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L VOL. XI N0.4 UNITED ST A TES NAVAL MEDICAL BULLETIN PUBLISHD FOR THE INFORMATIO~ OF THE MP.DICAL DEPAR"I Mt NT OF THE SERVICE !'\SUED BY THE BUREAU OF .\\EDICINE AND SURGERY 1'AVY DEPARTMt::\T OIVISIOS OF PURl.l\.ATIONS MF.()ICAI 1:-.;sPFCTOR J. S. TAYLOR, l'. S NAVY I" CHARGE OCTOBER, 1917 ( Ql.'ARTERLY) WASHl!o!GTON GOVFRN.\IEST PRISTING OFFIC.F. 1917 VOL. XI N0. 4 UNITED STATES NAVAL MEDICAL BULLETIN PUBLISHED FOR THE INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY TllE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF PUBLICATIONS MEDICAL !!\SPECTOR J . S. T AYLOR, U. S. NAVY IN CHARGE OCTOBER, I 9 17 (Q!JARTERLY ) W ASHINGT ON GOVJ::RNMENT PRINTING OFFICE 1n 1 ~AVY DEP.\RT){F.:'\T, Tl'ashington, March idO, 1907 . . Thi~ l.JxrrJ::o S1'ATES NAVAL MEm;-AL Bm,LETIN is published hy direction of the depnrtment for the timely information of the .Medi- cal nnd Hospital Corps of the X a:vy. TRU:\IAN H. NEWBEitnY. Acting Sec:retary. NOTE. Owlni? to the ex11aust 1on of certain number>< of the BuLu;nN nncl the fnqa<> 1t dem:rnds from libraries, etC'., for copies to complete their file.~. the retnrn of um· ot tlie following issues will be greatly appreclntE>tl: • Yolume I. Xo. 1, April, 1007. Yolurue. I, No. 2 .. Jul~·. 1907. Yolumc I, No. 3, October, 1907. Yolume II, No. 1, ,Jnnunr.1•, 1908. Yolume II, No. 2, April, 1908. Volume IV, No. 2, April, 1910. Volume IV, No. 3, July, 1910. Volume VI, No. 3, July, 1912. Volume \II, No. 3, July, 1913. Volume VIII, No. 3, July, 1914. SvnscmJ?TION PRICE OJ•' THE But.r.B'rIN. Suhsl.!rlptiom; shoultl Ile sent to Super!nteutlent of Documents, Gowrnment Prlntlt.g Office, Washington, D. C. Yem·J~· subscription, heglnning Jnnuary 1, $1; for foreign subscription nu 1 !!a •·tmh for postage. ~ln:!1e number", dome.~tlc, !!3 c<>nts; fore:gn, 31 cent~. wltlch lnclutles forelen JIOslnge . • Exchnngc of publications will be extended to me<llcn.l anti !;dentiflc Ol'gaulzn· tions, societies, luborntorles, nntl journal;;, Communicnt!ous on this subject shouhl be nddrcssecl to the Sur~enn GenPr:tl, Unit1'<l State~ NnYy, Wnc:hlni.1011, D. C' u TABLE OF CONTENTS. l'llre. PREFACE.......... ............................................... .. ... v FRO XTISPIECE: Yr1:w or CIIA.RLOTI'E AMALIE, ST. THOMAS, VIRGIN IsLANDs OFTHB U.srrEo gTATES. sPEGIAL ARTICLES: T uef:RCULOSIS AND MILITARY ORGANIZATION. Dy Dr. Arnold C. Klebe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 439 0IAO:SOSIB AND PROGNOSIS IN CARDIOVASCULAR RENAL OISEASE. By ~urgeon Ilobart A. Hare, U. S. N. R. F. . . . . . . . . . . . . . . . . . . . . . . . 459 gOllE nns·r IMPRESSIONS OF TIIE VffiGIN ISLANDS. By Surgeon C. S. Butler, U. S. N., and Assistant Surgeon E. G. Ro.ka11BSon, U.S. N....... ... . .. . .. .. .. . .. . . . .. . . ... ... . .. .... .. 465 THE TRAISLSO CAMP, SECOND NA.VAL DISTRICT. Uy Medico.l Inspector D. N. Carpenter, U.S. N. ................... 4i5 TEllPORARY BARRACKS AT CITY PARK, BROOKLYN, N . Y . Ry Surgeon W. S. Pugh, U.S. N., and Assistant Surgeon R. Jansen, U.S.N ......... .. .. . ........... .. . .............. . . .... ......... '479 0RGA:SIZATION OF NAVAL MEDICAL CORPS, SIXTH NAVAL DISTRICT. Dy As..'li.stantSurgeon G. W. Calver, U.S. N........... .............. 49i Tt1E PRESENT STATUS OF CEREBRO·SPLSAL FE\"ER. Dy f\urgeon H. S. Cumming, U. S. Public Hoa.Ith Service........... 504 SY~TEM U. HANDLING DENTAL PATIENTS ABOARD SHIP. lly Dental Surgeon R. Barber, U.S. N.... ... ....................... 515 llAlllUM·FORYALIN DISINFEC'fION. Dy Medical Director R. P. Crandall, U . S. ~. . . . . . . . . . . . . . . . . . . . . . . 1>19 HISTORICAL: OSWALDO CRUZ1 1872-l!ll7. By \Villiam C. Wells.................................. . .... ... . .... 521 EDITOHIAJ,: Tue lllXOR AlLMESTS...... .............. ...................................... .. {l27 :5UGGE~TED DEVICES: .-\ CO~V f:~U:~T DEVICE FOR TESTING VISION. By Assistant Surgeon W. S. Thomas, Medical Reserve Corps, U.S. X. i33 A .~lloll!LffIED EYg·TEST!NO CASE. Dy Passed Assistant Surgeon R. B. Henry, U.S. X. ... . . . . • . . . . . . . . . .:;33 T:nE YOTOR·OPERAT!NO FIEI,D THEATRE. By Assistant Surgeon E. K. Tullidge, U.S . ~...................... ii:» i"'Ll~IOA L NOTES: ,\ DIUTU FROlt SUARK Bin:. Uy Assistant Surgeon P. F. Prioleau, U. S. N....... . ............... .>3!1 DEn\1.\TJ'rIS l•ltOM MATCHES CAURIED IN THE POCKET. Dy Passed Assistant Surgeon W. E. Eaton, U. S. N................ ... 640 AMO!i.UIASIS WITH CONSTIJ'A1'ION. Dy Passed Assistant Surgeons E. A. Vickery and J. J. A .. McMullin, U.S. N.... . .. .. ......... . ..................................... 540 II I JV CO~TENTS. CLIXICAL XOTES-Continucd. ~fULTIPLE O\TX. UOT WOU:'\D!" PROll DEFLECTED BULl.l.°T"· By Pa.'\Se<l Assistant Surgeon W .• \. Bloedorn. U.S. X .....•.•....•.. • \ llULTILOCUL.\R CYST rs HERS LU. ~ \C. Dy Pa scd .\,....j_otJLnt Surgeon W. L. ~Iann, U. S. X .. and .\!!<!istant Surgeon F. J •. Conklin, U. S. X .......•.......................... h!P!;R)l&.rnu: DRESSIXGS FOR Bl:RNS. Bv Passed Assi~tant Surgeon J. J .. \. )fcllullin, U. S. N ........... . .\. !4E :·:r• D OF LOCATI»G BULLETS BY THE X·ItAY. Ry Dr. Sinclair Tousey ..... .....................................•.. PROGHESS IN MEDICAL SCIENCES: GEsERAL MEDIOL'IE.-Latent tuberculosis and military preparation.- Prevention and cure of lobar pneu.monia.-Perlcche.-Arrest of ccrehru- spinal meningitis in wartime.-New treatment of bronchial asthma ... . Sunoc1tY.-Amputation of stumps.-Limits of bleeding ................ . UYOTENE AND SANITATION.-Sterilization of drinking water.-Prevention of pediculosis.-Food ration of the Italian Navy ..................... . HEPORTS: REPORT OF 112 OASES OF CEREURO·SPINAL FEVER. lly Pu.ssed Assistant Surgeon J. T. ~Iiller, U. S. N., and Assistant Surgeon D. D. Martin, U.S. N .................................. . SPL'IAL IRR!OATIONS L'I EPlDf}MIC ?.U:NIN(}ITIS. By Passed .\ssietant Surgeon J. J. O'.llalley, U.S. N . .. ............ . S.\NITARY WORK .\T CAPE llAITIEN. By Passed Assistant Surgeon R. li. Henry, U. S. N.................. 5i5 X-n.\Y PI<"Tt;rtFR OP WAR rnronrns. By Assistant Surgeon E. K. Tullidge, U. S. N...................... 5i!* Cl\'IL UOSI'ITALS ASD OTHER AIDS IN REORUITINO. By Surgeon W. G. Farwell, U. S. N ., and Assistant Surgeon E. W. Gould, U.S. N. R. F... . . . .... .... ..... ... . ... . . . . . . . . . . . . . . . . .. . 580 VENDREAL PROPHYLAX IS IN SANTO DOMINGO. By Passed Assistant Surgeon P. E. Garrison, U. S. N................ 5 3 .\uOITIONAL BORDER·l,INE CASES AT TUE RECRUI1'lNO OPFICE. By Surgeon W. G. Far,vell, U. S. N., and Assistant Sul'geon E. F . Du 13ois, U.S. N. R. F.......... .... .. . ... .. ........ ........ . ... 584 JlOR TUE IIOSPITAI. CORPS: ECONOMY IN SUROICAL DRESSINGS..................................... 5S5 LIN'EN AND DLANKETS L'i NAV.H HOSPITALS. By Chief Nur'e Sara B. Myer, U.S. N........... .. .. . . . . . . . . . . . . .. SSS faSUES DY SUPPLY DEPOTS.... .. ............... . ...................... 590 Tiu:: ROUOII FOR:lr t' CARD. By Passed Asfilatant Surgeon J. R. Phelps, U.S. N.................. 590 l~DEX.................. .. ......... .. ........... .. ................ . .. .. 'i93 PREFACE. The publication and issue of a quarterly bulletin by the Bureau of :Mediciue vncl Surgery contemplates the timely cli~lribution of such information as is deemed of value lo the personnel of the :Medical Depnrtment of the Navy in the performance of their duties and with the ultimate object that they may continue to advance in proficiency in n'-o;pect to all of their responsibilities. It is proposed that the NAVAL ~IEnroAL BULLETIN shall embou.r m:tttl'rs relating to hygiene, tropical and preventive medicine. pathol- ogy, laboratory suggestions, chemistry and pharmacy, advanced therapeutics, surgery, dentistry, medical departmeut organization for battle, and all other matters of more or less professional intere;,t nml importance under the conditions peculiar to the service and pertuining to the physical welfare of the naval personnel. It is believed that the corps as a whole should profit, to the good of the !"•>rvice, out of the experience and observations of the individual. There are many excellent special reports and notes beyond the scope of rn~ annual report being sent in from stations and ships, and by communicating the information they contain (either in their entire'y or in part as extracts) throughout the serYicc, not only will th£'y he emplowd to some purpose n5 merited but all meclic<ll ofiicer::; will thu::. be brought into closer professional intercourse nnd be otrer<'d n means to keep abreast of the times. Rtn iews of ndrnnces in medical sciences of special profcssionnl interrst to the service, as published in foreign and home journnls. will be gi,·en particular attention. 1Vhile certnin medical officers will regularly contribute to this work, it is urged that nll others cooperate by :::ubmitting such abstracts from the literature as they ma.v at any time deem appropriate. Information received from all sources will be used, llnd the bureau extends an invitation to all officers to prepare and forwnrd, with a 'iew to publication, contributions on subjects relating to the pro- fession in any of its allied brunches. But it is to be nnderstoo1l that the bureau does not necessarily undertake to inclorse all views nnd opinions expressed in these pages. W. C. llr:.\IS'l'ED. Surgeon General, United Statc8 iYa1'!I· v l ( " ::. " 1:m lJ. S. NAVAL MEDICAL BUIJLETIN. ___ .._ - VoL. XI. OCTOBER, 1917. No. 4. SPECIAL ARTICLES. TUBERCULOSIS AND MILITARY ORGANIZATION. By Dr. Aosor.o C. KLEOS, Wnahlnglon, D. C. Whether the organization of the new Army and Navy is an ctncrgency measure destined to meet a temporary urgency or whether it is the beginning of a permanent policy toward an efficient organi- zation of the physical resources in the entire popul!ltion for future e111ergencies are questions foremost in the minds of a great many people. The decision will have to come soon. "Wbate>er it mt"ty be there can be no question that the feeling for determined action has heen aroused l1nd that the conviction gains adherents daily that measures in order to be effective require careful and unimpassioned consideration, expert and systematic application by agencies which prnctically have to be created. It is the time for tremendous oppor- tuuities to take the right or the wrong path. That the problems of physical fitness and health are bound to attract painstaking attention will hardly need emphasis if it were not for the well-known tendency to give the questions involved a secondary consideration. The time, however, is bound to come when the medical services will have to shoulder the heaviest responsibilities. Thanks to a persistent propaganda the problem which tuberculosis presents to civilized populations has been kept in the foreground of the public interest in health matters. The antituberculosis movement in this country, very active and ably managed, has come to cover p1 :1ctically every phase of modern life which directly or indirectly is thought capable of making new victims of the disease. Its >igorous advocacy of measures of personal and public hygiene has had already visible success, especially the bad habit of indiscriminate spitting has been restrained nnd fresh air has lost some of its terrors to those formerly apprehensive. That its success is also measurable spe- cifically by an effect on the death rate, is an opinion which some maintain by a persuasive display of figures held to be unconvincing by others. The latter argue with equal plausibility that death rate 439 440 KLEBS--TUBERCULOSIS. '\'ot. ::n., from a given cause is no reliable index of public health bee . does not appraise. or only inadequately, the cnu:-:es of ~hysi:l~ •t ficiencies during life, and also because it is computed from fi e.. who:,,e vnriations are influenced by many uncontrollable f;:res (especially lacking uniformity and standards of the pntholog·o~ nomenclature). But even if the success of the movement is '.:\ accurately determinable by vital statistics it undoubtedly constitut one of the most potent influences in the promotion of henlthv lhin es conditions in a wide sphere which is constantly widened fu;ther b; cooperation with other agencies. Like every campaign, this one against tuberculo:-is hal' to lune its formula, its platform. This is naturally based on the :::cicntific con- cepts of the day, but not always applied in the ~pirit of true sCJence, which furnishes only approximations, contin11011sly subject to reYision. It brings out the salient features: emph:u;ize them, :m<l even overstates them. In our age such a propaga111l11 se<>m~ to be needed for the success of public mensurcs; be th<'y suffrage. prohihi- tion, or nntituberrulo."is. Its comitc-rprrt is arherti emcnt in budi- ne.ss. 'Vaste of energy and money. false i<le:1s ~omdimes, are the by- eft'C'cts of such methods, but it is a curious fact that on the whole they nre W"ll balanced and of indubitable utility. Its danger. if of such we can speak, is that its undue emphnsis o · onr:,iatement of factors and conditions influencing the disease may find hlin1l ac- ceptance among those whose grave responsibilitieR rlC'mancl an un- biased and critical attitude toward all questions. It. is the ol<l dnnger that threatens sound judgment by deductions from do~ma. And it can hnrdly be denied that the tenets of the antituberculo:sis move- ment have assumed the nature of a dogma; i. c., a.n overmastering sentiment which hns found expression in a formnla. 1 But let ns examine the formula itself. Tubercul<>:- is is a ,·ery prernlent <lisense caused by a well-known microorganism. It is communicable from man to man, rnrely from nnimal to man. The cause being known nnd determinable, it can be destroyed nn<l the clisense prevented. When infection has taken place it can be ascer- tained by expert examination of the patient and the dise11se arrested or cured if in its incipiency. If not discovered and properly <'ared for. the disease is extremely dangerous, almost fatal. Its preva- lence in general, its marked predilection for the young and ,·igorous. its insidiousness, chronicity, disabling, and therefore pauperizing power, and especially its infectiousness mark the disease as n Eocial problem of prime importance. But it can be prevented and stamped out by special well-tried measures. This is a fact shown by the 1 This definition of dogmn IR from the recent work by the l!'rPnch academician, Emilt' Faguet: The cult ot Incompetence (N. Y., Dutton & Co., 101!1). Its peru~al can be warmly recommended to everyone Interested In questions ot government. KLEBS--TU.BERCULOSIS. 441 declining dcnth 1:1te from the di .... ease wherc,·er the measures ha'e been applif'tl. 'fhis formula cont:iin:-. a dl'nr-cut propo:,ition an<l u warning at the s.ime f me to the n~::;pon~ible bea<l::- of nny ~ocial conmumity and at this moment particul.1rly to those of the new .\.rrny and .·a\'y. In plni11 wunh it :,ays: '· Disqualify from service eYeryone found rnber- culotb or suspect by an expert; apply the well-tried measure:-. of prl'Hntion. If then tuberculosis occurs, the responsibility will clearly foll on yourself." Herman M. Biggs 1 places the re::;ponsi- bilitv for the present appalling tuberculosis situation in France un- t:'(!lli~·ocally on the nl'gligence of the responsible military nntl civil nuthoritic::;. 1£ the responsibility can be plnced tts l\Ccuratcly as Higgs thinks it can, those re::;pon::;ible for the health in our Xavy. for instance, hacl better take notice, for their statistic~ i;how n Yery rnuch higher incidence of tuberculosis than that in the principal Europru.n 1mvies,2 and one can hardly expect the ratio to dt>crease in ncttral war conditions. Since the warning in the antituberculosic; formula i:; largely based on the infectiousness of the disease, we can not hut recall the dismal experience the Army has had with an- other idectious disease during the Spanish-American 'Var. There :!0,000 :-oldiers, or about 1 in G of the Army in the South, although they ne er saw hostilities, became infected with typhoid fewr, a higher r,ltio of incidence than that in the British Army in active sen·ice (luring the South African \Var (1 in 9). It was the opinion then of many authoriti~s that proper camp sanitation and hygiene ou~ht to haYe prevented the calamity. 'fhe chief representative of the antituberculosis movement, the X ational Association for the Study and Prevention of Tuberculosis, hns lately been requested to appoint a committee which in cooperation with the War and Na ''Y Departments and with the antituberculosis aJ!<:'ncics of the country was to devise and execute a war program for tlw :)1 eYeution irncl control of tuberculosis. This progrnm 1 i~ before u.,;; it elaborates for the special purpose in view the formula outlined aboYe. It concerns itself: (1) With recruiting examinations, (~) with reexaminations during service, (3) with the treatment of incitlenbl cases in the sen·ice, and (4) with their clispo. ·11 after treatment. The greatest stress is placed. on (1) and (2), the com- mittee being of the opinion "that any mun with even a V('ry limited 1 A war tub\>rrulosl11 program for the Nation. The Amcrlcno Review for Tuben·uloels. naltlmorc, llll 7, I, 2118-:!0G. 1 For tbe lhe yenra ending with 1906, Inclusive, the morbitllty per tbousaud men wn!< the followlni:: Oermnu Nnvy, 2.4; English Navy, ::.2; UnltPd StutNI Nnvy, :i.6. !'lee G. II. Butwr: •rb<> lnchlencc of tuberculosis In the Navy, etc., :'\AVAL MEDICAL Rt:I.Lt.'TIN, lOli, xi, :!90. 442 KLEBS-TUBERCULOSIS. v :at!' amount of pulmonary tuberculosis that is latent or arrest<:-d is al certain to break down under the physical strain of military t .ln_Olt and army life and u focus of dise:1se prl!Yiously Inteut 0~ rauung ·11 l . l be . ,. Tl . n rrest~ w1 1 a. mo:stbcertadm y cdomb e .actn e. 1 . i~ com1111ttee does not Ftate w int is to e un erstoo y ·a very nu h. l ~.mount of pulmo tuberculosis that is latent or arrested ,, and ": focus of disl'a e llary viously latent o~· ~1:reste~,,, that "almost certainly·· ,, ill ll'll:r;~ trouble. The ummtrntecl 1s not supposed to grn:-p the iutricaC'i f a cla~ification to which an excessiYe craving for mnthl'matical 0° curacy in things biological or pathological has drin'H the speciali ~ Therefore in tl.rn program no disqualifyi~g ~onditi ons are mention£><! ~s such, only 1t .recommends th~t exammations !'l 1c uld be made by •· Yoluntary qualified experts,, m the case of e\ ery cn11clhl11te for servico who (1) has a history of illness possibly t.nherl'ulou::;, or (~ ) of p11eumoni11 or pleurisy, or who (3) had pulmonary tuherculosis in his immediate family. or (4) has a flat chest and is 1.-> per cent under- weight, or (5) has a history of chronic catarrh, or n cough or nny symptoms of chest disease, or (6) has abnormal physical signs of any k·nd in the chest. How these voluntary examiners have to qualify as experts and how far they are e:-."Pecled to Juve knowlt'uge of service conditions is not mentioned in the progr'lm: it simply offers to furnish the War Department with a list of ll Jnrge number of ~uch expNts who would volunteer; because the committee is of the opinion thnt "the work of the Medical Corps of the .\.rrny and Navy could he much facilitated and expedited and this corps, nlr<'ady greatly overworked, could be gi>en much needed nssistnne<>. • • • '' From this it is seen that the program presupposes two condi- tions: One, that the Medical Corps is qnantitntfrely in:ulequnte to the task of recruiting, and the other, that qualitatively it does not possess the expert knowledge necessary to detect whether or n :>t certain anamnestic features in the history of recruits or physical signs in their condition are to be regarded as disqualif.ving them for military serYice. As regards the first point, of quantitative inadequacy of the Medical Corps for recruiting service, we have no accurate data. A~ an expression of patriotism the proffer of expert assistance will no doubt be highly appreciated. We ha>e been under the impres..,ion that the creation of a Medical Officers' Resen e Corps and its organi- zation was intended to supply competent men, especially for rt>cruit- ing service, whicli has to go on more or less independently of the medical service of the enlisted body of troops, although under the :.nrne genernl direction. As regards the qualitative inadeqmtcy of the Medical Corps, which the program does not express specifically, although it is clearly implied so far as tuberculosis is concerned. we have no means of judging the force of the implication. It is evident that the creation of a. new Army and new Navy on principles essen- :>o. -'· KLEBS-TUBERCULOSIS. 443 tially different from pre,·ious ones will necessitate Yariou::; adjust- ments in this regard as in so many others. Xe\"ertheles-s: whnte\'er experience we ha ,.e gained, whatever guiding principles "\\"e have cYolved therefrom. mu::.t be of prime importance in the shaping of a future policy, if for no other reason but that it cotTe:spontls to our own and peculiar needs, which no other experience::. can !-llJ>ply. That the :Medical Corps, individually as well as collectively, has not been unmindful of the problems which tuberculosis presents in both Army 11nd X avy is clear from the publications by members of the corps, which show both insight and expert knowledge, some of them to a. very high degree. As a collective expression of past experience we have various oflicinl publications 1 and reports. As a test of how far the experience has been utilized in practice, and especially in the rec;uiting scnice, we may find an index in the variou:s rules and regulations go,·erning the sanitary service. The rules for the ex:uni- nntion of recruits are brief and to the point. Their careful study :.hows that the subject of tuberculosis was throughout in the mind of the writer or writers and that the difficulty of the task of discovering conrlitions behind which tuberculosis may be hidden was fully np- preciuled.2 There is a wholesome absence of intricate definitions and subtle <listinctions which are apt to burden and confuse modern text- books as well as the minds of conscientious students. On the other hnnd, there is abundant evidence of common sense, a full recognition of the need of " special standards and requirements, being more or lc::i~ subject to change," and providing for what is most important, the cooperation of the line officer and the medical recruiting officer in providing not only healthy soldiers but those fit to perform ::iatis- factorily the tasks with which these officers mnst be acquainted. The rules provide also for the study and observation of doubtful cases for a reasonable period, a most impor~ant point in the detection of tuber- culo"iq, which, however, has not even been mentioned in the otherwise specific directions of the program. It is ffddent, of course, that exc<'llent rules have value only when intelligently applied and strictly enforced. Guiding thoughts and suggestions as to how this might be brought about may suitably engage us to the end of this paper. Before we consider how tuberculosis might affect in particular the subject of enlistment and that of the care of the tuberculou? dcYelopecl •Jn pa ·stn~ we mny remind the 1·cnder only of one of tbcsp publications, thP lll'dleal and :O:uri:lcnl Olslory of the Ch•ll War, which probably more thou an:v other slmllnr 1111l>ll· cation bas exerted n world-wide loflueoce on military i;nnltatlon. The Tn1IPX Cntalogue or the 1-lnrgeon Gt•nernl's library is another wo1·k o! lnestlmnhtc wortll to t:ic "hole medical world. •War Il<'pnrlmcut: Gencrnl Ol'(lers, No. GG. Ilule~ ro1· tile Exomlnotlnn ot nccru't'. Washington, Ap1·. lA, 1010. Navy Department: Clrcnlor lt<'lntln;; to th•~ l'h~·skal Ex· amlcatlon oc Uecrults tor Enlistment in tllc Navy and Marine Corps. Washington .. July 10, l!llO. 444 KLEBS-TUBERCULOSTS. Vol XI. ufter enlistment. let us for a moment, based on the concepts out]' aho•e, meditnte oYer the aC'tnal role of importance which this di Ine.d plays among the multiple phenomena that determine the effic~~ and well-beiug of Army und Kavy. Quite g-enernlly it mu(.t be .} C'eded that the line di,·iding h ::ilth from sickne::.~ is one thnt dO(';;~~~ alwny .... nppear dearly and sharply marked becausP the two eonditio which we are in the habit of distinguishing are determined not 011~: by inherent differences but by individual consciousne:-s nnd nttitlid~ ns well. Modern medical science concerns itself almost exclusivch· with those factors, symptoms, or signs discernible and mensurable 0~ physical methods. The accent put on these not only limits our unde;- stnnding of conditions where the physical factors are not clearly dis- cemible, but it wetlkens our effective interference. The good physician instinctively evaluates both the pondcrablcs and imponder. nbles: his interest and solicitude is focused in the whole man not in isolated phenomena. "\Ve are aware that these nrc elementary. self- e,·ident c:oncepts, and still we feel they bear repeating again nnd ngain, especially in the subject under c:orn:ideration. For the fact that tuberculous infection is cxcPcclingly premlent. we have abundant nncl reliable e\·idenc1" Thi , howrwr, is con.1.;tnnth- disrcgar<led or :Cnnltily interpreted by those who nri> intr•· .. "tecl in th~ ::-pl'cificity of the disease and the effecti P'nc of spccilil' me:isures. 'Ye need not examine here the details of the statistics, but only wi-.lt to recall the significant findings by tube1·culin tests applie<l to the recruits of the Hungarian Army by Frnnz. which <lcmonstrntcd the presence of the infection in a vast majority of all the recrnits. i. e.1 nearing the 100 per cent. This was one corroboration in the li,·ing of identical findings in autopsies of the dencl from all causes mn1le by Naegeli, Burkhardt, and others. These are focts which have found genernl acceptance, but not general application. 'Vhntever their ex- planation they must inevitably lead to the conclusion that practicnlly e,·er:yone living under conditions with which we are fnmilinr 11ot only makes the personal acquaintance of the tubercle bacillus by coming in e<>utuct with it, but receh'es lesions ~o distinct thnt years after they are still discoverable. What does that mean? It means that prnc- ticnlly everyone some time in his life must present symptom::; and signs, discernible and measurable by physical methods, at le.l"t by the expert, of what we are taught to call "incipient tuberculosis: · And it is certainly not unreasonable to presume that a greater (kgree of expert skill would eliminate the qualitative "practically" anu allow us to spea~ of tuberculosis as a universal disease. But does 11<1t this lead inevitably to the conclusion that the specificity of the disease i · of relative unimportance unless there is, discernible uncl mea~ m·~abk a specificity of resistance against the infection? KLEB::Y-TUBERClJLOSIS. 