it is interesting to note the report of a death from acute ascending paralysis of a man from another vessel of the Naval Overseas Transport Service. The patient gave a history of having had mild influenza in August, 1918. He was seen by a medical officer of the Navy on December 15, 1918, and at once taken ashore to a United States marine hospital. The patient complained of marked weakness in arms and legs. There was no pain or fever. He died the next day at 11 pi m. At the hospital the patient stated that his symptoms—weakness of legs and difficulty in swallowing —had appeared the night before. On admission there was partial paralysis of triceps, brachialis, and hamstring muscles. The flexors of the forearms were somewhat affected. The patient could swallow liquids; his mind was clear; extra-ocular movements were normal and the pupils reacted to light and accommodation. By 6 p. m. on the day of admission movement of arms or legs had become impossible. There was great difficulty in breathing, ap parently from interference with the movements of the diaphragm. The paralysis of the arms and legs was of the flaccid type. In the morning both prepatellar reflexes were present, but by 6 p. m. the left reflex had disappeared and by 9 a. m. of December 16, the other also. In the morning of December 16 breathing was performed with great difficulty. Swallowing was impossible. By noon the breathing was entirely through the accessory muscles of respiration. By 6 p. m. it was evident that the patient was failing rapidly. The mind was clear; heart action rapid and irregular. Death occurred at 11 p. in. From this meager resumfi of the symptoms it would seem possible that this was not a case of Landry's paralysis. Landry's paralysis may be of a reversed type— i. e., with rapid paralysis proceeding from above down instead of ascending—but in this case the involve ment of the upper and lower limbs appears to have been simul taneous with dysphagia and not progressive from either direction up or down. The clear mind, flaccid type of paralysis, rapid onset and speedy fatal termination suggests Landry's paralysis, but this would constitute an atypical case. The dysphagia, the phrenic paralysis, and the paralysis of the upper and lower extremities, practically coexisting, suggest also epidemic encephalitis. The features lack ing to this picture are lethargy and some disorder of the extrinsic muscles of the eye, but considerable variety in its manifestations is characteristic of the disease and not all writers insist on stupor and involvement of extrinsic eye muscles for a diagnosis. REPORTS. HOSPITAL ADMINISTRATION, UNITES STATES NAVAL HOSPITAL, NEW YOBE. By 6. A. Lung, Captain, Medical Corps, United States Navy. There is presented herewith in graphic form the scheme of organi zation evolved at the New York hospital. It became apparent very soon after the outbreak of the war that the organization of this hospital as conducted in times of peace and under normal conditions would have to undergo great modifications to conform to the changes necessitated by war. On January 1, 1918, the number of patients cared for by the hospital was approximately 700. In about six weeks' time this number increased to about 1,700, and a steady increase has been in progress since until the number now approximates 3,000. The difficulties met with in caring for such a large number of patients, the corresponding increase in the staff, and all other activities brought out step by step the organization here illustrated. The affairs of the hospital could not be conducted under the general scheme outlined in " Instructions for Medical Officers." The method of performing duty imposed by these instructions on the commanding officer and the executive surgeon of a hospital had to be changed. The plan as presented in the diagram has worked out very satisfactorily at this hospital, and it is believed that its adop tion for other naval hospitals would prove of benefit. While the graphic outline shows probably plainer than any descrip tion the general scheme, it may be stated that the principal change, and the one considered to be the outstanding one of this plan, is the appointment of three assistants to the executive surgeon. They are called " first assistant executive," " second assistant executive," and " third assistant executive." The first assistant to the executive sur geon has charge of all matters pertaining to the medical side of the hospital. Naturally, this officer must be a medical man. The second assistant to the executive surgeon handles the personnel, which means record work connected with patients and staff in so far as it concerns correspondence and records not of a medical nature. The second and third assistants to the executive surgeon should be pharmacists, who by the nature of their training are better fitted for these duties than medical officers. The executive surgeon has, under this scheme, all the administrative work and a general supervision of all departments 847 348 Vol. IHI. REPORTS. ORGANIZATION OF U.S. NAVAL 5ASE HOSPITAL NLW YORK N.Y. DISCIPLINE NURSE CORPS HOSPITAL CORPSMEN P-JAJSl. IX. SURGEON MEDICAL MEDICAL OFFICII COMMANDING OFFICER U.S. NAVAL BASE HOSPITAL EXECUTIVE SURGEON Z™A5ST. EX.SURGEON MATERIAL PHARMACIST MARINE GUARD PAY OFFICE VISITOR. .5 l. WELFARE WORKERS 3« =ASST EX SURQEON PERSONNEL PHARMACIST MEDICAL STAFF AMBULANCE SERVICE MOTOR t BOAT MEDICAL RECORDS HEALTH RECORDS MEDICAL SURVEYS LABORATORIES AND X- RAYS. ADMISSION AND DISCHARGE OF PATIENTS MEDICAL SUPPLIES CONVALESCENT DETAILS MESSENGER SERVICE OFFICER.Of THE DAY SUPERVISORS STUDENT OFFICERS COMMISSARY REQUISITIONS PUBLIC BILLS AND GENERAL SUPPLIES CIVILIAN ENPLOYEES £ PAY ROLL CONSTRUCTION AND RE. PAIRS LAUNDRV POWER PLANT — AMBULANCE SERVICE EQUIPMENT ENTERTAINMENTS AND RECREATION POST OFFICE. — BAG ROOM PERSONAL EFFECTS CORRESPONDENCE PERSONNEL t RECOROJ OTHER THAN MEDICAL RECEIVING (.CHECK ING OF RECORDS 6. ACCOUNTS JACKETS t CARDJ NAVIGATION CEPOXTS L FORMS - REPORTS TO COMMANDANT OTHER THAN MFCIC6L PERSONNEL OF DUTY OTHER THAN DETAIL TO PLACE OF DUTY DISCHARGE OF OFF ICERS DISCHARGE OF ENLISTED MEN DESERTERS-DECEAStP TRANSFER OF ENLISTED MEN FUNERAL ARRANGE MENTS DISPOSITION OF REMAINS AND EFFECTS 'Solace's" motor boat bringing wounded alongside of U. S. S. "Solace." No. 2. 349 REPORTS. under the commanding officer, while he is relieved from the drudgery of minor detail work by his three assistants. This scheme is suffi ciently flexible to allow of changes to suit any naval hospital, as long as the general idea of duties and responsibility is maintained. REMOVAL OF WOUNDED MEN FROM V. S. S. NORTHERN PACIFIC TO U. S. S. SOLACE, JANUARY 3 AND 4, 1919. By E. H. H. Old, Commander, Medical Corps, United States Navy. This ship was ordered on January 1, 1919, to proceed to the vicinity of the U. S. S. Nothem Pacific, then aground off Fire Island, and take on as many wounded men as possible for further transfer to New York. We anchored off Fire Island that night. On January 2 there was a strong northeast wind and the sea was unfavorable for small boats, so, by order of the senior officer present afloat, no trans fers were made that day. On January 3, the sea having subsided to some extent, small boats (motor sailers) and submarine chasers were able to get to the lea side of the Northern Pacific during high tide to take on the stretcher cases and those with wounds in arms or legs. It was decided to send all the seriously wounded to this ship, conse quently we received all the above class of patients. Two hundred and ten were received on this date and 214 on January 4 ; in addition, 34 hospital corpsmen were received as passengers. At that time there were already on board 85 patients, which made a total of 509 patients and 34 passengers to be looked after, with facilities on hand for properly berthing only 180 to 200. All bunks were used for those who had to remain in bed. " Gosso " bunks were put up in the wards and used in three tiers. Cots were placed in every available space. As the ship reached New York the night of the 4th, 248 of the above number did not require berths for the night. We arrived at Hobo- ken at 9.16 p. m., but all cases were not removed until 5.30 a. m. of the 5th. The galley was kept in operation practically all the time, day and night, in order to provide for this excess of complement. A majority of the cases had to be dressed, and some of them needed frequent dressing, consequently the medical officers were kept con stantly at work. During the time the above transfer was made there was too much of a swell to allow the gangways to be used for removing the stretcher cases from the small boats, consequently they were hoisted aboard by means of the sliding crane, with traveler, to which a hoisting block is attached, as is installed on either quarter of this ship. The cases- were all placed in Stokes's stretchers, which are ideal for this work. We, fortunately, had 80 of them on board, an extra number having been obtained when war was declared, and these were sent to the Northern Pacific, also a number of blankets, so there would be no 350 REPOBTS. Vol. XIII. delay from the men not being ready in stretchers when the boats arrived. More stretchers could have been used, and it is considered advisable for a hospital ship to have on board 125 to 150 or more. They should be kept in good condition, examined each time they are used, and if one is found broken at any point it should be set aside for repairs and not kept with the others, for in hoisting men over the side a defective stretcher might cause a serious and unnecessary acci dent. These stretchers can be readily repaired in a navy yard by being welded and regalvanized, and should be so repaired as soon as any part is broken. The experience acquired by making such an extensive transfer at sea proved the great value of the submarine chasers for such work. It is believed that boats of that type, larger, more seaworthy and with a greater cruising radius would be a valuable addition to the fleet for the transfer of wounded from battleships to hospital ships. They would also be available for going to the assistance of sinking ships in time of battle to pick up the survivors. In time of peace they can readily be used as ambulance boats for the purpose of trans ferring cases from hospital ships to hospitals or from ships of the fleet to hospitals in the absence of a hospital ship. During our re cent experience the submarine chasers came alongside of this ship and both stretcher .cases and those on crutches, or with arms in a sling, were passed by hand through one of the large cargo ports taking advantage of the time the sea brought the boat near the ship, as the swell was too high to have the lines taut. In order to handle the stretchers and crippled two men were put over the side with bow lines, one on either side of the port, and they were able to pass the injured to the inside of the port even though footing at times was lost by the chaser being washed off. The only damage done by this work was breaking the chasers yard which fouled the rail of our hurricane deck; it is believed that this factor could be controlled by having the mast of such an ambulance boat made so the yard could be a cockbill, or lowered, for the same kind of an accident might occur when going alongside a battleship. Before going to a ship after action the ambulance boat should have a number of Stokes's stretchers and blankets to be used on the battleship, these should be kept on the hospital ship ready- for such an emergency and obtained when needed. If the sea is such that the transfer can not be made through a cargo port, the cases ran all be hoisted up by a crane such as is at present installed on this ship as mentioned above. It is believed that this crane could be improved upon by a few changes in the block so as to absolutely prevent the lines becoming jammed. During Janu ary 3 and 4, about 200 men were hoisted over the side from the motor sailers and there was not the slightest accident. After a little ex- Small boats alongside "Northern Pacific." on lea side, waiting for wounded to be lowered in stretchers. Stretcher with patient hoisted to level of deck and ready to be swung in and hauled aboard where section of rail has been removed. Submarine chaser alongside with wounded. Note the swell prevailing at the time. Submarine chaser with wounded. A number had already been taken off before the photograph. was made. REPORTS. 351 perience in the fixing of slings, etc., we were able to take on board about one man a minute, though at times the heavy swell would cause some delay for fear of the boat rising and striking the stretcher before it could be hoisted clear. The sling used has a ring from which four lines lead, to the ends of which snap hooks are attached. The two lines for the head part of the stretcher are a little shorter than those for the foot. These are snapped in the handles of the stretcher opposite the hands and the knees, and not right at the head and foot. Two lines to use as guys also have snap hooks attached; these are snapped on the outboard handles of stretchers right at head and foot and are controlled from the boat. There is great value in having such slings already made up and ready for use, as they can be hooked on in a few seconds and do away with the loss of time that would be necessary in tying knots and getting lines of equal length, etc. A sling and guys of this kind should be in the medical department of every ship for use in case of transfer by stretcher in a heavy sea. THE HEDICAL DEPARTMENT ON ROARS A TORPEDOED TRANSPORT. By E. E. Curtis, Lieutenant Commander, Medical Corps, United States Navy. On the morning of September 5, 1918, at 7.47 o'clock, the ship, steaming at an 18-knot speed in company with one other transport, well escorted by destroyers, was successfully attacked by an enemy submarine (German). The torpedo hit about midships, near the bilge keel on the starboard side. The medical department had under its care 133 sick and wounded from the Army being transported to the United States who had been received on board just before the ship put to sea the previous even ing on her homeward bound trip. At the time of the attack I was making the rounds of staterooms occupied by sick Army officers and was in a room about half way between the bow of the ship and the location of the explosion. At tention was first attracted by shots fired at the attacking vessel, fol lowed almost immediately by a loud explosion which jarred the whole ship, succeeded by a series of vibrations from bow to stern. On going to the sick bay, which was about one-half the length of the ship away, many people were encountered, seemingly very active. However, none displayed any indications of excitement but instead all were going about the necessary procedures for saving the ship and caring for the wounded. Staterooms occupied by wounded soldiers were visited and the oc cupants had begun to vacate their quarters, men who had lost an arm were assisting a comrade with only one serviceable leg. On reach 352 REPORTS. VoL XIII. ing the sick bay located on the uppermost deck it was found that breakfast had been in the process of being served at the time of the explosion, which accounted for broken dishes and food scattered about the beds and on the deck of the sick quarters. At this time none of the sick or bedridden cripples had left the bunks, but mem bers of the medical and hospital corps were arriving from break fast. In less than two minutes every wounded and sick man, includ ing the following classes of cases were in boats: 70 surgical, 42 of which were absolutely helpless, the remainder requiring assistance; 15 medical, 10 of which were nonambulatory, and 45 mental and neu rological, all of which were ambulatory. As soon as safely within a lifeboat, " Everwarm " safety suits and blankets were provided for their protection and comfort. The helpless were all carried to the boats by individual men, using the " by one bearer, in arms " method, which to my mind accounts for the fact that the sick and wounded were evacuated in such a short time. The use of stretchers would be a hindrance on this ship where the factor of time is to be seriously considered. As soon as all was in readiness for lowering the boats with their helpless occupants, details were made for preparing and serving hot soup and coffee, which was made possible within a very short time by having a diet kitchen in connection with the sick bay. Later on sandwiches were made by the commissary department and sent to the sick bay for distribution, and throughout the day patients who pre ferred remaining in the lifeboats were permitted to do so, and were served with hot soup, coffee, jam and meat sandwiches, and canned fruits. These patients were made so comfortable that nearly all of them chose to stay in the boats until port was reached, about 18 hours later. This was their desire, even after being assured that the ship would, in all probability, reach port and that they would not be encountering any additional danger by going back into the sick quarters. There was one case of pneumonia among the sick, who not only enjoyed swinging in a lifeboat from the davits, but was ap - parently benefited by the experience, as there was an improvement in his physical condition on the morning following this incident. Just as the sick bay was evacuated of the sick and wounded, in jured men began to arrive from the firerooms and coal bunkers in the vicinity of where the torpedo exploded. This included about 25 all told. Eight of them were seriously burned, 5 had received burns of less severity and extent and numerous bruises and lacerations on different parts of the body, inflicted by flying pieces of iron wreckage. In addition to these were several applicants for first-aid for bruises and lacerations of minor importance received in different parts of the ship from flying glass or due to being thrown down or against some solid object by the force of the explosion. Most of these injured, No. 2. 353 KEPORTS. however, were at the time in the crew's mess halls, which are located above where the torpedo struck. All dressings were hurriedly ap plied, regardless of the apparent seriousness of the injuries, and the injured put into lifeboats in the expectation of having to abandon ship at any moment with the exception of one, the most seriously burned, as it was considered that the disturbance incident to trans ferring him would be serious and that he could be gotten into a boat within a very short time should the signal be given to abandon ship. All those who were suffering in a marked degree were given relief by administration of morphine in addition to appropriate dressings, picric acid being the principal remedy used on the burns, which were of the first and second degrees, and extended over more than one-half of the body in most of the 8 cases. The most seriously burned case had developed a marked pulmonary edema, from which he died 10 hours later. When it was ascertained that it was safe to return the sick to the sick bay, the men who had been burned were again dressed. The dressings that had been put on so hurriedly were removed and others applied with more care and deliberation. Upon arrival in port all the sick of both Army and Navy were transferred to their respective hospitals. The manner in which the authorities on shore, both Army and Navy, cooperated by an imme diate response in removing the injured, sick, and wounded, and mak ing provisions for preparing the bodies of the dead for transporta tion to the United States was most gratifying. Two medical officers and three embalmers were sent on board from Naval Base Hospital No. 5 to assist in this work. It was 48 hours after the ship was torpedoed before it was possi ble to locate and recover any of the bodies, owing to the compart ments being filled with water which had been raised to a high tem perature by heat from the main steam pipes passing through them. This work continued for over 24 hours before all the 35 corpses were out of their death traps. Each body was identified as soon as possible and preparation for transportation was made, such as embalming, dressing, and inclosing each one in a Navy standard metal casket. Embalming all these bodies would have been a much greater task had it not been for the fact that three professional embalmers were discovered in the ship's crew. With this assistance, in addition to the three men sent from the hospital on shore, this work was accom plished as fast as caskets could be provided and properly prepared. Upon viewing the bodies it was absolutely impossible in practi cally all cases to definitely establish whether the death was the result of burns, of the explosion of the torpedo, or of submersion, as all the bodies had been subjected to a combination of the three causes, any one of which could account for the loss of life. With the above conditions to contend with, in combination with that of all bodies being subjected to a high degree of temperature 354 , BEPORTS. Vol. XIII. for from 48 to 72 hours, identification was very difficult, and at first seemed impossible, but was later rendered possible by seeking the as sistance of those men who had been in constant association with them under all conditions of everyday life in the fireroom. Some were recognized by the way the shoes were tied, the kind of shirt worn while at work, or by some other peculiarity such as the kind of pipe smoked, etc., and in all cases so recognized, measurements or other perceptible characteristics would be confirmed by comparison with the descriptive list in the health record. Three were identified by their teeth, two were wearing their identification tag, and one had his tag in his pocket. Seventeen others of the number had been provided with identification tags but were keeping them in their ditty boxes. Caskets required in addition to those already on board were pro cured from ashore and from ships in port in a sufficient number so that all the 36 bodies were thus provided for. After receiving a body the head end of the shipping box of the casket was marked with the name and rate of the dead and the relationship, name, and address of the next of kin. It was most gratifying to witness the excellent individual adapt ability displayed by all members of the medical department, which demonstrates the excellent material which is being enlisted into our hospital corps. To mention any one or more than one not including all would be an injustice to those not mentioned. Each and every one seemed to see the right thing to do at the right time and met any contingency that arose concerning the safety and comfort of the sick, consisting of 133 sick and crippled of the Army and 19 sick and in jured of the Navy. They went about their work as though nothing out of the ordinary was happening, providing food and many other necessary attentions required, under severely trying conditions and being constantly subjected to inconveniences. If one man did more than another, it was because he happened to be at the right place at the right time. A most difficult task was that of locating and removing those who lost their lives below. As soon as the water in the compartments had been lowered so that bodies could be located, plans were laid and provisions made for their removal. All went into any and all com partments where any one or a combination of the following ex isted—heat, water, wet coal dust, danger of being burned or injured, and intensely difficult work. Not one displayed a lack of interest, and everybody continued to assist in the preparation of the bodies recovered after hours of hard, gruesome work where the men met their death, and continued to work until 2 o'clock in the morning, this following the two days and sleep-disturbed nights of anxiety throughout a trying ordeal. 11*2. HEPORTS. 355 IHFLUENZA AT THE UNITED STATES NAVAL HOSPITAL, WASHINGTON, D. C By R. M. Kennedy, Rear Admiral, Medical Corps, United States Navy. This hospital received its first case of influenza on September 1, 1918, and pandemic proportions were assumed very rapidly. The admission rate soon rose to 25 and 30 cases daily. From its first appearance in this hospital the disease was of an unusually severe type. Those cases complicated by pneumonia showed marked prostration, early asthenia, and exhaustion of the cardie-vascular system. A few cases promptly died within 48 hours following the onset of the disease. A great majority showed a leucopenia and a red cell reduction. The ordinary methods of treatment were most unsatisfactory. Despite the very best nursing and other therapeutic measures, the death rate assumed startling proportions. After giving the usual methods of treatment a trial with unsatis factory results, they were abandoned, and the employment of "im mune serum" was resorted to with happy issues, manifested by a marvelous reduction in the death rate. In fact, but three deaths have occurred in this hospital since the serum treatment has been employed. The serum employed was obtained by bleeding patients recovering from influenzal pneumonia during their first week of convalescence. It was taken in 0.2 per cent sodium citrate solution to prevent clot ting and allowed to stand until the cells settled. Then the serum was taken through a pipette and kept in a container until needed. It was given intravenously in 100-mil dosage every eight hours until the temperature was normal or other satisfactory signs of im provement appeared. Some cases promptly returned to normal temperatures within 12 hours following the injection. Others had two doses administered, and a very few required three. The marked change in these serumized patients from the prostra tion and toxemia which characterized the pneumonic state to general improvement has been most remarkable and satisfactory. At one time there were eight serumized pneumonic cases from two to five days old in the disease, and all of them with normal tempera ture and no subjective symptoms of the disease. During the epidemic 568 cases were admitted. One hundred and fifty-seven of them developed pneumonia, of whom 31 died, a per centage of 20. Of those cases of pneumonia not treated with serum, 28 died, a percentage of 25. Forty-six cases were treated with serum and 3 died, a percentage of 6.5. 1 Extract from Annual Sanitary Report, 1018. 356 KEPORTS. Vol. XIII. NOTES ON POST-INFLUENZAL PNEUMONIA AT UNITED STATES NAVAL HOSPITAL NO. 4, QUEENSTOWN, IRELAND. By A. M. Bubobss, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force, and E. J. Staff, Phar. Mate 3, C, United States Naval Reserve Force. This report comprises post-mortem and bacteriological studies carried out by the authors in cases of post-influenzal pneumonia occurring between October 10 and November 15, 1918, at base hos pital No. 4. There are included, in addition, the results of necropsies performed on the bodies of 19 naval men who died outside the hospital at neighboring stations or on ships based in this region. It is hoped that at a later date a full report of the work done at the hospital during the course of the epidemic will be published by the clinical and laboratory staff. This short report is of necessity incomplete owing to the relatively small amount of material studied and to its having been carried out more or less under field conditions. The necessity, however, that all available data concerning the epi demic of influenza be collected justifies the recording of the follow ing brief notes. THE PULMONARY LESION. The 27 necropsies performed on the bodies of patients who died with a clinical diagnosis of post-influenzal pneumonia, although they showed a very wide variation in the extent and character of the pulmonary lesion, still presented what appeared to be convincing evidence that in every case we were dealing with essentially the same process. In the majority of instances the involvement of pul monary tissue was so extensive that but little functional lung re mained. Various stages of the lesion were as a rule present in the same case, and it was apparently possible to trace the probable course of the extension and to determine the location of the earliest involve ment. The lesion can not be described as " massive " or " confluent " broncho-pneumonia, nor as lobar or " septic " pneumonia, inasmuch as the use of any one of these terms serves to emphasize but a single manifestation or phase of the process. The commonest picture was that of an almost complete involve ment of three or more lobes in a process which at first glance ap peared to be lobar in type, but which on palpation was distinctly nodular and in section showed a more or less strikingly mottled ap pearance. This mottling was due to the presence of irregular areas of pneumonia, lobular in distribution, which usually were firmer, lighter in color, and dryer than the surrounding pulmonary tissue. In some cases these areas were clearly defined and often surrounded by a dark, deeply congested zone. The alveolar tissue intervening was, as a rule, dark red, containing no air, and represented a more No. 2. REPORTS. 357 recent superimposed pneumonic process which topographically could be considered lobar. In some instances the earlier broncho-pneu monic patches had become gray, opaque, and evidently necrotic, with a dry, almost caseous, type of necrosis and a prevention of struc ture resembling that seen in gummata. Some of these areas appeared to bear a relation to bronchi and others were pyramidal in shape, with the base of the pyramid at the pleural surface, thus resembling pulmonary infarcts and suggesting a vascular origin. Sometimes whole lobes presented the picture of a homogeneous process, clearly lobar in type. Minute miliary necrotic areas which closely re sembled tubercles were found in five instances, and actual softening with the formation of abscesses, miliary or larger and irregular, in six. An opinion as to the nature of the exudate in the alveoli could not be definitely formed, but was strongly suggested by the gross appear ances of the lesions. The rubbery, almost gelatinous consistency of the involved portions of the lung in the earlier stages of the process and the relatively smooth-cut surface appeared to indicate a very small proportion of fibrin in the exudate. In cases where whole lobes were homogeneously pneumonic the difference between this type of lesion and that seen in ordinary lobar pneumonia was espe cially striking. The liver-like firmness characteristic of the latter process and the granular appearance of the cut surface, caused by the projection of minute plugs of fibrin from the alveoli, were absent and the appearance more closely resembled that. of the "gelatinous pneumonia " due to the tubercle bacillus. Furthermore, the necrosis of pulmonary tissue, often with preservation of structure and little or no liquefaction, suggested that the proportion of polynuclear leu cocytes in the exudate was probably low and that there was such a lack of the enzymes furnished by these cells that in many instances solution of the necrotic tissues did not take place. Neither the time nor the equipment at our disposal justified an histological study of this question, but a single specimen from one of these lungs was put through and showed the alveoli to be filled with an exudate in which the proportion of endothelial leucocytes was high and from which fibrin was practically absent. The extent and character of the lesions found in our 27 cases is seen from the following analysis, expressed in tabular form : I. Cases. More than three-quarters of the entire lung area involved 12 Between one-half and three-quarters of the entire lung area Involved 11 Approximately one-half of the entire lung area involved 2 Approximately one-quarter of the entire lung area Involved 1 Very slight Involvement 1 Total 27 358 REPORTS. Vol. XIII. II. Lobar type In at least one lobe 10 Necrosis, early or advanced 15 Necrosis, with liquefaction (abscess) 6 III. Location of earliest Involvement, as judged by post-mortem appearance : Left lung: Cases. Lower lobe 7 Upper lobe 0 Undetermined G 13 Right lung: Lower lobe 4 Upper lobe , - 6 Earliest Involvement undetermined 8 Total 27 It was noticed that the anterior thin portions of the lungs that lie beneath the anterior chest wall overlapping the mediastinum were almost uniformly normal. The most advanced lesions were usually located posteriorly in the lungs, quite frequently in the upper parts of the lower lobes and at times also in the opposing lower portions of the upper lobes. Although pneumonia could be considered as the primary cause of death in all our cases save one, a number of other lesions were found at autopsy. The pleural cavities in 16 cases showed a serous or sero-sanguineous exudate with, as a rule, a relatively small amount of fibrin. But one case of empyema was brought to our notice, and this patient recovered following operation. In 18 of our cases a complete examination of all the organs was carried out with the following findings: Acute splenitis, nine cases; nephritis, very marked, two cases; general peritonitis, one case; toxic atrophy of liver, one case; adrenal hemorrhage, marked, one case. On the basis of the observations made at the post-mortem table it seems possible to make a few general conjectures as to the pro gression of the disease in the lungs. Thus the following may be regarded as probabilities: (1) The disease usually begins as a rela tively small area of broncho-pneumonia located ordinarily, but not always, in the lower lobe of one lung. (2) Under conditions of in sufficient resistance to the infection a sudden spread of the lesion to other lobes or to other parts of the same lobe takes place. (3) This extension may occur either as a homogeneous involvement of one or more whole lobes (usually including the lobe containing the original pneumonic areas), or may take the form of widespread broncho pneumonia, in which wedge-shaped subpleural areas resembling in No. 2. 359 BEPORTS. farcts are found. Both these modes of spread appear to indicate that the infection is disseminated by way of the blood stream. (4) If death does not supervene necrosis of the earlier areas of involve ment takes place with eventually softening and abscess formation. Sometimes throughout lobes homogeneously consolidated miliary necroses appear, which may go on to miliary abscess formation often so extensive as to cause puriform fluid to well from the cut surface of the lung on section. (5) In certain cases, as illustrated by one of our necropsies, presumably because of a better resistance to the infection, the disease remains localized in one or more lobes and later stages of necrosis and abscess formation may be reached. In our case several small abscesses had ruptured into the pleural cavity and an empyema would have resulted had not death occurred. (6) The lack of leucocytic reaction universally noted in the blood stream in clinical cases is associated with a corresponding relative lack of polynuclear leucocytes in the alveolar exudate and the course of the disease as well as the nature of the local lesion may be to a great extent determined by the proportion of these cells that reach the infected areas in the lungs. REPORT OF EPIDEMIOLOGICAL STUDY OF DIPHTHERIA AT THE UNITED STATES NAVAL ACADEMY.1 By J. E. Houohton, Lieutenant, Medical Corps, United States Navy, and D. G. HlCHBT, Lieutenant (J. G.), Medical Corps, United States Naval Reserve Force. From August 26, 1918, to September 13, 1918, seven midshipmen and three enlisted men from the crew of the U. S. S. Reina Mercedes contracted clinical diphtheria. They were immediately transferred to the United States Naval Hospital, Annapolis, Md., where the diagnosis was confirmed in each instance by culture: All cases re sponded to the administration of diphtheria antitoxin, making an uneventful recovery. The roommates of the individual patients were also sent to the hospital as contacts until they were proved not to be carriers of diphtheria bacilli. At the time of the arrival of the laboratory unit, on September 13, 1918, only the members of the fourth class were in session. Work was begun at once, all members of this class being cultured and Schick tests given. One week later the remainder of the midship man personnel returned from their 20-day summer vacation and the same measures were instituted. In addition, all mess attendants, cooks, and bakers, the crews of the Reina Mercedes and attached craft as well as the milkers at the Naval Academy dairy were inves- 1 U. 8. Naval Medical School, Mobile Laboratory Unit, Washington, D. C. 360 REPORTS. Vol. XIII. tigated by culture and with the exception of the mess attendants and dairy hands received the Schick tests. The technique of culturing consisted in a thorough swabbing of the tonsils and posterior pharyngeal wall with a sterile, cotton swab. This was introduced upon a slant of Loeffler's blood serum, incubated for 18 hours, at the end of which time a smear was made from each culture, stained by Neisser's method and examined microscopically. Those cultures which showed the morphological characteristics of corynebacteria, with bipolar staining, were then checked by Gram's and Ponder's stain. It was found that not infrequently Gram nega tive bacilli gave a very confusing picture. These upon further in vestigation were found to be in the main B. proteus vulgaris, B. pyocyaneus, and B. prodigiosus.. For purposes of comparing the efficiency of our method, 350 cultures were stained with Loeffler's methylene blue and 35 per cent of these showed diphtheroid organ isms. When checked by Neisser, Gram, and Ponder stains, we were able to eliminate all but a few, which gave the characteristic bipolar and barred forms. Those cultures which contained the morphologi cally typical diphtheria bacilli were plated on 5 per cent blood agar, incubated, and when possible, the colonies suggestive of diphtheroid organisms were fished and seeded in a tube of Loeffler blood serum. In some instances it was quite impossible to isolate these colonies, due to the symbiosis of such organisms as B. proteus and B. mucosus capsulatus group. If the organism could be isolated in pure culture, a suspension of a 24-hour growth was made in sterile normal saline (5 cc.) and 0.5 cubic centimeter was introduced into the abdominal cavity of a guinea pig. A similar dose was given intraperitoneally to a guinea pig previously protected by antitoxin. When the suspected organisms could not be isolated in pure culture, a suspension of the original culture was made in 5 cubic centimeters of saline and an intradermal injection of 0.1 cubic centimeter was given into the shaven abdominal wall of the guinea pig, a similar injection being made in a protected animal. Those animals which died were autopsied, particular note being given to adrenal congestion, peritonitis, and cardiac dilatation. Only those cultures which killed the unprotected pigs, in the absence of peritonitis or blood stream invasion, were regarded as virulent Death invariably occurred in six hours to three days. At the end of five days, if the pig was healthy, it was used again. The criterion of a positive reaction in the intradermal method consisted in an area of induration at the site of inoculation, along with a sero- sanguinous exudate and a coagulation necrosis of the surrounding soft parts. The shaven abdominal wall was so divided that four tests could be made on each pig. No. 2. 