445 En~n n supcrficinl consideration of the :,,uuject of specific re- sistance to tubcrculo:,,is would lea<l 11:-; fur awny from 0111· main ar~u­ ment. Of lnte it hns receiYcd much nttcntiou from the lnborutory \\'orker. the scientific physician. and the general biologist. especially :since the specificity of cau"e could not be made to yield ~ati::;factory conclusion~. At the preSt;nt l!J.Omcnt we can only sny that this rc- scnrch. extended even to th0$e elements borrowed from Darwinian speculations, heredity and environment, has furnished n~ no 1lata "hich would allow uniformly applicable deductionc;. We cnu not. thcrcf orc, agree with the definition of tuberculosis, ns accepted by Barber in his notable paper" Tuberculosis in the XaYy,» 1 deseribing it ac: a 11nirnrsal disease" producing death in: about one-tenth of the population in whom resistance is lost from nscertninnble cause.". but unable to kill in the nine-tenths in whom resistance <'ontinucs." The .. osrert:fr1.ablc causes" which he mentions nml describes. lb nl~o the so-called ··stigmata of tuberculosis" of Ilolcman,2 to which ho rofcrs1 11rc nil possible fnctors in the production of the disease, but by no mean~ ~pecific. \Ve must make a mental note of them and further e.-<nmine their relation to tuberculosis and other clisenses, but it musr not lead to a one-sided generalization unless we nre prepared to re· , ert to the ancient belief that the worshipping of one pct divinity \\ill frco us from all the demons tormenting our existence. Tuberculosis, therefore, does not present :my special problem that cnn be met Ly special measures. .As we understand it now. it is to a certain e ·tent, which is by no means exactly rlcfinable. an index of collecti,·e health and physical Yigor. In this aspect it de· l'n '; pains- .tnking L11t also well-balanced attention. It. ccrtainl.v has not rl•ceiwd dthcr by those who now alarm and warn our pcoph•-nnll c ·1eci11lly the medical nuthorities of .Army nntl Xavy-by prodnci1 g s.o-cnlled e\'iJenc1' from Frnnce intended to show that tnbet'l'Ulo::,::; has in- crenre1l enormously, nnd that this was due enlirt>ly to the no11enforce- mcnt of wcll-triecl measures by the responsible a uthoritics. \\'h~n once the time has passed tlrnt the authoi·ities c1o not longer ··deem it uuwisl! to publish certain figures," an..l we 11111)· i11ld. "or deem it wise to publish others." then, bnt only then, shall we be ahlc to ap- praise correctly the amount of damage inflicted on the French forces nnd population by t11uercnlosis. Nowhere in the world ns in France hn~ nu antitnberculosis c·1m11aif_rn been wugecl i'or a longer time, in· fluen1'i1 f! research. legislatnrl·, and every ngNwy of public or~:rniza. tion nn·l welfare. \s it would be preposterous to ll'akc this fact rc~-pou:,ihl«> for the present calamity, ju!'t ns mt!cb. aml more so. i::> I N.\YI! ~11:01('.\I, IlULLl:'l'IN, l!lli, xi. :.!!.lO. •'\feel. Hee., New York, Hll!i. lxu1·lll. 10:,7 to IU. 446 KLEBR-TUBERCULOSIS. it absurd to put the blame on negHgent nuthoritil's.1 If the t" enr came-may God forbid-thnt we had to fucc three cruel y~ine of intensest wnrfnre, had to bear the bruut of the battle unnide.l f rs the fir,..t months, our bert men killed in it. our mo:,i pro perou5 & tor ocenpie<l eithe1· h~· ioe or friend, upsetting complt:tely om irite11101 relntions. our entir<' economy, v:hnt significance wo:.ild it Jinye , h n under :-uch circumstances we picked here an<l there nmong the , ic- timi> n fow-say, CYen four or five in a hun<lrcd-that \\Cl"e tubercu. Ions, merely to show that they might ha.Ye been save<l by·· well tried meastlle'> "? What are "well-tried measures" in the midst of a eyclone or a. cataclysm? It is the entire Yitulity and power of re. sii;t:mco of a. nation that is on trial a.t such times. To learn hm, to strengthen nnd husband these is the task of true pl'cpnrntion in n 1- rnnre. In this the so-called tuberculosis problem is s11bmerged. The main fault we have to find, therefore, with tho" wa1· tubercu- losi:; progrum" is that it proposes against this disease the same measures that hase been found effective against the acute infection~ disenses and attempts to justify them by the order of reasoning per- taining to them, and especially that it is apt to becloud the main i:--::,11e J.y insisting on n minor one or. as we may put it, Ly trying to sub:-titnte tactics for strategy. The all-important tnsk of al'snring nnd maintnining the health of Army and Navy has to be di10Ctl•d by proper au horities, and much depends on their wisdom of coor<linat- iug i~~u<'s. Our Medical Corps has an excellent tradition which will be of great help in the impending new organization. It alone, if nothing else, must insure to it our fullest confi<lence nnd readiness to assii:l when required. It needs not only the moi:;t extensive nuthorit~· and powers of cxecutic)n, but also its prestige hfls to be rais>d as much us possible. It is almost a tradition in military sen-ice to look dmvn upon the sanitary brunches. Nothing shonld be left un<lone to counteract such te11dencies, and, of course, the best way to <lo it i<: to rnise the standards 1111d create facilities for special trnining, ecluca- tiou, and research which will attract the best M'ailable men. :N"e,·er can such n service rench the desired degree of efficiency if it has to rely on the a!"sistance of outsiders, no matter how expert they mny be. Just ns the other services have to create their own experts in navign- tion, in gunnery. in aviation, etc., the :Medical Corps should Le secured the highest degree of independence in this respect. The direction 1 Ten yenrN ni:-o the antltuberculosls movement In this countl'Y had hnrdly llc:nm to ~athnr momentum, whln In Fr11nce It wns n well·organlzell nnd wlclh'Ilr<•utl c•nrn:ul•~ (wbrni eruMc·m. the double red ct·oss, our nntlonnl ossoclntlon vcloptrd nml Htlll rnl'rlr• <:n Its henn··r.•I. ·ro thr Frrnch UJOl't'ment. whkh begnn tn the ~evrnll<'~ or lnfit crntury, ,.-., not only owe sll the lnspll'ntlon fol' our own lmt nl~o the lnltlntlve for International cuol'ern· tlon In questions of public health In mnny tuberculosis cons1·c~St'ij In l'n1·ls nnd !or thP last time In Washington, where n large dclegotlon from France certified to the cnnth1•1"'1 nctlve t'Ont1·l1Jutlon from tbnt country. KLEDS-IUBERCULOSIS. 447 l'\O. "· I c.'i:ecution of it:: \Hirk i::. so entirely different from that in civil llllC d d t . . . l k lif thnt indepen ence an concen ration upon its part1cu ar tns are f cpnrumount importance. While the daily tn~k of health uuthori- 0.cs nnd the medical profes~ion in general centers in the prcnntion, ti}lcYiution. cure. nnrl s_tudy of ills which befall nll individuals of a 11 pulutiou. the military medical sen·ice has in its care the flower p; the popuJation: specially and carefully selected £or its physical ~Qicicncy. It has more the position of a national trainer: not, how- e, ci-. ns n trainer for a particular feat or competition or emergency. but for an nll-·tround fitness of body and soul, in pence nnd in war. which nloue enables a great people to withstand succe siully the actual blows of un arrogant enemy and to parry the more insidious nttncks of :.11 civilization's worst enemies-increasing lo'e of ense. !usury, material ideals, excessive wealth, and sordid poverty. An nrtnY nnd unvy maintained for such defense against enemies within nnd without can hardly find objectors even in pacifist quarters. for it surely has its place in a "wider life of coordinated acti dty :· (Miss J nne Addams.) I. TUBERCULOSIS AND E'KLI&T111E};T. We hclieve that thf're are pertaining to this subject mainly three e:d~tin!! regulations which may deserve analysis and possible elaborn- tion.1 They are: (a) "Evident predisposition to pulmonary tuber· culo~is ., is fl special disqualification from i::enice; ( b) after the u~e of •· e\·ery possible diagnostic procedure (microscope and X-ray in- cluded)"' ha\·e been u~t'd, doubtful case<: may br aclmittccl ''to ho,;pitnl for ~tudy and ob;.c•1Tation," 01· in cn<.;e of" tempornry illness., unfit- ting npplirrlllts, the:>· may be admitted to hospital for treatment" with a 'iew lo their enlistment upon recovery"; (r) "candidates for spe- cial ratings" are not expected to possess" the phy:;ique nnd endurance of those actively engnged in strictly military duties." Ncvcrthele..,s it mu•-t he remembered that they are" enlisted for the performance of nll duties to the naval S(>rvice ashore and afloat." (!l) "EVIDf:NT l'REDJSPOSITION TO PUT.l[Q.'IAllY TUBERCULOSIS." Tlus phrase: we belie,·e, sho"·s clearly how much definiteness i~ stili locking in our concepts about the disease an<l how much con- fusion is cr(>ated by the use of anatomic and bncleriologic terms to design;1tc clinical conditions. The old terms of "status phthisicus.:: ·· ~cro:fulc us complexion," or "tuberculous din thesis'' con ,·eyed to the pn•-Kochin11 examiner u. picture which had fully as definite a sig- 1 We quotr. from the regulntlons cited in note 2, p. 443, not verbntlm, however, be<:aott 1••e are more after the prlnclples gove1·ning them tbnn nfter the vnrlous expregslons they may have received In the several services. KLEBS-Tt;BERCUI.OSIS. nificancr as the nboYe phrnse. The X avy Regulations in which phrase occur:-; do not mention tuberculosis among the ''general dia. qualificntiom:," although here under the heading of constitutioJla.l diS('nscs we find noted ·· freblene" of constitution (poor phy,..ique) :-.yphili ·· (HHH). In his r mnl report for l!lOi the Surgeon Gen~ ernl oi the X n ,.y stated that a material reduction of tuberculosis in the sen ice could not be expected "until it is more fully realized that tuberculosis is a disease of nutrition, and until a minimum standard of physical requirement is more consistently exacted." The Army Re~lntions are more explicit; they name "tuberculosis of whnte"er degree and whether general or localized" among the general diseases which a.re causes for rejection. They also attempt to define (under '·chest") tho conditions which "usually coincide with a somewhat enfeebled constitution and n. predisposition to disease of the. lungs." 1111 l«r '· lungs." definite signs, data from the history, and temperature variations are enumerated as leading to "suspicion" of pulmonnrv t11berc11losis. In the Navy Regulations "incipient tuberculo::.is ., is noted in the examination of the organs of the chest by percu..,sion nnd nu:-cnltntion. ,,.E' luwe already hnd occasion to speak of the condi. tions which Barber considers as marking the "phy:;ical defceth·e '' and to which he refers as "the source of the firbt increment of our rntio of tuberculosis for the service." The author thinks thnt liUCb Ca!l':es ~hould under no circumstances be accepted for any brunch of thl• ~Hvice . '\Ve may take this to be an individual expression of how tlw I hrase "evident predisposition" might be defined. Barber lnrthl r on in his paper,1 when discussing the positive evi<lences of the <li:sl'nse, insists that a diagnosis is possible in the early st 1ge.;.;, nncl that the grent importance of this fact should bt• realized by medicnl <•11 ct'rs. " a corn;iclcrable nnmber of whom,'' he :·mys, "do not con· cede " this possibility of diagnosis from the clinical history :md physical signs. The recruiting oOlcer, if he has taken in the reglllations and liter· ature from which we bu.Ye quoted, will find that he hns to use n !!rent great deal of judgment in c·trrying out the regnltttions. or practically none if he tries to emulate the scientific prec<'pts. E\·erything from a hypertrophied tonsil to a protracted use of ··Brown's mi.xture .. he will haYe to look upon as suspicious. shoulcl hP belon!? to the latter categor). Since he is told that he "cnn not he too enrefnl nnd stringent,·• he is very npt not to nsc 1'is juclgmcnt, but to lwld himself to definite conditions as he may find them clescribc,l. Th~ result ma~· be nn ~\rmy an<l X aY~' of suspicious cn~·l•s, or noue at nll. It is j11st here where it is prnposecl that \'olunLltL',\' experts shall help ns out of the dilemma by e.s:nmining every man who pre~cnh C;.lll!'e 'Op. cit, p. 297. KLEBS-TUBERCULOSIS. 449 for :,uspicion. It is pa1ticularly on account of their spcciul skill ·n tho c.xaminntion of the chest that expert assistance is deemed ~eccs.snry. Thi:; is curious, because when we look into specialistic Ji«-rnture "e find that there is a tli~tinct tendency not to rely too much on phy1>ical examination. Lawra:-on Drown, TmJcau's ex- cellent pupil. n mnn of great practic.\l experience, expressed this clenrly in n recent paper: 1 "Sympcoms arc n b~tter and more aL'Cll- rutc guide to activity than are physical !'igns .. nnd ··symptoms "ithout phy:-ical signs demand treatment, while physical signs with- out symptoms require often nnly cnrcfnl watching.'' A more pointed expression in this direction we find in u notnlile paper. nlso quite recent. by Louis Hamman of the medical clinic of Johns Hopkins Hospital. 'Jhe painstaking analysis of the ;;ubjecl, coming from u man who lins hatl a most extensive clinical e_xperience iu the tuber- culo:;is out· patient department, which he hus ntilizcd both practicnlly and scientifically, nnu '"ho has now worked for some time iu the wider field of the general medical clinic, merits the most careful considcr:ition.2 'Ye can give here only briefly some of his pertinent remarks: .. The undue emphasis that has been put upon the phy8cnl examination by distracting attention from other no less importnnt fnrtors, has rather obstruct<'d than :facilibtcd early diagnosis" nnd ··there must be some inherent traits in the progress of tubercu}o,,,is that render the det*'ction of early stages difficult and: irnleeJ, in mnny instnnces impossible"; and '·I nm conYince<l that early diagnosis would profit if physicians could be rid of the bugbear of physical examination: which exacts that eYery diagnosis be supported by gross changes in percussion and auscultation.'' We hare cited these various expressions to show that there is no unanimity on this subject and that if a really useful formula, u~eful to the recruiting service especially, is to be ernh'e<l. we must change entirely om· attitude toward the problems im·ohecl. Our object is not to complicate the matter by an analysis of the various factors nlle(!<'d to predispose to tuberculosis or of thn methods devised to diagnose them, nor do we wish to discuss all the more or less artificial phases between predisposition, eYident or supposed, un<l actual in- fection. But we belieYe it can not be emphasized too strongly that if society nnd especially our Army and ~ary is to profit from what we lun-e learned in our laboratories and autopsy rooms about these things we mnst fir;;t of all rid ourselves of our sln"dsh devotion to terms ancl names, and adjust them to newer and broader concepts. In this sence tnl>erculosis means one thing to the laboratory worker 1 TubPrculo$IS tbt>ses, cllagnostlc, prognostic, thernpeullt'. American Review ot Tn· hettt1losls, Baltimore, 1917, I, 194, tbe•es 12 and 13. •The dlsgnOllls of 11ulmonary tubercuto ... 1s. American Review of Tubnculo•I~, Baltl· more, 1917, I, 206-217. 8551-li--::! 450 KLEBS-TUBERCULOSI::;. I.mt :oomething essentially and fundamentally different to the Pta _ titioner and to society in general. '· Infection:• an<l " incipiency\ , ure experimental laboratory terms of vulue no doubt in their re- sperti \·e places, but of no significance in the broader issue of deter- mining the border lines between health and disea::;c, between physical deficiency and efficiency. Like the beginnings of all thing:o and Henls, they transcend our ken or at least mark only plausible theo- retical factors or phases in that continuous struggle of the organism to udapt itself to e>er-changing conditions of the t.>nvironment, "~~th the. use of terms an~ names current n,t presei:it our recruitin~ of11ccrs will undoubtedly discover that we are a nation of defecti\"ei:. Anyone who has his eyes open on his walks in the streets of our cities, on our popular bathing beaches, in our offices. will see if he wishes to, stigmata of degeneration, predisposition to tuberculosis. W'e o,·er here who for decades have attracted to our shores the out- put of what is most enterprising, tough, and persevering in the white race of the whole world, continue h1sisting that the highe,t stand- ard of human efficiency is to be found in the tn>e of tlu Apollo of BelYedere. w·c see our athletes, prize fighters. and others who come up to the""t- physical ideals ending pitifully as consumptin!s. while the under:-izc. underweight, narrow-chested clerks and laborers out work nnd outli n! th~m. But we refuse to learn from snrh e,·erydu., obscrrntion:>; tenaciously we stick to our test-tube and guinea-pig stan<lanls. Like Frederic the Great we clumor for our li-:Coot-nnd- more grenadiers and forget that warfare and life hHe changed entirely, that wholly new standards of physique and mind v ill deter- mine victory and success and survival. Therefore we believe that the somewhat vngue terminology in the .Army and ~ avy regulations, the expressions used by the Surgeon General of the Navy in 1907, as cited above, although they do not fulfill scientific requirements, betoken a much higher wisdom than the attempts to force a narrow, one-sided fixation of ~nndnrds. There are many hopeful signs that the medical military authorities nre Wl'll aware of the needs of a thorough revision of standard-.: and able nncl enthusiastic workers are devoting themselves to this im- portant task.1 (b) OBSERVATION BEFORE J;NJ,JSThU:NT. The pro,ision for study and obser,'ation in a hospitnl of recruit'> suffe.ring from a "temporary illness" in existing recrnitinl! reguln- tio11s probabl~·. had not in view the cases which we h:n-e been con- sidering. With the increasing anxiety to keep everybody out of the '~l'e the cxcrllent article by W. O. Farwell on the Important subjrct, " llordrr-llnt' C'a&CS at the recrultlng omce," Illustrated by photograph~ of the Ru~~rll s~1r-1 Institute, whldt urr most angge tlvc us to h•1w WC' may arrln! it a mnrc exact tleterrolnatlon of pbysleal stantlnr<ls. X\\'.-1, '.\lr.OI<'.\L BrLI.r.T::s, 1Hli. xi, :So. :i. - ------~-------- KLEB&-TUBERCt:LOSIS. 451 ser\;00 who by nny chance appears likely to develop tuherculo i~ it "°ould nC\'el' occur to n recruiting otlirer to reganl. for in tnnce. a cn<=e "\\"ith bloo<ly i:;putum, or with a rise of temperature in the after- noon. or with dnllne.c;,- O\er the left ape..". as one of ,: temporary ill- nc .'' He may possibly order the candidate to present himself again for ree...:aminntion, but obserrntion in a hospital with a view to ,; en- listment upon reco\·ery" will hardly ever be resorted to under present conditfons. In spite of the conclusions which Barber 1 draws from a ~udY of the admi~sions to the naval hospital at Las .\.nimas, Colo .. duri~1g the year 1916. and in spite of the alarm sounded by Diggs on account of the present F rench experiences and other le.-.;s ~pc-cific but equally insistent warnings, we believe that the pro\'ision for ob::;crva- tion should not only bo extended to the tuberculosis suspect but be made the basis of a distinct system of dealing with the l>O·_rallcd •· defecti,·es" or "suspicious cases" presenting themsehes for senice and otherwise fulfilling certain minimn stnndnrck A" for :t:-. tuber- culosis is concerned, we have already shorni that the ascertainl'd prevnlence of tuberculous lesions among modern populations inevi- tably forces the conclusion that praatically everybody is :;omctimes tempornrily ill from tuberculosis and that only a Yery small percent- 11~e of them succumb to it. Every practitioner of expc-riencc cnn gh·e direct proof of this and can testify to the fact that the later immunity of such cases was by no means always insured by propt'r treatml'nt or the hygienic ideals of the propagandi!'its, that indeed it persisted often despite eYery infraction of ru h•s nncl nncler actunl hard-.hips nn<l arduous occupation. The ::.cience "hich dOC':> not take these things into account is not science but sterile dogmu. To the unbiased it will be evident that among those rejected for such :ms- picions there must be a large number of just such cases, some uo doubt precious human material for every kind of senice. Toward these the Xution has not only a right but also a cluty. Obserrntion in u hos- pitnl, howeH>r, would not serve either. We belieYe that thc-sc c:i!':es- nnd we would not limit ourseh·es to the tuberculosis suspccts-onght to oo enli tecl and entered in a service to be created especially for the purpose of observation under working conditions. Such a corps should be officered the same as any other military unit, nncler strict military or<ler nnd discipline, encamped separately or near other troops. the only difference being that especially delegated nnd espe- cially selected medical officers would supeniso the training nnd the work, the strictly military part of which might be made theoretical ouly at rest intervals, while the actual work might consist in those occupations in the rear of an army which modern military prncticc tends more nncl more to nssign to specially orgnnizecl ancl trnine1l 1 Op. cit. In nOtt' 7, I'· 297. ·!52 KLEBS-TUBERCULOSIS. Vo1. x 1. bodies of w1armed men. The organization of ::;uch a .. workinrr corps" 1 might also provide that men who in the regular armed sen-~ ice "in line of duty:: develop :-uspicious symptoms or signs may be assigned for !'ervicc in this corps. Such cases nuturnlly occur, and sending them to a hospital or dismissing them will be neither to their interest nor to that of the service. This would place such a workin,,. ,, corp . .; in nn interme<liate position between the organization of the fighting lines proper and that vast organization in the rear with its provisions for casualties :from wounds and sickness which will meiit separate consideration. We believe that this working corps wisely crganized and ably led would not only demonstrate but develop the great potentialities which are in many of those presently considered physically deficient. Very c:imilar viewpoints to those jnst outlined must govern t11e oprortunities offered under this heading. Primarily the choice of c:rndidatcs will depend on fitness for particular tai::ks which they h:n·c ncquircd in civil life. A waiver of defects in such cases is proh- nbl~· recommended not infrequently but the injunctions to the cxnmining surgeon contained in the regulation cited nbove (p. 413) :::uggests that this is not done with deliberation and on the whole dis- couraged. It would seem that the subject merits study by line nn<l medical oJlicers who are thoroughly conYersant with the physical de1rnrntls made on the men in different ratings. The (livisiou of labor in n modern military organization and the utifomtion of special qunlificntions formerly not eYen thought of has created new !"er\"iccs and rntings which make different, some lesser, demands on the physi4uc and en<lnrance of their incumbt>nts. If this is so. it is e\'iclcnt that a systematic and careful distribntion of recrnits of known physique among different ratings of known demands will allow the proper utilization of many border-line cuses. Maximum stnndnr<ls of ph:--sicnl efficiency will be made to preYail where mo--t needed-that is: in the fighting line and the resenes-but the m1rny types representing stages between maximum and minimum standards cun find :ippropriate utilization. Also here we must remember that the fighting line represents only the sharp and hard edge of the we~tpon whoso shaft must be held solidly and intelligently by the whole social structnre, organized and coordinated. In the planning there is :\ great chance for the useful cooperation of medical prac- •Some Ruch nnme would be preferable to a deslgontlon hugi:cstlng pbysknl obF<'rva- tlon. esreclully !or nny pnrtlculnr disease. Every m!ln enrollecl lo this corps ought to be mad<! to f Pel that in the orgnnlzu Uon of nation a.I forccR the clu tics assigned to hlm are ot f'lJU'll Importance to those In any other corp~. KLEBS-TUDERCULOSIS. 453 titioncrs; physiologi:ots, ethnologist~, with the military authoritit''· 'I he drnfted thou:;ands 1mcl millions mu:-t furni~h the principnl dntn "hich nre probnbly dissimilar from tho:::c in nny other country. It b of fundamental importance that we fix our own standards arnl de' i:::e our own methods to deal with nncl properly distribute the physical I'C:oources of our population. It undoubtecllv can prevent the" aste which disgrace:. r-o many of our lnrge::t l·ntcrpris • in which "e otl1cr" ise take pride. In :mother but allied fieh1 "c hn ,.e a chn rac- tcri,tic example. lit the last hal~ year the hcnlth department of Ne'\ York City has had to destroy 10,000 tons of foodstuffs only because means for storngc and proper distribution were inadequate. By this the sanibry authority undoubtedly renders a senice but it certninly does not counterbalance the irreparable tl:11n11g-e done b.'' a Jack of fores:ght ancl organizution, particularly inc.xcnsable at n time when food is short and clear. The great rOle which "national service" can i Jay in the eons<'n·n- tiou and utilization of the resources in our young popubtion will be ob\'"ious to e\·eryone not biased against all military organization b cau~e of mor;tl convictions. The measures which 'le haYe sug- gcstP<l in the last two chapters. although they are concerned with only ono side of the problem, ought to go a long way to\\ nrd re- moving this bins. They abo ought to help trnn~form the fre- quent conflict between ciYil ancl military authorities into purposeful cooperation. The a version of the •'conscientious objector .. ngninrt any nrmed !'el vice can not be dismissed simply us a form of cowardice. In the general policy of armed preparedness we belie,·e be ought to be con::::i<lered rather to occupy a similar rlile to that of the 1 U" who docs not fulfill certain standards of physical requireme11t, to he dealt with ~imilarly :mcl uot by coercion or punishment. The British ex- periences in this mutter will deserYe our mo:ot careful attention. On their liac:is we hnn lately been warned not to repea·t their mistake in plneing the "allcrnatiYc serYices" under the direct or indirect con- trol of the military authorities.1 'Ihe;:;e are qul'slions which un- doubtedly Pll!!agc ut present our Council of X ationnl Defen~e. Gcn- ernlly speaking it seems of minor importance whether the "alter- native ~enicc organization "-and that of the propose1l .; working corps" woulcl nutl rally be nn intPgral part of it-i. plncecl under military or civil control. The essential requirement, as we ~ee it: is thut it insures discipline, on esprit de corps, uniform standard~ of lh;nl? cornliti011s oncl of duties such ns we are in the hnbit of asso- ciating with military organization. To the Xation at lnr~e the etl1- cient cooperntion of civil and military authorities in the training of those r.nlistcd for nlternatiYe services must be of the highl!.':'t value 1 ~ldney Wt>hb: Brit !sh e'Cptrlenre, !or Amerlc:inir. IT. .