361 REPOBTS. Later, for corroborative evidence, all strains which were isolated were planted on a " set," consisting of dextrose, saccharose, and dex trin serum broth. The carbohydrates were added in the strength of 1 per cent, using Andrade's decolorized fuchsin indicator. Without exception, those organisms which killed the unprotected guinea pigs were found to be dextrose and dextrin fermenters. The following Table I gives the results of the cultural investiga tions: Table I. Contingent. Midshipmen, first class Midshipmen, third class Midshipmen, fourth class Reina Mercedes crew Mess attendants, cooks, and bakers Dairymen Total Number cultured. 476 668 932 51)7 2(15 32 2,940 Number virulent. 1 2 17 20 0 0 40 Per cent positive virulent. 0.21 0.30 1.82 3.52 0.00 0.00 1.36 Morpho logical typical bacilli. 5 6 38 39 3 1 92 Per cent positive nonviru- lent. 1.05 0.90 4.07 6.87 1.13 3.12 3.12 It was our good fortune to have available a standard, stable, diph theria toxin, which was obtained through the kindness of Surgeon Leake, of the United States Hygienic Laboratories, Washington, D. C. The M. L. D. of this toxin was 0.006 cubic centimeters, and when used for the Schick test was freshly prepared by diluting with normal saline, so that 0.1 cubic centimeter contained 1/50 M. L. D. As a control, an equal portion of the diluted toxin was inactivated by heating to 75 C. for one hour in a water bath. The flexor sur face of the forearm was the site of election for the introduction of the diphtheria toxin. Both arms were cleansed with alcohol, 95 per cent. By means of a finely graduated 1 cubic centimeter Luer tuberculin syringe 0.1 cubic centimeter was injected intradermally. Platinum needles were used and heated to redness between injections. Few complain of pain from the injection other than the slight dis comfort which might be observed from a bee sting. It was noted that a successful intradermal inoculation caused a white, round, sessile, edematous elevation, varying from three-fourths to one centimeter in diameter, when 0.1 cubic centimeter of the saline toxin was em ployed. The active toxin solution was given into the skin of the left forearm and the inactive toxin solution into the right forearm. In the beginning, two injections were given in each arm. The rationale of this procedure was to ascertain if the same individual reacted similarly to a given dose of the material. It was found, however, that the reactions were so constant that the second injec- 103396—19 13 362 Vol. XIII. REPORTS. tion could be eliminated. Controls were employed throughout the entire work. Observations were made at 24, 48, and 72 hour intervals. We agree with other investigators that the most convincing information can be gotten after the 72-hour interval. The recording of the re action was as follows : The test was called negative when, at the end of 72 hours, little or no reaction was noticed at the site of inoculation and absence of palpable induration. The positive reactions were classed as +> H—h or H—h+? according to whether the diameter was from 0.5 to 1 centimeter, 1 to 1.5 centimeter, and over 1.5 centimeter. Red ness and induration proved valuable guides in judging the extent of the reaction. Where both arms showed a similar reaction, the test was put down as a pseudoreaction. These were found to be 9.3 per cent of all cases. Neither from the rapidity with which the reaction ap peared nor in the redness or induration could any material difference be detected in this group of cases. It is therefore our belief that the reading of a pseudoreaction without a control is an extremely hazard ous undertaking, if not impossible. Fully 5 per cent of the pseudo- reactions persisted for a week or longer. Our experience has taught us that as late as six weeks after the appearance of a positive Schick the induration will persist, the pri mary redness gradually becoming an area of brownish pigmentation and scaling. As will be seen from Table II, 2,643 Schick reactions were made. Of these, 1,342, or 50.7 per cent, were positive and 1,301, or 49.3 per cent, were negative. Pseudoreactions were included under the nega tive and comprised 9.3 per cent of all cases. Table II.— Table of Schick tests. Group. + + + +++ Nega tive. Total tests. Per cent positive. Midshipmen, first 182 239 345 138 35 115 210 2 9 10 3 255 305 371 370 474 46.2 543 60.3 34.5 Reina Mercedes crew 54 668 936 565 Total 904 414 24 1,301 2, 643 50.7 Further study of Table II reveals the fact that of the fourth class of midshipmen, where was all the active clinical diphtheria, as well as 85 per cent of carriers in this group of men, 60.3 per cent were found nonimmunes, in contradistinction to 46.2 per cent and 54.3 per cent in the first and third classes, respectively. The low per centage of positive Schick tests on the Reina Mercedes can, in part at least, be attributed to the fact that the average age of the personnel was higher than among the midshipmen. No. 2. 363 KEPOKTS. Twelve, or 27.9 per cent, of the carriers gave positive Schick re actions. Of these only one had had a previous attack of diphtheria eight years ago. From an epidemiological standpoint several points of interest were observed. The entire seven cases among the midshipmen oc curred in the fourth class. Of the 23 carriers found in the fourth class 4 said they had had diphtheria varying from a period of 2 to 10 years previously. Six carriers admitted contact with clinical cases. It is also to be remembered that all clinical diphtheria was among the young unseasoned individuals who had just entered train ing from civil life. In all instances the disease developed in from two to five weeks after entering the academy. Two of the 20 carriers from the crew of the Reina Mercedes gave a history of diphtheria, one having had two attacks, the last being 22 j'ears ago, and he has given continued positive cultures over a period of more than six weeks. All carriers from this crew were found to come under three groups, consisting of nine in the fire-room force, seven seamen, and four privates in the Marine Corps. All these men stated that they had been in more or less constant associa tion with the other members of their respective group. In fact, five of the seven seamen group belonged to a boat's crew. As in the case of the midshipmen, the three men who developed diph theria had been attached to the station from two to four weeks. One of these gave a history of a previous attack of diphtheria six years ago. By consulting Table I it will be seen that 1.82 per cent of the fourth class were carriers, while in the first and third classes less than 0.5 per cent were found to harbor virulent diphtheria bacilli. Again, with only three clinical cases on board the Reina Mercedes, the percentage of carriers increased to 3.52 per cent, due in part to the closer billeting and association. The midshipmen involved had at no time come into contact with the crew of the Reina Mercedes, All efforts to hojd the mess gear accountable were futile. No mess attendant, cook, or baker proved to be a carrier. Cultures from the drinking fountains yielded no growth of B. diphtheria. There was nothing about the outbreak which suggested the milk supply, but for sake of completeness the milk was cultured at various intervals and found to be devoid of diphtheria organisms. None of the milk handlers at the Academy dairy could be put down as . a carrier. All attempts to trace the more or less sporadic case to extramural sources were of no avail. Since the work was inaugurated no new cases have as yet developed on the station. The administration of the toxin-antitoxin mixture to those having positive Schick reactions was necessarily delayed by the advent of 364 Vol. XIII. REPORTS. influenza among the personnel. It is our intention to give three doses of 1 cubic centimeter subcutaneously at weekly intervals. Three months subsequent to the last injection it would seem expedient to do Schick tests on all those who receive the toxin-antitoxin mixture. The carrier situation has presented the same problems which other investigators have encountered. We were afforded the opportunity of observing the carriers and cases, following them by cultures from day to day. Of the 43 carriers and 10 cases which were in the diph theria isolation wards, all but 20 have returned to duty. There was no case or carrier permitted to leave isolation until at least three consecutive negative cultures had been obtained at not less than 24-hour intervals. Here again we have experienced what others have observed, that a case may yield a negative culture one day and a positive one the next. It was found that unless careful vigilance was maintained the carriers, in their ambition to return to duty, would hasten to gargle their throats immediately prior to taking the cultures. Therefore it was necessary to eliminate all opportunity for such procedure. By this precaution several carriers were found to be repeatedly positive which previously had given negative results. Other factors enter into the carrier state, however, these being par ticularly pathological conditions, and of these hyperlrophied ton sils, with deep crypts, and adenoids, seem to play the leading role. Most of them were found to maintain the infection in both nose and tonsils. Various methods were employed such as gargling and spraying with antiseptic solutions, local applications of silver nitrate, iodine, and dusting powders (kaolin). The efficacy of the local applications of diphtheria antitoxin in our hands is highly problematical. It is our conviction that a large percentage of the so-called " chronic " car riers will continue to be so until all pathological conditions of the nose and throat are corrected. In a few instances it has been possible to exterminate the organism by application of 10 per cent silver nitrate or tincture of iodine into the crypts of the tonsils. Our ex perience is confirmatory of the work of others that the efficiency of any method lies largely in the thoroughness of the application, rather than the agent employed. In the examination of the throats at the time of culturing a direct smear was taken from any suspicious condition. In addition to cul tures, a direct smear was made from 567 men cultured as a matter of routine. It was our purpose in this to ascertain in what percentage fuso-spiral (so-called Vincent's) organisms were present. Gram stain and dilute carbol fuchsin were used and 10 per cent of all smears showed long fusiform bacilli and evenly undulating spirilla. From brief notes taken at the time, the vast majority of these oc curred in those cases where small caseous plugs were noted in the crypts of the tonsillar lacunae. No. 2. 365 REPORTS. STUDY OF AN EPIDEMIC OF INFLUENZA AT PENSACOLA. By J. M. Ferret, Lieutenant, and C. M. Shaar, Lieutenant, Medical Corps, United States Nary. The great pandemic of influenza, which originated in Spain dur ing the spring of 1918, made its appearance at the United States Naval Air Station, Pensacola, Fla., on September 11, 1918. On that date 17 Marines came down with the disease. Why the Marines should have been the first victims can not be satisfactorily explained. There had been no new drafts among them for three months, and although the}' were somewhat crowded in their barracks, they fared no worse than the sailors. For four days preceding the outbreak of the epidemic 160 men were received at Camp Bennett, which is a detention camp about a mile from the Air Station, 30 of whom were a draft from Cambridge, Mass., and 3 from Great Lakes, 111., at which place influenza was then epidemic. As the epidemic first started at the Air Station, and among the Marines, we do not think that the blame can be laid on incoming drafts. It would be futile to try to determine absolutely how the station became infected. The men go on liberty in Pensacola, which is about 6 miles from the station, and may have become infected from the civilian population. The disease follows the lines of travel, and naturally when it crossed the Atlantic Ocean our big seacoast cities were tfie first attacked. Afterwards the cities in the interior got their share. This could have been easily noticed by reading the news papers. The war, with its massing of great numbers of men in Army camps, naval stations, shipyards, munition plants, etc., offered favor able conditions for the rapid spread of the disease. At the Naval Station, Pensacola, Fla., a good many men live in tents, two occupants to a tent. It was interesting to note that the number of cases was about evenly divided between men living in tents and those living in somewhat crowded barracks. It is well known that of all pandemic diseases influenza is the one which attacks the greatest number of the population. The com plement of the Air Station is 5,359, and as we had 1,451 cases of influenza, this shows that 27 per cent of the personnel became in fected. These 1,454 cases developed between September 11 and Oc tober 27, 1,018 of which occurred between September 22 and Octo ber 4, a period of 13 days. The epidemic reached its height on the nineteenth day, September 30, when 117 cases were admitted to the sick list. It was under full control on October 27, seven and one-half weeks from its onset. Chart No. 1 shows graphically the number of cases developing daily and also the daily temperature of the weather and the rainfall. It will be noticed that the temperature and rainfall did not seem 366 Vol. XIII. REPORTS. to have any important bearing on the course of the epidemic. The mortality rate of influenza is put down by Osier as being very low. He cites 55,263 cases in the German Army, with a mortality of 0.1 per cent and 22,972 cases occuring in the civilian population of Munich with a mortality of 0.5 per cent. These figures do not have reference to the present epidemic. Unfortunately in this outbreak the disease has exacted a much higher toll. Thus in the October 5, 1918, number of " Notes on Preventive Medicine for Medical Officers, United States Navy," 39,503 cases are tabulated, with a mortality of 4.26 per cent. Our deaths at Pensacola numbered 24 out of 1,454 cases, a death rate of 1.6 per cent— a comparatively low figure for f Identic of lalluuza Ccroeltmcnl3331 CrtAB-T U« 1 III. Narol Ait Jlc'ion. Ptn«c«!a ft, Mf\ -Ocl-HIS Tofol Mumfcir <i Jut 1434 hrenl 27 the present epidemic, but high in camparison with previous epi demics. The above figures, of course, relate only to the immediate mor tality of the disease. The expectation of life of millions of people has been shortened by it. The damage which the respiratory tract has suffered will probably weaken its resistance to the pneumococ- cus and meningococcus so that pneumonia and cerebro-spinal fever may show a marked increase this winter. The well-known fact that an attack of influenza may light up a dormant tuberculous focus must not be forgotten. It is too soon, as yet, to estimate how much injury the heart muscles and kidneys have suffered. The strenuous work incident to military life will certainly throw a heavy No. 2. 367 REPORTS. burden upon the cardio-vascular-renal system of the convalescents in the Army and in the Navy. During the epidemic our medical personnel consisted of the fol lowing : Medical officers. Nurses. Hospital corps men. 12 12 14 0 58 62 Out of this personnel, which numbered 158, we had many un complicated cases of influenza, and one broncho-pneumonia, but no mortality. We have gone over the records of 566 uncomplicated Pa- Cent Nolic* Mai 82 % of Me eases had1 sJcA c/aya varying from 4 Jo II days. cases to get the average length of the disease from the number of sick days, which was found to be 6.2 days. This appears on the whole to be rather short. Like the " line " we will have to plead military necessity. During an epidemic, just as during an engage ment, conditions are not always ideal and we must do the best that the circumstances will allow. Our object was to send the men out as quickly as was reasonably possible, so as not to interfere with mili tary activities, and also to make room to care for those who were sicker and needed more attention. Chart No. 2 shows graphically 368 Vol. XIII. REPORTS. the number of sick days of 600 cases at the naval hospital, and it will be seen that the average number of sick days was 5.8. This number is smaller than that of the sick days of the 566 cases, be cause some of these cases had been kept at the dispensary a day or two before being transferred to the hospital. The average of 6.2 days was calculated from the date of admission to the dispensary to that of discharge from the hospital. The naval hospital has a capacity of 237 beds and during the epidemic we handled at one time as many as 386 patients. This of course necessitated the putting up of tents. At the Naval Air Sta tion it became necessary to take over two bungalows with a capacity of 80 cots each, and one officers' quarters with a capacity of 30 cots, and convert them into temporary hospitals. The dispensary itself accommodated about 30 patients. We had 66 relapses, 4.57 per cent of our cases. Had we been able to keep our cases longer we be lieve that the relapses would have been fewer. The following table shows some interesting facts with regard to the cases that relapsed : Number ot cases. Average sick Average sick Average sick Per cent. days before days between days during relapse. attacks. relapse. 66 4.5 2.78 9.8 2.77 It will be noted that the average number of sick days for the cases that relapsed was very low—2.78. The minimum was 2 days, and the maximum 27 days. The clinical course was essentially that of an acute infectious dis ease. The earmarks of the disease that we studied conformed closely enough to the clinical description of influenza, as put down in text books on medicine, to make us feel that we were dealing with true influenza. Clinically, we had no doubt as to the diagnosis, and the finding of the influenza bacillus could hardly be considered a coinci dence. The reason why the influenza bacillus was not found more frequently is because the organism is so hard to grow. The onset of the disease, as a rule, was marked by sudden elevation of temperature, headache, muscular and joint pains, burning of the eyes, severe backache, and great weakness. The prostration was well marked and often the patient would sleep most of the time for sev eral days. A few cases complained of slight sore throat. The marked prostration and the severe pains in the lumbar muscles were the outstanding features. After several days the patient would com plain of pain in the chest under the upper part of the sternum near Z °H *SIHOcI3H 698 •sisougmp psi^ua.iajjip aq} uu jaAaj ipuaj} puB 'anSBjd oiuoqnq 'jsabj a\oi[3A 'enSuap aapisuoo 0} AJBSsaoau 41 apsui stusA*xojBd ajqnop q?iAV J8A8J jo adA^ siqj, 'JaAaj jo amoq fz a^buu puB 'sjnoq fz JOJ jaAaj ou 'jaAaj jo s^Bp aaaq? uaqj 'A"Bp puooas aq^ uo sanoq fz jo Btx8jA"dB ub pBq asBo auo "sasBo anoj 'sA*Bp anoj isasBO oav? 's£bP aajq; isasBO aajqj 'ABp auo — sA*Bp jnoj 0} oav} wojj pa;sB{ jaAaj A".iBpuoD8S aqX mbabj ^sau aq} UBq; J8avo[ sbav 'oav} ;nq sssbd {[B ut 'qoiqAv 'asu AJBpuooas b A*q paAVOjjoj 'sjnoq f z ^sb[ pjnoAi. pouad ejuqajB aqj, •jaAaj jo uisA"xojBd 3[qnop b qjiAV ssanoa b ubj (luao J3d 8'9) sasBO o{K)ip0Do20l u»»Mjaq sjtiid»<1cu?i d udj wds aq; p }"1t m.Vn j»qopo - J>qu)»^»f •d|4'oio3dcus<j '|oji<l90H ]dadp( <;■]] »q| jo (njuTmo ozuanuuT 10 sasDO paioawdoiosun O09 to aJniDjedoiai lsaq6iu ■ c on ravuo OX ?Bq} pdotjou a^Y "SAJTio jsabj aq} }noqB jBtpaoad SutqiA'uB stjai eaaq? aaqjaqAv aas O} sjJBqo J3A3j ffi jo apBui sbav Aprils pnjaaBO y 'A fOl PUB 'A 501 uaaAv^aq aan^Bjaduia^ b puq ';uaa jad z% *° 'iS8 aouBjS b ^b aas a^ "J8A3J ^saqSiq aiatp q^iAv sasBa jo jaqumu aq; pa^B[nqB^ sjb uiajaqM. 'sssbd pa^Baqduiooun jo s^JBqa JaAaj 089 }° sisajbub ub jo ^pasaj aq:> SAvoqs g 'o^ ?J^qO •sasBO a"ubui ut qSiq sbav jbasj aqj, •umjnds eqj ^noqB opsija^DBjBqo Suiq^ou paAjasqo 8jV\ "qsiuiunp ppaoAV suiBd )saqo aq? aAipnpojd auiBoaq q3noa aqi sy qqouojq puB BaqoBJ^ eip 370 Vol. XIII. REPORTS. The fastigium would not always be reached within the first 24 hours, as the following illustrates : Admission. Third day. Fourth day. Fifth day. Sixth day. 102.1 101.3 101.5 101.5 103.2 102 103 102.1 104 105.5 105 103.5 In some cases an early marked remission was noted, which was soon followed by a secondary rise. The next table makes this clear : Admission. Second day. Third day. Fourth day. Fifth day. 104.3 99.2 101.3 104 98 101 103.4 99.2 100 100 103 103 103 103 101 103.3 99 102 102 101.3 99 101 103.2 99 103.2 99 103.2 99.3 103 103.2 99.3 103.2 98 102.2 103 98 In the vast majority of cases, however, there was nothing remark able in the fever, which was usually at its height within the first 24 hours and then terminated by lysis, reaching normal usually in from three to six days. We have found the pulse rather slow, as can be seen from the fol lowing : Number of counts. 103°-104 F. 102M03 F. 102MO4 F. 100 100 200 93 86 89 The following table will show the respiratory rate : Number of counts. 103M04 F. 102M03 F. 102M04 F. 100 100 200 22 21 2i+ No. 2. 371 REPORTS. Eighty- four and five-tenths per cent of 200 cases, with a tem perature between 102° and 104 F., had respirations between 20 and 24. The marked predilection of the influenza bacillus for the respira tory tract has been a noticeable characteristic of this epidemic. Only a few cases had any gastric symptoms and in these it was no easy matter to decide whether the nausea and vomiting were from the disease or from the medication which had been given, such as calomel, Dover's powder, sodium salicylate, etc. Physical findings in most cases have been conspicuous by their absence. Injection of the conjunctivae and slight redness of the throat were usual. The lungs were clear in most cases. A table of the total white count per cubic millimeter is given below : Number of counts of uncomplicated casos. Average white blood count. Highest count Lowest count. 40 7,800 17,600 4,000 The urine examination of 200 uncomplicated cases follows : Number ofcases. Nega tive. Per cent. Number with al bumin. Per cent. Number ofcasts with al bumin. Per cent. Number ofcasts without albumin. Per cent. 200 142 71 32 16 16 8 10 5 It is interesting to compare these urinary findings with those of the pneumonia cases as tabulated a little later in this paper. The cases at the onset and when the epidemic was at its highest were the most severe ones. The first complication to appear was an acute otitis media, which occurred nine days after the onset of the epidemic. The following day four cases of pneumonia developed. The follow ing table will show the complications and sequelae that we noted : COMPLICATIONS AND SEQUELAE. 1. Pneumonia, 79 cases. Unresolved pneumonia confirmed by X-ray, 2 cases 2. Empyema; 1 case. 3. Nephritis with pneumonia ; 7 cases. 4. Otitis media acute ; 13 cases. Otitis media acute with pneumonia ; 4 cases. 5. Subcutaneous emphysema; 1 case. 6. Psychosis infectious ; 2 cases. 7. Frontal sinusitis ; 3 cases. 8. Acute thyroiditis; 1 case. 372 REPORTS. Vol. XIII. 9. Phlebitis of left leg ; 1 case. 10. Acute cholecystitis; 1 case. 11. Corneal ulcer ; 1 case. 12. Acute laryngitis with aphonia lasting two weeks ; 1 case. Pneumonia. —This has been our most frequent as well as most serious complication. Pneumonia has accounted for all of our fatali ties. All of the seven nephritis cases have been associated with pneumonia and had they existed alone would undoubtedly have been responsible for some of our deaths. The average number of days from the onset of influenza to the development of pneumonia in 63 cases averaged 5.6 days. The onset was insidious. A chill, pleuritic pain and herpes were very uncommon. Delirium was frequent. A dusky color of the skin and cyanosis were earljr and striking features. The rusty, thick, and sticky sputum characteristic of penumococcic lobar pneumonia was rarely noticed. A few cases early in the course of the disease ex pectorated bright, bloody sputum. The fever was high —102.5° to 105 F., continuous, and having slight remissions. In the majority of cases it terminated by lysis. The respirations were increased as in ordinary pneumonia cases. The physical signs were fairly con stant. They were always bilateral but far more marked in one lung in most cases. The first evidence of the trouble would be found at the bases posteriorly. In one lung there would be evidence of a small consolidated area deeply seated, i. e. : slight dullness, bron- chovesicular breathing, distant bronchial breathing or whispered pec toriloquy. At the opposite base one would hear subcrepitant rales. If the case was reexamined at the end of 24 to 48 hours evidences of a massive consolidation could now be made out in one lung and the physical signs would not be well marked in the other lung. This will explain why in our table we show broncho-pneumonia in one lobe. This really only means that this was the lobe most affected. Whis pered pectoriloquy was our most valuable aid in arriving at an early diagnosis of lung consolidation. Although the cases as we have gathered them from the records show a large number of lobar pneumonias, we believe that the re verse was the real state of affairs. It must be remembered that the broncho-pneumonia in this epidemic was not typical and that so much lung tissue was involved that the diagnosis of lobar pneu monia made on clinical findings was excusable. Usually a diagnosis of broncho-pneumonia has to be made on signs of a localized bron chitis with symptoms of pneumonia. The insidious onset, the rarity of the pleural involvement and rusty sputum together with the low blood count ought to have made us favor a diagnosis of broncho instead of lobar pneumonia. The autopsy findings which are being reported have shown that the lesions were those of broncho-pneu monia. No. 2. 373 REPORTS. The following tabulations of our pneumonia cases are of some interest. LOBAR PNEUMONIA. Num ber Site of lesion. > Resolution. Total num ber of pneu monia. Aver age age. Per cases noted. of Right lung. Left: lung. Crisis. Lysis. Deaths. deaths. of 25.... Upper lobe, 0; middle lobe, 2; lower lobe, 10. Both lowei Upper lobe, 0; lower lobe, 9. 14 14 47 25 13 31.9 lobes, 5. BRONCHO-PNEUMONIA. 19.. Upper lobe, 0; middle lobe. 1 ; lower lobe. 3. Both lower lobes, 10. Upper lobe, 0; lower lobe, 5. 14 32 24 28.0 The following table shows the results of our blood counts : Infliienza cases with pneumonia. Total number of counts made. Average count. Lowest count. Highest count. 29 10,200 2,777 65,000 It will be recalled that the average count of 40 uncomplicated cases was 7,800. The kidneys in our pneumonia cases have suffered severely as the following will show : Number of cases. Nega tive. Per Albumin without Per cent. Albumin with casts. Per cent. Casts without albumin. Per cent. cent. casts. 51 3 5 14 27 32 62 2 3 Of our influenza cases 5.4 per cent developed pneumonia. We be lieve that as high as this figure appears it would have been much higher had the epidemic occurred during the winter. The treatment of uncomplicated influenza cases was on the fol lowing lines: Calomel, gr. 5, followed by magnesium sulphate, was given at the onset. Aspirin, gr. 10, t. i : d., and Dover's powder in gr. 10, b. i:d, were used in some cases. Another class was given sodium salicylate, sodium bromide, and sodium bicarbonate; still others re ceived phenacetin, salol, and quinine in capsules. Kest in bed, hydro- theraphy (internally and externally), and a nutritious, easily di 374 . Vol. XIII. REPORTS. gested diet were the main factors in the treatment of the disease. Of the drugs used aspirin and Dover's powder were probably the best. During convalescence elixir of iron, quinine, and strychnine was em ployed as a routine measure. The treatment of pneumonia cases was symptomatic, plus the routine administration of creosote 1 drop on crushed ice every four hours, kept up for a few days after the temperature reached nor mal. Captain G. T. Smith, Medical Corps, Unted States Navy, the commanding officer of the United States Naval Hospital, Pensa- cola, Fla., says that he has seen excellent results with creosotal in about 50 cases of lobar pneumonia, not losing a patient. As we did not have creosotal, creosote was used instead. We could not see that it had any effect on the course of the pneumonia. It is worth noting that creosote was tolerated and caused nausea in but very few cases, and this subsided promptly when the drug was discon tinued. Creosote was stopped in the nephritis cases as we did not wish to increase the work of the kidneys, which were already over taxed by the toxemia of the disease. Our main reliance was on fresh air, hydrotherapy, plenty of fluids, liquid diet, stimulants as needed, and last but not least, careful nursing. To facilitate the handling of all cases they were placed in one ward. An ice cap was applied to the head and chest on the side that had the most trouble. Tepid sponging was used every three hours for a temperature of 102.5 F. or over. In some cases compresses wrung out in water at 60 F. were applied to the chest every two hours and seemed to do good. Although we believed that the cases should have a liquid diet while the temperature was very high, we did not hesitate to give the patients solid food with a temperature of 101° to 102 F., if this occurred during a protracted lysis. We are of the opinion that, be sides calories a patient needs plenty of food even if he has fever, to supply him with antibodies to overcome the infection. The solid food was well tolerated and we could not see any bad effects that could be charged to its use. The treatment was begun wtih calomel 5 grains, followed by a saline. The calomel was given in one dose as we did not wish to disturb the patient any more than was absolutely necessary. As our patients were young adults and in good physical condition before the onset of their present disease this treatment did not seem too drastic. We have gone over 780 routine urinalyses made at the United States Naval Hospital and found indican in 450, or 57 per cent of the urines. This gives us an idea of putrefaction going on in the bowel and makes us feel that a purgative at the onset of an infectious disease is not superfluous. Whisky, one-half ounce, well diluted with water was used every four hours as a matter of routine when the pulse became weak. We could notice no striking beneficial results following its use. No. 2. REPORTS. 375 Tincture of digitalis, 30 drops every four hours by mouth, or 10 to 15 minims by hypodermic in very bad cases, seemed to be of real value. If we were asked which was the one best stimulant in pneu monia we would have no hesitation in saying that it was digitalis. The tincture by needle is a little irritating and painful and is some times followed by some induration, but we did not see any abscesses. Another drug that appeared to do good when the patient was rest less and could not sleep was codeine sulphate one-half grain by hypo dermic. Trional in 5 to 10 grain doses acted well. In the early days of the disease, when bright red blood was expectorated a hypodermic of atropine sulphate acted beneficially. Later on when there were coarse rales present and edema of the lungs was developing atropine would do no good. The patient would drown in his own secretions. Camphor in oil, grains 5 ; strychnine sulphate, grain 1/30 ; caffeine and sodium benzoate, grains 2, by hypodermic, were all tried, but seemed to be of very little value. Spinal puncture, using cocaine i per cent solution as a local anes thetic was used in one case with delirium which had lasted three weeks. Twenty cubic centimeters of clear fluid were removed under pressure and the patient was quiet for six hours after the puncture. Spinal puncture to relieve delirim in pneumonia is based on good grounds and is a valuable procedure which ought to be used more fre quently. Venesection was done in two cases, showing cardiac embarrass ment. From 180 to 200 cubic centimeters were removed. The pa tients were relieved for a few hours. Both cases died. We believe that venesection should be kept in mind and used more often than is the present practice. Oxygen was given by inhalation when the patient became cya- nosed, and proved useless. In two cases we gave it by needle in the subcutaneous tissues of the abdominal and thoracic walls. An im portant precaution in carrying out this procedure is to insert the needle subcutaneously and see that no blood flows out, as the giving of oxygen directly into a vein would cause an air embolus. The purpose of using this method is based on the theory that the red blood cells are capable of utilizing the oxygen and make up for the difficulty of oxygen absorption in a lung which is extensively in volved and where the exudate is so excessive as to diminish the sur face of contact between the blood and oxygen inhaled ; that the latter is not absorbed in sufficient amount to sustain life. Another advan tage is that the oxygen is held in a reservoir as it were, and can be utilized continuously. The patient would be allowed to sit up in bed for one hour, using a back rest, seven days after the fever had been normal. The time was gradually lengthened so that in about two weeks after the fever subsided he would be walking about. 376 Vol. XIII. REPORTS. Bacteriological work.—The present pandemic of influenza has been characterized by the great divergence of bacteriological findings as reported by various workers. Influenza vera is a disease caused by the bacillus of influenza. Influenza nostras on the other hand is a disease, the cause of which has not been definitely determined; the micrococcus catarrhalis, streptococcus, etc., have all been incrimi nated. A considerable amount of bacteriological work has been done dur ing this pandemic to determine the cause of the infection, and in a majority of the reports the evidence seems to be in favor of influenza nostras. Bacillus influenza has been reported at times, but in many of the reports it was not blamed as being the chief mischief maker. We have examined the sputum of 120 patients who had been clin ically diagnosed influenza (respiratory type) and 28 out of 66 un complicated cases 'and 33 out of 54 cases complicated with pneumonia showed an organism which morphologically and tinctorially was con sistent with that of the influenza bacillus. Pneumoccus, micrococcus catarrhalis, staphylococcus, and streptococcus were also found. The following technic was used in collecting specimens for cul tures: The patient was instructed to cough and the sputum which came from deep down in the bronchi was immediately received in a sterile Petri dish. A small amount of this material was at once taken up with a platinum loop and planted on freshly prepared blood agar and blood-streaked agar. This media has a slight alkaline reaction. The Petri dish was then incubated at 37 C. After 24 hours incu bation the colonies were barely visible, but after 36 to 48 hours they appeared as minute dewdrops. When touched with a loop the colony could easily be picked up and formed a smooth and even suspension with a drop of water on a slide. The microscopical examination of the smear showed that the in fluenza bacilli prepared from the culture were much larger than those prepared from the sputum. Another striking feature was the variation in the size of the bacilli in smears made from both the sputum and the cultures. The staining that gave the most satisfactory results was Gram's stain, using dilute carbol-fuchsin as the counter stain. Four cul tures out of 31 uncomplicated cases and one out of eight cases com plicated with pneumonia showed the influenza bacillus, micrococcus catarrhalis, pneumococcus, staphylococcus, and streptococcus were also found. Agglutination test. —In five cases the influenza bacilli obtained from subcultures on blood agar and blood-streaked agar were ag glutinated by the serum of convalescent pneumonia patients. The method consisted in picking up the influenza colony and emulsify ing in normal salt solution. This emulsion and the serum of a pa No. 2. REPORTS. 377 tient recovering from influenza were mixed on a slide in dilution of 1 to 40. At the same time horse serum and the bacterial emulsion ■were mixed on another slide in the same dilution and was used as a control. Both slides were examined after 20 minutes incubation. Only the slide with the patients' serum agglutinated. The slides were then dried, fixed and stained and the results confirmed the above observation. Bacteriological findings. —The sputum of 120 patients clinically diagnosed influenza (respiratory type) were examined. The follow ing information was obtained : Number examined of uncomplicated cases, 66. 1. Influenza-like bacilli, 28—42.4 per cent. 2. Gram negative diplococcus, probably M. catarrhalis, 20—30.8 per cent. 3. Pneumococcus, 51—70.3 per cent. 4. Streptococcus, 4—6.6 per cent. 5. Staphylococcus, 3—5 per cent. Number examined of influenza cases complicated with pneumonia, 54. 1. Influenza-like bacilli, 33—61.1 per cent. 2. Gram negative diplococcus, probably M. catarrhalis, 7— 12.9 per cent. 3. Pneumococcus, 48—88.4 per cent. 4. Streptococcus, 4— 7.3 per cent. 5. Staphylococcus, 2—3.7 per cent. Thirty-nine cultures were taken from bronchial secretions, col lected in sterile Petri dishes and planted on blood-streaked agar and blood agar. The 39 cases showed the following flora : Number examined of uncomplicated influenza cases, 31. 1. Influenza bacilli, 4—12.9 per cent. 2. M. catarrhalis, 29—93.8 per cent. 3. Pneumococcus, 20—64.5 per cent. 4. Streptococcus, 11 —38.6 per cent. 5. Staphylococcus, 9—29 per cent. Number examined of influenza complicated with pneumonia, 8. 1. Influenza bacilli, 1— 12.5 per cent. 2. M. catarrhalis, 6— 75 per cent. 3. Pneumococcus, 4— 50 per cent. 4. Streptococcus, 1—12.5 per cent. 5. Staphylococcus, 5—62.5 per cent. Ten nasal cultures were negative for influenza bacilli. SUMMARY AND CONCLUSIONS. 