\tl1tntlc 'lontl.ly. 1 !Hi. Au- cust. p. 108. 454 K LEBS- TUBERC ULOSIS. in wnr nn<l in peace and '\c will do well to re.member in this re~ard the suggestions about ·· alternafo·e industrial service" mnclc by on of our best thinkers. William James. e 11. Pl.E\'E.YfIO:>; A!'\D CARE FOil THE 1 Uilll!Cl l.t.>l'"· The precaution<: during enlistment and He en orccment of :-nnitut'\· n'gulntions in the :,;enice ought to, theoretically at l<':lf•t: prcnnt th.e development of tuberculosis in Army and Navy. Certain nuthoi·i- ties. some of whom we have quoted, assert that this is even pos:,.ible in prnctice. This is obviously a fallacy: not only on the !!enernl g1·ouncl of humnn imperfection, but because tuberculosis lot infre- qnent ly llc\·clops snd<lculy and without any warning, a fact to which Hamman has also called attention. At the present rate o! i 1cid£'nce we would h:ne to reckon with a minimum of about 2,000 C!l!'b in ,1 force of 1,000,000 men. We believe that this rntio will be increased or dccrense<l more in proportion to those factors which <lep •ml on the discipline. morale, ancl c:pirit which permeate the whole organization than on the applicaticin of specific measures. An attempt to base thl' JH'e\·ention of tuberculosis and allied conditions on methods of prophylaxis ngainst acute disease.~ would be a short-sighted blunder. On the othel' hnnrl it ic: certain that the natlll't' of the serdce itsclf and thnt of the se!'Yice environment so far as it u tl'ects the health of the men must require careful scrutiny. It b often assumed that the outdoor life, the rigidly enforced hygiene, the stmitary arrangement of living quarter:; naturally offer to thoso enlisted in cithel' ~\1·my or XaYy the advantages of n health resort . The assumption is, of comse, rather exaggeratPll, bnt it l'ontains t•lemcnts of truth. "When, howcYer, t.he senite is prolonged nnd c. pecially in actual warfare the strain becomei:; great, s:u itatiu11 nnd hygiene are neglected, particularly in trench warfare llll!l when billeting in primte houses has to be resorted to. The tra"i1in!!' nt home has to anticipate these conditions and therefol'e "health re- "Ort standards:' or the elaborate hygienic and sanitary arrnn~l'ment:; of many of our public institutions ought to be barred from military £•.,tablii-;hments. \Ve have become Yery dependent on those nrrangl'- ments nnd it is difficult for us to realize how healthy liYing conditions can be obtained without them. To teach the men how this is po,,~ible unde1· almost every condition, to harden themselves, to :lYail them- seln;; almost instinctively of healthful opportunities where' er they nre present (washing, bathing, etc.), is infinitely more important thnn the proYision of the best sanitary appliances unless they cnn be n~c<l under all conditions. That this principle of aiming at the ht•st with the simplest menns ought to inspire also those who have to plan the sanitary measures would hardly need emphasis if it were 11ot for the inc-Jinn ti on to OT'erdo in this diredion. KLEBS-TUBERC U T.OSIS. 455 In our nim nt simplification it ought to help "hen we realize that pr:icticnlly u.~l our prophylactic. mea:>111·cs come un<l~r the hcarlin~ .. cknuliness. Thu:; cleanly hab1l..; and clean, open air arc now our mainstays nguin t tuberculosis. A$ep::-is and :rntisep::,is. en~n pro- tecth e inoculalion ure nothing but measures of microscopic rlcan- lincss. extl'rnnl or iuternal. ureek nml Latin etymolog~· changes "ord~ and udds ln::1er: but <locs nnt change the ~en.se. Mainly by increasing clcnnlines::. h1H"e we been able to control n ~rent number of diSl'a~c::;. some ,·cry fatal especially in war. But the realization of ti is fact hn~ brought us Yery little ne:irer to a ::;.'\tisfoclory under- ... tnruling of what makes and unmakes healthy liYing t·omlitions. Open-air life, perfect Yentilation indoors, outdoor ,,,lccping lny so much emphasis on the one factor of air in the prc,·ention of tnber- cnlosi:- that we haYe become accustomed to nccept its priml' irnpor- tanc·l' ns n matter of fact. It will be regarded as h~·per-C'l'iticism, a::. heresy to question its primacy. _\ncl still it mnst be done if e\er we "ant to see clearer. Tho Indian who hunted in wood and prairie lived up to the tenets •1f oprn-air life in perfect form. He wns free from tubcr·ulosis and o•ily when he adopted our mode of life <lid he succumu to it. Pro- pagandn: of course, has utilized this example, but it pro\ c;, just th' upposite from what it intended to prove, for we know YC'ry "dl thnt the Indian ancl probably all hunting and nomadic racC's haw hardly any rC'sistnnce against tuberculosis when th<'y do come in conbwt with it. ~\nd with them it takes the form of nn acute infection;; di::-- ea~e. Long generations nre needed to develop a resistant(' as the case of tho American negro demonstrates. Hence the Indian's mode of life in the open is not necessarily healthy for U!' whose main ex- istence is bound to be under shelter. It will benefit us for n tim(', but if we pnri;ue it indefinitely we not only would have to girn up nll that means a useful existence but very likely ·we would <liminish our rrsi,.,tance. The Indian's mode of life, therefore, cnn not determine our stanclnnls of healthy conditions of liYing, no mntll'r how much the modern imitators 0£ J. J . Rousseau mny proclaim it from the housetop:;. \Ve mnst look :iround for other factors. The possibility of artificial imnrnniz:•tion pl'rhnp;:;? Does not the Incl inn l'~·:unplc directly suggest its possibility? 1t i.- an impor- tant :mbject the rl'i-earch of which will continue to occupy ur::. but. so fnr ns tuberc11ksis is concerned, it m~1~t seem hopelr"s wlwn WP con- !>ider the 11ah11·<' of the disease. T...iet ns <lo thi!-' for n mom •nt. for "hile it shuts up one line of attack. at the snm<' tinw it opelli; others. Consumplio11. as we sec it. p!·rscnts nothing- hut nu nltcrnnting ~cries of accident!:> and rcco,·cries in the one nntnmlly immune to tu~r­ cuJo,.,is. It is the factor of inherited :rn<l acquired re~istance thnt dct('rminc the chronic nm! clebilitnting- course of the 1liscnse. .\.ml 456 KLEBS-TUBERCULOSIS. duriug t11e prolonged nnd tediou,,, struggle other factor~ thnn tho of ~pccific i1111mmity become effective. It is not :-pcculntiou but : c:uefol consi<lerntion of pertinent. resenrch which forcibly lea~ us to this apparent pnradox- that tuberculous con~umption ii; a disea:-e of the immune. Xow. to immunize the immune at times of failing resi::;tnnce is u tn~k Leyoncl our power nnd therefore the hope fur protecth·e immunization against the disease a priori unlikclv to be fulfilled. ~\. great{!r theoretical possibility may be seen iu tl;e sterilizing therapy as conceived by Ehrlich, but we consider this ::;light also because we must assume that the struggle between the :-;pecific factors of immunity and the nonspecific ones, which "'C' will still haYe to consider, must havo set profound ch. nges in the whole constitution which an influence on the specHic factors alone would hardly alter. It is important that this reaHzation remove tuberculosis out of the class of diseases which can be influenced by specific measures. Our efforts must therefore be conce~fod again ·t the other nonspecific factors by whatever means, medicnl or non- medicnl, we mny find eff ectiYe. . The greater part of the nonspecific !actors which we believe to be of decisive influence in the genesis of tuberculosis belong to thnt large category of factors which were determined in the laboratory of human ob:,ervation and experience. Some of these factors at tim~ undermine the natural resistance; others strengthen it. They must ham a phy!'"icnl bllsis, though at present we ignore it, n&Signing mauy of them to that ethereal realm of the psyche, so much dreaded by the accurate laboratory worker. All the vu.rious emotions Lelong hereto; fear and nnxiety and worry especially, and against them the i::ensutions of relief that mn.rk their passing. We believe that in this regard the experiments of Crile and the conclusions to ''hid thev led him haYe the greatest heuristic value. His postulating '' thnt the mechnni:-.m ·which produces musculnr : ction nncl emotion ib the same us the mechnni!'m which generates heat, maintains consciou .... nl.'.s.c:, nnd causes the splitting up of foreign proteids by 'l\hich the chemit•al purity of the body is maintained" hns a. significant hearing on our problem of tuberculosis and snggests a more t:rngible cxpla- uat:ion and perhaps may lend to more direct measures of prevention.1 The reluti ,.e importance which the specific and nonspecific factors haYe in tlrn production of the disease tuberculosis must determine our prCYentive measures, ns it should guide also our therapeutic met hod!;. To place undue stress on the importance of the !:pecific :foctors wonlcl not seem justified from "·hat we hn Ye ~aid a bow. ".bile "e will not relax our Yigilnnce as regard the specific ea uses • G(-orge W. Cr!I(': Mnn, nn adaptl\'e mPcban!Rm. N. Y., Macmlllnn. 1010 (31i'i J•P· lllu<tratcd, !j• ), "· lGI. KLEB&--l''GBEllC ULOSIS. 457 of infection (cleanline'iS. sputum de:rtruction. etc.) aud the naturn] rnriations of specific immunity (hereditary: ethnic. etc.). we will hn', to admit, and dir~ct our actions nccorclingly. that the non- specific factors "hich tend to undermine naturnl re,i .. tance are. foi· the pre ent at least. outside of the reach of strictly medical interference. A new profession: that of the medically trained l educator, the:. social phy::.icinn,'' will ham to co1,e 'rith these prob- lems ior which tl1e general physician with his :-pecinlistic preoccu- pations is little fitted. The new ~\.rmy and Na,·y might well offer nn immense uncl most fertile fleld for the rni-:ing of such a profession lVhich at present is recruite:l almost entirely from amnteurs. wcll- to-do, philnn t hropicl1lly inclined pl' ysicinn:-. "110 wi II gh e ~omc of their pn:cious time to committee mecting~. Lut 'l'l'Y littll' in- dcpemleut thought or work. That there is need for ::.urh trained and paid experts, and th'lt the neell is felt especially in the problems centered in tuberculosis, a glance at the literntnre shows immediately. It is well expressed in the words of one social worker ,,hen he ~uys: " The effort tc combat tuberculosis without changing the fundamental errors in our economic life is n futile fosk. 1 III. INSTITUTIONAL PTIOVJSION. W c cnn bo brief in the discussion of this subject. II ere as in no other part of the tuberculosis problem Amtrican contribution hns been original, eminently practical, and successful, nchie' ing with the :-:im- p lest menus thc ends in view. From the earliest creation of a Tru<lt'an and Ilowditch to those of a Herbert ~fa:xon King, whose death Wt' deplore at this momt'nt,~ nn 1 in many other privnt<• aml public snn- atorio we find types of planning and com;trnclion thnt prcclulle nll nocessity of looking :for models elsewhen'. It is evi1lent that the military authorities, which must be prep:1red to take cure of c\ery kind of "casualty,'" o:f the crippled as well as of the wounded. of the chronically ill as well a.:; of the acute case, will have to inclnde in its provisions such ns arc suited to the needs of the tuberculous. Whether an cnlnrgement of existing proYisions will ~-ufiice nn<l whether, in gcnc1'3l, these patients be cared for in military ins1itu- tions or be distributed in prin•te or public sanatori11 and hospit:1l>'. those are questions which " ·ill ha'e to be settled in accord with the general policy and financial nnd administrati,·e considerations. •Boris J). Bogen: An nd(·quntc rcl!c! ptogrum for tuberculosis cru. ~. Journal of Out- door Ltrl', !'\ew York, 1017, xiv, 232. •King 1111'<1 Jnn!\ :?4, Hll ';'. To him l>clong• the honor for Im\ Ing 11 t evolved an<.I e:sP<:Ut«I a IYI'" of Rimple lean-to tor the accommodation ol a group o! patlPnt., pro- viding for out<loor 1<lee11lng lo nll climates. Thl~ lltlle Dlhdcl hns been <'OPh'd In almo!<t every Inter Institution. .ls a type, ln IU. original slu1pllclly and usefuln11;<, It ls ~till Ullsurpassed. 458 KLEBS- TUBERCU LOS IS. ''01 XI. In reg-:ml to t lie mnnngement of the case.'- confined in speciul inr.,ti. rutionc:, we belie,·e thnt an entire chnll!!C of nttitu.le townr<l the "llb- ject will hn,·e to come about if u real benefit to the men and to the scr' ico is to re-ult. \\'e can not eutcr iulo llct:iil-.. but it mu t be clear from wbut wn-. snid in the foregoing chapter thnt nl. o in the institutional treatment of tuberculosis strictly medienl mea-.ure::-. will have to plny only the minor role. ~1:-o we do not think that the strict sepnrntion of the tuberculous cai,e::. from those sufTeriu~ from similnrl.' debilitating disor<lers is either llt~._s.-.ar~· or <lesirnble. A distinction of type of institutious will be necessar.\·, bnt the assign- ment to them of cases should be based le::-:; on the .• n1ll m1icnl and 1,.ll'teriol< gic fiiHli11g:; bm rnt.hcr on the degree of ph,r::.ical inca- pacity for definite kinds of work. ~forked inn1lidity will re11uiro mfirm.try or hospitnl pro' i!:>' on, wlde all the other co nu it ious short of it ought to be accommodated or better employed in institutiom,, which might be cnllt'cl ·' s:urntoria,'· '· health work camps,·· a vocntional colonies." in accord with their fundamental purpose nnd method which mnkes useful vocational training and work its prirnnry nim. re.;,t nncl rccrrntion, prerniling in ~xisting ~annt0:·i:1. h,~i11g a~si!?:ned to a econd11ry. 1:omplcmen,a. :"' l'' ition. B l!bH~l'll the t wo type"' of institution-. there ought to be closest cooperntion and exchange of patients. The mention in the "war tuberculosis program" that "the ('Stah- r I nt of GoYcmment :farm cofonies * ~· * is worthy of careful con · d ration:: is n. timid and insufficient recommendation of n meas- ure the efft>cti \·cness of which docs not need any further c:xperimentn- tion nml theoretical consideration. It needs purposeful und energetic intrc duct ion. follo,ring example:;; which ha Ye prored eminently suc- cessful abroad und \rbich to a limited extent ha.Ye found successful imitators in this country. Farm colonies provide satisfactory oppor- tunilie.:.. only during the summer months. But the scheme of organi- zati<'ns such n.~ we lrn \ ' C in 'it w must provide for such opportunities continuou!?ly throughout the year and also be fairly independent of particular cli1m1tic a<lrnntnges. We recommend the establi~hment of central institutions for vocational training of the tuberculous, under medical supcnision, but managed by one or more experiencecl rncati1 nnl teachers; any kind of vocation, farming included, to be on the progrmn of such in,:litutions. For what ma~· be tenned the '· convnlescent period" of the patients, beginning with their '' ~ndn­ ution •: n::. rcgarJs physical and •ocntionnl fitne:::s, the forrnation of sqnacl'l for .. Y<'cation:il health '\\Ork., might he made a feature. Such ·quad . le<l by some responsible graduate. may serve to form nuclei of 1ww im,titntions throughout the country, where suitable work might offer itself. The whole scheme in onler to be trul)· ~ueec<=sful. we believe ought to be organized on business principles. subsiclized ~ o. 4. HARE-CARD!O·VASCUl.AR RE~AL PATIEXTS. 459 by the Gm cnunem. but aiming nt :-;elf-support on n profit-shoring bn9~. In the nttack on the tuberculosis problem. which is of vital interest to Army nn<l X ~n y becau:;e it is submerged in the general problenb of physical fitness nnd efficiency. the mnin thiug i,, thnt we make "ulid the commnnds of n broader. deeper 'i~ion. which trnnscen<ls ~peciali!"tic conceptions. Expert a lvice and assi~tance without such a vision "ill give us i::.olated schemes and iustitution., which in their well-groomed appearance will delude us into a. sense of perfect .1chiewment ' "bile, in fact, they will lack coor<linntion: ,·itnlity: and 11ll thl" el<'nll'nb of trne efficiency.1 SOME OF THE PJ.1,0BLE:&IS OF DIAGNOSIS AND PROGNOSIS IN CARDIO- VASCULAR RENAL PATIENTS. lly lloH.\!ll' .\. 11.\Ht.. Surgeon. United i:\lat1•s N:irnl U1·scrh' Foret". There are certain c-onditions of the canlion1scuhn tcn·1l system "hich 111·0 constantly presented to the prnditioucr of medicine nnd ,.,urgery whether he lie in ci·•il or military life. It is not neee.-..:;nry. nor is there space at tl1is tim€, to enter i11tn a fnll cliEcH~sion ns tu "' hethe1· renu 1 disease is the primary en use nf c•:n<lio'."'nsculur chnnge. ~ hether cardiovascular change is the primars canst• ot rennl tlisens<'. or whether some c·onmwn factor ind uccs. changes simultaneously in the heart, Ye:ssels nn<l renal tis.-;11es. In certain instnuc.e . n;-;. for ex- ample where syphilitic: infection has takcu 11lac~. there cnn I e no doubt of the common etiologicnl factor J,ein~ prc .. cnt, nnd. fo1 tu- nntely for onr diagnostic. prog110:-:tic and therapeutic purpose-.. the rnrion5 tests which hn rn been introduced to determine the presence of ti recent or olcl infection may give us such a clefi11ite amount of infm,11ation that thl' c:rnse is exposetl nnd the indicntion:s for treat- ment nrc tliscoYered. It is not my intention, howc\ cr: to deal with cases of cardiovascular ren'.ll djsease from the ordinnry tandpoint. but rather to di~cuss certain points in conn<!ctiou \rith the manife:;- tations of these conditions, which points are of impol'tance particu- larly to medical officers1 ~·ho are not only called n pon to exp re"~ l xpert opinion~, ns arc ci,-il pructitioner~ 1 bat Hpon whun nn nddi- tionnl graYc re~pom;ibifay rests in that tl:c opinion ghen to nn indh·idual, or to tho~l' in authority oYer him. if correct. mny Io ~ibly :nc n !-hip and many liYes. or, possibly, be C\'Cll 111ort> far-re.1ching 1 Horner Folks, onr ot our ruo~t experienced workers le tbc llcltl of sodal control of 1ubcrculusl•, In ndvoc1\llng the coo1·dl11ntlon of gcncrnl nod tullerculo.ts relief, lately 1>IJc<1I bis nn~er on thlg F• r(' spot In our rell,•f '·ork 11t h11nU.' nn1l nt prcs~nt al<o ahroa1l. lie noted pnrtkulnrly ho\\ the 1•ar.tlkl separ:itc o~ncles "hrlng Into the fieltl con•tant <Onfu Ion oncl dh lslons of rc.sponslhllltle-." Jnurnnl or Out<Jaor I.lfo, !\cw York 1!117, 'ti\", ;.?:.?~. 460 lIAIUO:-CABDIO-YASCULAil RENAL P.\'I1EX'fS. in its influence should the function of a particular ship b(' of •ital importunce nt n (•titical moment. On the other hnml. nu en-or in dingnosi:s nnd prognosis m:1y <lepri' e public in titntious in ch il life. or the Nn'y in professional life, of an eXC('edingly nble officer nnd ma~ block the cnreer of a man in "hom C\ l l'~ 011e ho confiJenc nncl whose prof:}>ects huYe hitherto been con idere<l exe<'llent. The first proposition which may be tnken up is the di Co\ery uf ulbumin in lnrgc or smnll quantity in lh" uriue. In much the same way thnt yen1'S ugo sugar in the urine meant n di-tgnosi · of dinbete;:,. but does nol hnve thnt result to-day, so some yea.rs ago albwninuria was supposed to be a pathognomonic sign of nephriti~, or, to use a morn acrnratn term, of a chronic degencr:1tirn chnugi.l iu the kidney1;. The ml'rt' finding o:f albumin, unless it is found rcpe:tteclly, is not suflicicntly <lingnostic to do anything more than etrnse n physician to investigate the cuse still further. It might almost be sai<l that lie who makes n dingnosis of Bright's disease on finding albumin iu the 11rine is in much the same category as the man who makes the dia!!nosi" of tnbel'culm.is because the patient is somcwlrnt un<ler weight and ba- n cough. The microscopic examination of the urine untl a careful c.xnminution of the cardiovascular apparatu::; are essential before :m opinion is expressed. If side by side albumin ancl granular casts are found. nnd particularly if along with them granultu· easts red cells cnn nl o be seen, then: a diagnosis of chronic parenchymntous nephritis with 'some acute exacerbation can be made, purtic11l1trly if the number of red cells is considerable. A multitude of people in all wnlk:-; of life are going about attending to their affairs with ordi- nary elliciency who, nevertheless, have parenchymatous nephritis with ,·ery consiclerablo amounts of albumin a.nd grunular casts in tlwir urine aucl who do not come to grief until by exposure to l'Ome infection or other en.use an acute or subacute process i~ supi>rimposed upon the chronic degenerative change in the kidney which so impair:- its ncth ity that acute nephritic symptoms promptly ckl't•lop and often cause dcnth within n few hours or clays, :i !though the paticut hit11erto mny hnYe been looked upon as one in perfect health berau:-e of his efliciency nnd general appearance. The finding of albumi1,1 constantly in any quantity associated with the presence of g1·anu]a1 casts shoul<l, therefore, put a man, holding a re.-.;ponsibl" position. "on shore," and if, in addition to albumin and casts, red blood rcll~ nre found, not only should the recommendation be m:1cle that he ~ rcliewd of bis responsibilities, but that this relief should he gi .. eu at onC"e, i::ince ordinary e:-..lJosure may be highly detrimental to the in<li ,·i<lnal and possibly detrimental to th~ serdct>. Where renal <'hanges are manifestly present and where laboratory facilities, e\eu of modernte degree, are at hand it is of very considerable importanc~ ~o. 4. IIARE-OARDIO-VASCULAR RE:XA.L PATI.E~ TS. 461 thnt nn e:;timation of the nonprotein nitrogen of the blood should be made, nncl if the nonprotein nitrogen content of the blood is incren*d -the danger to the man is mnrkecl. Thus. n prominent lawyer of 58, with a blood pressure systolic lSO. din:stolic 110. whose urine contilined only n trnce of albumin 11nd n few hyaline casts. hut "ho!"oe blood showed ():l milligrams per cent nonp1·otein-nitrogen, felt H> well that he insisted on ::,tnrting on n pleasure trip. but he was seized by an uttack of pulmonary eclemn within ~4 hours of the es:uninntion of his blood and died before he could be gotten to hi:s bed in the hotel \\ i1c1·e he was staying, yet I think thnt nuyone who hod simpl~· in:-peC"tecl this incliYicluul would haYI! passed him us being more than a foir specimen of manhood at hi;; uge. It \\011lcl seem to be pn1tty clearly established that in patients ::;uttering from fail- ing circulation resulting in renf!l con!!e:st ion there is 110 increase in the nonprotein nitrogen of the bloocl eren if some hynline casts and nlbnminuriu are present with edema of the lower extremities, but in chronic nephritis oi either type at the stage when the patient is in dnnger the nonprotein nitrogen is greatly incretsccl. ~omctimcs being :is high as 180 milligrams per cent. and if il b" only 40 milli- grmus per cent he is out of bounds. ·when the!':e cases thnt hn\'e blood as well ns granular casts recoYer from an attack they nre nlwnys prone to other attacks of pulmonary edema or other e\'idenccs of uremic poisoning, so called, which attacks mny come on with the suddenness of apoplexy on slight exposure after some nerrnu;; str<?&;, indiscretion as to diet, and sometimes apparently without c:rnse. On the other hund, it 1s not to be forgotten that in some instances it would appear that the chronic degeneratiYe p .. occ.~s in the ld.clneys is really very moderate; that the symptoms are precipitated by ncnte cong· stion or inflammation of these organs; and thnt absolute rest in bed with proper additional treatment, and later the tn·oidnnce of exposure, may be promptly followed by apparent complete reeoYery for a ,·cry considerable period of time, saYe that nn exn.minntion of the urine mny constantly reveal the prnsence of some renal trouble.· It mny fairly be said th:i.t, if such a casr presents n considerable number of granulnr casts, he is unfit for active duty eYen if his general symptoms for the time being clear np~ but he mny be 1::uffi- ciently well to work for a brief space if these casts arc few. It is not to be forgotten thnt a considerable number of hyaline casts has not the grnve significance at one time attached ~o their presence. ~ince many normal urines if carefully centrifuged will revenl a few hyaline casts and some temporary renal irritation or C"ongestion ma:y induce n shower of these casts and thereby mi!::lend the physician if SC\'ernl exnminntions nre not made. It i~. howe\'er. in connection with so-called chronic intt>rstitinl nephritis with associatt>d cardiovascular change that the physicinu 462 HARE- CAllllO-VASCCL.AU REXL\l. P.\TU:N'fS. will most frequently hn,·e to deal wit!1 a compll'X problem. The duration of life of the parench~·urntous nephritir is nearly alwnvl' brief; in inlcr:-,titinl nephritis it may I!" on for 20 ye.nr:-' and duri~f! the mnj01·ity of the::-' yenr .... the patient may he dlieicnt and pre ent no mnnifcstntions to himself or to his fellows of impairment of health. If he appear:; for a physical c.xnminntion it will be found that he hn!:!. as a rule. n blood pressure con~idernbly hif!her than norma 1, sometimes 'ery high, and it is a noteworthy fact that not infrequently u man with inter:;titinl nephritis oncl high blood pr!!!. sure feel:; t lint he has quite his usual vigor and. possibly, seem~ to be more energetic and to hnYe a greater feeling oi well-being thnn ~omc one whose hlood pressnre is in norm al bounds. Such a man is pre- cisely tlw one in which the most accurate diagnostic and prognostir skill is rl'qllircd. Under ordinary conditions his rlliciency may bent the maxiunun, lmt 110 sooner is he placed under nnnsnnl !,tram nnd stress thnn his faults become manifest. Either his pressure is sharply incrensc<l so tJrnt nn undue strain is thrown u pon his heart :m<l Ye!'