1. Complement of station 5,359; total number of influenza cases, 1,454 —27 per cent. Number of pneumonias, 79; number of deaths, 24. Mortality, 1.6 per cent. The epidemic was under control within seven and one-half weeks. 2. The number of cases at the isolation camp has been much smaller than that of the station (not previously mentioned in text). 103396—19 14 378 REPOBTS. VoL XIII. 3. The men living in tents at the Air Station have suffered equally with those living in barracks. 4. The present epidemic has had a higher death rate than preced ing ones, as noted in the literature. 5. The very low white blood count leads us to believe that most of the pneumonias were due to influenza bacillus, as pneumococcus, streptococcus, or staphylococcus would have caused a leucocytosis. 6. The pneumonias are in the majority of cases massive broncho pneumonias. TBAINING SCHOOLS FOB NURSES IN HAITI. By L. D. Jordan, Chief Nurse, UDited States Navy. The treaty of September, 1915, between the United States and Haiti provided among other details for the establishment of a public- health service under the control of a sanitary engineer nominated by the United States. In December, 1916, Surgeon N. T. McLean, United States Navy, was appointed to this detail, and plans for the organization of the service were begun. In July, 1918, Chief Nurse L. D. Jordan, and Nurse J. Y. Kay- mond, United States Navy, were detailed to duty in connection with the establishment of a training school for Haitian women. The necessity for Haitian trained nurses was early appreciated, but until the development of the service had been brought to a point where the school could be properly administered it was deemed inadvisable to begin this work. The negro Republic, with over 2,000,000 inhabitants, the great mass of whom are illiterate and without the most elementary ideas of hygiene, had no organization from which even inexperienced nurses could be obtained. The deplorable hospital situation in Haiti at the time of the forma tion of the public health service gave great concern. During the time of the occupation the naval medical officers attached to the Marine regiments in Haiti undertook such improvement in the local hospital as was possible. Their work brought the city general hos pital in Port au Prince from a condition of filth and squalor to a real working basis. This hospital, as most others in the Republic, had been more or less under the general administration of French Sisterhoods, who, in the face of greatest difficulties endeavored to attend to the needs of the sick. The Sisters were not trained nurses and at best could but administer such funds as they were able to obtain from the Government and private sources. No organized plan existed in relation to the care of the sick. if? fy t f \ Mw n ... >> if f | f Nurses' training school, Haiti. The school building. Group of nurses, sisters, and pupils, 37* • I No. 2. BEPOBTS. 379 Preliminary work having been accomplished, one of the buildings of the city general hospital was set aside for a training school. Interest among the better class of Haitian women was established by means of a number of articles in the daily press, and the influence of the Sisters actually in the hospital and through their associations at the various schools throughout the island. As a result, from a large number of applications from all parts of the country, 38 were selected, and on October 15 the school was opened with 24 pupils in attendance. French being the national language, all instruction is given in it. The school is conducted as nearly as possible along the lines adopted by standard American schools with such minor changes as were advis able to meet local conditions in a tropical country. The uniform is blue with large soft white collar and cuffs. The first three months are the period of probation, after which the cap is received. Lectures and practical demonstrations are given. The course extends over two years with a diploma at the end of that time to those who have satisfactorily completed the course. The usual in struction will be given in medical and surgical nursing, operating- room technique, children's diseases, dietetics, and a special study of nursing in tropical diseases. The first month's work at the school shows that the pupils possess a high ideal of the qualifications of a nurse. They show great in terest in their practical work and already give evidence that they have the ability to understand and put into use the instructions which they have received. Two Sisters live in the nurses' quarters and maintain discipline. The pupil-nurses will receive their practical experience in the wards of the city general hospital, which has a daily average of over 300 patients. In addition to the hospital instruction proper, an out patient dispensary, located in one of the poorer sections of the city, will be used to give instruction in social service. It is believed that this training will be of inestimable benefit in teaching the poorer classes the elementary principles of hygiene. From the interest taken by the pupils themselves, their families, the Sisters, and the people generally, it is evident that the spread of a knowledge of the hygienic principles necessary for good health will be increased as the pupils graduate and return to their homes in the various towns of the Republic. 380 REPORTS. Vol. XIII. OBSERVATIONS ON 200 MEN EXAMINED FOR CANDIDATES FOR THE LISTENERS' SCHOOL. By F. B. Galbraith, Lieutenant, Medical Corps, United States Navy. After having examined a large number of men for the Listeners' School I noticed that about only one in every five qualified. To de termine the cause of the failures I decided to keep records of all the men examined. The records of 200 men examined consecutively were taken for the basis of this report. The following instructions furnished by the Bureau of Navigation were followed, with slight modifications. (The numbers and letters are not the ones given in the examination for obvious reasons.) DETAILED RECOMMENDATION FOR THE EXAMINATION OF CANDIDATES FOR THE LIS TENERS' SCHOOL. 1. Qualifications of candidates for examination. (a) The general training of a seaman, especially military discipline, care of seaman's belongings and person, and the ability to handle firearms effec tively. (ft) General Intelligence sufficient to profit by an Intensive course of school work. (c) Loyalty to and interest in naval work. (d) Enough self-reliance and initiative to carry the responsibility of the listener's task (e) Enough team spirit to make him livable in cramped quarters. 2. On the basis of these requirements, the best available men should be recommended for examination by the drill officers from the senior companies at the several training stations. (a) It should be made clear to the officers In charge that all candidates for this examination should be selected men. It is a waste of time to examine men who do not meet the above requirements, at least presumptively. (6) At least four times the quota required by the communication on the "quota of men for Listeners' School" under date of January 29 should be ex amined at each naval district. (c) In the absence of other clear indications the requisite general intelli gence to profit by school training (1, 6) may be decided by actual school ex perience. Wherever practicable candidates should have had at least two years' high-school experience, but any other indication of superior intelligence should be regarded as satisfactory. 3. The examination of the selected candidates should consist of two parts, (a) A general medical examination to determine the candidate's general fitness for the tasks of the listener, with especial reference to the Integrity and normal functioning of the auditory apparatus, and possibly with less em phasis on the visual equipment. (6) A special examination to determine by approximate trial the men who seem to be best fitted for the special and peculiar task of a listener. 4. The ideal special examination would probably mean to try out every candi date with the special apparatus used under the actual conditions of service. Since that seems to be impracticable, a set of tests had to be developed that would correspond to these tasks as closely as possible. After a considerable ex perience with the men selected by these tests, consequent to which the tests have been checked and corrected, it seems important to give them as uniformly No. 2. BEPOKTS. 381 as possible In all naval districts and to make no Intentional changes either in substance or method until that change has been fully considered by the Bureau of Navigation and checked by correlation with the actual work of the man at the school. 5. Examination blanks similar to the inclosure should be used as far as prac ticable for all examinations. Until enough printed forms can be supplied for nil the districts, sufficient similar blanks for one or two examinations may have to be prepared by hand. In this case It will be unnecessary to duplicate the 6-inch rule at the bottom. The graded examination papers should be forwarded to Pelham Barracks with the successful candidates. It is important in the final selection to take all available data concerning the candidate into account. 6. Groups of 12 to 20 men may be examined together. Each group examina tion requires from 15 to 20 minutes. 7. The examination room should be at least 30 feet long. It should contain (1) a table at least 8 feet long for the examiner's sound screen; (2) provision for seating 20 men in two rows, the nearer row being 20 feet from the sound screen; (3) provision for the candidates to write their papers, including pen cils and appropriate tables or lap tablets; (4) no disturbing noises should be permitted either inside or outside the room ; (5) a petty officer and an orderly should be present throughout all examinations. 8. Introductory statement: Before the examination of any squad begins the examiner should state (o) that the object of the examination is to select those men who have the special qualifications for a special and very important naval task which demands the best possible hearing and the ability to locate the direction of sounds; (h) that the closest attention is required and instructions will not be repeated; (c) that looking at the paper of another will disqualify a candidate immediately. Note it is the business of the orderly and petty officer to see that this rule is enforced. 9. The first two lines should then be ordered filled in by the candidates as in dicated by the printed directions. (a) The first line should have the candidate's name in full, and the date. (6) The second line should give the candidate's rating, billet number, bat tery station, and the name of the naval district or training school. 10. Test 1.—The memory span, 7, 8, and 9 place digits. Procedure: The examiner should state— (a) "The first test is your ability to remember numbers. ( & ) "In column 'A' you will write 10 series of numbers, one series on each line, after I have read them to you and given the order to write. (c) " I shall give the order, ' Pencils up.' On that order you must raise your pencils from the paper at least 2 inches. Then I shall read 7, 8, and 9 place number digits, each second. You should remember these numbers and write them In the order that I gave them, when I give the command ' Write.' " (d) For example: Pencils up; 1, 9, 4, 7—write. (e) Now pay attention: Pencils up ; 3, 7, 2, 8— write. Pencils up ; 0, 8, 6, 9—write. Pencils up ; 5, 1, 8, 3—write. Pencils up ; 9, 4, 1, 6, 3—write. Pencils up ; 2, 8, 9, 4, 1— write. Pencils up ; 3, 7, 4, 8, 5—write . Pencils up ; 6, 8, 2, 7, 1, 9— write. Pencils up ; 0, 3, 6, 2, 4, 2— write. Pencils up ; 7, 9, 1, 3, 0, 5— write. Pencils up ; 5, 9, 2, 8, 3, 6— write. 382 REPORTS. Vol. XIII. This series of numbers may be used for all examinations until further notice. 11. Test 2.—Ability to read a circular scale to an error of 1 degree. (A) Apparatus: (a) A circular scale at least 15 inches in diameter, di vided into 5-degree arcs and numbered every 30 degrees with number that should be legible at 30 feet; (6) a hand lying close to the scale and capable of being set with an accuracy of 1 degree: (c) both scale and hand may be constructed of heavy cardboard divided and lettered by hand. (B) Procedure: The examiner should say— (a) " In the column B you will write the setting of this hand on this circu lar scale, when I give the command ' Write.' (6) " Note that the circular scale Is like a compass scale, reading from 0 to 360 degrees. Each division marks off 5 degrees. Each 30 degrees is numbered. (c) " You are expected to read to an accuracy of 1 degree. For example, this (setting the pointer to correspond) would be 90 degrees, this would be 95 degrees, and this could be 92 degrees. (d) "Now pay attention to the settings and write each on a separate line In column B when I give the command ' Write.' Set the scale at 180 degrees ; give the command ' Attention,' and after 5 seconds give the command ' Write.' " Set the scale at 0 degrees ; command " Attention " and after 5 seconds " Write." Set the scale at 50 degrees. Set the scale at 65 degrees. Set the scale at 70 degrees. Set the scale at 27 degrees. Set the scale at 133 degrees. Set the scale at 107 degrees. Set the scale at 201 degrees. Set the scale at 96 degrees. 12. Test 8.—The location of sound. (A) Apparatus: (a) A cotton cloth screen about 8 feet long and 30 inches high, on which are printed six vertical lines 1 foot apart and about 8 inches high. Above these lines should be printed numbers 1 to 6, one for each line. The numbers should be legible at 30 feet. ( 6 ) A steel snapper such as Is some times used In elementary telegraph instructions. Any other convenient source of uniform sounds would do which can be made to give separate clicks close to the cloth screen, (c) Since it is important that no other indication of the source of sound be given other than the sound itself, It must be carefully arranged that no part of the examiner is visible above, below, or through the screen. The snapper must not touch the screen, though It should be as close as possible without touching to avoid parallel. Neither experimenter nor snapper should cast shadows on the screen. (B) Procedure: The experimenter should say— (a) "Now we shall test your ability to locate the direction of sounds. This is the most difficult and the most important of all the tests. (&) "I shall sound the snapper (sound it) behind that cloth screen, directly behind one of those numbered lines. In each case I shall make six slow clicks and six rapid ones. (c) "You must try to tell by the sound which number it is behind, and when I give the command ' Write,' set it down in column C. Do not try to guess. Do not look at one number and try to make it seem behind that one. Turn your head slowly from side to side, looking at each number in turn, to tell whether you are getting nearer or further away. No. 2. REPORTS. 383 (d) " Now we shall try It once just for practice." (e) The experimenter should then hide himself behind the screen, taking par ticular care not to indicate by his eye or by the direction of his disappearance where he intends to sound the snapper. He should then sound the snapper as previously described (six slow and six fast snaps) behind the line numbered 4. Raising the snapper above the screen vertically above No. 4, he should say, " I sounded that behind No. 4. Those who got it right, raise their hands. Those who made it either 3 or 5 raise their hands." According to the showing he may then say, " That was pretty good," or " That was poor. Now, try it again for practice." This time it should be sounded behind 2 and demonstrated as be fore. (/) The examiner should say: "Now we shall try it in earnest Pay strict attention, and when I give the command ' Write,' write the number where the sound seems to be in column C. 'Attention.' " Sound the snapper as before behind line 3 and give the command " Write." Then in exactly the same way behind 2, 5, 1, 3, 1, 4, 6, 1, 4. 13. Test 4- —The discrimination of familiar sounds. The examiner should say— (o) "In the last column, D, you will write the syllables that I shall pro nounce. For example, I shall cover my mouth and speak a syllable very softly." (Covers his mouth and speaks the syllable KAZ, then spells it and asks how many got it right.) (b) Then the examiner should take up his position directly in front of the cloth screen and say, " Now pay attention when I cover my mouth and write the syllable that I speak in column D when I give the command ' Write.' " Attention. (Clovers mouth and speaks softly) DON —Write. " Attention. (Covers mouth and speaks softly) EY —Write. " Attention. (Covers mouth and speaks softly) DER—Write. " Attention. (Covers mouth and speaks softly ) LY—Write. " Attention. (Covers mouth and speaks softly ) PU—Write. " Attention. (Covers mouth and whispers softly ) CNT—Write. " Attention. (Covers mouth and whispers softly) TARA —Write. " Attention. (Covers mouth and whispers softly) MAR—Write. " Attention. (Covers mouth and whispers softly ) DES—Write. " Attention. (Covers mouth and whispers softly ) SEA—Write." (c) The exact degree of force with which the syllables are spoken by the sev eral examiners is incapable of standardization, and it doesn't matter how they differ, provided each one maintains the same standard for all the groups that he examines in filling one quota. 14. After this test, candidates should be ordered to leave their papers and pencils, rise and file out. Another group should take their places and the ex amination be repeated until all the candidates are examined. 15. Grading the papers is best done by making first a complete list of answers, (a) Grading test 1.—Begin at the bottom of the list of figures. Mark each error. Inability to get tvjo or more figures of a series counts minus 10. Fail ure to get one of the numbers of a series counts minus 5. Numbers all right but with one inversion counts minus 5. If the six place numbers are right the others may be graded correct without reading. (6) Grading test 2.—An error of 1 degree in reading the scale counts correct. It may easily result from differences of position. An error of 2 to 4 degrees counts minus 5. An error of 5 or more degrees counts minus 10. (c) Grading test S.—An error of any sort counts minus 5 for each place. For example: The first source of sound was line 3. If the answer is 2 or 4, the 384 BEPORTS. Vol. XIII. answer is graded minus 5; if the answer is 1 or 5, the grade is minus 10; if the answer is 6, the grade is minus 15. It is evident that one question may count minus 25, as for example, if the place were 6 and the answer were 1. (d) Grading test 4. —If one sound is wrong the answer counts minus 5. If two sounds are wrong, the answer counts minus 10. 