-~ scls with the result that he suffers from carc1iat symptoms, or from retinal hemorrhages or renal sym1Jtom,..,. m· he ;;11clclt'nclly Lu·ome, enfe<>bled nnd dyspneil· on Pxcrtion and pre~t>nt ~ l'\ ic1c we-. oft 1xemin. Tu -.n<"h u 1 n,1: thc1·e m::,v ht· few or 1w gra n11l111· 1·ast-- nlbuminurin mny 110 1 he crn:stant. and tLe ronclitinn of his l'L'tinal w els and hi:- rn:-;1:11lar syst<'m, as shown by t he fingers nnd the sphygmomanometcr. m:iy rcYeal to the physician that at :rny moment some ab!'olnlely incapucitutiug complication may arise or death ens11e. Rctinnl hemorrhagt>s nre not the only things to be looked for with the ophth:ilmoscope. Marked compression of the retinal Yeins by pressure e-xercised at the point where they are crossed by t he arteries is significnnt ·of threatened trouble. The prolrnblo durntion of life can to some extent be determined by the ~tate of tl1e retinal Ye~sels . De Schweinitz has studied this mat- ter mo~t carefully :from the standpoint of the ophthnlmologh;t and w" have followed a number o:f cases together. The! e facts are well emphasized by the following figure:>~ which illu~irnte the duration of life in chronic interstitial nephritis nfter tlrn occurrence of retinal changes. Belt rollected 419 cases, of which I~ per cent tlied within 1 year and no per cent " ·ithin 2 years. The ca--es reportccl from IT:rnb's clinic by Pos,.;tnwr showed that none of the men applying for treatment l iYccl more than ~ years; of the women. GS per cent died within the &nue period of time. Of prirntc patient:- who c~uld liYe comfortably, only :rn per cent of the men nnd .i3 per cent of the women had died at. the encl of 2 years. Gruen- ing collected 100 cases, none of which sunin::cl more than 2 ye:m- after retinal changes began, ancl Bull fou nd thnt {\f) out of 10:3 eases diet! within~ yenrs. Of the l'<'maining 34, J 7 died 'after a longer ~o.4. lI.\RE-C,\IlDIO-VASCCI-\R RESAL l'ATU!STS. 463 period. :m<l 1 i were alive at the time his pn prr wns published. Jfarlnn analyzed 4-0 cn~e<; with the f1)1Jowin!! results: Thirt:r-three ended fntnlly nt ,·nrious period~. a\crnging 4: monlh~: ;~ Jh·ed n year nft<>r the cliscon.•ry of retinal chang';,: a 1·cco,·ered. nn1l 1 regained hi:-. eY£'sight. although the urine wns albumiuom: at the cn<l of 2 years. irnot ttnf'ed :J4 <'fi"'C' and found the aYernge duration of life to be l~ tbnn 4 month~ frc,m the time eye changes were fin-t ob~encd. One of hi pntienb li,·crl 1 months. but all the others died within a year. On the other hand, 'Web~ter mentions the ('O~e of n clergyman :::utl'criug from elm nic inter!>titinl nephritis: in whom retinal changes hncl beE'n recogni7.ed 10 or 1.1 years befori~. and .. who is still living.:: nnd " "'-'rt ha<l a woman m11.h r ob~ervation in whom retinal change~ had been notked more than l years liefore he rC'portecl the Ctlse. Iler general condition w:Hi mueh tbc "ame ns when she came under his l'h:trf!('. I htffe ha<l under my care a number of patients who have Jiwd from (; to S yenrs, during which retinal hemorrhnges harn re- peatedly O<'currctl, nnd whose arterinl tension has been astoni~hingly high. )fost of these cases, however. with very high tension nnd re- tinal cl anges die from apoplexy or an acute m~·ocardial failure soon ofter retinal changes de,·elop, the patient often dropping dead with- out warning symptoms. Diifc"e11t obscrn•1·s give ,-,!rying percentages of OC<'lllTetwi> of retinal le~ion!". Out of n:15 cas;.>s of renal disease, Uroe11011w found retiunl lesions in :!O!l, or ~2 .. 4 per cent. The age at which they most freqtll'ntly are met with is from .30 to r.o ~·ear:- . but they hnH' been ~ei.:n in :Hlolescents. Fi Ye types of these lesions are recognized hy ophthn lm okgi~ts: (n) ty piral :1lhmninuric retinitis; (b) degenerntiw :1 lb11minuric retinitis ; (c) hemorrhagic albuminuric retinitis; (d) nlbnminuric 11p111·on•tinitis, and ( e) nlbnminuric papillitis. In the first form irregnlnl'ly sl1ape.1 white dots or spots appeat· in ancl around the rnncula nnd mu~· take n, stellatc form. Whm the condition is well dt•\Cloped a zone of whitish yellow may smround the head of the optic ncrn. Flamelike hemorrhage may also nppe~1r. The con<li- tion i>: at first one of hyper£'min., then of degeneration, an<l finally one of a.trophy. In the second form the white spots nre small: hemorrhages are more limited, an<l the white zone nbout the nen·e ht'ad is not well de•eloped. The third form: as its nnme imlic:ne::-. i!" chiefly hemorrhagic in type and the hemorrhages are large or pro- fuse. while the other changes are insignificant. Only when the hemorrhages arc absorbed do these areas become whiti::.h. The fifth form shows that the process has been confined to the optic nene, so that n papillitis or t'hoked disk is present. the retinn being but little i m·oJ ,·ecl. 464 IIARE-CARDIO-VASCULAR RENAL PATIENTS. Yul X.t. It is important to remember that mere excess of blood prcs;:ure. while it may bespeak abnormality, is by no means suflicient justifica- tion for shelving an efficient indiYi<lnal. It mui-:t Le recalled that the use of the sphygmomanometer may, through 11cn•1m:;. css :llttl appre- hension from the HO\ elty of the proccrlurc, give n l'lcortl 1:> or 20 points higher than that usually present and, if the reading is 18.., systolic, undue importance may be attached to this, \Yherea:; :i set·- ond examination within a few minutes, or on a 11other oceJsion, par- ticularly after a period of rest, may show that the itvcragc pre.ssurl' h; probably as low as lGO or 165, which. in turn, is quite wiLhiu houncls for some persons. The point to be remembered about blood p1ess11re8 ranging from 160 to 180 is that their prognostic nn<l diagno:otie im- po1·tance depends more upon what is found as to the heart und a.3 to the kidneys than upon any other factor. If the kidneys arc right, or repeated examination shows that they arc only slightly m ong, a pressure of 180 has not the evil significance that n pressure of mo would haYe if the heart is feeble or tired and the kidneys much im- paired. If the urinary examination is fair, the point to be deter- mined as to the indi' idunl's efficiency should be reached not only hy ordinary methods of examining the heart but by studying the differ- ence between the diastolic and systolic pressure after rest and after exercii::e.. If the diastolic pressure is constantly high, above 110 or 115, the high systolic pressure indicates a still gl'cnter strain upon the heart, and if the difference between the diastolic pressure and the sytolic pressure be only 10 or 15 points in a case of high tension, in all probability the reserve power of the heart is so impaired by C'xhaustion or disease that a cardiac crisis 01· the development of rapid cardiac failure may be expected. Under these circumstances there can be no doubt as to the val\10 of stair climbing or other forms of effort in determining cardiac efficiency. Going up 20 or 30 steps at a fair speed if followed by no rise in systolic pressure, or if followed by a fall, is very significant as indicating that the indhidual is in- capable of being subjected to severe mental or physical stress. In other words, the mere height of the systolic pressure, unless it is so extraordinary as to endanger the integrity of the blood vessels, has nothing like the significance that is possessed by a very high diastolic pressure, n poor pulse pressure, or by a definite fall in pressure on moderate exercise. Many persons with a high blood pressure haYe developed n compensatory hypertrophy which enables the henrt to o,·ercome this vis a fronte with impunity, whereas many others with a comparati,·ely low systolic pressure are conslnntly on the border- land of more or less acute cardiac breakdown. In other words, as was indicated at the beginning of this al'ticle, there are few conditions met with by the medical mnn in military or civil life in which his diagnostic and prognostic acumen is so .,; <( ::?: 0 J: f- ;. ....: -0 c VJ " o; ui :::; c ~ <( ::?: > <( I c 0 :; c " UJ f- f- 0 ..J .>< " :r a:: <( :c -0 c (J " ~ z ., "' ~ 0 Ill <( 0 a:: 464-1 Butler and Hakansson-Vlriiln Islands. BIRD'S-EYE VIEW OF CHRISTIANSTED, SANTA CRUZ. A PICTURESQUE OLD WINDMILL. 464- :? Butler and Hakansson-Virgin Islands. HARBOR OF ST. THOMAS, LOOKING TOWARD WEST INDIA COMPANY'S DOCKS. GOVERNMENT HILL, ST. THOMAS. Government House Is where ttie flag is flying on the extreme right. the bulldlng on the apex of the hill. Blackboard's castle Is Butler and Hakansson-Vir&ln Islands. STILL FOR EXTRACTING THE OIL FROM BAY LEAVES, ST. JOHN. EXPERIMENTAL SUGAR CANE PATCH, SANTA CRUZ. 404-4 ~o.4. BUTLER A1'0 HAK .\NS~O"'-\" IH<llN lSlM\NDS. 465 thoroughly tested as in the sttHly of canlicl\·ascnlar n•ual ,..tatt:'sj ther.! a re few ill which his profcssioua l j udgml'llt mny he followell lrv :;o mnch cr<.'dit. or discredit, and there u re f<•w in which the llllllte- ciintc unrl pos.-,ibly the remote future UJl(l happiness of till' p11tie11t JUlll'l' brgcl.} llepcmb. Thi~ :::ubject illustrates once ruore that he who attempts prognosis 1111d di11g110Ris on one major symptom is faulty, nnd that c·o1-r<.'rt and :il•ruratt• conc:lusions can only be reached by thorough im·<.':::tigntion awl a c11rd'11l balnncing of all the pros and cons in the cnsc. Finnlly. I would like to emphasize the 'nluc of the estimation of 110uprotein nitrogen in the blood for its prognostic importance in n·nal t':tscs. I nm well a.wnre that it, like nll other !actor::; in cliag- 11osis, is not to be given too great importance, but a high nonprotein J1itrogen pt•rcentnge, in association with the other symptoms dc- sc·ribed, will, like a sudden change in barometric prc!:>Sul'e, put th1· physician in 11 po'-'ition to he ready fol" the storm thnt mny nris1>. SOME FIRST IMPRESSIONS OF THE VIRGIN ISLANDS, MEDICAL, SUJl.GICAL, AND EPIDEMIOLOGICAL. 11~ C'. 8. UUTLEll, Surgeon, nud E. 0. HAKA:ssso:s, A~slstnnt Surgeon, United l'ltt\ll'~ Navy. The Yirgin Islands were discovei-ecl by Columbus \\bile on hi~ sec- ond >oyag<.'. It seems that he gave them the name" Lns Yirgenes" in -- . . -r I I .. lio11or of 1-:;t. Ursula ~tll<l the thou~•' nd vi1gi11P who wore murdered .·.hilt· nn a pilgc·intnl!<'· so !he l11g·~n1l goes, by tlir Huns :rncl buried H~i:il -- 17 {l 466 lll .. , Lhtt .\SL> llAKA~S::.O:\' \IHI,).!\ 1::;1...u;u::;. Yo! ~ I near Cologne. (~<'e Encycloptl'dia Hritannicn: 1 lt h ed .. \. ol. XXYII. pp. u:!-... OJ.) '!'here nre ubout 100 i~lnrnl-.. iu tht• group. mo~th­ uninhnhitcu. nnd their total area i:,, not mer :;ou ::.qu.1rc mile:-. Th~ group bdoug::. to the Le<>war<l Islam.I:;. which extend from Porto Rico in a chain to l'n:-t n11J :-outh a:-. far n~ )farti11i1111e. LccWttl'd refer-. to their le::,:-. l'.'\J>O:'<'d p05ition as regards the northe<bl ti .des than the Wind\\ artl group. Great Britain and the United State::. now own the whole of the Virgin Islan<ls. Vieques and Cnlebrn, l>elong geo- grapbicn lly to this group and were in possession of the Unit<>d State ... befol'e the pnrcbase of the Danish I sland,.,. This purchase increase<l by about 135 square miles the area hekl by tho United States in the group, and tho islands transferred in this pur·chnse comprise St. Thomas, with the pretty little city of Charlotte Amulic as capital; St. John, the 900 inhabitants of which are mostly colleded around Coral Bay and Crnz Bay, on the east and west ends, respectiveh·. ·JHJ· ·f [.0· ·>.l.H ·Hl ·l.\AY I JUIJL· JULY· ·AUG jLPT· ·OCT ·NOV· :n.c· la I L- '- -- ._..;;:;-::::;. ~~ fl1- ·-'- ~ v/J - 1 .. 1 I~ • ,,,~\. ·~// r ~, \\ \ l.tl.. ~ r---..... I ' ~ h / / ~ ~ ,,,, [/ '---'- 7~-: " iif 7 -- ~ ~~ ~ " ~ . - LJ'lf' ~ ~/ ,,,, ... , .. '\,_ lz ~ ---- --- 1$H •1'•1 ~~ ,_....... i:::1'/ ,.1,. , •• . ·- . 1e•1 ,., ,,,,, • 111 n MOOOMIOllQ .,. ......... IJ,,I •Ill ·CHu:r'I f.,!A/f1.;,, (11rv:.J TlxtJJ /'.I f:.t;:;.! .,, Iii tntJ' !tJ.'1. I.Ill) .>~fJJTI '~fl .. ~ of the ~n1nll (21 square miles) mass of land; und SL. C1·oix (~anta Crwr.), the lnrgest of the three populated islands. This islnnd. aft.er ib cli~covery in 1493, was owned in tum by Duich, British, Spanish nn<l French. and finall~· was purchased from the French b) Den- mark in 11:1'~. Jn 1H53 the island was gi' en by Louis XIY tv LH~ Kni~ht:- of ~falta : from whom it was purchased uy the Dan<>s. .. ... t. Croix .. il' uppnrently a name inherited from the French. '· ~!mta Cruz·· is the prior name and should be the only one. In nd<lition to beimr the c:irlier it is also the prettier. Snntu C'ruz has an nren of ! s11m11'C mill's, an<l its population is about 14.000, which, like the other islands, is prin<·ipnll~r composed of negro~s. The totn I populn- t iou at present of the three islands is approximntely 2;),000. The Virgin I slantls lie between the seventeenth and. nineteenth p:unllels of north latitude and in longitude b<>twecn ()-1-0 10' nnd 6fi 0 30' \\C.St. The mean temperature is 74° F. nncl Yn1 ·i~ bont :-;o . .f. Hl"'fLlm ..\~D 11 . .\K,\. '::-::'O::\- \.IROIX 1:-1.AXD:-.. 467 10 degrees on either side of this figure fol' ... ummcr und "int.el'. The trudc wind-.: blow owr the islands for u 1•1msidcmbl · part of the year 1rnd add materially to their healthfulne:>:- uud comf1111. Rain- fall on the ~everal islands i::> about the sunc and umounts on an nver- 11.,0 to 46 inche.;; in the year. .January. Feb1·u:U'y anil Murch nrc the d~v months, after whi<'h there is a gradual rise in the rnin cun·c till O~tober, which is the month of greatest rainfall. Thl· ruin curH· ~how:-. a slight rise in May, but there do not nppear to be two ruiny :-easons, and the cause of this secondary rise is unknown. .July . . \ugu:-t, September and October are the months during which hurri- l'anes nre liable to occur. The configuration of the thrN· islnuds j,., mountainous, so that water quickly ·tumbles homt- to the ,.l'a 111· "ot1J,., into the ground, usually not to appear ugnin. ·JAN ·fLD· - .I.t.- ii ,, I ,,. ' .. I .IL- I " ' ~'---- I I . ~.1- .1.,_ J ~ MH AP£ MAY· JUIJL JULY ·AUG SLPT ·OCT ·NO'I· I I \. I I \ I I \ I I \ I \ I \ I \ I \ I I I ' I I f \ I \ I , I I I / ""' I I ' / ,, / '"" /1'. v ......... / \ ., I / ,,_......__ ,__ (\ --- . --.:l _ ...... _,,/ \. I \. I I ' 'I ' ' / \. / ·~:;-t. "'- ·- - ·'- - ,,~,, ~---- i ·····-.. ······ ··· -~'" Ctwtr'L f1:~t11t Cue-.'~ (31•1>.u Yun) .JH;,N& TH~ /Jm:r Or f/.,cc1a~~ )[u< f>,;>.J /:'/6 ..J•< ~ C"e<'Z· ·t'LC - -- ., -1 There are few springs or running streams un<l the question of wnter supply is one of the numerous knotty problemc: which confront the na\'a] govemment. To create nn axiom, it may b<' sb1tRd thnt the hnppiness of a race is in direct proportion to tho abundance and purity of its water supply. .Judged by this i;tandnrd. tlw people of the Virgin Islands shonld be abundantly unhappy: and it is thought that this is a fairly accurate description of their present 1~01Hlition. Cis- terns filkd "'ith an emulsion of roof wnshings in which mo qnito lan·ru ::;pernl their tender moments of life absolutely unhampered l1y any enemy and v. ells whose proximity to somebody's privy seem~ to be n studied effect and guarantees that bacillus coli shnll not peril•h from the enrth constitute the sole water supply of '.!5,000 people. The nornli'-'pO. n 1 of night !'Oil i!' effected genemlly by pride:- or pits, nnd the~e nn' cleaned when the householder ic: focecl with the necessity of emptying the pit or moving out of the premises. It. is 468 \'ol Xt :-aitl chat he often chooSC:> the httll'l' allcrn.1ti\\.•. "~lieu one of th .. pits i:, cmptiL>d it di:4urb,.. the atmo,..phcrc of the :-tilly night f< . mnny square mil~ nml remind-. ont:> of dear old Baltimore n fe, ~·curs hack. 011 one oc<'a:-:iou one of the writer:, ''a~ :rn akcned from a :-ound sleep by the odor from one of tht'"'C e111ptyi11~'· lh• imn1c- <.liately reuclml for hb g1m. thinking it "u:-: a ga,; uttack by the Gernrnn:,. Thi::; i::, a ::ilight exaggerntiou, bnt, may gini p oint to th~ nssertion thnt pits are not good for the health and eomfo1 t of n communit~·· St. John j,, the best watered of the t.hree islands. and it i::. the~ thnt mo,..t of the malaria is seen. The Anopheline responsible for il;.. transmi--sion has not been identified; and though repeated Sl'nrcbe:; hn n bccu made, these hn ve hitherto been without success both there :iwl here on St. Thomas. It is notable that the few foci of mnlarin urc in the Yicinity of smnll swamps or brackish ponds. an<I it jg ·J/iU ·f l~ ·!'.H· ·Af'£ JUY J~lll· JULY AUG ·JC.Pf· {)(T ·.'!~PLC I - ·~----=f--_:-_--+_,...-_ -+-+-~,___ --+-7-+v-_7°'l"f-.;--·~-tl'\-----lr-·- -I ~ / ---- ./"" "' I~, / I t _::s::....-, A...-~--==---=---~-+-~--+~__,f--~+-~-+-~-l-~--1f--~+-~-f-~~ Ctrtrer'~ l"r1A.',,., .. /J.: .'L•,lfl~ l/vu-tiu /":i.e lo Yc•r-• ~~14 -.•., t1't'.!" i 10bublc that the malurial transmitter brcccl!' in crub holes or in .1tcr-containing crypts of trees or plnnts. Malignant tertum nncl unrt..'ln nre the types of malaria hitherto seen. Benign tertian i~ rare, if. indeed, it occurs at all. St. ,John is interesting rather from the beauty of it.s ~cenery and the large nnmber of ruins of old estates than from the chnrncter or Yaricty of its diseases. It must, in former years, have supported n con~i derablc population. This is shown by the number nnrl 5ize of ruin which mark old estates. These doubtless required lnrg(1 num ber. of slaves to properly run them. Tho island is dissected l.ly mil~ of ancil'nt stone walls and narrow roads, often cut out of the solid rock. over which carts curried the sugar to one of the port:> for ship- ment abroad. In riding over the island one got~ some exquisite views of lnnd and sen. Tnrquoise-colo_red bays fringed with mnrble-whitt> corn! benches Yi<' "ith 11z1irc skies in the proflignc~' of tlwir bN\uty. 469 ()utlyin~ keyl'> protect llU!! little harbor:--, which m:ulr. th1• :--ection a parndi:-o for till' bu<'cnne~r in t?e s~Yenteenth centt~ry. _ ~inco ... fnniry wn:-: obolil-lw1l m IS-L. the population of ~t • • John hn:.; -u-ndilv dccreaS<.'d until now no more than !100 nativ~ remuiu. The .}oth ~f tho negro. combine-ti with bad land law~. ha:. reduced the remnant to u state of abject destitution. The :-oil in many places is fertile', rnttfo rni-.ing ic: en:-y owin~ to th~ guinea gra•-. and fish nbound in the snrrournling water:-i. Y(•t in the mi<lst of these pos:,,i- bilitic~ the people are ou the verge of :-tarvation and the once beauti- ful e,..b1te.-. I t'<' rt',·erted to tropical jungle. The bny tree (Pimenta :icri:-) gr1rn s well 011 the island of St. John. The lea \'l'~ n re collected, their oil l':Xtrnctcd b)· cfo;tiUalion, and bay rum mnde either by mixing the oil with a low-grnd<' alcohol or, better, by distilling this mixtme of oil aml nlcohol. :-'t. ,John's highest land is Camel Mountain. l ,~;;o feel. ~\nntlH'l' point almost ns hi~h i:-i Bord<':rnx, which hns the <lbtinction of hnvin!! a dlln_!!l on its ::;mnll apl'x. Most of the time of the villagers is con- .,umed i11 trying to get food and water from the lowlands up the dif- tiC'nlt trnils. A short clistnnce south of Bordeaux, near Reef Bay. i::. o clif upon which one of the few remnining Onrib in-.cription:- mny he seen. 'lbl.' 11ntiv<'s of the Vil'gin Islands are n :;ubject for the ~tndy of the .1nthropnlogist. Brought over in slave days from ,\ fricn. they. of cour~c. tetched the 1liscnses and habits prevalent in their natiYe land. Such of the diseases ns found conditions favorable for their spread h:I\ c been passed along down to the presenl time. Hookworm di:-- ea!'e. schi~tosominsis, filnriasis, an<l. other infections have. in all prob- ability. been introduced into the \\est Indies in this wu~-. Slecpinf! ,...frk1ws:-. was umloubtedly also brought over, bnt ll<'Yer !-.prend hc- caus<: of the absence of tsetse flies. Hookworm infection ha:. been found on Santa Cruz in the neighborhood of one o{ thl' sugar fnr- tories, where, with soil pollution in evidence und n. barefooted popu- latiou, one could easily predict its presence. This di!'ense i:> not widt•- -.pn•ad. however, nnd the reason is that the rural popul11tion i~ sparse. the people tending to live in the towns: lhc night soil from which. while pqorly disposed of, is nt least preYented from wi<le:-preud pol- lution of the earth. The fact, too, of the dry1w-.s of the ... oil dudng a considernblo part of the year Yery likely interferes witl1 the proper e,·olution of the life cycle of the worm. In tt>mperamenl the negroes here :uc quite different from th<' negrne.-; of om· South or from those hrollght up 11nrl<'r Spanish. Frenrl1 ot· English rule. Two cash; are recognized-nt>groc.-. arnl colored, the latter not being pure blacks. Thei1· metho11 of speech i:- p0(!11fiar ancl not tlevoid of interec::t nncl amw::enwnt to tlw foreigner. It is Ene-lish mo<lifie<l hy contnct with mnny other rncl':-. The in- 470 lll1 11.t•:t: ,\:\0 llAKANStiON-VllWlN i8LANO~. tonutiou 1111<l modulation of the voicP. are D1111i,.;h, perhups, which with English words give the t•ffect of n negro i:;pe·tkiug with an I1+•h accent. They are polite, cleanly in per~on nntl inclined to be melanchol,,· (this, too, is doubtless a Danish inheritance). ll"r{o. sponsible in tho discharge of their work ancl comparuti\'cly ineflic:ent, they are, nevertheless, dignified and capable of being ''insulted." .\n employeo reported two separate insults :from his ns:;ociatcs in tlin 1·ours(' of om• cln,v's work. A peculiui· habit whil'h mtrny n:tti\es have, nnd which may be psychopathic or normal to the specie·: L talking aloud to some imaginary person ns they walk along the l'treets. '!'his comersation is, at times, quite spirited though one- sidecl ::llld is nccompanied by all necessary facial and gesticnlatory punctuatio11. The outlying natiYes pay no atLm1tion to these c011vc;. sations, though they appear to urnlersta111l what its nil about, nntl the replies being given by the absent parLy. They are quite snper:-;ti- tious and many of them believe in obiism. This is u kind of sorce1T or l'<mj11ri11µ-.. It is an inheritance from Africa urnl i:s pmcticed h)· neg roes of' otlH'r " ... e:-t In<liun island&. Certain imliviclnu ls are snp- po...,t>d to lw uble to work a conjure to the clisaclnmtagt' or l'n>n th" dPuth of tlwsc 11n1k1· the shadow- of tlwir displeasure. Filarial conclitiorn~ ::trl' widespread! the percentu.ge of people :-;h1h~- 111g m1e or lllOl'l' of them Yar~·ing in the di lfcrcnt islands. A l'Oll- ~en ath-e e~timnte of the extent of this infection is 2:> per eent. lllegitimncY is tlw rnlc. about one child in' fi\·e heing l<'gitirnate. <-Erle; of 13 or 11 often become mothers. Pellugrn is quite common 1rncl results in mnny deaths. Venereal diseases n re wides1wea<l nnd 11mongst the nntives little attention is paid to them. With n<lmiruble nai'.vet6i a chancre will be explained as the resnlt of C'l\tching cold, 111· gononhca ns due to a strain. Drinking is common with Loth ~.e:xpc;, 'I'his is of lhe steady rather tbnn the ncute hilnrion-; type. Two foirl.v l':ttisfoctor~· drunks can hr p111'C'hnsccl for from 10 to 20 <-f'nts. This is <lne to the high \Ol!age of Snnta Cruz nuu. Tlw teamwork. or touncco smoking and alcohol drinking, i8 thus ad- mirably expressed by St. Thomas's chief physicinn, Dr. 'Mortensen. •·There' is no cloubt in the mind o:f the unrrator thnt the smoking of toba.tco grently fmthcrs drinking: it is soon fo1111cl ont that alcohol i•· n splendid antidote for languidness. Lrought 011 hy the nse of tobut'l'Oj nftPr the 11rinking the\ feel !-O re\·iwcl that thPy nrn st.1rt smoking agnin.'' lJrnler thP Dimes the practice of medicine was rPgnlate<l largely from Denmark. Crown physicians were nppointed, nnd these (one iu 1-'t. Thomns and one in Santa Cruz) had charge of practically nil meclical aud public-health affairs. They also had charge of the marine quarantine. Public physicians looked after the needs oi the populntio11, nnd those people who roukl not pny were not charged. Butler and Hakansson-Virgin Islands. SMALL NATIVE DOORWAY MARKET, ST. THOMAS. HEAD WAITER OF A HOTEL, ST. THOMAS, IN " FULL CRY." 470-1 Buller and Hakansson- Vlrgln Islands. AN OVERRIPE SURGICAL CASE. 470-2 Buller and Hakansson-Vire:ln Islands. HOSPITAL AT CHRISTIANSTED AFTER THE HURRICANE OF OCTOBER, 1916. 470 3 Butler and Hakansson- Vlrjj;ln Islands. FRONT VIEW, UNITED STATES NAVAL HOSPITAL, ST. THOMAS. A PAVILION OF THE NATIVE HOSPITAL, ST. THOMAS. 470-4 JH"'l'L~;tt A:'.lill llAKANS::;oN-VIRGIN ISLAND~ . 471 fhi~ 1101q>H) J'OI lion re1H·e,..c11ts u mnjority 0£ the population. There re tln't'l' hospiti1ls in the islnnrls, one at each of the principal towns. JJ.id· of 11H>lll',\' 1.o properly build, equip, and m11intnin the,,e 1:stali· Ii ·hull'nb hns greatly haudicappecl thefr usefulness. All 0£ them aH' crmH!cd with poor pntients. nnd the doctor::; who haYe hilherlo h:11l (•luugc of them hnYe been so overworked and hnd snrh n mnlt.itudc of o11tsicll' duties that it "\\as impossible to look after the work as it should be <lone. Thi!=: is no criticism of the Danish phyl'ici:ms who h1Hl h:ul to struggle with the proposition. They should hwe hee11 hncked with money: a working and nursing force sufficient to care for the needs of the people and buildings and equipment proper to tlw amonnt 0£ work. Owing to the lack of snnitntion tlmrnghout tl1t' il']nnrls, disease incidence antl death rute are high. Poor water ~11pplie:-, hwk of sewage disposal, lack o.f effo1·t to limit mo!>quito hrcecling nnd other Rhortcomings have made of the Virgin Islands H'r it:tble lazarettos. Yet there is not a laboratory in the entire group. There is a mass of potential snrgi.cal work jn sight, but practically very little surgical work is ever nttempted. Imagine u hospi.tu 1 of 100 patients of all types, including insam·, with on 1~· <•IH' 11111·:,e who lrnows anything about prnctical nursing-. with no laboratory, no facilities for modern diagnosis and only one tlnctor to nm the place. This lli tlw stute of affair<! in ench of the tllr<'I' hospitals. o.r conrse, one cnn uot inrnriably clingnose 11mla ria, ty- phoid, dysentery, syphilis and a hundred other complaints to which man is h<>ir. if all he has to do it with are his bare hands and a ther- mometer. O! course, st1rgical work must stnnd as it tlicl in tlw day:-. of Ambroise Pare, i£ such essentials as sterilized dressings must nP11b he prepared in Denmark ~nd shipped ont, supposedly rPo.c1.y for 11!