16. Total grades. — (o) The highest possible grade is 400. The highest grade that I have ever seen is 370. Passing grade is 300. (6) There are some exceptions to this. Thus, if a paper Is marked perfect on the first two tests and only 100 on the second two, the paper Is lacking in the most essential part. So the last two tests are regarded as unsatisfactory if they fall below 120. Again a candidate may fall down completely in reading the scale. This is a serious matter, but it may readily be learned and if the rest of the paper, especially the sound tests, are excellent the paper should be passed. But In this case the candidate should be shown the paper and passed only on the promise of learning to read the scale immediately. It should be borne in mind that the main point of the tests Is to find listeners. Any correctable errors should not invalidate a candidate. Memory span for figures does not improve with practice to any considerable degree. A candi date who makes serious errors with 5 place figures is probably not fitted for the school work. Two errors of two or more points in the location of sound Is a serious matter. Two errors of three points should disbar a candidate, even if the rest of the locations are all accurate. If other evidence shows that the candidate is an otherwise exceptionally good man, he may be given another test in the location of sound. 17. Individual examination for the listeners' school. (A) Purposes: The purposes of the individual examination are: (a) To check other sources of information concerning the personal fitness of the candi date, (b) To test the auditory discrimination of differences of intensity with the same type of apparatus that they must rely on in actual service. (It ap pears that the ability to locate the source of sound is not infrequently greater than the ability to discriminate the differences on which the location chiefly depends.) (c) To test the quickness and certainty of the reactions to differ ences of Intensity. (Slow hesitating and uncertain reactions appear to be fatal to a good listener.) (B) Apparatus consists of a stethoscope earpiece to which is attached a rubber tube about a yard In length. This should be marked at its middle point. When scratched with a quill toothpick faint sounds are produced which may be located as at the middle or toward one side or the other. (C) Procedure: (o) The candidate should be watched with care to discover any Indications that may appear of personal unfitness. (6) Seated opposite the candidate with a table between, the experimenter should say: "We are going to test your hearing with this apparatus. When you have put these ear pieces in your ears, I am going to scratch this tube with a quill. If it seems to be more in your right ear raise the fingers of the right hand ; if in the left ear raise the fingers of the left hand ; If It seems Just the same to both ears, exactly In the middle of the forehead, raise both hands. The point of the trial is to find quickly and accurately when it Is in the middle. But If It seems just a shade over one eye or the other, raise the corresponding hand, (c) Now put this earpiece in your ears, bow your head, and shut your eyes." (d) The first test should be for practice, 6 inches on one side, 6 Inches on the other, ana then In the middle. If the candidate gets them right, he should be told so. If there are errors that distance, the existence of gross differences in the two ears No. 2. REPORTS. 385 should be suspected. The reactions of the appropriate hands should be Im mediately decided. If these reactions are correct, the examiner should say: " That was good ; now we will make It a little finer." From now on, no informa tion should be given whether the answer is right, (e) Various points around the middle should now be scratched and occasionally the middle. Starting from 2 or 3 inches to one side move by half-inch stages to the other side, well beyond where It is correctly discriminated. Then back again until the ex aminer Is convinced that he can tell how wide the candidate's center is, and whether the center is displaced toward either ear. (D) Grading these performances. A perfect performance would be con sidered when no personal fault was discovered, when the reactions were im mediate and certain, when the middle exactly corresponded to the middle of the tube, and when a displacement on either side of one-half inch was uniformly accurately discriminated. Such cases exist, but they are not common, (a) Five grades are given for each of these characteristics, perfect, fair, average, poor, impossible. I represent them on the alphabetical list by symbols rather than by numerals. (6) Five points are noted: Personality, quickness or reaction, and assurance, breadth of the apparent center, displacement of the center, consistency, (c) There can be no fixed rules for grading personality. The possible varieties of criticism are too numerous. But most of the clearly bad cases should have been eliminated before the individual examination, (d) Quickness and assurance of reaction is also difficult to give rules for grading. But a little experience will enable the examiner to make a pretty accurate judgment. In practice, this quality may very properly be left to the final reviewing officer, (e) Breadth of center: Average is 1 inch, poor Is 2 inches, anything more than that is impossible. (/) The same dimensions hold for displacement of the center, (g) Consistency is determined by the number of different variations. Impossible consistency is usually a matter of pure guesswork. The Intermediate grades will be proportional parts of the total number of stimuli which lie just outside the candidates center, and those which He just Inside the center. Mixing right and left of the true centers is poor. One-third of centers called right or left and of the proximate rights and lefts called centers is average. Anything between that and perfect is good, (h) No one should pass this test with less than an average " good." Permission was given any man on the station to take the ex amination, irrespective of his education, as it was necessary to do this in order to fill our quota. I found that the same percentage of men passed with only a grammar-school education as there were men with one or more years in high-school in the first series. In the second series the high-school trained men did better. The room used for the examination was on the third floor of a concrete warehouse, where the accoustic properties were very poor, allowing a great deal of echoing. There was also considerable noise from the streets below, of mechanics working and men drill ing. This was considered, however, somewhat of a desirable feature in that it compelled the men to concentrate their minds on their work and to eliminate extraneous sounds, as they might possibly have to do on board ship in eliminating noises from machinery and the propellers of their own ship. 386 REPORTS. Vol. XIII. The procedure in test 3 was varied somewhat. Before beginning the test, the snapper was sounded in front of each number where the men could see and hear the location of the sound, and then twice behind the screen, allowing them an opportunity to tell the number and then telling the correct one. In the test of auditory discrimination of differences of intensity I believe that a method I have adopted is a little more satisfactory than that given in the instructions as a better opportunity is given to determine the candidates mental alertness, since invariably the candidates that did not grasp the instructions, failed in one or more parts of the test as well as the individual test. The candidate seated in a chair in front of the examiner was told to " Hold up the hand on the side on which you hear the noise the loudest; if it is equal in both ears, hold up both hands. Fit these in your ears." Hand him the stethescope connected to the rubber tube. " Now watch where I scratch." The center and each side, 6 inches from the center, is scratched. " Do you get the difference ? " If the candidate answers " Yes," he is then told to close his eyes and the test is proceeded with. I graded candidates on assurance and reaction in this manner. If the candidate responded quickly I credited him with excellent reac tion ; the other marks good, fair, and poor in keeping with the time in which the candidate responded. Assurance was excellent if he showed no element of doubt. If he apparently hesitated it was " good," if he showed plainly noticeable signs of doubt it was " fair," and if he changed from one to the other side in indicating the side on which the sound was louder it was considered " poor " assurance. A candidate of poor assurance and reaction usually failed in other parts of the test. The men taking this examination were those who were not able or who did not wish to qualify for the officers' class or other special training branches offered at this station. This accounts for the low number of college-trained men. Two series of 100 men each were taken. The second 100 were used as a check for the first series. By comparing the two columns it will be noticed that there was very little difference in the results ob tained. The results of the first series of 100 men are shown in the first column, the second 100 in the second column of each table. The following are the tabulated results : Soccxid scrios. Number of men examined 100 100 Number of men passed ' K H Number of men failed No. 2. 387 REPORTS. OCCUPATIONS REPRESENTED. Farmers. Mechanics.' Students. Clerks.' Laborers.' First series. Second First series. Second series. First series. Second series. First series. Second series. First series. Second series. series. Passed 4 5 1 3 8 3 15 2 6 2 8 3 23 7 26 6 30 1 Failed 11 26 Total 9 12 11 18 8 10 26 33 36 27 1 Mechanics included electricians. 2 Clerks included business men, newspaper men, and bookkeepers. ' Laborers included painters, miners, railway men (street-car men, etc.), teamsters, firemen and the like. This classification reduced to a minimum the number of profes sions and trades given as the occupation of the candidates before enlisting in the Navy. Passed. Failed. First series. Second First series. Second series. Education: series. Grammar school 8 9 2 1 37 26 11 42 57 College 2 3 4 Grammar school included up to the ninth grade, included those of one to four years' training. Results of those who passed. High school First series. Second Number of men that passed Average total grade Average age (years) A—Memory test B—Reading circular scale C—Location of sound D—Discrimination of familiar sounds. Breadth of center: No breadth of center Breadth of center J inch Breadth of center 1 inch Breadth of center 1J inches Displacement of center: No displacement of center Displacement to the right only Grouped as follows— J inch 1 inch 14 inches 18 315 21 85 97 07 09 G 6 0 4 5 4 3 1 14 317 21 84 94 08 68 4 2 2 3 388 Vol. XIII. EEPORTS. Results of those who passed—Continued. First series. Second series. Displacement of center—Continued. Displacement to the left only Grouped as follows — i inch 1 inch 1J inches Displacement to the right and left. . . Grouped as follows — £ inch to right and J inch to left.. J inch to right and 1 inch to left. 1 inch to right and J inch to left. Reaction: Excellent Good Fair Assurance: Excellent Good Fair Consistency: Excellent Good Fair 5 . 2 3 3 14 1 3 2 "i 2 12 13 1 5 13 1 13 The highest mark was 360, made by a clerk with two years' college training. His marks were as follows : A—Memory test 100 B— Reading the circular scale 100 C—Location of sound 80 D—Discrimination of familiar sounds : 80 Breadth of center None. Displacement of center * None. Reaction Excellent. Assurance Excellent. Consistency - Excellent. Results of those who failed. Number of men who failed Average total grade Average age A—Memory test B—Reading circular scale C—Location of sound D—Discrimination of familiar sounds Breadth of center: No breadth of center Breadth of center, $ inch Breadth of center, 1 inch Breadth of center, 1J inches Breadth of center, 2 inches Breadth of center, 1\ inches Breadth of center, 3 inches Breadth of center, 3J inches Breadth of center, 4 inches First Second series. series. 82 86 252 251 21 21 70 73 76 78 42 44 53 45 2S 43 15 10 11 17 3 4 15 8 0 2 1 1 1 0 1 1 No. 2. 389 REPORTS. Results of those who failed—Continued. First Second series. series. 30 31 7 12 7 8 0 2 0 2 13 13 7 8 5 2 1 1 0 1 0 1 32 30 10 15 3 1 0 2 15 6 0 2 0 2 1 0 1 1 1 0 1 1 18 13 53 01 5 10 6 2 15 12 47 58 11 13 9 3 6 17 46 48 14 11 16 10 61 72 15 10 9 3 6 2 14 12 27 17 Displacement of center: No displacement of center Displacement to the right only Grouped as follows — J inch 1 inch 1J inches Displacement to the left only Grouped as follows — Jinch 1 inch li inches 2} inches 3 inches Displacement to the right and left Grouped as follows — J inch to right and J inch to left i inch to right and 1 inch to left 1 inch to right and 1J inches to left 1 inch to right and 1 inch to left 1 inch to right and J inch to left 1 inch to right and 1* inches to left li inches to right and i inch to left li inches to right and 1J inches to left. 2 inches to right and 1J inches to left. . 2 inches to right and 2 inches to left. . . Reaction: Excellent Good Fair Poor Assurance: Excellent Good Fair Poor Consistency: Excellent Good Fair Poor Causes of failures: "C" and"D" at or below 120 Consistency poor Assurance poor Reaction poor Breadth of center 2 inches or more Failed in two or more parts CONCLUSION. I find that very few college men take this examination, because they can qualify for better ratings. It is not desirable to exclude a man from qualifying for a listener if he has only a common-school education. All but 7 candidates of the first series and 11 of the second series were able to pass the membory test and circular scale test satisfactorily. The test for the location of sound and the discrimi nation of familiar sounds was the cause of the greatest number of failures. 390 Vol. XIII. REPORTS. In the test of auditory discrimination of differences of intensity it seemed very difficult for many of the candidates to discriminate between i inch to either side of the center with the following pro cedure : Scratch the center of the tube, then 2 or 3 inches to right or left of center, then £ inch to right or left of center. This manner of testing appeared to be more difficult than scratching on the tube at i inch intervals, beginning at 2 inches to the right and passing through the center and to 2 inches to the left. Very few of the candidates knew anything about the kind of work to be done, where they were going, or their rating and pay, as prac tically the only information that has been received was from men of this station who had been to the " listeners' school " and had written to their friends here regarding it. Most of the men took the exami nation because it seemed to offer a good opportunity to be trans ferred to an eastern station and early sea duty, the ambition of practically every man on this station. I believe that it would be a greater incentive to the men if definite information could be given them regarding their status in case they pass the examination. Following is a sample of the form of examination paper used : NRF. Examination of candidates for listeners' school. Name in full Rate (Surname first.) V. 8. NAVAL RESERVE TRAINING CAMP, SAN PEDRO, CAL., TWELFTH NAVAL DI8TRICT. Date , 1918. Examination. Marking!i. A. B. C. D. A. B. C. D. Total. Grand total Final examination — Sound test: Personality Reaction Assurance Breadth of center Displacement of center Consistency Candidate{^ed} Examiner Age Occupation Education. U. S. N. No. 2. BOOK NOTICES. 391 BOOS NOTICES. The principles and practice of obstetrics, by J. B. DeLee, A. M., if. D., pro- lessor of obstetrics, Northwestern University. Third Edition. W. B. Saun ders Co., Philadelphia, Pa., 1918. This is a superb volume, thanks to the author's direct, clear style and the completeness with which the subject is handled and owing also to the excellence of the many illustrations, the good type, and other features of the bookman's craft. The procedures described are primarily those of the writer and have all the force of his authority, but the reader enjoys in addition a wide survey of the methods in vogue in Europe which are referred to with truly judicial discrimination. The many historical refer ences and the summary of the literature of the subject at the end of each chapter give to this work a scholarly finish lamentably rare in the medical press of America. Massage and the original Swedish movements, by Kurre W. Ostrom, from the Royal University of Upsala, Sweden. Eighth Edition. P. Blaklston's Son & Co., Philadelphia, Pa., 1918. A small, handy volume written for those wishing to employ this valuable therapeutic measure under the direction of physicians. The author's ethics appear to be sound, and he makes a very earnest and proper plea for the regulation, by competent authority, of mas sage in this country. Paper work of the Medical Department of the United States Army, by R. W. Webster. M. D., Ph. D., Major, Medical Corps, United States Army. P. Blaklston's Son & Co., Philadelphia, Pa., 1918. Physiology and biochemistry in modern medicine, by ■/. J. R. Macleod, M. B., assisted by Roy Q. Pearoe, B. A., M. D. C. V. Mosby Co., St Louis, 1918. The tendency of modern medicine is to place less and less emphasis on pathological anatomy and more on pathological physiology. We are, for instance, beginning to classify diseases of the heart, kidneys, and many other organs according to the studies made while the patient is still alive rather than according to the autopsy findings. Macleod has therefore written " an advanced text in physiology for those about to enter upon their clinical instruction, and at the same time a review for those of a maturer clinical experience who may de sire to seek the physiological interpretation of diseased conditions." There is a real need for a book of this sort which will emphasize the newer laboratory studies of clinical importance. "Physiology and Biochemistry in Modern Medicine" furnishes an excellent re view of a large mass of work which should be more or less familiar to every physician who pretends to keep up with his profession. Many hours can be profitably spent in skimming over the whole 392 BOOK NOTICES. Vol. XIII. book and reading carefully the more important chapters, especially those which deal with respiration. The medical man will be disappointed in finding the work con tains comparatively few clinical references. The physiologist, in turn, will consider that certain subjects are treated rather sketchily and hastily. The ordinary reader can obtain but little informa tion from the brief discussion of the clinical applications of the electrocardiograph and polygraph. The endocrine organs are treated with reticence. Apparently the authors feel that much nonsence has been written about internal secretions and hesitate to expand on the subject. This is somewhat disappointing because a critical review by such careful workers as Macleod and Pearce would be more than welcome. We must remember that the field covered by this book is vast and that only a portion can be included in 900 pages. On the whole the style is good, the type is clear and the illustrations excellent. (B. F. DuB.) Information fob the tuberculous, by F. W. Wittich, A. if., M. D., in charge, Tuberculosis Dispensary, University of Minnesota Medical School. C. V. Mosby Co., St. Louis, 1918. It is a very dangerous thing to put a medical work into a patient's hands, as he usually lacks the ability to get the proper focus on a topic which so vitally concerns him, and the medical phraseology proves a serious stumbling block. The task of preparing for the tuberculous a special volume free from technicalities and not likely to fasten the sufferer's attention unduly upon his symptoms has been very successfully accomplished by Dr. Wittich, who writes without dogmatism, simply and clearly. The volume is, however, distinctly one for the patient of intelligence, education, and means. Mental diseases, byW. T". Oulick, M. D., Assistant Superintendent, Western State Hospital, Washington. Illustrated. C. V. Mosby Co., St. Louis, 1918. The subtitle of this modest volume of 139 pages is " A Handbook Dealing with Diagnosis and Classification." The book aims to stand ardize nomenclature and classification of mental diseases and to be an outline guide to the study of this branch of medicine. It is dim- cult for the general practitioner to get his bearings in the intricate mazes of the larger and completer workes on mental disease, and for one who desires to begin the study of this subject by a prelimi nary review and to seize only the cardinal points of the principal types of mental alienation it should prove of service. The sub heading would have made a better title than the one chosen, for it is manifestly impossible to present any adequate picture of mental dis eases in a work of this size. No. 2. U. S. MEDICAL SCHOOL LABORATORIES. 393 Dietetics fob nurses, by Fairfax T. Proudfit, former Instructor in Dietetics, Lucy Brinkley Hospital and Baptist Memorial Hospital, Memphis, Tenn. The Mncmillan Co., New York, 1918. Books on this topic should be based on sound scientific principles and yet be thoroughly practical and simple in style. The present volume appears to meet these requirements fully. Section I treats of food and its selection. Section II is entitled : " The Human Ma chine and its Relation to Food." Section III discusses nutrition in disease and includes formulae for infant feeding, the regimen of the obese, etc. U. S. NAVAL MEDICAL SCHOOL LABORATORIES. Additions to the pathological collection. United States Naval Medical School, October, November, December, 1918. Acces sion No. 1552 1555 1557 1558 to 1574 1575 1576 1577 1578 1579 1580 1584 1586 1588 1590 1593 1594 1595 1599 1600 1601 1602 1604 1606 1607 1608 1609 Tissue. Ovarian cyst. . Various organs. do Appendices. Goiter Bladder (cancer).. Kidney - - Caecum and ascending colon (gangrene). Submaxillary calculus. . ....do '. Tumor Testicle Mesentery Ovary and tube Humerus Dog's breast Kidney Diagnosis. Small tumor. . . Lymph glands. Cervix Appendix Breast Lymph glands. . . Epithelial tumors. Breast Lymph glands. . . No report Malaria Tuberculosis. No report .do. .do. .do. .do. ....do ....do Mole, benign Tuberculosis ....do Subacute inflammation. Benign tumor Carcinoma Genito - urinary and nephritis. Adeno-myoma Hodgkin's disease Collected by or received from— Adeno-carcinoma . Appendicitis Carcinoma Lymphangioma. . Carcinoma Myxoma Tuberculosis Lieut. J. J. Mundell. Lieut. T. T. Gately. Capt. L. W. Spratling. Capt. R. Spear. Do. Do. Do. Do. Do. Do. Capt. J. G. Field. Lieut. T. T. Gately. Gulfport, Miss. Capt. R. Spear. Key West, Fla. Lieut. T. T. Gately. Norfolk, Va. Lieut. J. J. Mundell. Lieut. Commdr. L. M. Schmidt. Capt. C S. Butler. Capt. J. D. Gatewood. Do. Capt. C. S. Butler. Do. Paris Island, S. C. Commdr. H. F. Strine. Reports made on all cases, except those sent only for museum collection. 103396—19 15 NOTICE TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing and wide margin 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 letterhead, numbered paragraphs, and needless spacing between paragraphs, all of which require correction before going to press. The Bulletin endeavors to follow a uniform style hi headings and captions, and the editor can be spared much time and trouble and unnecessary errors can be obviated if authors will follow in the above particulars the practice of recent issues. This is not only important in special articles, but still more so in reviews. The greatest accuracy and fullness should be employed in all citations, as it has sometimes been necessary to decline articles otherwise desirable because it was Impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors in orthography in many contributions is conclusive evidence that authors often fail to read over their manuscripts after they have been typwritten. 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 material supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. Only the names of actual reviewers for a current number appear. The Bulletin intends to print only original- articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assumption that they have not appeared previously and arc not to be reprinted elsewhere without an understanding to that effect. 394 o ■ vol. xm NO. 3 UNITED STATES NAVAL MEDICAL BULLETIN INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PUBLICATIONS CAPTAIN J. S. TAYLOR, MEDICAL CORPS, U. S. NAVY IN CHARGE (QUARTERLY) WASHINGTON GOVERNMENT PRINTING OFFICE 1919 PUBLISHED FOR THE 1919 Navy Department, Washington, March 20, 1907. This United States Naval Medical Bulletin is published by direction of the department for the timely information of the Medi cal and Hospital Corps of the Navy. Truman H. Newberry, Acting Secretary. NOTE. Owing to the exhaustion of certain numbers of the Bulletin and the frequent demands from libraries, etc., for copies to complete their flies, the return of any of the following issues will be greatly appreciated : Volume VII, No. 2, April, 1913. Volume X, No. 1, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1917. Volume XII, No. 1, January, 1918. Volume XII, No. 3, July, 1918. Subscription Pbice of the Bulletin. Subscriptions should be sent to Superintendent of Documents, Government Printing OfBce, Washington, D. C. Yearly subscription, beginning January 1, $1; for foreign subscription add 25 cents for postage. Single numbers, domestic, 25 cents; foreign, 31 cents, which Includes foreign postage. Exchange of publications will be extended to medical and scientific organiza tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy, Washing ton, D. C. ii TABLE OF CONTENTS. Page. PREFACE VII SPECIAL ARTICLES : Preventive medicine at training camps and stations. By Captain C. E. Riggs, Medical Corps, U. S. N 395 With marines in France. By Lieutenant F. E. Locy, Medical Corps, U. S. N 41T Bone grafts. By Lieutenant Commander E. M. Foote, Medical Corps, U. S. N. R. F 433 Internal derangements or knee joints. By Lieutenant ( J. G.) C. F. Painter, Medical Corps, U. S. N. R. F_ 442 Clinical manifestations of tropical sprue. By Lieutenant Commander E. J. Wood, Medical Corps, U. S. N. R. F 449 Isolation and cultivation of Pfeiffeb's bacillus. By Lieutenant DeW. G. Rlchey, Medical Corps, U. S. N. R. F 453 Nervous element in aviation. By Lieutenant G. U. Pillmore, Medical Corps, U. S. N 458 Administration of the U. S. hospital ship Solace. By Commander E. E. H. Old, Medical Corps, U. S. N 478 HISTORICAL : Devices and uniforms of the Navy Medical Corps 505 EDITORIAL : The reform of funerals —The apotheosis of dungarees 515 IN MEMORIAM : Henry G. Beyer. By Lieutenant (T.) P. J. Waldner, Medical Corps, U. S. N 521 Washington Berry Grove. By Lieutenant Commander L. M. Schmidt, Medical Corps, TT. S. N_ 522 SUGGESTED DEVICES : Improvised mess tables. By Captain H. C. Curl, Medical Corps, U. S. N 1 525 Apparatus for submersion cases. By Captain G. F. Freeman, Medical Corps, U. S. N 525 Recording dental operations. By Lieutenant W. F. Murdy, Dental Corps, U. S. N 527 CLINICAL NOTES : Rupture of the esophagus. By Lieutenant Commander L. Sheldon, Medical Corps, U. S. N 529 Anthrax cured by vaccine. By Lieutenant (J. G.) J. K. Leasure, Medical Corps, U. S. N. R. F 581 Foreign body in antrum. By Lieutenant J. B. Greene, Medical Corps, U. S. N. R. F 534 m IV CONTENTS. CLINICAL NOTES—Continued. rage. Traumatic rupture of kidney. By Lieutenant Commander P. H. Bowman. Medical Corps, IT. S. N., and Lieutenant Commander H. D. Meeker, Medical Corps, U. S. N. R. F 53G Thrombosis of popliteal vein. By Lieutenant C. A. Frink, Medical Corps, U. S. N. R. F 538 Alopecia Universalis. By Captain A. R. Alfred, Medical Corps, U. S. N 539 Operations for rupture of kidney and spleen. By Lieutenant C. O. Tanner, Medical Corps, U. S. N 539 Traumatic aneurism : Five cases. By Lieutenant Commander F. H. Bowman, Medical Corps, U. S. N.. and Lieutenant Commander H. D. Meeker, Medical Corps, U. S. N. R. F 541 A DEATH FROM 8ALVARSAN. By Lieutenant E. F. Crofutt, Medical Corps, U. S. N. R. F 543 Perforation of Meckel's diverticulum. By Lieutenant W. F. Pearce, Medical Corps, U. S. N 546 Syphiloma of cererrum. By Lieutenants A. W. Hoaglund and P. F. Prioleau, Medical Corps, U. S. N 547 Extra-genital chancre. By Lieutenant Commander C. B. Camerer and Lieutenant J. R. Poppen, Medical Corps, U. S. N 551 Chancre of the thumb. By Lieutenant (J. G.) L. Herman, Medical Corps, U. S. N. R. F_. 553 Typhoid fever with severe complications. ' By Lieutenant F. N. Martin, Medical Corps, U. S. N. R. F 554 Cholangitis followino influenza. By Lieutenant R. S. Reeves, Medical Corps, U. S. N. R. F 557 Diphtheria complicating fractured mandible. By Lieutenant (J. G.) J. B. Goodall, Dental Corps, U. S. N. R. F__ 559 PROGRESS IN MEDICAL SCIENCES : General medicine. —Tests of physical efficiency —Malaria as a mili tary problem —Anthelmintics as tested on earthworms —New treat ment of bichloride poisoning —Corpeus luteum and vomiting of pregnancy 561 Surgery. —Post-operative parotitis —The empyema problem — Skin dis infection by picric acid — Reconstructive surgery of the hand and forearm 573 Pathology, bacteriology, and animal parasitology. — Bacteriology of tuberculous kidneys —Hermann-Perutz reaction — Experiments with virus of grippe 578 Eye, ear, nose, and throat.—Perineural anesthesia for surgery of maxillary sinus —Intraocular pressure and tonometry 5S2 NOTES AND COMMENTS : Transmission of venereal disease may constitute assault — Interde partmental Social Hygiene Board—Sir Charles Wyndham —Har vard surgical unit—Retail druggists and quack remedies — School of Hygiene, Johns Hopkins University — Legal decision re vaccina tion —American merchant marine —Meningococci in blood —Radium conservation —Andre Chantemesse 585 CONTENTS. V REPORTS : The U. S. hospital ship " Comfort." By Captain A. W. Dunbar, Medical Corps, U. S. N. Page. 591 Voyage of the U. S. S. " Leviathan." By Commander F. A. Asserson, Medical Corps, U. S. N 602 Ship life in Constantinople. By Lieutenant Commander E. P. Huff, Medical Corps, U. S. N 605 A record ship. By Lieutenant Commander A. E. Lee, Medical Corps, U. S. N 609 D. S. Naval Aib Station, Patjillao, France. By Lieutenant Commander H. A. Garrison, Medical Corps, U. S. N 611 U. S. Naval Air Station, Rockaway Beach, L. I. By Lieutenant ( J. G. ) A. A. Shadday, Medical Corps, U. S. N. R. F__ 616 Increase of weight under service conditions. By Lieutenant H. Halstead and Lieutenant (J. G.) E. A. Mallon, Medical Corps, U. S. N. R. F 620 Poisoning by trinitrotoluol. By Lieutenant (J. G.) A. Saska, Medical Corps, U. S. N. R. F 624 The marine shoe. By Lieutenant Commander W. L. Mann, Medical Corps, U. S. N__ 625 X-RAY WORK AT A NAVAL HOSPITAL. By Lieutenant C. H. Jennings, Medical Corps, U. S. N. R. F 628 Dental work at the navy yard, New York. By Lieutenant Commander R. Barber, Dental Corps, U. S. N 631 Dental work at the navy yard, Mare Island, Cal. By Lieutenant Commander J. L. Brown, Dental Corps, U. S. N 632 BOOK NOTICES 633 NOTICE TO SERVICE CONTRIBUTORS 635 PREFACE. The publication and issue of a quarterly bulletin by the Bureau of Medicine and Surgery contemplates the timely distribution of such information as is deemed of value to the personnel of the Medical Department of the Navy in the performance of their duties, with the ultimate object that they may continue to advance in proficiency in respect to all of their responsibilities. It is proposed that the Naval Medical Bulletin shall embody matters relating to hygiene, tropical and preventive medicine, pa thology, laboratory suggestions, chemistry and pharmacy, advanced therapeutics, surgery, dentistry, medical department organization for battle, and all other matters of more or less professional interest and importance under the conditions peculiar to the service and pertain ing to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good of the service, out of the experience and observations of the individual. There are many excellent special reports and notes beyond the scope of my annual report being sent in from stations and ships, and by communicating the information they contain (either in their entirety or in part as extracts) throughout the service, not only will they be employed to some purpose as merited but all medical officers will thus be brought into closer professional intercourse and be offered a means to keep abreast of the times. Beviews of advances in medical sciences of special professional interest to the service, as published in foreign and home journals, will be given particular attention. While certain medical officers will regularly contribute to this work, it is urged that all others coop erate by submitting such abstracts from the literature as they may at any time deem appropriate. Information received from all sources will be used, and the bureau extends an invitation to all officers to prepare and forward, with a view to publication, contributions on subjects relating to the profes sion in any of its allied branches. But it is to be understood that the bureau does not necessarily undertake to indorse all views and opinions expressed in these pages. W. C. Braisted, Surgeon General United States Nwy. vn • U. S. NAVAL MEDICAL BULLETIN Vol. XIII. July, 1919. No. 3. SPECIAL ARTICLES. PREVENTIVE MEDICINE AT TRAINING CAMPS AND STATIONS. UNUSUAL OPPORTUNITIES IN THE MILITARY SERVICES FOR THE STUDY OF EPIDEMICS: OUTLINE OF A WORKING PLAN. By C. E. Rioos, Captain, Medical Corps, United States Navy. About two and a half centuries ago Sir Thomas Browne wrote, "Physic is either curative or preventive." This classification of medical knowledge and activities is scarcely made nowadays, and yet it conveniently meets modern needs. It was made a century and a half before Jenner's discovery which marks the beginning of pre ventive medicine, and, of course, centuries after the establishment of the curative branch of medical science. Browne was both a physi cian and a philosopher. He spent much time serenely absorbed in metaphysical speculation on the mysteries of life. It is therefore fitting and to be expected that his division of the medical sciences should be both comprehensive and fundamental and likely to suffice for all time. It is the preventive branch of medicine rather than the curative one that appeals to military interests and actually marks military efficiency. It is no longer proper for the military physician to with hold his activities till disease or injury has reached the threshold of a disabling manifestation. His highest military duties require that he use the special knowledge he has obtained in the study and treatment of past incapacitating disorders to the prevention of their recurrence ; that he surround the soldier with the protection of mod ern sanitary science so that through good health the soldier can con tinue to enjoy his maximum efficiency as a fighting machine. The glamour of surgery has been cast over the duties of the physician in war time; but, as a matter of fact, the work of a surgeon usually begins only after the duty of the soldier is done and he is out of the fight and consequently a military burden. On the other hand, preventive medicine belongs with the healthy, active soldier or sailor. The association begins at the recruiting 395 396 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. office by selecting for the service only those who may be expected to stand the test of military hardships. It continues and is especially watchful during the period of training. This surveillance follows even to the front-line trenches. Besides present military efficiency, a further object is to return the discharged soldier to his home a healthier and stronger man than he was when he enlisted, and also a more valuable citizen to the community. Of course, any means to this desirable end should be encouraged. In the prevention of ill health and in the promotion of good health the military surgeons should use the knowledge they now have —all of it. Furthermore, the excellent opportunities for investigation and research along preventive lines which a military organization affords should be utilized to the fullest possible extent. When the funda mental causes as they relate to disease and injury are better under stood in their relation to known results the fatalism which is now associated with accidents and epidemic visitations will be largely eradicated. " Even accidents, viewed largely, are not isolated causes, but the outcome of events which we can understand and control." 1 Preventive medicine is so new a study that its existence and mean* ing are still unknown to many informed persons. Human psychol ogy has seemed to prefer for our ills curative and remedial agencies rather than prevention. As an act of public caution quarantine is more familiar than medical inspections, and appeals for the support of hospitals and sanitaria are still more urgent and general than demands for the spread of knowledge of the rudiments of sanitation. It has not yet been properly understood that the manifestation of disease is a last call, not a first call, to action.2 A new viewpoint should be acquired. It is preferable to recognize that disease is a terminal condition which has been brought about by the occurrence of one or, perhaps, a considerable number of preced ing events. These events, in most instances, lie within the very recent past and a proper analysis of them, if it were possible to make it, would demonstrate the actual incident by means of which they were brought about. It is safe to assume that a specific knowledge of the usual mechanism of a particular infection would be followed by the solution of the problem of avoiding it. Unfortunately, with most persons the happenings of the predisease period are marked with considerable complexity. Many difficulties are encountered in attempting to ascertain from the infected person the source and mode of his infection. Memories are particularly short for the smaller incidents of everyday life and events are crowded. Also, the amount of variability in the period of incubation of a dis ease gives just that same degree of latitude as to the time of infection. i Cooley : Social Progress. New York, 1918. p. 165. ' King : Industry and Humanity. Boston and New York, 1918. p. 356. No. 3. 