-E'. There has been too much long-distance control of the medi- (':I I J>l'Oposition here, too much of the "you-do-it,, 1tltitudc, with uo pro\ i•.fon mnde for proper farilities :m<l u sufficient n11<1 trnine<l p1 'l'l'OUU(' J. Medical pructice is furlher complicated by the :-mnll 11umber of people whu can pay a doctor's bill. Of th<' 25,000 people, it is Yery uulikel): that four or five thou..,ancl of them are able to pay for nwclical service. This throws a considerable burden upon the Gov- ('rr11ne11t. for as stated abo>e, the disease incidence ic; high. There 11111st h1• nn outlay fo1· hospitals, medicines, midwives ancl doctors, and those cared for mnst include lunatic.c:, leper::;. pellagrinc: and tho!'P disabled from filariasis and syphilis. In other words. there is a l:tr~P number of chronics who are a perennial expense to the State :rnd nn economic burden long before death termiiHttcs their woes. Af'. regards the social and sanitary aspects of the Vfrgin Islands. it wouln seem that the causes which operate to give high morbidity :incl mortality are: (a) Lax obser\·ance of the lnws relating to mu- 472 Ill' rt.bit A!\l> J!AJ~A.);660."-\·rnm:r-; l::iLA~D:-;. Yo! XI. riagc. To this is a11rib11tahll• the high ruH• of ilkgitimncy an<l of ,·encreaJ <li .. cn:;e nnd in1lirectly the high jnfnnt mortality. (b) Pour food condition,.. leading to undernourishment an<l pellagra. (c) Poor sewuge dispo::;al nnd 1lefectiw water supplie::;: lending to numcrou::; i11te.-,tinn l tli<.orclers: diarrhea. dysentery. and typhoid. ( d) Long-1•.ontinued encoui-agement to house breeding of mosquitoe,.. which ha cau~d the high rate of filn.rinl infection nnd high morbidity from this cnuse. In this connection it may be pointed out that Stegomyia, which is the common house mosquito here, breeds prefl·rab1y in rain water. It. is common in cisterns and yet rare in wellsi e•en though these be shallow and open llt all times. It has occurred to tl1.c writers that a. possible explanation of this is that the ins<>ct ma) lny her eggs after 11 rain in the water-holding depres- sions c·ommon in house gutterings. The eggs stan<l drying well and lnkr rains may wnsh th<>se into the cisterns where they hatch nnd thus increase the numbers of insects in the cisterns. If correct. this would complicate the question of rendering cistem~ mosquito proof. Re~nrding the botanical features of tho islands, it should he :.tuk1l that the hurricane in October, 1916, wrought destrnction to the palm ... ancl other trees of the islands and the tlry season tlmt followed this calamity allowed the plant Ycgetation to lirn only by its root-:. So tlmt on their arrival. the .\.meric1rns fo1md barre11 islands with ashy gray hills. ,\ month l::iter the daily sho\\ er:, of the t·ainy seusou begun: ,, nd within a week the hills were green, cornred with thriving tufts of the nnturulizeil guinett grass (Panicum maximum), ttnd a multitude of tropien l plnnts which soon hnd their richly <'olored flowers giving fra:.r1·nnct• lo the nit-. Of the 1.000 floral species found on these islands, only a £cw arc important in pharmacology. Ricinus communis, from the seeds of whirh thl' ca:-tor oil is pressed, is •ery common. The natives are fumiliar with the physiological action of the seed$ nncl harYcst their dose of c:1~tor oil a~ nee<led . . \<::u·in arabica is naturalized iu ::.ome place::; around <lw<-lli11g:-. Tlwr~ nrc many other v:u·jeties of acacia. Acacia :fornesiana grow:' ahuudantly. Its wood is nsed for making charcoal, an importaut i11ch1 ... try on the.Sl· islonds. where practically all eooking is done on the c·oal pot. Guaiacum oflicinale (Linne) or lig-nnm-Yitll', from th<' re. .. in of which the gun.inc is obtained, was formerly common. ~\.. frw 111' the . .;e benutiful trees are still seen in parks and along the ~a,,hor •. Thymus \'Ulgaris is cultivated in many places. From the flowc·r~ l'llll be obtained the oil of thyme, which contains the important thymoJ. Zingiber officinale (ginger) and Pimpinclla anisum (aui:-;) ar11 cultiYntNl extensively :for use as spices in "mnbee," th<' n'lti\'!• I l'i'O. 4. Bl. rr.HU .\Xll JI\ KAX;,,:-1).!\ \ Iltl.12' 1::-1 \.Nii:-. llrink of till' ibl:111d. Thi:-, is 11mue from tht> l.a1·k of l 'olulmna reclinnt:i l the mahcc troo). Other phnrmacological plant.-,. fouml here ure: Capsicum frute:-5- ccns. or C"ayenne pepper. callecl hinl pepper by the natives i Cimm- rnonum z<•yl:rnicum: Focniculum vulgare, from which the fennel .;ecd nrc !!Otten; Chenopo limn nmbrof;ioidc:- b'TO\\..; in n few plnce::. on wall"'. .\ few ... pt•cie ... of Gossypium nre common: they were fonnerl,v c11ki' atctl on the island. Ci. harbn<le11~e (:,,en-i~lnnd cotton) cun 111.i :.rrown. ('offrn arabica grOW$ in !'hndy localitie . It h., s been cultirntccl 011 :t ::;mall scale, principally on tlw isl:mrl of St. .John. J_,imc (Tripluu;iitt trifoliilta) is abnn<lnnt. Dnturn ~lr:imonium, Quas...;iu :unnra, oue of. the plant,; from which q11ns.-;i;i is obtained, Hosa gallicn. and Rosmarimus officiualic: ahout 1·omplete the list. 'I'he unwritten pharmncop<Pia of the negro inhahitnnts comprises, howcnr, :1 larger muuber of plant~. Tlwir thern pt•uti<' wil'tlom is not limile1} lO tL few medicine men, but i::; a JllatlCI" O( lllOl'e general knowledge. E,·en the children willingly inform one how to treat the ailments of man. Every disease or symptom hns ih remedy. A certnin kind of leaf is pnt on a. wound, another kind on a sore joint. The colic has its tea, and the cough its balsam. For worm:'. take ,,·ormseecl (Rpigelio. anthelmia); for indigestion nnd fcwr. drink the tea mn.cle from sour sop ( Ai10na muricatn). In their tn•ntmcnt of" jaunuice/' the natfre name for malaria~•· similia ::::imil- ihu::; curnntur" has hecn the guicling principle, a tea nlllde of the yellow lo•e weecl (Cus..:;ntu nmericana) being inrnriahly used until the doctor's little white tablets stop the chills. The ~Ianchineel tree (Hippomnne mnnciuella} 1le:;en·es to be mentioned. Its innocent appearance and tempting fruit hnve letl newcomers to do more than look upon it-a. disastrous mistake. The tree is highly poisonous in all its parts, and its milky juice exuding from the slightest cut protluces an intense inflammation at the site of contact. It is said by the natives th'lt even the rain water •lripping from its foliage will produce an eruption on thl• skin nnd 11 seYere conjunctivitis. There are many othel' poisonou;; nncl sup- pO:iC<Uy poisonous plants feared by the nath-es an<l OC<'nsionally used for homicidal purpo!';CS. Th.e fl.om of these islancls offers many in- terestin~ fields for investigation. The small area on which the n11111el'o11s species grow makes the islands as connmient to the hotoni~t ns 11 botanical garden. The practice of pharmac~· is carrie<l on accorcling 10 l hi' Danish laws :md regnlations. .A few remarks about thic.; ')':-tl•m. whi<'l1 1li ffcrs :"O widely from ours, may be of interest. In the Kingllom of Denmark the Gon!rnmenl has <'0111pld1• t:<)lltl'lll of the 111m1h1•r an1l lo<'ation of rlntg- ::-tnrl'"-. Tht> pri1wipl1• n1'<·ordina 4 74 DU'.l'I Ell ,\NU HAK XSSOX-nRGIN ISi.ANDS. to" hich dru!! .::tores ure e,,,tublishf'd i,.. thnt th<' popuh1tio11 should get their medicine wHl1011t too m11ch trawl nnd irn.:onn~nicnce . nnd yet that the apothecary ~honld get n trade that ini;:ures him n good income without the :,;train of competition. If locnl nuthoritic find their community in need of n clrn!! ~hm?. nu upplicntion for such ic: made to His Majesty the King. 'ia the supreme bo:ml of health. Should these uuthoritics find that the demand is justified and thnt the place can support a business of tli.: t kind: it is granted that a chug store be established in such and such corner or house. i.\ n announcement of the vnc.nncy is made and applications from pharmacists ore in order. There nre three grades of diploma issued from the Danish College of Pharmncy. Only p'harmacists rated one or two aro q11ar ii ·d for the privilngo of running n drug store. The grade of diploma. mnn- ber of yenr~ or experience, professional merits nnd srientifh- work done urc the main factors to determine a choiee. Tlw pridlege of hnving :t clrng store is granted fo1· a lifetime to the successful candi- date. Ht• pays no tax for this monopoly a11<l is independent of the Government in his business. He may resign nt any time. with the permission of the authorities, and his successor. appointed in n simi- lar manner. is obliged to buy his stock nncl plnce of busines.c.:. ThL-. form of dru!.{ :,tore is cnlJed "real." and is the only kind estahlished since l~~O . Refnre this y<':u· the prh·ilege of hnving drng store..; did not return to the Gm-errunent with the death or resignation of thl' nppointee. but the privilege was his personal right, which he rould sell at any time to any qunlifiecl pharmacist for nny price he could get. These drug stores are called "personal" and were nol rhnngecl tci "real" when the new law went into effect. There ore thl'ee clL"ng stores in the Virgin lslnn<l~. one in 1·ach of the three towns. The ones in Charlotte Amalie ancl Chrislinnsted nro '·real"; the one in Fredericksted is "personal.'' The history of Apothecary Unll, in SL Thomas, illuslrates the sysh'm. It was estnb- ti.:;hed about 18:30 aucl kept by the succe.;;c;ful pharmacbt until 1 3. whe11 he transfeITed it to his two sous and retir<>d. spending the remainder 0£ his day - in a -.;uburb of Copenhagen in his magnifiC'ent Yilln! " t. Thomas," entertaining royalty and nobility. Bis sons managed the b11sine:-;s np to 1913. when the pre~f'nt ownPr bought 1t for $i6,000. Th ;!'l skPtchy and unsatisfactory article will perhupf> suggl'"t to the reader some idea of the problems pertaining to medicine : nrl the public health which must be solved here. Under the Dunes medi- cal matters have e>olved to the condition of paternalism. This was. in ~ome wnvs. n matter of necessity. In others it woulcl seem thnt there hns b;en u failure to make the island population aR>ume all the responsibility it should bear and to educate it to :t complC'te scnst• of self-re-"pon~ihility. To bring thic; nbout will tnke mnny yen~ OARPENTER-TllE TRAIN ING CAMP. 475 and mnny kind of teachers. It is our opinion thnt the medical teachers 1111d nursing teacher:; should not come to the Virgin Islands "ith the idea of monl'y-!!etting. but rather with thnt of serv:ice- serdcci whiPh will cYentunte in better thinu::,. Jn the preparntion of thi article the writer,,, hu,·e to thunk Lieut. ( ommnnclrr William R \Vl1ite. "Gnited States Xnvy; Dr. Oliver L. Fnssig. of the United Stnte::. W eather Bureau: and Mr. J omes .\. Donohoe. Fnitccl States Ntn·y, each of whom hn:- renderr d much • :-.-.1!;111ncc in its preparation. THE TRAINING CAMI', NAVAL RESERVE FORCE, SECOND NAVAL DISTRICT. By D. N. CAlll'fJSTf11. 'kdlc,il In-r cctvt, l 11itnl litalt .:-;"a,·y The pn·:scut interest in training-camp organizatirn1 und lrnildings y, a1·rtrnts the publication of this description of the Xnrnl Reserve trnining camp at Newport, R. I. 'When it became necessnry to em·oll a large number of men for the defense of this Second Naval Districti it was found difficult to -.ecure i:;uitable buildings ns barracks in Newport. The mission of the mili- tary ('Ommandcr of the district was to call into active sen ice nn<l quickly train as many men as possible. Although the militRry situa- tion was paramount, it became necessary :for sanitary rea~on:; to limit the number of men until proper accommodations could be J>ro,·ided. I t wu:s a source of considerable anxiety to the medical oflicers that the personnel was scattered through the town in various bonrding houses. hotels, Army and Navy Y. M. C. A., Newport Y. M. C. A .. and chnrch parish houses. During the first three weeks of organization the men wero attached to the naval training station, but, owing to the great influx of recruit::. for the regular service, it soon became necessary for the Ticserve Force to move to Newport: where headquarters were established in a State armory on Thames Street. At first this armory wns used to quarter men bnt, :i,, it is dark and gloomy, it is now nsed for members of the reserYe crew while on duty. In this armory, which i,.; nt the head of the wharf where the patrol boats come in, is located the <lis- pens.iry for this section base. Proximity lo the boats is essentinl for dispensary i;ervice throughout the uistrict. . Then> were several Rchemes :for housing till' mc11 pending the cou- ,.,truct ion of barracks that for one reason or :mother fell throu~h. such ns utilizing a Fall Rh·er lin<.'r. renting hotel:-: at .T:imc-.town. ll'as- ing the bathing eslnblishmcnt of the Newport Ileach A'-sociation, etc. The <'amp ::;ites nvai.Jablc in the Yicinity were lirnite11. The Cloyne ~choo l nthlPtic firld lwtw«:>en th<' T!·ninin!!" ~tntion Hoad nncl t he hos- t'ARPE::-\'l'f.R-TllE '.fRAlXI"G C,\Ml'. pitul \\ n~ ti.nally otlc•rctl. free of chargl!, tlmn1gh the patriotic "tll- pro,.:ity of the nw1wr. D1·. 0. """· Huntington. Thi:; field ,..]op~ iu two din'clions- toward die \\ater nnd town rd the mnin road. "'at •r nn<l sewer comwctions were both near by. Th..i tiel<l is 111.-.y of nccc-.-.. for :;uppli.-:-; of nil kind:; nnd is relatively :,bcltered from the ble ik "in<ls of winte1-. Proximity to the nnYal hospital was an objccti011• able feature. bnt with the pre~nt method l)f hnndlin~ contn!!ic IL"> di:-ensc._ iu the :-ame grounds and eYcn in the rnml' huilding of n gt-n- eral hospital this objection was not suffici<'nt to onl weigh the• '<'Yer ii n<h·::mtng<'s of this site. It wa" firl't intended to haYe the men quartered in tcnc ou tht• ticld, hut n:-. it" as impossible to obtain tents it wns <i<>cicled tn build wooden barracks. Plans £or these barracks were modified to '-'llit the :c.1wcinl needs of this camp. The general plnu wa-; thnt of the type for mobilization camps issued by the (_Juurtcrma~ter DPpurt- ment of the Un itecl State~ .Army. The appended skPtches h11 ve bCf·u tnken from the blue prints of the plans used in the conslru('tiou of t he~l' hnilt in~s. ~\. general description. furnished by tlu• public works ullker. :;amuel Gordon. C'ivil Engineel', United State,, i. ~nvy. 1 ~ n:- follows: 'ill~: Two pieces 2 by 6-inch ~prncc , supported t'\t'I'.\' T feet by i:. inch cedn r po!'>ts. Floor joist: Two hy 6-inch spruce, 17 inchrs on ce11lerfl, 10-foot ,..pan. Stud-.: Two by -!-inch sprnce, 7- foot ('e11t111·s, with :2 hy Ci-itwh plate. Rnflt•rs: Two by ·~-inch spruce. ~1 i ncht•s on C'Cnt{11·s: pitch of rnof. 1/ 4. Si1h•-. of building,, are coYered with 1 by 1~ - inclt lwniloC'k. plun•d "•rti1·:1lly. and one layer of single-ply ready i·oofin:r. Batten:- of 1 by :3-inch i:;pruce are nailed over the joints of thr l b.\ l:.?-i1wh boards, holding the ready roofing in plact'. Roof consists of 1 by 12-inch hemlock boanls. 1·on'l'P<l with l wo- ply ready roofing. Floor is 1-inch ton~ned-aml-groon~d sprncC' of r:mclom len!!'th:" :1ncl widths. Int\ll'ior walls urc sheathed with 1-inch tong:n<'il-an<l-l!rooH-'<l ,..pru<'e of random widths. Ceiling:-; 1H't:' of tlH'l'l1-pl~· wn 11 boa rd. The interior fittings of these barracks are qnitc complete an<l pmt'- tic·al. The kitchens nre equipped with electric o\·ens, :rnd the mc-..- hnlls are provided with tables and benches, utilizing the ca fet(•ri·1 m<>thod to quickly :fmnish hot mealc;. Outsiclc the kitchen doors an' "4'J"el'lll'rl racks for garbage cans. :Each halTacks can accommodutc-. without O\'<'rcrnwcling, 80 men. ·whi1·h provid(1S n minimum 1fr-ram·e of :! ft'l'l betW<'<'ll cot frames. CA.Hl'E~TEH-'.lHI': TUAl~lNG GA IP. -!ii .\lt]iough tJ1t• barracks .lre da:,;:-;ccl a:; ·· tempurnry :· they cnu be mn<le uituhlc for wiuter b~· closing in the out ·irle space betwee11 the floons and the ground nnd sheathing nml ceilin:,? the interior:::. The numerous window:; will prodde adequate nmtilntion for :-ummer. \\ hile :for winter u:-;e when the '~indows urc clo~d. ,·cutiluting 1011\'er::: ~;u be in tnllccl in the roof of the building-.. _\ ~team hc.1ting sys tem "ith 11 ccutrn 1 hen ting plant has been heen appro,·cd for winter use nn<l ib iu~tnllntiou begun. The bar111<·k:. will not only be heated hy thi 111c1hod, bnt the hot water for the kitchen and for bnthin~ and w11shi11g pmposes in the l:walor~ will be thu:; supplied. The bnrrnck::.: mes::. hall, la.vutories~ sick bu~·. bt1pply and 111.hniuis- tr-Jtion buikling,; are screened throughout and hu,·e scn•en door:-. _\ ll the buildings are lighted with electricity obtained from tlw 1·ity of Xewport. Between each cot are hooks fo1· m<.'n·:. rlufRe bug~ . und it is expected to pro,ide racks for their ditty bows. Euch mes.-; hall \\ill haYC u twin bubbling drinl..-ing fountain with nn ice cooler 11ttncbment, :-;upplying Newport water. A group unit of the::;e bar- rack:; consist::. of u mess hall with n. barracks on each f;ich• and n latrine in the rc:n·. The latrines nre equipped with R:rnitary toilet -- ................. O;:.o 0 0 0 0 0 O O 9 ll. ···-·... ll- \ ..... ·- LATR.IN~ bowb: i;howcr bath::. and wash sink:.. Concrete !tours permit these buildings to be easily cleansed. In the wash room the men ~crub thl'ir clothes and dry them on lines in front of the barracks. Tho building for general stores has u lnrge refrigerator for the ~tor:ige of fresh meats, butter, etc., und a butcher shop, bukcry and dry storeroom. The sick-bay building is divided ns shown in the plan nnd i.> used ior the cases of trivial illness not sick enouf!h to :,end to the hospital. Such a building permits ca~s to be rt-moved from bJrraclrn ancl placed under observation. This is considered to Le of special value to check contagious cases early in their incuba- tion nnd ~ecnres a certain amount of isolation. The 1lnily ~ick call i~ held in this building and dispensary service rendered for the cnmp. J<'or the destruction 0£ garbage and refuse the Guthrie incinerator of the type re{·cntly used by the Army on the Mcxicun border has been built. The following recommendations made by the senior medical officer of the Newport section. Surg. "William D. Owens, United Stn tl'., • ya\')\ go cm the sanitary n<lminist mtion of the camp: The mt'dical offircr of the dny is on duty for a period of 24 hour:;. cluring which period he does not letn-e the camp except to answer nn 4i 8 <.:AHl'g~T:J.l{· -THB THAl~ l~tl llA;\lP. XI emergency call. Sick eull:- are bdll at :-<.l:i :i. m. and nt 3 p. 1u. The me<lical oflicer of the 1lay is re::;pon-.ible for Lhe cnre of palieuls in lf the -.ick bay. The :senior nwdiral ofiiwr "~~.t~~ p 0 make.::. tlw nece -.ury in,.,pcctiou of thl' t· 11111 • 1r-..... -~ ;---~1 i11cluding the :-.anitnr~· condition:-. emu in- i ~ ~ :,peel::. all fre,..h pro\ i-.iuu:: thnt urc 1·ecei' e I. I I "~: [ wJ;(• - ; " i: " ~ He ;1bo inspect:, the 111cn \,.., to n~ccrtnin if ~ v r. rhey are properly cookecl. .\. ~:i nitury police '1 I l " ' 0 ~ ti~ 8 s " forcl:! to elimirrnte mosquito-bl'ecdin~ place •. tties, etc., is under the direct ion of the :-ien1or medical oflicer. The ca mp f.:ttnitar.' order:- include the prevention of urinatin~ uucl llefeca.ting on the ca.mp g rounds, the rnuin- tenance of propel' ventilittion in all huild- in!.!;s, the nse of handkerchiefs nncl im;truc- tion <'Oncemiug the spread of disease by coughing and sneezing, daily airing of bed- <ling) orders against the nse of other mcu·,,, towels. borrowing pipl'S nnd c1garettc:-i. h-in!! around the camp grounds nnd on othN· me.n's r cots. and inst ructioni:; ugn inst puttin!! dirty ( hai11ls in the mouth and 1111:-.l'. The hnncls il) '• i. must be washed before meab. Tiu· fly " menace is combated by or<lers for the use r{) of :flytraps in every building, preventing men ·~ I~ I ~ I:! - ..... .J ... " 0 ~ ! "' 0 • v .. J1 - ., .. 0 .. ~ 0 'Pt ,,.,.ZZ,... ~ l =--= ... ti •• 't: .. ~"'=~! from cont:nninatjng the grounds with foods and other materia I in vombJC' to the breed- in~ of Hies, keeping the gn,rbngr cans in special ily-proof mrks 0111:-; i dc~ each mes:- hall 1tnd IDOYing these l'OVCt'Cd CllllS to the in- 1•iuerator for the destruct io11 of contents. t.:fforts are madti to eliminnll' the mts :dong the adjacent bench. .\ libt•rnl munber of ~pit kits are proYicle<l and w11ste-papcr cnns to pre,·ent throwing wni,te papers about the !!t'nmi<ls. Eclucationnl prophylaxis ngninirt 'enereal disease is Y<'l'Y acti ,·cl~· ronclucted by the senior mcdi<•al ofliccw, W. 0. Owen:o. Posters. le<'tnres, and the resenist newspnpcr :1re the means employrd, nn<i it is e:xpcded to mie stere:opti1·on \'iews ancl mod11g pic- tures when possibl<'. To qnote D1·. Owens in his talk to the reservist!'! : " Dnring the w:n· tt man is dii-honcst t~i hi1 iself and to his co~mtry who contracts through self-indulgen<'e n venereal dis- enc:e. 'l'he individual wbo rleliberately in<'npncitates him-.elf for l'l ltll \XO .JAX:-EN- ll \HHA1 'K::> AT BltOOJ\L) ~. X. Y. 4 79 rendering tlint ::,crvice to hi:; ~ountry for "hich he c11 I btl'd i in the s.une category as the mnn who intentionally rni:-1.?l hi, hnml aboYe the trenches thnt he may be shot nn<l thus <LYoid further :-<>rvice. 1 des.ire to imprc:;s upon every man the need to keep him,elf l'icnn of \enerenl diseases, and also by hi" good exnmple to help encourag-c his shipmates to avoid temptation. If we are to be victoriou..; in the pre.-;e.nt struggle, it will be nece&ary for everyone to inculcate sti'<'ngth of chnrncter so as to resist temptation, for only by giving the Ue;t cun we win the war.'' Surgeon Owens also keep" u watchful eye on the <'Ornmunicable diseases by means of a diagram in hi~ office. A measles census was made of the camp and is kept a\:ailahlc for consultation in cases of transfer of men. The conlrnct for building the camp was awanled to Darling & :-;lade. n111l on :\fay 14 the work of construction hl•gun. The fir:,l two unit~ were ready for occupancy on .June 21, and :320 men were mo\'ed into the camp. The remaining units are being occupi<.'il ns fast as they nrc completed. Close by the camp is the Cloyne llou~ school: 6 large Mmmodions building with beautiful grounds, filled with rare plants nnd trees. When the resel"rn force began to enroll Dr. and Mrs. Olh·er W. Huntington established a clnbroom in the gymnasium of the school, with books, mngazines. games. etc., nnd pro' icled a lunch counter for the use of the men. .\..t pre1'ent tlw l luntingtonc: are u~ing Cloync School for n cooking clnss. n sc·hool for 1·obbling ud repairs for dothes, which 'the~· conduct under tht! auspice.-.: of the Go,·ernmrnt. A roarl at one side of Glo~'Jle School lcn1l~ to Cod- dingf 011 Point, over a bridge that was coni-trnctecl to 1·1·1)5." 11 :-111nll e,,(11ary. 'I'he Pl:iy~rnund :l!H] Herrcatinn .Association of ~\mericn h11il1 lhi,; bridge 11n1l lnicl ont t'ecrl'nfion gromHlii, and i11 !'001wrntinn with thP Nc\Yport ( 'hnptl.'r of the Red Cross sec1u·ctl aml equipped 11 hou. e which has been opened as a senice club for the men. The barracks on Cloyne Field will proYide quurters for li600 men until the buililings are sheathed and ceill'd for winter use: when the cubic oir space pel' man will make it necessary to refluce the 1rnmbcr of men in cuch barracks from 80 to fiO. The camp will then prO\ ide quarters for 1.200 men. TEMPORARY :BARRACKS AT CITY PARK, BROOKLYN, N. Y., A PRE- LIMINARY SANITARY SURVEY. B7 W. S. l'ucn, Sur~eon, and R. JAss&.s. Assistant Snr!:t?on, United :-:tatl!I! ~.n·y. General conaideration.q.-The temporary barrack-; nt Cit,r Park nr~ located in the heart of o. congested clistrict. On the Xa,·y Street nnd St. Euwnr<l Street f'idc,; nre thre~-story hrir.k tenement!' occnpic<l by Itnlinns of tho poorer cia "· Thi.' nnvy ynrd is Jocatell on the l<'lushing Avenue\ side, nnd on the Park ,\ Yenne !>idc are n numher of diln.pi- 480 l'PGll AXIJ ,J \~:,.;gx-B.\llR.\ l'K~ AT lll!O(JKl.YX, X. Y. dated. two-~tory buildings. ubo occnpicd by lt-1lia11'. The neighbor- hood. from n sanitary ,tnnclpoint. l" 1111clesirnhle. Tlw park l'Orn- µri:-e:, about li nC're~. The followiug buildings con:-Litute tlw e. tnhli hm<!nt at City Park: ~ine unn11ck. ... (quurter--): three lntrines; n kitchen: two mes halls: lift otlicf'rs· me"· hall: a ho~i>ital: 11 guardlwu~: nn administration .... ILl a: J. ... :I ... 0 0 "' "' ., .. <!. 0 < :; ..__ 3: CJ ..; ~ . ., PAR.K · AVE.NU E. • .. .i KITCH!.H .. L. < .. 7 ... " ~ L &AP.,,llACK.:i 504 M.!.tJ l'LU.SHING AVE.MUI:. • PLAN· OF· TE.MPOR.AR.Y · BAR.R.ACK5· ·C ITY· PAR.K · BR.OOKLYN· N·Y ) " I~ .. ~ • .: "' I >- ft > " < " < z .;. "' < "' Luiluiug; a canteen, untl :1 public-com!<: rt --lntion. Collectively they occupy 114,240 square feet, or about 35 per cent of the pnrk area. The buildings nre disposed about a t•entrnl aclministmtion build- ing. Six of the barrncks are located 011 lim•s radiating from the ad- ministration building. Three of them and the mess halls nre situ- ated parallel to the sides of the park. Thi• latrines: of \\ hieh there nre three. :ire T-shapcd, and are phicc·ll with the \'et-tiC':tl extension$ rnc1inting from the ndmini~tration building nn<l the ero&.1>ieces Ned. l'l'tlll \NU .J;\NSEX- BARR..\CK::i .\'1 lHlOOKLYN, X. Y. 481 purolld to the :-.ide:. of the yark. The granite publi~-comfort :,t:ttion. the boiler hon,.e, and the kitchen are located on the St. Edwnr<l Street side. 'fhe hospital is located in the southeast corner. pnrullcl to :t. Edward .Stn'et. The !!U1trdhonse j,.. ,..ituace<l nt the northwe.st "nte. ~ Thi:s ammgcmcnt of buildings is quite arti,..tic on paper, for it ,rive£ the nppearnnce of a ro,,eltl.'. In practice it has oue objection- ~ble fen tun.. Except fur the barracks facing X 1\\ y Street, the me!'-. hnlb nnd the hospitnl, only one ~ide of the bnrracks can ever rccciw direct sunlight. The shaded side is liable to be clamp. The lmilcl- ings excepted lie in 11 north and south line and, therefore. rccei\'C nn t\l'Jtllll umou nt of sunlight on each sicle. The strncture of nll the buildings is practically the ~u111c. regard- le~ of their use. They are wooden, frame lmilllings. with double ~1onti11g roofs, built over two layers of beams resting on concrete posts. The finished floor surface is raised about 18 inches above the ground. The floor is of two thicknesses of wood, with u layer of pnper between. Tlw sides are constructed from without, inwnrd of i-inch :-iding, heavy paper, i-inch sheathing, 2 by 4-inch !>tud~ spaced 16 inches apart. heavy paper, and i-inch sheathing. The roof is of ~-inch ,..heathing covered with heavy tar paper. The <"eiling is of t-inch sheathing. Doors and tr.msoms arc cut in the inner side and windows in the outer side. The kitchen and mess halls h:He a clear :::tory with window::; cut in both sides. On the iru1er side of the barracks the roo.f projects about 8 feet and the ground is covered with concrete. The floors of the latrines nre to be of concrete instead of wood. The kitchen floor is mnrbeloid. The buildings ure painted ~rny without, and with linseed oil within. The construction of these bulidings is as good as one c:rn l'Xpcct in i temporary cantonment, and wm meet the various sanitary require- ments. The thickness of the tar paper on the roof will prevent leakage for a long time. The three thickuesses o.f wood. two thick- 11P-.ses of paper, and the air space between the inner and outer sheath- ings of the walls will afford good insulation to pre,·cnt the escape of ht>nt. The floor will probably be dry. although it would have been much more desirable to have concreted the ground beneath the har- rnck~. '/'ho ban·acka.