397 PREVENTIVE MEDICINE AT TRAINING CAMPS. It is rare that circumstances are such that the time and method of infection may be actually demonstrated. But when these instances do occur they should be carefully recorded, as they are likely to throw useful light upon practical means for avoiding the disease. The newer science of preventive medicine is more dependent upon the causes of disease than is the curative one. It requires a study of that period of time prior to the oiiset of disease and of sufficient remoteness to include the causal incidents. In making this study medical science has found itself in some new and unexpected relation ships with other branches of science. For instance, former Surgeon General Gorgas has pointed out that low or high wages have an im portant bearing upon the health of a community; that a poor eco nomic situation is reflected in a low state of public health. Also epidemiology is intimately associated with sociology. Practically all germ diseases come under the head of " social diseases," as they are disseminated through physical or social contact of men with each other, and hence spread most widely and rapidly where social rela tionships are closest.1 This broadening of the scope of preventive medicine by the neces sary inclusion of parts of other interdependent sciences tends to com plicate its study. The cause of the spread of an epidemic is often so completely hidden in a complexity of economic, sociologic and other related factors that it is impossible to unravel. Opportunities for the observation of an unobscured phase of an epidemic are rare. Where they have occurred they have generally added to our knowledge of the epidemiology of the disease. For instance, the first introduc tion of measles among the inhabitants of the Faroe Islands was so helpful in determining the period of incubation of this disease that the incident now has historical importance. Simplicity of situation, in particular as manifested by uniformity of the activities of indi viduals composing a community, is a very desirable condition when carrying out research work in the cause and prevention of disease. The military services excel in this respect as compared to civil com munities, and, therefore, offer practically unequaled opportunities for students of preventive medicine. When a group of men is assembled under military control, such as that existing at a training camp, for instance, they present a greater uniformity of physical and social conditions than can be obtained in any other community. The reason for the presence of this uniformity is, of course, the singleness of purpose of a military organization. The different ways in which its results are manifested in the behavior of the individual are so numerous as to be almost incalculable. Such factors pertaining to social conditions as age, sex, and occupation may 1 Fatrchlld : Applied Sociology. New York, ]916. p. 245. 398 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. for practical purposes be considered as reduced to single components. There is uniformity of housing, food, drink, clothing, exercise, work, and play. Also, there are for all the same environment, discipline, routine, and drills which have a strong tendency to mold to a likeness all activities of the individuals who compose ths organization. Another feature of military camps is the marked concentration of individuals that it is necessary to have in order to satisfy military requirements. This concentration is so great that it frequently amounts to five times that obtaining in the worst civilian rookery.1 This increased density of population naturally increases the intensity of human intercourse. Therefore, a military camp exhibits not only an intensity of physical and social relationships on the part of the individuals therein, but also those relationships are fixed and unvary ing as compared to those met with in civil communities. These comparatively fixed physical and social conditions of a mili tary organization can be utilized to great advantage for the study of the methods of transmission of the acute infectious diseases. Given the presence of an epidemic disease its further transmissibility is prob ably more dependent upon the social comminglings of its locality than upon all other attributes that may be present. In fact, modern prac tice for the control of infectious disease consists not in the physical surveillance of whole communities, but in the sociological study of infected persons in them.2 In other words, an epidemiological study in any community is fundamentally mingled with the applied sociol ogy of that community. A study of the means of spreading of a germ disease in any location requires a considerable acquaintance with the sociological conditions with which the disease is coexistent. This modern conception of epidemiology has been made possible only by means of the knowledge obtained through the new and wonderful science of bacteriology. It is only a few years since this science was little more than a " germ theory of disease." Yet nowadays one does not stop to think that bacteria have an essential influence upon all forms of living matter and that life upon our earth is actually dependent upon the continued activities of these tiniest living things. It is not to be wondered at that the science of bacteriology has been the great reconstructing force in pre ventive medicine. Credit for the correct application of bacteriology to the problems of infection is largely due to Chapin and to others who sat at the feet of Chapin. His " Sources and Modes of Infection ' marks the real beginning of scientific public health in America. The great value of Chapin's work to public health consisted in the new methods which he applied to the study of the means of trans mission of the communicable diseases. These methods, through keen 1 Lelean : Sanitation in War. London, 1917. p. 96. • Hill : The New Public Health. New York, 1916. p. 77. No. 3. 399 PREVENTIVE MEDICINE AT TRAINING CAMPS. analysis, gave new and admittedly correct values to many of the different factors that promote or retard the processes of infection. As a result several theories that were based largely upon the germ theory of disease in its early stages had to be abandoned. For instance, the air-borne theory, which seems to have been a combi nation of bacteriology and demonology, was no longer applicable in explaining epidemics. The supposed efficacy of terminal fumiga tions did not stand the test of critical analysis. When these and other theories of infective processes were no longer workable it be came necessary to find substitutes. The epidemiologist assumed this task and he has already made considerable progress. He has found that the field is broader than it was in the early bacterial days. He is endeavoring to answer the question as to when, where, from what source and by what means did the recently infected individual receive the germs causing his disease. The reward sought is great, for it seems safe to assume that when these processes are understood the menace of acute infections will be practically destroyed. The path of the progress of science is paved with abandoned theories. These theories were for the most part abandoned because in the light of present knowledge they are absurd; some on account of newly discovered facts, no longer serve even the purpose of theories.1 A theory has been defined as an explanation founded upon inference drawn from principles which are established by evi dence. This definition of theory gives emphasis to* the first impor tance of evidence. In epidemiology, opportunities for collecting evi dence are to be found only in field work. If anything of value is to bo discovered it is to be expected that it must be done by those whose duties are in the midst of epidemic devastations. They, so to speak, are on the firing line, or to use a more up-to-date term, in the trenches. Particularly advantageously placed are those who are engaged at training camps among the well and the sick before hospitalization takes place. This constitutes the zone where infective processes are actually operating before one's eyes. In such places the collecting of data should be most rigid. Any medical officer who has had the golden opportunity of watching the course of one of the infectious diseases at a training camp and, in the end, has nothing new to add to the knowledge of preventive measures can well afford to " count that day lost," for the sun has set upon his opportunity. The achieve ments made by Lynch and Gumming,2 and Rossiter, during the recent influenza epidemic, in attempting to solve the problem of the trans mission of infection as they found it in their respective units, strik ingly demonstrate the assistance afforded by the definiteness and ]I>ay: Man's Unconscious Conflict, p. 51. •Lynch and Cummlng: The Role of the Hand in the Distribution of the Influenza Virus, etc. Military SurKeon, December, 1918. 400 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. simplicity of a military organization for the carrying out of re search work in preventative medicine. It goes without saying that every military organization should have some relatively definite plan to study and to control the progress of any epidemic disease that may appear among its personnel. Such a plan for the acute infectious diseases may be conveniently viewed in two general aspects —the sociological and the bacteriological. The sociological side will depend largely upon local conditions as they exist in the military organization and have lo do with the social relationships of men with each other. Here local conditions vary considerably and are created by the purpose and function of the group of men under consideration. A receiving ship, on account of its continuously changing personnel and comparatively unfixed or ganization, offers almost the same difficulties in tracing a source of infection as are met with in civil communities. On the other hand, ideal conditions are to be found among a group of men in a permanent camp or barracks having a fixed organization and few changes in personnel. Whatever the organization and its purpose may be, it is incumbent upon the medical officer to be conversant with it, so that he may intelligently act immediately upon the incipiency of an epidemic. The classification of the bacterial aspect of an epidemic situation is based largely upon the available knowledge concerning the known germs of infection. Unfortunately, the bacteriology of the seven prominent camp diseases—measles, mumps, influenza, tonsillitis, diph theria, scarlet fever, and cerebro-spinal fever— is not fully understood. For measles, mumps, and scarlet fever it is practically nil, and for the four other diseases it has a wide range of completeness. On account of this lack of knowledge any plan for opposing the bacterial forces of disease during an epidemic can not be marked by a high degree of definiteness. But some plan or classification is desirable, even though it have no further merit than to state the order of the oc curring of events. The plan to be submitted here attempts to take up the bacteria at their original source and to follow them through out till their final destruction by disinfection. It may be roughly classified as follows: I. Location of the germs before Infection takes place. 1. Aside from the human host. (a) Fomites borne Infection. (6) Air-borne infection. (c) Food and drink borne infection. (d) Insect-borne Infection. 2. Within the human host. (a) Recognized cases. (6) Missed cases. (c) Carriers. (d) Latency. No. 3. PREVENTIVE MEDICINE AT TRAINING CAMPS. 401 II. Method of transmission of germs. 1. Direct contact. 2. Indirect contact. III. Germs subsequent to time of infection. 1. Period of incubation. 2. Earliest symptoms. IV. Methods for control of epidemics. 1. Isolation. 2. Disinfection. The theory of infection by fomites such as toys, books, or clothing was practically demolished upon the appearance of Chapin's classical work in 1910. It is singular that only a few years past yellow fever furnished what seemed to be the strongest support for the fomites theory in the transmission of disease. Now newly discovered evi dence has shown that fomites will not transmit this infection, and the actual method of transmission by means of the mosquito has been established beyond cavil. The fomites theory was no longer tenable when it became understood that bacteria aside from their normal host are extremely short lived. In other words, the real danger con sists in contact with persons, not things. The theory, however, can still serve a useful purpose in the warning that frequently associa tion has been mistaken for causation. The air-borne theory of infection has been discarded even more remotely than the fomites theory. It is an interesting fact that from time immemorial, the air as a causative agent has appealed to the imagination of those who have attempted to explain natural phe nomena. The air served primitive man as an instrumentality for the greater number of his few beliefs. With the exhalation of his last breath his soul was thought to depart from him.1 His demons were resident in storms, solitary chasms and other uncanny places. The evil spirits supposed to cause sickness and other ills were of various kinds, and each class appears to have had its special function. Some clearly represented shades of the departed, who return to earth to plague the living; others are personifications of disease.2 It is not to be wondered at that in the beginning scientific men accepted the air to explain the contagion they only imperfectly understood. There is more cause for amazement in the fact that the superstitious be liefs of primtive man should so closely conform to the findings of modern science. Indeed, primitive demonology has been repeatedly associated with modern bacteriology by the ethnologist as a parallel etiological concept.8 Nowadays the former belief that the air was the habitation of agents which had the power to injure man's physi cal welfare forms a fascinating study, if not a practical one. 1 Wundt : Elements of Folk Psychology. New York, 1916. p. 192. * Jaatrow, quoted In The Scientific Monthly. Vol. 4, No. 6. p. 505. • Wright : " Demonology and bacteriology in medicine." The Scientific Monthly. Vol. 4, No. 6. p. 494. ■ 402 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. XIII. Food and drink are now considered less important factors as car riers of infections than formerly. At the time of the beginnings of bacteriology there were a few striking demonstrations of the spread of disease through the medium of drinking water. Among such instances were the Broad Street well in London, which became in fected and caused the dissemination of cholera, and the North Boston well, which was instrumental in spreading typhoid fever. These and other spectacular instances led to unwarranted generalizations giv ing undue importance to drinking water in the spread of disease. Of course, good food is of great importance in maintaining the health and contentment of a command. But food and drink are spoken of here only as carriers of infection. Naturally any medical officer of experience is able to recall several occasions when food or drink has caused outbreaks of sickness. Since the time when typhoid fever was stricken from the list of military diseases these outbreaks are important only for the moment and immediately disappear with the removal of the cause. Recently, at a training station there was a severe outbreak of so-called ptomaine poisoning involving several hundred men, or more than a third of the command. By question ing the sick and the well as to whether they did or did not eat of the different dishes of the menu it was easily demonstrated that the ice cream was the contaminated article of food. This was confirmed when the ice-cream factory was inspected and found to be very in sanitary. Another instance of an acute outbreak which might have been considered as caused by food or drink was witnessed on board ship. This was the complete subsidence in a tropical climate of an epidemic of about 40 cases of tonsillitis, which subsidence was coinci dent with the thorough cleansing of the ship's scuttle butts and fre quent sterilization by boiling of their drinking-fountain cups. If this were not a mere coincidence, it is likely that the epidemic was kept alivo by contaminated drinking-fountain cups. In such case it should be considered as an instance of indirect contact infection and not as caused by food or drink. The point to be made of these in stances is that in the military services food and drink infections form a factor of relatively little importance. Insects may transmit disease as biological carriers or they may do so by acting in a merely mechanical manner. Malaria, yellow fever, typhus, and plague are instances of insect-borne diseases of which it is generally believed the insect acts as a true biological carrier. The role of the house fly in the spread of typhoid fever is an instance of the mechanical transmission of germs. That insects could transmit infections has been known to science for only a comparatively brief period of time. Yet a record was recently made of 226 organisms of disease that could be transmitted by insects to man or animals. Two hundred and eighty-two species of insects were recorded as capable of disseminating the 226 infections. Notwithstanding the great de No. 3. 403 PREVENTIVE MEDICINE AT TRAINING CAMPS. velopment of the subject, Dr. Howard declares that there is a dan gerous tendency to exaggerate the importance of insect transmission as compared to other modes of infection. In the military services, aside from special circumstances such as duty in the Tropics, for instance, the number of infections caused by insects is insignificant. The recognized or known cases of an epidemic form that part which is directly visible and tangible. They are practically the only means that define the epidemic in size, location, and progress. It is estimated that recognized cases form not more than half the total sources of infection.1 The percentage varies, of course, for different diseases and probably for different epidemics of the same disease. For instance, the percentage of known cases is relatively high in an epidemic of measles ; at the other extreme, it is so low in cerebro-spinal fever as to present the curious anomaly in which a contagious disease appears to be contracted from the well instead of the sick. Other things being equal, it is naturally easier to deal with an epidemic if the percentage of recognized cases is high, or, in other words, if a greater number of the sources of infection is known. Known cases are the basic points in epidemiology and every endeavor should be made to ferret ouj; and convert unknown into known cases. Also, an accurate statistical record of the epidemiological data of each case, and of the doubtful cases as well, should be made upon prepared forms. As this information is being compiled it should be carefully studied not only for the immediate needs in controlling the epidemic, but to "throw invaluable light upon the problems of preventive medicine and guide us in our preparation for the next great conflict." 2 Lelean recommends an elaborate blank form for the purpose of collecting epidemiological data from those who have just been stricken with an infection. This form asks for information upon more than 40 items. If so extensive a blank form is used it re quires considerable training to properly fill it out. At our training stations it is more satisfactory to use a simpler form that can be placed in the hands of a hospital corpsman for execution. A form that was recently satisfactorily used at one of our training stations asked for information concerning each epidemic disease that ap peared, as follows: Name - Rate Date Diagnosis Camp Street Bungalow No Company School section Date taken sick Date isolated Date of appearance of rash Source of infection Names of exposed 1 Hill : The New Public Health. New York, 1916. p. 93. * Lelean : Sanitation In war. London, 1917. p. 106. 116025—19 2 404 PREVENTIVE MEDICINE AT TRAINING CAMPS. Vol. …