-The various buildings for barracks arc di\·itled into compartments 40 feet long. A detailed study of nHy of them is applicable to nll. They are 26 feet wide and 12 feet high, except at the -.icles. where the roof, which slopes to both i-::ide~. cuts off the cor- m•r::. The floor space is l~O!O square feet. The gro:-!~ nir space iR 12,000 cubic fC'et. Each barrack is being equipped with 2-l clo11ble· dnck beds: the frames of which nre of iron piping. R<.'ing plnnnecl 8551-17--4 4 ~ l'l'c:11 \~ ll .l \,·:--11\ H.\.lrn.:\l'l(:- \ '! »HOOK!.\.:-;. x. Y. \'ot :XJ for 4o 11w11 1•J1ch will ntfonl 11 floor :-pace of :H.U :-qunrc foot per 111111• or 43.2 ::.q11nrt' feet per clonble-deck bed. nnd an nir space of ::!:iO cubir feet per man . • \.., will bl• :-cen below. the >entilation b rather bett~r than ,, hat 11:-11ally obtains in barrur.ks. Ilut. npart. from ,-entilntion. there l"(I sanitary rc1p1ircments rclati•e to nir :-pace and lloor :-pucl'. Double. deck beds are very objectionable, for. in spite of libP.ral n·ntilntion in a compartment or in the absence of o. separate JouYe1 for each lowt.>r hunk. the circulation of air in these i:; Yery slight. The :;preud of tlw orclinar~- contagious diseasm,, ns measles, m11mps nnJ menin- gitis. und of tonsillitis, influenza and pnetu11oni11, is fa H11-ed L, cromling hoth as regu1·ds floor space and air spucc. At ll•a:.t th.e nose nnd mouth, as in sneezing, coughing, and even in t11lking. Their firing 1listllnce, so to spenk, is not very great, <lllcl is nsnnlly lwl'm :; feet. Still. their prewntion is more certai11 wlll'l'<' men arc not crow<lecl. Danger .from these diseases is relati ,·ely greater n"hure nlHl in a large cit.'' than afloat. Hence, it is desir11blc to avoitl over- <'rowtling both ns regards floor space and aiL' sp:tcl'. )._t lea:-t tlae l nited ~tnte.,; Army n•quirements of 50 square feet of floor ,.pnce nnd :>OO cubic· fe<'t of air space per man should be met. It wo11hl lw eHn bettet· to meet the recommendation of Army meclieal officers :for n minimum of GOO cubic feet. However, ns planned we shnll have only :H.6 ~qunre feet of floor space and 250 cubic feet of air space p('t' mnn. To meet the higher requirement the medical -0fficN· recommends thnt Pach compartment be used by only 2J. men instead of by ±8. The nat urn I ,·ent ilntio11 of each compartment is quite ample a~ regarcls tlw Yoltnne of air that may enter and escape. The distribu- tion of pure air, however, will not be so satisfactory owing to tbe nse or cloublc-deck beds. Each compnrtment hllS two door!': two transoms, and fonr wi uci.ows. Collecti \'cly, I hl'Sl' measure 14,:; J i -..qunrl' i1whes. By figuring on the basis that 8 c;q11:1re inches of inlet and squa1·e inches of outlet permit the extrnnce and exit of 1.000 <·ubic feN or air per hour in natural ventilatio11 und1.1r a ,·erag1' con- clitions, t.'nough nir will circulate through the room for 7;1 complct{' renewal~ of i1i1· per ho11r when all the aboYe npel'tnre;; :ll'<' fully oprn. Thi" is mon• tlrnn snffiC'ient. Howe\'et'. it j~ not to lie expectc<l that 1111 1loors and windows will be fully open at all times. Xor wlll n uni- form distribution of pure air be found. Instearl. there a1·c liable to he pockets of foul air, especially between the upper and loweL· bunk-... In cold weather ventilation will be accomplishc'l b~· clirect-inclireC"t heating and suction Yents. Each compartment hns I wo rndintor,: with rncliator vents measuring 10 hy 14 inch<'s at tlwir mo,.t co11- :-.trictc1l port ion, an1l t \\ o 2'1:-ineh >illl't ion \'C'nts of tlw Larsen type placed on the roof and opening into the attic O\'t'I' the 1·ompnrt111e11t. Between the nttic nn<l th<' e<>mpartml'nt thPrl' n1·p nitw eeili11!! 't·nt-... ttich !llCH!-<llring ti by IS inche8. Colt! air entering through tllf' ndi- itlol' \·ents will be he11ted by the radiatot· nn1l will asct>11<l to the utlir to make it~ esit thron~h the Pxhan!'t wnts. Th<' sy-.tc111 will furnish 11 Je-,,irnble combination of heating :md n'ntil11tion. J"hr mu<.~ halls.-Tlwn• nn• two me~-. halL t•nch :ll'('ommod:1ting i -10 lll<'ll :it om• tinw. Thry :ire ,..jt11:.te1l 1 n n li111• frn111 JllH"lh to south with t lw kitelwn hN we1•11. The!· art> entHe<l from tht• 1•.1-.t a-.pect. "lwrc th1 tnhk-. :111d ... heh es .ire l<X'..th•cl, :-o that thr men 011 entering , ill tnlH• tl11•ir mei-s gear and recen e their foorl. Tlw ~rt>atcr part of r:i,•h hall is tak1•11 11p liy tables. Tlw ceiling is \'t'l'~' hi[.!h thrnu!!h dt1• C'l'llll' I'. 1 hPn' tlw rnof ltai:; n clo11hl1· f'lopP. and lmH•r to Pither ,.j1[e. '' hPrP the 1·oof hns a single ~lope. 'l'h1• tlool' spn1·e of t•:wh hn !I is 7.fili8 :-;1p1;11·1• l\•cl. Thi• :1i1· ... J>:l<'l' 1s :1s.n:r1 1·11liil' l't•t>t. The area of window::,. door:', a11d u·:tn:-m11:- i:-; l ~\!l,ifi·t ~ pinn· indws. Thi::, "·ill permit alio1tf ~.i rem·wnls of air per hour 1111dcr 01·1linal'y conclitions \vhirh is quik ;unple. The pro\ ision for :1rlifirial 1·t·11til:1tion of r:lCh hall consists of th1'l't' :!1-irwh :-11cti•m H'Ilt nf tlw Lar'-'Pll t,\ pe, 10 ceiling Yents, mensnring Hi ind1e,.. sq1111re. wlail'h l'' no.,t1tutc the outlets, and 12 radiator n'nt,,, 111<':hm·i111! ;tt their 1111 ,.t c·on~t.rictetl portion 10 hy 1+ inches. These r:1dintol' \Cmt ... '' ouhl ndmit enough air to permit l wo renew a ls per hour under m··li11:1 ,.,,. coucl it innc;. but with the added i 111 pet us of c·om·1•ctio11 cur- n nt ... w Ill' rt tit<' ste•1m is on they rnn he rel iect on to deli H'r -.t•\ 1•1-.tl time,., that nrnm Yolmne:-- of air. Hence the~· wi II probably fnrui:-h the 111cr,.;sary l~ renewals of ni1· per hour. 'fhc t·eiling ''<'lit' utford 1111 arP•t ~u flicieut. irt'l'SpectiYe of theil' location, to pcl'mit thl' dis- chnrgl' of nbont thrN' times the nil' l'Ol11me per hou1. But owing to tlwil' loculi(ln i11 llw pnth of natnral ('Oll\'N'Lion l'111·1·<•11t .... tl1l·~· can ht• r1•lied 11pon lo dischn.l'g<> 1:2 Yol11me~ nf ail' per h1111r. Th~ pl'O- ,·h-ion for Yl'ntilation is thrreforc considered 11tleq11nh. l'H'll when the \\l':tthe1· will 1wce<.-<it:1te closing :ill <1001·" n1td win1lov "'· '['\\Pin· rndiators art> proviile<l for henting. Lightinir tlw mr:-;s hnll is nccomplisl1P1l liy T:! -l:O-watl I.imp:-. nr- ra11~nd i11 I l'O\\~ of JK each. The lamps will b<• plnced I fe<'t nbow tlw flol'r and prodded with illnminntl'cl ste<·I ::.hntles. Ench hunp will ilh•· 11i11all' :d1011t 100 sqnnre fert of "P:tc·r. This will prm·ide -.11flicie11t li~ht. Thi· 1·q11ip11wnt or l'HC'h llH'~:-. hull eon,..ists or :{4 rahJp ... _ llll'il'llriJH! lti fet•t and 7 ineht•f: h.'· :! feet and Ii incht'S: :W tal>lc-. mea,..urin!! ::W fcl't and " i twill'-. h~ :! l'PC't n ncl () ind1es. Bt>,.;idr:- tlw o ho,·p thr1·c 1111: t 1hlt• .. and shelves for mess gear nnd food. l>Por~. ,,·indows, trnnsonrn. and radiator wnts nre prm ided ''ith 11y ~l'l'el'llS. TIH kitchrn. /)(lkuy. f f1·.- There is a kit<'hen. hakl'l'.''. h11td1er :-hop. 11wnt rl'fri2'ern tor. ~E'tll'r:l l n'friµ-t'l'n tor. \ i>gptn h Ir -.torrrnoni, 4b 1 l'l GH A::s'D JAN!i~:X-.BAIUL-\UKS \ '.I' Hl!OOI'1.YX, N. Y. 't•!!etnblt! prepnmtion room! flour room. hrend room. rccch·ing room. i~suin.!! room: nml office. These are to be situated bebn~e.n the 1nes:.; halls uud behind the boiler house. The ceiling of the kitchen is to be wr~· high, us the building hns a clcnr story. The roof has a rlouble slope toward th<' me.~s ha lh-. Doors. winclo" s. Pl<' .. will ~ provided with screens. / 'fool' space, ai1· SJJU<!C, 111111 n:mtil11t io11. floor spooc. Squart fW. =~n:;::::::::::::: :: :::::::::: : :::: : ::: ::::::::: : ~:~ l"loor room.............. .. . .. . .. .. .. . . .. .. .. .. .. .. .. .. . m \'~table room, stOl'l\'?O...... ... . .. . . . . . . . .. . . . . . . . . . .. 272 \'~tllblP.prepamtk>n room.................... ........ 3!1~ Batcher alwp..... ...... . . .. . . . . .. .. . . . . . . . .. . . . . . . . . . .. 3i2 lle:lt r<'lrl!?eiatlni: room................................ 32S ~~~~'.1'.:~~~~-1~ ...... ::::::::::::::::::::::::::: ~ I Receiving room.......... .. .. . .. . .. .. .. .. . .. .. .. .. .. .. . 2ill lssulni: room.. ...... . .. .. . .. .. .. . .. .. . . .. . . .. .. . .. . .. .. 168 r..ooks' rooms (11, t)a(·b . .... . .. .. . .. .. .. .. .. .. .. .. . .. .. . 140 .\ir <pncc. Cubicful. 35,000 23,320 2, 9!12 2, 99'J 2,9'J"l 3,872 ~,M 3,Si .'.> 3,5i5 7,260 3, 069 1,848 1,6l0 Na turn I \'e!ltllaUoo. lnlots nncl outlets. Sq. In. ftJ,1112 11,0IG 6,69!1 ft, &00 6,<He 13,:r.Y.l 4,860 4,860 4,llllO o,m 3, 024 10,030 6,600 Estimated rencW&ts of air per hour. ,\-. the number of renewals of air desired for such rooms is about l:! per hour, it can readily be seen that the natural Ycntilatiou i-: quite ample. Besides the natural inlets untl outlets there nre three ~4.-inch suction vents of the Larsen type and u 12-inch .flue for the kitchen. The radiators in the cooks' rooms are pro,ridec.1 with radia- tor vents. l!:quipment.- 'l'he kitchen has 12 ranges, 10 80-gullou boilers. 8 :oiuk~. 2 toffee urns, 1 water urn, and 2 dish-washing machines. The 1fo•hwaghers will be supplied with steam at 40 pounds pressure. whiC'h will make it possible to sterilize nll mess gear. The vegetable- pl'Cpuration room will have 1 Yegetable purer and 2 sinks. The butcher shop will be equipped with 2 sinks, 2 meat blocks, nnd a meat chopper. The bakery will haYe 2 cloHgh troughs. ~ dough 111ixers. 2 sinki::, and 3 bakers' ovens. The lighting of the kitchen, bakery, and adjoining r ooms will be n•·<:omplishcd by forty 40-watt lamps, which will be adequate. Two small outbuildings are provided for the cooks. Each il' dh·ided into three compartments. Two of these measure 13 by 14 feet anc.1 ha Ye four double-deck beds each. Each hns two \\ irtdow,,. a door. n radiator nnd a radiator vent. The third compartment con- tains two showers, a urinal, and u washstand. It is a pleasure to l'emnrk thnt nowhere in the kitche11. or ndjoining it, is th(!l'<' n single lll'inn I or wnt('r-clo!'et. Thi~ fentnrc i<: quite unusunl. for n rchiterts PUGH AXD J.A~SE:X-BARUAOKS AT BROOKLYN, N. Y. 4o5 nud Jlll\ al constructor:-. ha Yo alway:::.. in the pa::.t plnn!ll :1 \\' Ull'l'-clo.,('t clo::::e to the kitchen. J'he [at1 iue~.-There are three latrine,,, each of which i::. a T--.hape1l buildiug. In the Yerticnl segment of the T are two compartment-.. one for the water-clo,.,ets, the othe1· for the hn 11torie-.. The cro-.:-- piece of the T hus nt either enJ. a compartment fur :,,lllH\ er:; and in the center a urinal compartment. All tolu there are 141 water-clo:.et::.i i:lb sho\\ er:-: :t5:l la\ ntol'iE:-, nnd :t4 urinal racks. Ench urinal rack is H feet u inclw,, long and will nccommounto about G men. Urinals •trc thercfo1·<' !-Ufticient fo1· H4 rnen at one time. For a complement of :3:000 men the UVl·r- ngc will l>e 1 water-closet to 21 men, 1 shower to 13 men: 1 la' a tor~· to 12 men, and 1 head to 21 men, which is sufficient. The compartment for water-closets is 39 feet long, iii feet wide, and 11 feet high, except at the sides where the ::.luuting roof cuts off the corners. The gross air space is 9,750 cubic feet. ProYision fol' ,·cntilation is similar to that for the barracks, with the unfortunate 1nni&>ion of the underground radiator vents. The doors, windows. aud tranf:oms afford 33,352 square inches of inlet and outlet, or about 100 sqnnre inches for each water-closet, which is ample. Thi:; per- mits about 210 renewals of air per hour. The ceiling \ ents afford un outlet of .376 square inches, or about 12 square inches for ead1 wnter-clof:et, which is not enough. Each water-closet in nntnrnl , rJ1tilatio11 should have an area 0£ inlet of at least 48 sq narc inches and un equal are:i. 0£ outlet, or 2,304 square inches for 4 water- clo:::ets. It is desirable to increase the outlets. Instead 0£ 4 ceilin!!; yenb there should be 16 and instead of 2 suction ,·cnts there should be li. In cold weather there will be a strong clruf t of col cl air blow- ing in at the doors, which is undesirable. It woulcl be better to hn ve vestibuled doors which would stop dra£ts and h:H e rndintor ,·ents, as in the barracks, to act as inlets. This compartment is prn- ,·ided with steam-heat radiators. The laYatory is 43 feet long~ 26 feet witle and 11 f•el high. except nt the sicks where the ceiling slopes. The gross air space is 10.l."10 cubic fef. t. There are the same ample provisions for natnml Yenti- lntion ns in the water-closet compartment. The recommendations for incn·nsing the artificial ventilation of the latter compartment npply here. There should be nt least 16 ceiling -vents nnd nt lenc;t l rmction vents. It would be desirn ble to have :lir admittctl hy rndi- ntor ''eds instead of from the door, which shonhl be doubled with vestibules between, to prevent drafts. There arc l stenm-heat l'lldiators. The compartment £or urinals is 26 feet square nn<l 11 feet high. except at th<.' side.::. where the ceiling slope.c:;. ThP gmss nir .::pn<'e i~ 4 (, l'I 1.ll \~ ll .J.\. ,...~ ;\ HAIWA( 1-\,... AT lll:UOld.\ N, •• '\. ahu111 li.:ilJO c11bi1· fet'l . 1he prod::.iou, fol' 11ntur11l \ t•ntilat1011 ttl"(> a, ample u-. in the \rnter-clo;-ct compartment. l<:uch compn11 mcut for -.bower::: i-. 40 fl.et long. 2fi f cet '' iJe. anti 11 fe<·t high. The gro-.,.; nir -.pace b 11.440 cubit} feet. Pr1nbion.., for natuml \'Pntilntion al"e a, mnple lb in the other 1.'0lllpartmentJ. A'quipntt nt.- Thc water-clo:oet::: uni to Le plncc<l in battcrie-. of 12 ,..eat . carh battery to ha\'e :m automatic flu,.,hing nppliancl.!. Flu bing :-upply will come from an oYerhead tank. The di::ichnr"e j, by un n11to111atic siphon e<luction appliance. Regurgitation is pre- Yentcd 11~ 1111 S wat('J' 'ahe. Foul gases will escape from the pi pin~ h,\ u 'l'lll to lhl' rnof. The ~eat:-. are lo be fixed UJlll of enurnelcd imu. .\II tlw;;c feulure!-i are ,·ery commcu<lal,Jc, except perhup,, the fixed .... cat::.. Thb will make jt t1iilicult to clt•1u1 their 11n<ler::;urfaccs. Tlw l.1 nnor) units con~ists of hot and col1l 1Y11 tel' faucets, a trough nnd a discharge pipe with P water trap. Di:;chargc of scwur gu~ i,, l\l'Complishccl by n vent to the roof. The showers are 4-inch raiu head provided with n single self-closing valve. With the exception of four showers in each set all will deliYer hot water only. 'Ihe other four will deliver cold wat.er only. The best that can be said for :-uch nn arrnngement is that it is practical. The urinals are trou;rhs It; feet long and 14 inches wide abo,·e. They are of cnam- elc•d iron and constructed without angles or corners, which will facilitate denning. They are flushed through perforated pipes con- trolled b~, an automatic flush tank. The waste pipe is interrupted by n P water trap. Foul gas escapes through a. vent to the roof. 011 the whole the equipment is as satisfactory as can be desired in n fempornry lutrine. 7'l1e l1 0~71ital.-The plans for the hospital provide for a building 10i feet long- and 17 feet wide, with extensions for the isolntion 1 ard and \ Cllcrcal lrC'atme11t room. The buildings 11 ill be sitnatcd in the south a.-.t cur11c1· of the park and will lie iu a north-south direction. 1'his jc; Yer.'' fa ''orul>lc, Lecarn,e it permits both ::;i<les of the build in!.{ to trceh·c ::.unlight for :-ome part of the llny. The roof slopes to either ide. Thl: ceiling will be about 11 feet high. It will be cli\ ided into rooms for the sick hay. isolal ion wnnl. ui pcnc:nry, examining room. 'cnereul room. dental office. waiting room. surgeon·., ()flicc. oflicc for cxccufo e medical officer and ofliccr of the clay, the offict:1· of the day's quarters, Hospital Corp.,' qnarfrrs, galley und buthroom. Dt•rthing nccommodations are for rn mt•n 111 the ~ick bny. :; i11 the h;olntion ward. 6 Hospital Corpsmt'll nnd :! merlit·al oflkcr;. !'/o.'4 Pl"t.ll \NI• .r \,. :;E~ B~RRH'K:' Af 1:1muK1.\":-.-. ~- Y. 4oi The prO\ i ion for natural n·11tilal io11 b 't•1·y :1111ple. 1h 111ny be ,.Nm from the following table: floor •patt. - - I Sqv .. irr/at. ha)' •• ... . .. . • . •• . • • .•• • . . . • . • • . . . • • . •• . . .. • a.;7 tsol:llkm wnrd .• . . . . . . • . . • • . . • • • • . • . . . . . . . . . . . • • . • . • . • . . 1 ~ l ~~n~r~~~~ ~~~ ~~;:~~~~~~:; ~ ~ :~~ ~ ~ ~~~ ~~ ~ ; ~ ~ ~ : ~~: :, ~ ~~~·~ii.;.:: :: :: .. ·::::::::::::::::::::::.:::::::: ~ kJlol o" ccr ortl1t' dny..... ...... ....... .... .. .. .. ... !JU Exct11U\"o mcdlcnl otll~r..... . ............ .. . . . . .. . . . . . llrl u~,P~~-~~I.18:::: .'. ::: : : ::: : '. :: : ::: : ::: : '.: :: : : : : : : : :: : ~ G:I :;roor.1 . • • • • • • • • . • • • . • • . • • • • • . • • • . • • . • • • . • . • • • . . • • . 10.; :>;aturnl "reDtilatlon Inlets nnd ootlets. Estimated l'til~WtlU olalr per hour. ··~ 204 2t~ 150 ~ 175 43~ 217 15.l !Ml 130 250 Ut The uir space in tlw t•ompurtmenb for the l:lick ba), isolation wurd nnd Ho::.pit.al Corp:; i:; in.ulequate. T he space per man i11 each is, re"5.1>edh·cly. 3~.I. :~80 nncl ~20 cubk feet. .\s the sick bay nnd i:-;ola- tion "uni wi LJ probabl~ · nerer be filled to their capacity. thb l.1ck of nil' &pncc is relativel~· unimportant. nut in the quarters for the lfo=:pital Corps oYercrowding should not be permitted. It is ~;ug; gestccl that the room assigned as a dental office he also usecl for the Hospitnl Corps nncl other provisions be made for the denti.-.t. Or only two Hospital Corpsmen should be quartered in the ho:::pital nnd the others should sleep in the barracks~ which ure only about 13 feet from thP- hospital. There is ample provision for heating. It is to bo regretted that only u few of the radiators nre provided with radiator \ cnts. There nre four suction vents on the roof and ceiling nm ts in the sick bay 11rnl some of the rooms . ._'ufficient toilet facilities will be provided. There will be n lnrge bathroom between the sick bay and the isolation ward. which will be <lh·idcd by partitions into two small lnn.torics and a wnter-clc ~"t. I'ach luvntory will haYe n bnthtub. a washbn~in and a watcr-clo ... et. There will he a. large enameled iron sink uml a washbasin iu the dic:. pen_ iry: :t washbasin and an enameled-iron slop sink in thr venerenl room; n sink in the galley; a washstand in the room for the officer of the clay. ThC'se facilities are adequate. It b strongly recommc.ndcd, for obYious reasons, thnt the sink in t.he ,·enerenl room be proridecl ''ith either knee or pedal 'a1ves instend of the urnnl fom·ets with handles. It is also dci:;ircd that a steam pipe be run into the g<llley sink to permit sterilizing of mess ~ear. Lighting will he accomplishcrl hy fort,\" 40-w:ill Ja111ps loratPu iu thl' 'nriom.; comp:irlm<'n ! ~. Thc·r·· will lie six lnwp~ in tlw examin- 488 1•um1 ,\XD JA~::;i:X-BARRACKS .\·r Hlli.lUKl.YN, ~. Y. \'ol XI ing room, four in the <lispcmmry, fh·e in the :;ick bny. four in the Yenerenl room and one or two each in the other 1·0111pnrlnw11t..:. 'Phi should be sulficient. The equipment. apart from the plumbing futture:; and medical ... tores: consihts of six double-deck beds for the :;ick bay, fh·c c:int!le heds for the i:;olntion wnr<l, two double-deck beds for the Hospital Corps, n. storeroom, desks: chairs and sheln~.s . .l/i.vrellane011s buudings.-The canteen i-; a small building rneas11r- ing H by 24 feet. It is pronded with t'vo rn din.tors. The gu:mlhouse is a building measuring 11 by 15 feet. J t i"' arl"- quately provided with light, heat, and ventilation. The former recreation pavilion is being remodeled as un a<lmini"- trntion building. It measures 54 by 112 feet. It will have offiec. for the commanding officer, the executive officer, officer of the day. paymaster. and five rooms. It will be heated by the direct-indirect method. Ettch room will have one radiator, except the payma;;ter's office, in which two will be installed. Lighting will be by 4:0-watt lamp~, provided with reflectors. There will be two lamps each in the executh·c ollice and the paymaster's office. and one <>a.ch in the other rooms. This will not be sufficient for the performance of dericnl "ork. It is recommended thd n lamp :rncl rt•flector be installed for ench desk and typewriter. The granite public-comfort station, which l111s eight w:1ter-c:Jo,l't::.1 fh·e urinnls, and two lavatories, will be dhrided for the use of officer", and room!:: nre being uddecl at each end for ofllcers nnd the nrmed guard. It is :idequntely provided with rncliators and lighting fixture!'. An oflicers' mess ball is being erected in the renr of the boiler hon:-::e. It mensures 32 by 22 feet, and will consist of n. pantry nnd mess room. The building is of the usual construction and has one :-11ction vent. Heating, lighting, and ventilation are. ndequntely JlfO\·i<lecl for. lleuting.-The heating of the various buildings will be accom- plished hy steam under pressure generated in the boiler hou"-e locntecl in the park, and distributed to the Ynrious buildings by the uncler!!Tound two-pipe system. The radiators are double row..: of "ertical columns. The number of columns differs according to the requirements. Each radiator is controlled by a hand vake :mcl has a compression air valve. The radiators in the latrines and some of tho~e in tho hospital :ire of the direct type. Others in the mess h·1ll"'. the bnrrncks, nnd several in the hospital are of the flirect-indirect type. In this type air is admitted from without by vents, and is heated ns it rises through the radiator. It is n very desirable form of hcnting. because it suppHes fresh air withont causing rold drnfb. The amount of air entering the vent mny he diminished by closin~ l'fo. 4. pn;u \SD .J AX::.ES- 1:1.\lU\.AOK::. .\'I llllllO)\:J,'\: s' ... Y. 4o!J the vent trnp. .\.ir will escape through the ct•iling \cnb nnd suc- tion venb. Regulation of bent will be accompJi;;;hed by using the hand rnlYe on the radiators. Heating of an interior compartment of the barracks will appar- ently be adequate except at extreme low temperatures. The ditli- culty in heating the barracks arises from the large volume of air thnt must be admitted to furnish sufficient Yentilation for -18 me11. .\t 2,400 cubic feet per man per hour this will be ll:J.200 cubic feet per hour, or about 10 renewals. .A.ssuming that the radiators will Jrnw an efficiency equal to that of indirect heating, or of about 600 B. t. u. per foot per hour, the two radiators having 72 square feet each will be able to make up the loss of heat through the walls an<l heat .'l renewnls of air per hour when an inside temperature of GO dee:ree.c: is to be maintained with :m outside temperature of zero. Thi!' wonld rut the air supply per man to 1,200 cubic feet per hour. which is too littl<'. If, however, the compartment should be limited to 2:1 men. the heating and ventilation would be adequate. Fortunately the temperature rarely falls to zero in this vicinity. The usual mea11 temperatures for the winter months are between 20 and 30 degrees. Hence the heat required most of the time will be within the capacity of the r:idiators provided. Assuming an outside temperntnre of 30 degrees nnd an inside temperature of GO degrees, the radiators will be ublc: to supply the heat lost through the walls and to heat about 10 rcn,.wals of air per hour. From the end compartments of the barracks the heat lo'"t throu~h the walls will be greater. To offset this, a lnrger radiator hns been instnllcd there. The radiating surface is lGS square feet. This will not only meet the additional loss through the end wall, hut will also heat. an additional renewal of air per hour . • \. similar consideration of the heating of the mess hall-.. which b .lso by tho direct-indirect method. shows that under extreme con- ditions there will be only heat enough for the loss through the walls nnd for () renewals per hour, which is not sufficient. Under average conditi .. a~ ther<' will be heat enough for 12 renewals of nir per hour. which i.; adequate. The 'flrious compartments o:f the latrines are to be heated by the direct method, in which the efficiency will be about 300. They will "upply enough heat for the loss from the sides and for 5 renewal~ of air under extreme conditions and for 10 renewals under n ,·ernge "inter conditions. This is adequate. Some of tho compntments of the h1;spital will he heated by the direct method, others by the direct-indirect mrthod. '!"hr -.ic·l;: hay will ha Ye two large <lirect-iudirect rail in tors with 11-1 square fl.et of rnclinting surface. This is ample for, in ad1lition to the heat lost from tlw wall.:, it will be ~ufficient to heat nbout :m l'<'llC\\'al:-: of nir 4~10 l'l'llH A~W J\. :->1''~-IUI!HAC'I\::. .\'J' BH<HllO.YN, N. \. 1wr hour 11nd1.,r c..\'.trt>nW c11111litio11-.. The other 1:0111pun111Pnt:s hn\t• hcatintr -.nrf1u·r ~ufticienc for f1 om HI to :20 re11t•\\ ul~ of air p r hoar. 'fhe ~mall miseelln11enm; lmilrlin!!'::-, ll<'h :ii;; the <'•llltl'l'll, Cfok · hou,,es. guanlhou~e and udmi'li-.1ratio11 buildin!!. have n prupor. tionntely !!renter he:1t1I1!! ~urfuc·t>. Tiu• kitcht>11 will he -.:i.1pplied \\ ith Loth ~t<.•tuu u11d ga~. l'hc 1,rng~ an<l bnkers: on~n.., nre for gas and the boilers for steam. N' o c:pecinl pro\'ision is mnde for heating the::.e rooms. Ou the whole the heating system appears to have been well planned and will mel't sanitary requirements nnder the usual winter con- ditio11~. ulthongh in extremely cold weather it will be inadequate. Thi:-; inadequacy will not be in producing the desired temperature. for this will be maintained at the expense of ventilation. The equipment is good and if properly and intelligently cured for a ~atisfactory degree of ventilation and heating will be obtained. This should be a part of the work of a sanitary corps. To facilitate Hs work e:ich compartment should be provided with at leii::it one thermometer and outside et~ch barrack there should be several more. The important thing is proper supenj,sion. With it the equipment will be nbh• to meet the requirements for comfort and phy ical (•fliciency. Li9hting.-Proper lighting of the various buildings in this can- tonment is a subject of no small importance, for though it has been called :t temporary cantonment it has been planned with a view to being us ·d fin~ years. It is well worth while to consider if the light- ing pro' ide<l is sufficient to meet physiological rP,quirements and if the distribution is the best that can be obtained at the expenditure of energy planned. Before proceeding it is well to point out the principal physiological nnd sanitary applications 0£ light. Daylight can hardly be excessive except where reading or writing is to be done, when the direct glnro of the suu would be objectionable. To overcome this, shades should be placed on the windows of the sick bay and oftices. Except for the;~e the greutest daylight obtainable is desired for general comfort and for its destructive action on germs. The coloring of the compart- ments is not bud. They nre of pine, finished with linseed <lil, which gin•s a light Luff color. Thi~ is Yery desirable for walls. fi'or the ceilings white paint woulrl girn a bette1· reflecting surface both for natural and artificial lighting. In artificial lighting there should br enough light in each compartment for its various uses. In the berlh 9 in::r ('Otnpnrtments there should be enough light, at. some points nt le.u..,t. for re:iding and for mending clothrs. For this about 2 foot candles arc rC'quirecl. In the me~s halls about 1 ~ foot-candles arc re- quired on the tables, and 1£ they can be adapted ns reading nnd writ- ing rnmuf:. tlwre shoul<l be nn illuminatic·n of fro111 2 to 3 foot-eimtlle~. l'l'GH AND J ~X::-EX- ll.\ltRACK:; AT JHWOl\'.L\'X. X. Y. 4~1 Ju tbl.I lnt1·ine" the lighting ~houlu be about l~ foot-1·:1n<l1C',., cm the , .irious fixture . Further. 11 well-lighted latrine will Le kept cleaner thnn u gloomy oue. "'hilc every etfort ~hould be mnJe to get the desired illuminntion on the working plnne. as in i·eading. me~sing . etc., the geneml illmninatiou of a l'Oom :;hould uot be ignored, for the evo frequently wanders from the page to the ceiling. If the cht\nge i · from bright light to comparatiYe darkne..; nnd bnck ugain. rapid nud hurtful pupillary accommodation is necc&:>nry. A::- for as possible till' direct x1 osurc of irn'.andescent iilanwnt~ :-hould bl' :\\·oided, lit•cuusl' the.\ produce retinal strain. The~ an• th1• rhief s:initar~· conshle111t ion~. In natural lighting the transparent i:.urfoce of the wiurlo":;· ck . ... 1iould be about one-fifth of the floor surfocQ to 11dmit the tlec;in•d nmonnt of light. In lhe n1rious buildings this ratio is 11ot mnin- tniue<l. In the barracks it is one-fourteenth: in the mc-.s hull:;, onc- eighth: in the kitchen and bakery, one-ninth; in the watcr-clooct com- partment, one-sixth; iu the lavatories, one-sm·enth; in the urinuJ,, one-ninth: in the shower baths, one-eighth; and in the ho~pitnl. onP- iourth. The nrl ifkial lighting of each :-;t:mclard compiutment of the Lar- 1 ncks now being installed l·onsists of six bare 40-watt ~laz<la lnmp, J1xcd in ceiling receptacle;;. The illumination in the following e4i- 111ntr.:=: ha:-; bt'en eakulated l'rnm c111·n•s of distribution b1tlnnitted by the m:rnnfnct un•rs of lhe lamp::. alt(1 fnn11 tlw di,1grams of loc.1tion uf lamp~. Tlrn illmninutiou on the floor will vary froni n mnximmn of 0.4 foot-cnndk in the eenter of th~ room to n minimum of O.:.! foot-candle in the corner:-; and will :n erage nlionL 0.3 ft ot-cnncllc. At a pl:me a feet abo,·e the floor, which is the nsual rc.1ding height, tlw il111111ination will Yary from 0.5 foot-candle to 0.2, with nn 11,·crugo o:f OA. Iiemcmlwriug that 2 foot-camllr•s are necessary for rending. one can see that tho lighting is not sufiicient, nncl if: more light will not he proYi<led the medical officer recommcncls thnt men be pro- l1ibited from attempting to reac.l. write or sew in the bnr1 nck . If, Lowc,er: in~tead of 40-wntt bare lamps 60-watt lumps, "ith dis- tributing shades should be 11sed. the illumination at ::. plane 3 feet uhove the floor woulcl vary from a maximum of 2.3 foot-rnncllcs at the four points midway between the lamps at either end of n rom- partment to a minimmn of O.G in the corne1-s: with nn a,·crnge of :;Lont 1.2. This would permit reading anJ nwnding at the four point..-. of maximum i11umination. Or, if instead of increa ing the \rnttnge and using reflectors, the latter be merely ad led to the pre5enl equipment. :t maximum illumination of 1.1 foot-cundles ~ould t,,. obtained. This wo11l1l be :l better illumination than thnt afforded by lhe hnrc lnmp<- without any incrcust' in opPr:1ting C'Xpen l'. Tlw nwcli- -19'.Z l'UGU A.·o JA);!:)J-:.S-HARRAU.K:> AT BROOKLYN, :-;. l". Vol XI. cul officer recommemls the Utie of liU-\\ att lamps with distributi11,, shades. ~ The mess halls will be lighted by 40-wutt lamp::. plnceu T feet nbove the floor and pro,ided with G-inch bowl-shaped illuminate l steel shades. These will be arranged in rows over the tables. The distribution of light on the tables will range from 3.:J f oot-cnndle;; directly under a lamp to 1.3 at the ends of the table,... This i...; ample. Unfortunately all the light will be rcilected downward. The space abo>e the lights will remain in darkness, except for what littlo light may be reflected back from the floor und table. It would he much more desirable to use bowl-shaped holophane reflectors. With these the light would be more evenly diffused. It should be noted here that the lighting in the mess halls will be ample for reading. writing, and mending clothes. It is therefore recommended that ona of these halls be a"Vailable for these purposes. Tn the kitchen and bakery the lighting will be by 40-watt lamps, provided with bowl-shaped illuminated steel reflectors. This will giYe an a>erage illumination at a plane 3 feet from the floor of 2.5 foot-candles. The maximum will be 3.9 directly under the lamps, and the minimum 1.1. By using h<m I holophnnc reON·tors the dis- tribution would be more uniform. The l:ttrines will be lighted by 40-watt bare lamp!;. The illumina- tion on the various fixtures will avernge O.il foot-candle on the water- clo,ct seats, O.G foot-candle at the lavatories and 0.4 foot-candle on the urinals. By the use of distributing shades this conld be increa~ecl to O.i for the seats, 1.2 for the lavatories irnd 1.2 for the uri.1n1::. or Ly the use of 60-wntt lamps with shades to 1.2 for the seats, l.S for tlw lavatories and 1.8 for the urinals. Though very little light is necessnry, it is well to remember that the clcnnliness of n lntri11c is clepenclent 011 the lighting. The outside lighting will be by 60-watt lamps, provided with 14- inch enameled-iron distributing reflectors. These will be pln.cecl o'er thl' doors ol the latrines at a height of about 12 feet. They will prm·ide sufficient illnminntion to light the paths to these buildings. The ho:ipital will be lighted by thirty-six 40-watt lamps placed i feet nbove the floor ancl provided with 6-inch illuminated, steel; bowl- "hnpecl ~hades. Estimation of the lighting power shows that nt a plane !l feet abm·e the floor the maximum in the rnrious rooms will be '1 cn11<1les, the minimum zero, and the average about 1.8. In the ofliccs lights hnYc been arranged so thnt the desks will be ''ell lighted. Bcca11c:e of the opacity and the narrow angle oi the shndes some part of cnch room and the ceiling will rt'cei"Ve only reflected light. It would be much better to replace the opaque shades by holophnne glns:; reflectors. With these the distribution of light wonld be mQre :;o . .._ l'UOH MW JJ\NSEX-BAlUtAOKb .\1' BBOOKLYX, :X. Y. 403 uniform. It i!:' nl::o rccomrncndcd Llrnt iu the ~ick ba.r at letL::-l bulh;: \\ith frosted tips be used to nYoid hnYi11g men lying ou their backs • uffcr the discomfort of looking dii·ec:tly at ban' filament~. There should nlc:o he n plug or two in the :-:-ick bay. isolation w;1rd and c,;.xnmini11~ room for attaching u portable lump. Ji'rom the :foregoing considerations the medical otliccr mukcs th(' following rc.>couunendations: (a) That in the barracks and the latrine>: liO·wntt l:nnp:- with dis- tributing shades be used instead of 40-wu.tt lamps without rcfl('ctor:->. (h) That holophnnc reflectors be used in the mes;; hall!';: kitchen, nnd ho~pital instead o.f opaque shades. (c.) Tlrnt a mess hall be nYailable for use for reading, writing 11nd mending. (d) That frosted tip bulbs be used in the hospit:d. Water .~upply.-Th.e disadvantages of locutiug a cnntomnent iu n lnr!!e city are compcm:nted for by the adnrntage of un nbun<lant and '-'xcellcnt water supply. The source of the water supply i~ in the Catskill ~fountains. It is a pure surface water which require:. neither physical nor chemical purification. Its purity is mnintnincd by protectio11 irom pollution. It is conyeyed by an aqueduct and di .. tributed to iron water mains. From the mnins water is led in through galvanized-iron pipe and distributed to the latrines, kitchen. hospital, boiler house, etc. Bclov· is the nYerage of analysis of tap samples from the Yicinity of the barracks for the week ending July 7, 1917, tnken from the 'Haekly report of distribution system, department of wntcr .;;upply. g-as. md electricity, city of New York: Ph~·slcal examination: Temperature (° F.) - -- - -------------------· ------- 6-1 Turbllllty (silica scale)____ - - ------------------- _ 2 Color (platinum col>alL standard)--------------- ---- H Odor _ _ __ _ ----- ·---- -------------------------- 1 ,. t 'hcrulcul unnlp•is (purL'i per million) : ~ltrO~\'ll as allnnnlnol!l ammonia_. °Nltro~C'n ns frPe urumonia _ ____ _ _ • -------- ---- "ltrni::cn us nitrite -------------------- -- • Nitrogen ns nitrate ____________ ·------ --- --------- , 115 •rotnl rcsld11<> on eniporntion___________________ • Hnrtl11ess ___ ------------------- -- ..... ---- -- - ..,.. • ..:\Jltnllnlt~·--- .. __ _ lS Chlorlnl' ------------------------ ·-. -- - -- - • 1. U frou ~llcro><coplcnl cxarolnatlou: )fl<"rnscupic organisms (stum1111·d unit!:! 1wr 1·11!111' 1·40n tl- mctcr) --------- __ ---------- - •. rn.-. Am111·phous matter_ 1 mpurtnnl ucncrn. . 10 4!~4 l'tTOll .\."II .JA.\":--E.\"-BARR\C'lh A'I JlROOl\J'JS' . ::\". '· ll:H•te1·wlw·l<'nl exarult1tltlo11: :-;um\l('I" .. 1 h3('ft•rln ]l('r "· ••• (ll~'llr a; l - '1'1 -t for n. roll- H. l e. c 1.0 ... (" llJ. ,-, '"· {' 11cr <."l'lll __ 1ln _ do u ft 14 Tlw wnt{'r -11pplil•1l to Brooklyn during the pa:.t \\eek ha:- beP11 of .. a1i~factory quality. Daily tests for B. typhi wern negatiH•. !'1w11 rl'lftio 11/ul prcpn1•ation of fooJ.-Two ice refrigerators nt"\• b{'illl! constl"l< ted. Tht'ir wnlls and roof are made up of iu!>11lating mut~l'inl l'Ompdsing paper, cork board nnd asphall cement. The floor is of c·onrrck. They each ha,·(• an air i::pa<'e of nhont ::,;,oo .. ubi(' fr•et. Thl' irl' platforms are <i feel G inchc> aborc the floor. The drip pnns ore 0£ gal•anized iron and disch1trgc is by a Huor <lrnin connectecl with the house sewer :rnd intercepting S tr:1p ... One i:- to be used ns a ment refrigerator; the other as n gcnernl r\'frigel'ator. They sho11ld b<' adeq11nte to me<'t the n•quir<'m~nt::: of n dny". ... refrigerating in ti sanitary manner. Tiii' rooms fo1· the preparation 0£ meats an<l 'cµ:ctablc» fol' 1.:ooki11~ :.1"(' lnrge 1•n011µ-h and mt:<•t ::-anitary rc11uil'ements. "h•nb will bl' cooked in !!ns ranges. Yegetnblcs will lw hoih·1l in ·l1•um mldt·ons. Brea cl will be baked in gas O\ ens. ·'t wage 1111<1 1 rf118( rli.~po.~al.-DisposaJ of cxcrel 11 is nccomphshecl n·r~' simply h~· <li,.,ehug]ng it into fh(• city c:ewers whence ;t i .. di:-ichnrgetl into tlw riwr. The hom;e plumbing appen1·s to be s:mi- tHI'." in ull it" features. The flushing ... upply of the wnter-clo:;eh -..)1011lcl he :.utlirient to <'1tnsc eduction of the l'Xcrcta by siphonagc. Re1?11r1.ritat ioll is pn•\·C'nted by S tn1ps. The b'onghs empty into fi- i1wh wustc pipl' whi('h joins the 8-i11C'h honse R<'wer. The other units in tilt' latri1ws l'l1lpt~· into t'itlwr :3 or ~ i11ch pipl'S "hith join the ho11s<' sew(•1·. The Yario11s waste pipe!:> arc provided with t>ither S or P traps ond the honSl' sew('n; with an 8-inth hollsc tl'np. Ventila- tion of the wn~k pipes is arcomplished hy n>nt pipes of gukauized iron either 2 or !3 inche~ in dinnwtc>r·. These extend to I he roof where they dis<'hnrge foul gases. Dispot'al of slops and cxcretn from the kitchen ;rncl tht' hoi:;pita 1 j, :-imilarly accomplished. Food refuse and waHe will be disposed of by cal'tage to the offul d1)Ck. Previons to rnrtnge it will be storecl in C'OYcred gn l nmized-irou 1·an~ placed in the garhng<.' r<.'frigerator. Tlw garbage n•friger1:: or measures 1fl by G .fret and ha::; a height of 11 feet. Thii:; would !'.l'l'lll hardly large enongh to hold a clny's garbnge. It "ill ha ,.e a cenwnc floor and an ice compnrtment. Rubbish will be disposed of by cartage to the rubbish dock. T t j .. re<·ommPruh•il f hnt numerous receptacles be plncecl around the h:u·- :-;o. 4. iuck:s to l'l\{'t'i''' \\H"ll' papt>r and otlwr ruu!Jish 111111 that a larg1• n·- ceptndc he pluel'd lwhind th1• kitchen. \\ lwre fruit ('rnte::-. bnrreJ, uncl rulihi!-'h may h<' kept prior to <'artag1• withonr IH•roming 1111- ,jgbtly. frtJnNal CfJmiort. •llld sujety.-lt i:-- to be hoped thnt :-pit kit. ... will he i11 .... wllec1 in the h:irrnck.... There should he ahout t•iaht in eadt 1·omparl mcut. There j,.. one fountain with three ~nitary scuttle butt" in the park. It ,rnulrl he <.lt·sirable to haYe more. However. 1lrinking wat('r can b<' , bt:Jirw<l from thl' hwatorie:::. so that the rwe<l of the:-P j ... not urgent. Flie" arc prouauly the greate:-t unisum·c in any n1111p. Ewry effort hnR been made to prevent this nui.81mce n rising in this can- tonment. ,\ ll the doors, wirnlow::; and radiuto1· ,·ent..: ha Ye been pro\'idrtl with fly screen8. The sewage connection:-. nn· "0 excellent thnt tho latrines are not likely to be. favorable to fl~· lift•. Tlw kitcheu and mess hall!; ha\'e been provided with :;creen;.. whi<'h "ill prohahly be effecfrve in keeping out flies. Garbage will be kept iu an inclcs<.•d refrigerator until carted awa~· and will not drn w flit~ .... Still, while adequate provision bas been made to check the 11y nui- ,..nnce, the Uies will not be kept out unless proper supt•n·ii-ion i::. rnnintnine<l to "ee thnt the.c;e provisions are being H"ed to the be ... t arlvantage. rt i:-- to be regretted that ll Jaunclr:r ha,.; not bel'll provided. It j ... ... ugge;.ted that wash lines be put in u sy::.tematic mn1mrr between the latrines and barracks nnd not in the·haphnzard way that. the yeoman guarcl is now doing. .\.hove all, it is urgently reqnest<'<l thnt mm be forhiclden to hang wet clothes in the barrack.;;. To preYent the park from presenting a.n untidy nppt>unrnc·e. it i,.. sugge:-;ted tha.t numerous receptacles be placed about the grounds for paper anCl rnbhiRh and that proper attention b<' ~iwn to tht>ir utilization. It. is :.11ggesterl thnt beuchPs be pla('ed :tloJJ!! tlw c·ont..-1•tt• \\a)k, 1111 the inuel' "ide of tlw barracks. ft j.; to be regrettecl that 110 pro,·i,..ion h tb ht· 11 mad<• for drui11i11!! nwny 1·:1in drippin:r 1'1·om the root:-.. It appear·s prnl1ahlP that wh<'ll tJ1ere i.._ hea\'y rninfnll grc>at pools of water 1vill l'ollcd i11 the :-pal.'l':. hctw1•1•11 huildin:rs :rnd ma.r PYen on•1·ilo'' tlw •'ollt'l'Ptl' pat It' n1111 ,o g-et 1111der the floors, which will be nr,r object iormhh•. nec:rn-.e of the inlfommable structure of thl' l111il1li11:!, \'\l'I',\ pit·· ( 0u11tio11 ,houlcl be taken to preYt>nt fin•. It j ... 1·t>1·on11111•111ll'Cl tl111t · smokin!.! incloo1·:- be prohibited and that nH.'11 d<>kd1·tl ut it or in throwiul! aw:ty lightNl cigarette:; he phu·1•tl 011 n•port. [t i:- <h• ... fr- ablo to <•q11ip l'ach con1partm<'nt witl1 a hnnd extiugnislwr· iu addition to th1• ··lwmienl t>ll!!ine>s whi<·h hn1·e '11><111 ,11ppliPtl. [111111P1liatl'l~· 496 PUGU A::-.""D JAN:::>EN-B.rnRACKS .\T .1rnookLYN, N. Y. \'ol out.<.ide of the park are 10 public pumps, some of which are cot nected with the local high-pressure fire mains. It is recommendc that a number o.f hose carts with fittings to attach to these pump be placed at the entrances to the park. It may be notecl in this con uection that the wiring system I:> nnticpiate<l. The circuits are o insulated wire laid on porcelain bases. This system has been con demned by Yarious boards of underwriters. But be that as it may the medical officer recommends the installation 0£ as murh fire-fight- ing material as is practica.ble to preYent a big conflagration. Sanitary 7wlicing.- In almost all details the planning of the can. tonment and its equipment meets the best of sanitary requirements. To some extent automatic appliances haYe been installed instead of those controlled by hand. The flushing of the water-closets and uri. nals is under automatic control. Water flows in the sho\Yers only while the chain is being pulled. There are no basins in the lavato~· I to stancl filled with dirty water. But, nevertheless, many things re- quire constant supervision. Some one must be responsible for the cleanliness of the latrines, barracks, etc. Some one mu:;t see that toilet paper is al ways provided. Some one must see that a set of plumbing fixtures which is temporarily out of order is not being used. Some one must see that the men do not hang wet clothes in the barrack:;, or if they do, must confiscate them for the lucky bag e.nd place their owners on report. And of still greater importance. flome one mui-;t be responsible for the proper utilization of heating and ''entilating appliances. Without supervision of these it is easy to predict that in very cold weather every door. window, transom, ra- diator vent and ceiling vent will be closed. But if they are intel- ligently managed it will be possible to get a satisfactory degree oi' ventilation and heating. Further, it may becorue necessary to in- crease the humidity at times. This can be accomplished by placing shallow cans of water in the radiator boxes. But unless some one is assigned to the task, all the details necessary for sanitary condi- tions and comfort will be neglected. The equipment is good; it now remains for us to get the best from it by good methods. To get such supervision of sanitary features the medical officer recommends the organization of a sanitary corps responsible to the officer in charge of the ca·ntonment. As a tentath'e plan of organizu- t.ion he suggests that the cantonment be divided by diagonal line::; into four divisions. Three of these divisions will then compri&· three barracks and a latrine, and the fourth will include the mess halls, kitchen, hospital, canteen, etc. It would be desirable to hav(' a chief petty officer for sanitary work only in charge of each di vision. Under him there should be one man in each compartment of the bar- racks responsible for the conditions in his compartment, and one man in each compartment of a latrine responsible for <'Onditioru. there. I~ 0 -;; > ., z -5 " iii ! "' > ;; u 400-1 ::> Cl: u w Cl: IL 0 ~ w > w >-w J, 0 Cl: iii 406- 2 Calver-Sixth Naval District. MESS TENT. ~96-3 :-:o. 4. CAL\'ER-::ffXTH XAYAL DISTRICT. 497 Rbumi.-In this preliminary surny the metlical ollil'~r ha ... un- dertnhu to point out an1l corumen<l the sanitary features included iu the cnntonmeut. Cnfortunatdy there are 11 few conditions which do not meet -.nnitnry re11uin•tne11ts. Chief among: these an• the crowding of wen in the burrnck,.., crow1ling of buildings in the square and poor lighting of the barracks. The installations for lwntin:r. lighting, ,-entilntion, messing and toilets will \'ery SRtisfact<>rily meet the 11,·crnge requit\:ments. The nil.Yance made from quartering men on ::-hip:- which are out of commission and umlergoing rc•pairs is cnor- IDOll"'· With this fine equipment and with an equnlly excellent "ani- cnry ::ur uvision the me<lical officer is confident that the department will he ,.-ell repaicl by ha\'ing a healthier and more 1-'piriteil per- sonnel. .\s the men are expected to do their best in thei1· cou11t1-y's :-cnice. it is for the department to do its b<>st in pro\'icli11!! n :-ani- tnn· cn11tonment for them while on shore dntv. . . ORGANIZATION OF THE NAVAL MEDICAL CORPS, SIXTH NAVAL DISTRICT. By G. W. CALVER, .l~'lstant Surg~on, Vnlt1•d !4tnll's Xnvy. In 11 cliscu!':sion of this snhjl'f't it is thought. bettel' to di,·iclc it into lhree heads, giving the three important phases of the work pedormed by tlrn naYal medical oflicers of the regular corp1-; and Uesene Force. in pre} nring for nnd handling the rnrious situation!:) which ari~e in their territory: 1. Preparedness organization of the Sixth X arnl Di~trict. :?. Organizntion for reception and care of recruits. :t Emergency hospital facilities. l'reparrdm;88 orr;anization of the Sixth Naval JJist1'ict. -In the organization of the Sixth Naval District, preparing for fir-...t-uill work amt handling of wounded in cases of emergenc~·, or di~cm­ barkntion of troops or sailors, it was thought, adYisable to diYicle the territory into nine sections. establishing a section base with a <lis- pen~ury in each seaport. The m dical orgnnizntion of a section ba!':e i!:> founded upon the dispen~ary. In the organization of the section base di~pen ... :irie". plan ... were formulated to pro,·idc medical cal'e and attention for two !!ro11ps of personnel; first. those directly concerned \\ ith lhe nrlmin- i::-trntion of the Sl•ttion base. including the office force. de.. ancl. second. tho crews of the coast patrol boats. To fulfill thc:;c require- n ents an ofii ·c \\'lhi established in each seclion ba~l' for n medical officer. which was to consist of two rooms, wherc,·cr possililc. orn· lo be used as nn office and dispensing room and the other for :111 cx- am~mnl? room. S;;;>t-17--:l 498 CALVER-SIXTH NAVAL DISTRICT • ..\. medical officer of the Resene Force. with one llo~pital Corp,._ man and yeomnn. when nece::;sary, compri~e the per.::-ounel of eal'}1 section di:-pensary; nn out~t of <lrugs wa:-; pro\ icled for each medical officer, from the narnl-supply clepot re<1uisitione1l on Form Il. np- proYecl by the medical aid. Regular weekly reports of all work per- formed by the medical officer of each section base is forwarded direct to the medical aid of the district, who thus keeps in touch with the details of each office. These reports are complete and full in eYery respect. The work performed by the medical officer at each section base consists of examining recruits for enrollment and the care and treat- ment of the sick on all patrol boats which make the section a port of call. To assist the medical officer of the section base in keeping up his records and treatments a Hospital Corpsman of the Reserve Force has been detailed to each coast patrol boat, when the size of the crew warrants it, and who, being provided with a reasonable amount of drugs, is able to continue the treatments and keep up the maxi- mum effectiveness of the personnel of each ship. These Hospital Corpsmen are especially selected men who haYe received an inten~iYe course of instruction at the navy-yard dispensary, Charleston, S. C. Contracts were entered into by the section base medical officers for the care and treatment of sick in hospitals in case of emergency and are utilized whenever a case arrives which requires hospital treat- ment. Where practical, the serrices of the United Stutes Public Health hospitals are utilized. "\Yith this dispensary personnel as a nucleus, information was ob- tained and organizations were started which will be able, in time of emergency, to handle the injured. The first information gathered was concerning the docks locatecl in the various cities with a sufficient depth of water for landing pur- poses und which the owners would loan for· use. Next, the distance of these various docks from hospitals or other available locationc; where the injured might be taken. A canvass was made of all hospitals and an estimate obtained frorn each. determining the number of patients that could be accommo- da tecl. as well as the cost per diem for each patient accepted. Through the Boy Scout authorities, viz, the chief scout master, the st-ctional medical officer arranged that as many boys as were nec- essary would be detailed to act as messengers, etc. Comfort squads, consisting of from 8 to 12 Indies, were organized. with the assistance of one captain for each squad, whose name is on file in the section base office. The purpose of these squads is to be at the clocks, temporary hospitals, or barracks, to assist in the trans- fer of wounded, act as untrained workers, and render such assistance as is feasible. :\o. f. CALYER-t>IX:TH NAVAL DISTRICT. 499 ' .\. cann1:-s wns mn<le of the city for nutomobile truck::, to be placed at the disposnl of the sectional base medical officer for emergency CD- ..... und resulted in obtaining a number of trucks in each city. The owner'::. name, truck capacity, and telephone number in each case was obt~ined and filed for referenec. A. cam·a~ of automobiles was made in the :-nme manner and listed. The latter were intended for use for such sitting cases as might arrive . • \. circular letter was sent to each of the trained nur:-cs in each town. nnd those who volunteered their sen ices were listed. .\. uum- l>C'r of nurses agreed to se1Te if they were off of duty when the call c3me. while others have volunteered their entire scnices in case of emergency. One of the biggest questions was the prepnration of such places as might be M 1ailable for use as temporary hospitals or barracks. Such hospitals and sanitoria already in existence were usually unprepared for the handling of any great emergency and such an oYerload as might be thrown upon them had to be provided for in the location of meant buildings, such as might be used for temporary ho:,pital~ or barracks. Clubhouses, armories, schools and dormitories of Ya- rious kinds were the type sought for and desired. To make these buildings fit for temporary use, sanitary squnil~ wen: organized which were headed by business men who agreed to be rc~pousible for the appearance and remuneration of fi,·e negroe:-- who would do this work, each man paying and supervisinJ the men of his squad. To feed Lhe patients in these temporary quarters, u \'idualin~ rommittee was organized in each section base. These men agreed to sec that, in case oi emergency, all of the men quartered at auy point in the city would be properly fed. To assist in the more rapid organization and efficacy of this committee, a canvass was made of the hotels, reslauranls and bakeries for the loan of cooks or the promi~e of their assistance in preparing food wherever po:;sible. The proYision of equipment for these hospitals in cases of emer- gent•y "as met by securing promises of loans of beds and hc1lcling from 'arious hotels and the securing of estimates of quantities of artidcs the n1rious dealers would be able to clefo·er on notice. with the l'Urrcnt prices on each article. Last but not least, practicing physicians in each town who "·ere members of the medical society were asked for instruments: sterili- ze~. tables and such other equipment as they would volunteer to loan. They were also asked to volunteer their personal services in case of nC<.'essity. We found in some places that many of the physicians were members of the Red Cross and decided that they could not sene in both places. 500 O.\L\.ER-SIXTH XAVAL DISTRICT. Yol. XI. From thb it will UC ~een that an attempt has been maue Ht each !'.lt'ction ba~e to pro,·ide: 1. Docking facilitie,., for the wounded. :L A1·commo<lation5 for the injured to the extent of the citil·s· l·apa. hilities. in the m·1ttl'1 of housing nt either hospitab at pre~<>nt in eom. mi. ·ion or in such buildings us might be con\'erted. :t The proper cleausing and preparation of these buil<l.ing::.. 4. Their equipment with arrangements for feeding all patient" . . i. 'I'rnnsportation and care of all wounded from the time of their land in~ until they nre finally deli\·erecl to the hospital by t hl' ti-.e of :111tr-mobile trncks or priYate automobiles, for those ~lighth' in- j11n•1l. nntl with the assistance of registered nmscs <lilcl comfort ~cptacls. H. )[edical attendance and nursing until patients are fit for d11tv. Th(l greatest diflicn lty in each of these section bases wns to < ·ure nrnilable build in~ space in case· a large numebr of men \\'t'l"l' ~11cl­ denly thrown upon the community. This. howeYer. wns pattially met in certain town~ b~· the offer of some hospitals to build tem- pomr~· paYilions or additions to their present building. 1n·oyided they would receive snllicient patients to repay them for the outlay. Orgn .tization for rer:eption and can of 1•erruits.-The navy yard r.t C'hnrkston, ~. <.' .• is exceptionally \H'll lcwatt'<l as far as its rnil- ru:id <'onnections are concerned for the handling of bodies of men aniYin~ from recruiting stations. There are <;everal long sidin!!~ from the Southern Railway and the .Atlantic Coast Line and ::-Pa- hoarcl .Air Line Railwa~·s which come direct to the navy yard. A cir; tt of men arri,·e. cars are pushed in on a siding, ancl the men nre marched to the detention camp. The camp consists of two units of :>OO men, each with separate toilet facilities, and a large mess hall nccommodating the persm 1 el of h\CJ nnits. This comprises "·hat is l'alled a regimental unit. Small houses haYe been built accommodating 2.3 men each. Each of the,p houses, as will be seen, allo"·s 25 men. including 1\ petty ofli1.·cr in charge. to swing their hammocks and proYicles a maxim un cirl'nla ion of air 1rncl protection from the weather. ~\n aclditiona l pers•mnel of 15 men may be added to each house by the use of foltl- ing c:11np cots placed on the floor, thus accommodating 40 men p<-r house in <'nse of necessity. Owing to the exceptionally mild clim:itc in thi,.. locality, it is unnecessary to provide heating facilities for a !!reater period than two months. These houses will be heated by :;mall wood-burning iron stoves with Yentilation around them. Of nll the various types of heating apparatus which ha ,·e been under cc n- sicleration this appears to be the most economical for this climate an<l type of house. C.\J.\'1-:R-SIXTU X,\VAL DlS'I HICT. 501 T wenty hou:-e:-. an• ne<.:e:.:,;ary for thl' uccommo1lation of .JOO men uormnlly nncl four of the,..e housl':, with one toilet room form" the :-.mnlJe!'t did:-ion or unit which can be completely se~rcgated from thl' re::-t of the t>ntire c.nmp. except in thO!"l' hou~e~ wlwre nn infec- tious case ocl'Ur". U111lrr t he:'e circumstant l's the f'ntire per,onncl in the hou:-e "hicl1 ha:. bet:n exposed to nn infol'tiou,.. dbl'n:-=e nre quar- nntined to the house, a separate toilet room being de-.i~nnted for thl'ir u.;;e. They form and march to the mess hall. to tlwir cm n par- tic11!:11· table ancl are kept together for work and i·ecn•ation. under thf' chnr!!C of their own petty ofiicer, during tlw n l'cesrn r~· qunrnn- tine per :o. l. Tlw 1·liject in dil'icling the cnmp into units of t hi~ ~mall :-ize i~ to prc,·ent n greater rlnmage being done by q11nruntining a lar:.re nnm- lwr of men. Instead o:f its being neces~ary t o quanrntinl' a hmulrr.l or more men, if n larger type of bar racks had been U;;l'd. it i" here only ncces'lnry to lose the services of about 25 men, dt:crca ing- th~ damage by 75 per cent. Tlw mess halls ha\·e been so constructed us to nllo\• l'ach ~quud holM' to ha,·e it;; own table. the men mnrcbing in to this tnhle and not h<'ing allowed lo Yisit or use other table:;. The me<:l:i gear of f'ach sqund of 25 is kept sepnr ate and, haYing been washed in ~calcl­ in!! hot water , n minimum chance of infection by this means of infec- tion <·xisls. Dish-washing machines arc to be installecl to l'nable thi~ work to be more expeditiously handled. The ml'«s hall j,.. screened to preYent the entrance of flies, an<l the galley ha!' heen :-crel'ned, portions double screened. t o prewnt the entrnnc<· of flies ancl their access to articles of food. Men are kept u minimum pc·ri0tl of :n clays in the quarantine camp. They are then mo,·l'1l to the lnr!!e l'nmp which consists of four regimental units, nrcom111ocl:1tin!! .J.1000 men. Thus there is a practical amount of precllution tnk<'n to prevent infection occurring in the main body of the camp by carriers from the recruiting stations. The majority of men comin~ to this cnmp will he men who have been in a recruiting camp, and who han• been suppli('cl with their outfits, typhoid pr ophylaxis and rnccination ha,·- ing been completed, or at least commenced in each case. Administrntion buildings have been provided, and the Y. ?.I. C. _\.. or re<'reation building is in process of construction. _\.mple toilet fncilitic." and b:1thing space for the proper Sl'l'llhbing of <'lothe..- hns been provided. These toilets have been dh·ided with a long lengthwise partition into two halves, and each of thc::;c hakes i:- di- vided into fhe sections; each section is equipped and cornpri:;e~ a toilet unit for 100 men. They have cement floors. shower baths, wash hnml 8pigots, and individual automatic· closets. No lmsins were in- 502 CALVER-SIXTH NAVAL DISTRICT. stalled, it being thought desirable to eliminate them, as a possible source of transmission of infection. Separate quarters have been provided for the chief petty officers and cooks to keep them away from both the quarantine and the larger camps: the object being to preYent if possible the occurrence of any contagious cli~ea~c among them. · The question of dispensary location and accommodation has not been definitely decided. It has been suggested to build one large dispensary for the main camp to care for 4,000 men, with a separate dispensary for lhe detention camp. Another suggestion is the con- struction of dispensaries for each regimental unit of one thousand men. The factor deciding this question will be the avnilability of the necessary personnel. It is believed that the latter plan will per- mit of greater expedition in holding sick call and .facilitate the hand- ling of men reporting at that time. T~'mcrgenc,11 110.q11ftal fac-ilities.-The rnwy yard clispensnry at Charleston, S. C .• prior to the present war generally carried an aYerage sick list of about 30 patients, the total bed capacity being auout rn in the main building. 1Vhen mobilization orders were issued to nll Na, al :Militia organi- zations of the Southwest States as far west as Texas, to proceed to Cha L'leRton ~ aYy Yard. no special preparedness plans nt this place hacl li<'en contemplated. Later a training station of 1,000 men was deciclecl upon and buildings were hurriedly erected to accommodate this number. The problem at the nanl dispensary was how to tnkc charge of this marked increase, the high mark on the sick list being 108 patients. To clo this, small tents were first procured, all the standard hos- pital typo aviiilable being used; then tents wct·e borrowed from the Marine Corps, until a total of 22. capable of nccommodatiug 4 men each. were put in conuuission. Later orders were received for the marine quartermaster to turn in all his tentage to the marine supply depot, which necessitated putting out of commission 10 of these tents. Plans were made for the construction of hospital-ward tents at the sail loft of this navy yard, and 4 W<'re procured. These tents ha,·e pro,·en a great suc- cess, accommodations for 35 men being made in each full-sized tent; 2 of the tents being of shorter length could only accommodate 25 men. Construction of hospital-ward tent is as follows: The tent itself is 66 feet 6 inches long and 20 feet wide, supported by n ridgepole diYidecl into four sections, with five upright poles, each section being 16 feet (i inches long. The ridgepole fits into a half socket as an awning strong back on board ship, the socket being 18 inches from the top of the pole. A second ridgepole is :fitted on pins on top of Calver-Sixth Naval District. REAR ENDS OF TENTS. "MODESTY" CLOTH IN PLACE ON TWO TENTS. WARD TENT, "MODESTY" CLOTH REMOVED, SHOWING ARRANGEMENT OF BEDS. 602-1 Calver- Sixth Naval District. I' / ( f ( f I • / '' I I , · ~·~ - I 1 ,.;, ··,. ~ INTERIOR OF WARD TENT. CONNECTING SYSTEM OF BOARD WALKS AND GENERAL OUTLAY OF TENTS. SHOWER BATHS FO R PATIENTS IN T HE D ISTANCE. ~o.4. CALVER-SIXTH NAVAL DISTRICT. 503 tlie upright teJJt poles, which is 4 inches thick, giving a clearance of ~:2 inches between the tent and the fly. The tent is 20 feet wide, side walls 7 feet high, supported by poles :2 inches in diameter, 7 feet long, with a galvanized-iron spindle running through the tent. The tent is bound by a 21-thread manila rope, running from ridge to side walls and spliced in at both ends. Siile walls are made in sections to correspond to the sections of the ri<lgepolc. They are secured in place by leather thongs "ith snap hooks on the ends, snapping into galvanized-iron rings attached to the binding rope at the top of the wall. The front of the tent is diYicle<l into two sections. each of which may be rolled up inde- pendently. A ventilator 9 by 18 inches is placed in the penk nt hoth front nnd rear. The height of the peak of the tent proper is lil feet !I inches. The fly projects 3 feet at either end of the ridgepole, which exten<ls for this distance, and projects 5 .feet beyond the walls of the tent, to give additional protection against inclement w·eather. The tent is set up on a tent floor 72 by 24 feet. The center of this floor is raised 2 inches higher than the sides to allow for easy flush- ing and drainage of these floors. The upright poles and poles of the side walls are set in fitted blocks nailed to the deck. This makes the tent absolutely steady and prevents the poles from being knocked around. The guy lines from the tent proper are taken to pipes se- cured lengthwise to the tent by driving stubs in the ground 3 feet 6 inches apart. Two lines of pipe are necessary, one .for the tent itself, the other for the fly guys. These two lines of pipe should be 5 to 6 feet apart. The long guys to the pins in the top of the tent pole nre crossed, one guy to each side, on each pin; for the end poles, preferably two guys to each pin to the central poles, which permits of the crossing of the guys when the tent is pitched. A "modesty" cloth is made of 8-ounce ravens, edges hemmed, turned in 1 inch, and brass grommets are put in for each post. Tie- ties of white line, the size similar to clothes stops, are used to secure this cloth in plnce at the top and bottom. The purpose of this cloth is to prevent people on the outside seeing too much of men inside the tent when incompletely attired. ~[flsquito har fram"S were constrnctecl 3 foC't hi~h. !3 feet "·ide, of 11 inch square stuff, set in wooden blocks 4 by 6 by 6, braced diago- nally at all corners at front and side. This frame has given consid- erable satisfaction, as it holds the standard Navy mosquito net just down to the deck. It has an advantage in being made wider than a folding cot and thus keeps the mosquito bar awa.y from the side of the cot and prevents the mosquitoes from biting the man if he inad- Yertently sticks a leg or arm off of the nanow cot, as one is prone to <lo. The galley and mess hall facilities then proved inadequate, and it was necessary to convert one of these tents into a mess tent. 504 CU:\I.MI.XG-CEREBRO-SPIX..\I. FE\'1,R. E:wh tent has been connected by a system of boarll walks, nnd a n•ncreal prophylnxis and treatment booth. t•meq.~ency head'. and shower hnths hn,·e hePn cons1:ructecl: wnter piped into c:unp nnd s:mitnry drinking ntt:1chmenb im.tallerl: all of thi:-- work h:n·ing been <lonl' lff llospitnl Corp<: men an<l conYalescent patient~ . The medi- cal camp nml dispcu-:ary building is now in condition to care for and feed :wo men ~ithout difficulty. Thrrc is in procci:;s of construction an emergency hospital of ~i>O he<li;. which will be the base hospital for this clistrid. Beir !.! oon- l:ilrud l'tl on the p:n-ilion plan it can easily be en lnrged to m ~d our iequin•nwnts l>y the addition of fiYe 50-bed wnnb. This hospitnl "ill he in commission on July 20, 1917. A hospitnl or, rather, ambulance ship woulcl Ul' desirnbk in O!'cler to ct>ntrnlize the cure of the men of the naval l'OllSl patrol on this hospital. The enrly nrrirnl of snch n Yessel to fncililate the cure of thl' men of this scn·ice is earnestly desired . • \ school of instl'uclion has been organized at the nn vy-yard di ... - pen:-a ry. Charleston, S. C., for the pmpose of instructing both the new me1l ical oflicers and Hospital Corpsmen; besides this a special inten h·c school of instruction in recruiting has been or~anized :for the pmpose of preparing certain selected men for duty at section ha<:e,... Thl' nwdical officers receive instructions in na ml forms imd pro- cedure...:, drills and general routine of naYal life. They also haYe been giYPn a special course of instruction in Swedish moYement'. lumllina. wrestling, wall scaling, etc., to equip them as thoroughly as po-,:-.ible for nny field service. The Hospital Corpsmen are given a three months' intensive com:::e of trnining, co,·cring the course prescribed in the J\fonual for the ::\leclical Department. Besides this they are given drills, Swedish mo\"erm•nt!''- nncl other exercises to bring them into ns good physieal ~hnpe ns possible. THE PRESENT STATUS OF CEREBRO-SPINAL FEVER WITH SPECIAL REFERENCE TO DIAGNOSIS AND CONTROL.' 67 II. ~. CUM:\lllSO, Surgeon, 'Cnited Stutes Public IJealtb Rcr~k<'. Cereuro-spinal fever is one of the communicable clisenses whose ap- pearance hns been considered an almost ine' itaule conseqnence of the mobilization of large bodies of men under conditions of sudden change of en\'ironment, overcrowding and lack of adjustment, which usually jnitiate such action. The hitherto mysterious mode 0£ trans- 1 ~Ince this arll~le was prepared n v.a.luable cont1·lbuton to lhc knlowledgc or dlagnORls and treatment at lbe disease has been written by Dr. Simon l•'lcxner : " :Mode of Iufectlon. :\lean~ ot l'rcv<>nllou 11nd Spcclllc T reatment of Epidemic Meningitis." (The Rockefeller ln•tllutP fur .llledtcal Research, 1917.) Ct:l\DllXG-CEHEDRO-SPIXAI4 FEYI:R. 505 mi. .... jon ..... ml<lm on:-l·t. suffering. hi;:rh mortn lity an<l seriou:- scqnehc ottrilmte<l to thi,.. malad~· ha,·c made it one of the mo:,t dreaded of camp <li .... ea e:-; nnd the 111ethods to be :alopte<I for it" control worthy 0 f mo:-t careful stud.'· hy me1lical ollicer:::. Prevaler.ce.-Cerd.1ro-::;pinal fen!r nppenred among the newly mobilized nrmy n1 c1 :·:t'Y of Great Brirnin an•l continued in Hll:> and imG. It has been reported present this year in nearly e?•ery State in thi' wuntry and, as was ineYitable. in consequence of cxtensin recruitin~ ol yo11ng men ancl boys for the Xtn-~·. it has appeart><l at some of om· ti·aining stations. Cases will almost certainly appear next wintN' and spring in the cantonments and camps arnl lite follow- lll!!' Jl'\ iPw of present knowledge may be of m;e in prHl·ntin!! its :.pren1l. L'tio1nr;y.-The cnusati,·e agent of epidemic ccrebro-~pinal fen!r i:,, the di;)locol'cns intmcell11lnris meningitidi:; of \Yeid1 elba11111. a Grnm-negati,·c organism found in 1.he cerebro-spiMl fluid (c:harnc- tcri·4: ,1 Jly in pol~1rnorphonuclear cells as a rule), .in the na,.:ophnryn- !!Cal secretion. and during certain stages in the blood of patient:-; :-uffering with the cliscnse, as well as in thP nnsopharyng('a! :,e<'l·c- tions of certain persons who ha>e shown no clinical symptom ... of the di:-en ...... l'r1•tlisposi11g causes.-It is evident from the large numbt-r of persons without clinical symptoms who are carriers of the menin- ~OCO<.'<'llS, that something in addition to the presence of the orgirnism j,.: 1H'<'e::.sar~· to produce the disease. The disease is more prern lent <luring the winter and spring when there is more indoor life with in- crea,e«l expmrnre to in:J:ection, overcr~wding, bad Yentilation nncl :-11clcle11 changes in climatic conditions, all of which ttre conduciYe to rnriou~ other depressing diseases with catarrhal conditions. The clisea!.'E.' is apt to follow these conditions and also to follow lowered vitality due to excessive fatigue, or incident to such dbense.:o as mea:-le:-::, German measles. and influenza. The mere pre:-::en<'e of chronic c:ata1Thal conditions, however, does not seem to increa"e s1i:-;- ceptibility. ~lfode, of transmi.ssion and infeetion.-The meningo~·11ccu~ is '}>rend by being carried in the nasopbarynx of normal incli\'iduals, conn\le:.cent patients, and those actually suffering from the di~ease. nntl is imparted to other individuals by direct contagion. ~uch con- tagion tnkes place either by absolute contact, snch as kissing. or by the spraying droplets or discharges of the nose and throat. tb in coughing, speaking, singing, or snoring. While there is a possibility that the organism might be spread by the contamination of cloth- ing, or of floors and walls, the extreme susceptibility of the menin- gococcus to drying renders such methods of spread quite unlikely. 606 CUMMING- CEREBRO-SPINAL FEVER. Yol. Xt. The fact that by fnr the greater number of carriers hnve normal throats and therefore no excessirn discharges from the no-,e or naso.. pharynx and that there is no inclination to spit is an acl<litional factor in making such a method of spread unlikely. The portal of infection is from the nasal mucou::. memhnne abo,·e the turbinate and the posterior wall of the nasopharynx through the connecting channels to the snbarachnoid spaces. ]Jia!lnos-is.-Both for the cure of the indh·idnal victim nnd for the safety of those exposed to infection early diagnosis is mo,.,t im. portant. There is available a store of clinical observation of !!rent value whereby an accurate diagnosis may be made basecl on the appearance, sequence and relative severity of certain symptom::,, hut a 1liagnosis based on clinical evidence in the early stages can not be cone lusi Ye. The 1lisc0Yery of the meningococcns, the introduction and perfec- tion of the technique of lumbar puncture, and the discovery of bac. teriological and se+·ological methods for identification of the orgnn- h::m ancl the preparation of curatiYe sera. have recently afforded op- portunity as well for early diagnosis as for the institution oi !'peeific treatment. The question is, therefore; What cardinal symptoms nre Fufficiently suggestive of the disease to justify the immediate per- formance of lumbar puncture? .\ p·\tient who has been seized with sudden illness ushered in by a rigor, accompanied by severe headache, rapidly growing worse and soon accomp:inied by vomiting, is a suspicious case. When Kernig's sign i:-. present, when there is pain and stiffness of the neck, and if retc-ntion of urine occurs, the probabilities are sufflciently gre11t to ju:-.tify lumbar puncture. Other symptoms, such ns delirium going on to coma, a petechial rash, or head retraction would merely con- finn these probabilities. The differential diagnosis is mainly concerned in <listingni»hin!? the disease from acute febrile infections on the one hand and from other diseases of the brain and meninges on the other. The chief confu~ing febrile diseases are influenza and pneumonia, while the chief cerebral affections are meningitis, due to other organism"' nnd cercbml abscess. The differential diagnosis of early cases of cerebro-spinul fm·er from influenz:t is often clifficult; both ha.Ye sudden onset with head- ache nud fever; in both pain and stiffness in the neck, back. and legs are prominent symptoms; in both search for Kernig's sign may reveal stiffness, and for the first two days cases of cerebro-:=-pinal fHer which ultimately become severe may show no obvious difference from influenza. Constantly increasing headache, vomiting llfter onset. retention of urine, and increasing Kernig's sign justify lumbar puncture. Sf'.4. CU:\DIIXG-CEBEBRO-SPIX AL FEVER. 507 Pneumonia in children and young adults, in whom headache and ,-0miting ore striking symptoms, may be easily mistnken before physical si~s of consolidation occur. The absence of Kernig's sign, ris~ in pul"e re::;piration ratio, and beginning consolidntic.n indicate pneumonia. Tvphus fenr is difficult to differentiate in its early staues. owina • • b 0 to sud1len onset with rigor, intense headache, c.lclirinm. and reten- tion of urine. The points of difference are absence of head retrac- tion. later onset of delirium, and contracted pupils in typhus. If doubt exists, lumbar puncture is justified . .Malignant forms of scarlet fever, measles, mumps, and "mnllpo~ 3rc liflble to be confused with fulminating cases of ccrcbro- pinal fc, er and the urgency of symptoms justifies ]um bar puncture. It should be remembered that there may be cross infection nnd tlrnt :m attack of any specific :feYer may be :followed by cerebro-:-.pinal fcnr. or. indeed, by cerebro-spinal meningitis due to the cau,,ativc or~nni::;m of the original disease. The mnin difficulties in differential diagnosis are in distinguishing cercbro-spinal f eYer from other diseases of the cord and brain, par- ticularly those affecting the meninges. The commonest variety is tubercular meningitis. The gradnnl on- ~et with failure in health, slowly increasing headache, only ~lightly incren--ed temperature, marked photophobia and paralysis of ocular nenes indicate tubercular origin. Examination of the spinal fluid gives the only definite dingnosi~. In tubercular meningitis there are comparatively few cells present, of which 70 to 100 per cent are lymphocytes, while in cerebro-!"pinal fever there are few lymphocytes (about 30 per cent or less), and polymorphonuclcar cells comprise the bu}k of deposit. Tlw ill~uti­ ficntion of the organism clinches the matter, but fluid from a hyclro- ccphalic case of cerebro-spinal fever may cause difficulty as the c~'to­ lo~ical picture there is identical with that of tubercular meningiti~. Purulent meningitis caused by any of the pyogenic group of or- f!ani--nis may occur and the pneumococcus is one of the commonest cnu:-c." of primary meningitis of this kind. The course of the dis- ease from these organisms is very rapid, lasting only from three to five days or even less and leading inrnriably to a fatal result. The differential diagnosis is to be made by lumbar puncture. The on~-ct of the acute epidemic form of poliomyelitis may simu- late cer~bro-spinal feyer. The early palsies or hemiplegia of ordi- 1111ry fol'lns and the convulsion which invariably 11shers in the cerebral form, as well as the seasonal prevalence of poliom~·elitis in the smnmcr and autumn, should serve for differentiation. Lum:/Jur puwture requires little skill provided the position of the patient is correct and the landmarks are accurately ascertained. :rn LT:>DfJSG-CEREBR0·:5l'IX,\I. PEYER. \'ol XI. Any trocar :uHl cannul11 at lea::;t 4 inche" long will sene, if no :-pecial in::-trument i:-. at han<l. The patient ::;hould be on his side. hi:. but- tl)ck:- on the edg-e of thl' be L the knee:- fll'xed on the abdomen. and tlw lwnd nut! body hl'nt forward :-;o that the intcnertehml fornmina are opc•ncd :tncl the li~nmcnta :,nlJfiarn l'l'nclered tense. The puncture ,l1011ld be ma<lc in the intenertebrnl foramen between the founh and fifth h1mh:H' n•rtebrrc. The i-pine of tlw :fomth Yertebra can be felt on a line joining the s11111111it..: of the cri!ita ilii and in adults the interspinon~ spa('e "ill be felt t 1• 11t 1~ inches below the spine. Perhaps the lateral rout~ i,. preferable in adults as the interspinous ligament trnn•rscd in the mNlittn line intederes with delicate manipulation. It is imporhnt thn t the trocar shonlcl be sharp. General anrosthesia has many advantages, particularly with n lll'l'\"011~. reralcitmnt or delirious patienl. The onl)' (fo•arlnintn~e i~ the possible clanger therefrom, which is practically nc~l igihle. The English fa \'Or the use of a general amcsthc>tic a nil Foster m.r! Ga ~ kt:'ll adrnrn·e three reasons for making such practice ~cnernl : eac:e in making the pundure, increasecl amount of fluicl secured and temporary relief from intolerable pain. General amcsthesia ,, ob- \'iou~ly adYisable in active delirium and in cases wi1ere lumber p11nc- t11re has to be repented from day to <lay. The operation without r.mesthesia. taxes the fortitude of patients, whereas with it in ca~, of l'e\·ere suffering they even look forward to the relief afforded. •·"'hen headache is senre it is no uncommon thing to see a p:•tiem. who had preYiously been restless and moaning. pass straight from the aml':-th"tic to a peaceful sleep of four or five hours.'' Study of the cerebro-spinal flnid is oI the greatest importance. for not only is recovery of the meningococcus neccssnry for dia:rnosis ancl of value in prognosis, but its remoYal is an importnnt factor in trt>atmcnt. The normal cerebro-spinal fluicl is a perfectly clear. colorless liquid of low specific gravity, being usually 1.001. with allrnlinc reaction. The normal pressure is such that when lumbar puncture is performed, the fluid flows nt the rote of only one drop t•\·ery two or three seconds. and never more than 10 c. c·. can I •e ob- tninecl: often lesR. Reduction obtained with Fehring's solution j._ appreciable; nllmmin is usually absent. The cellular con~titt1l•nt, of n normal :fluid are extremely scanty, averaging about one to :'enn lymphocytes and an occasional endothelial l'ell per cubiC' millimeter. Polymorphonuclear cells are absent in the normal fluid. Change in the cerebro-spinal fluid in epidemic meningitis con~i:-t in irn:1·cased pres.'-un•, alteration in chemical and ccllulnr constituent'. Increase of pressure is present in almost all stages of the rlis('af:'e. HNI on the first clay, and is often so great that the fluicl !"purts out and a~ much ns 40 to 70 cubic centimetc>rs nre often obtained in acute 1 Cl')Dil::\G-OEREBRO-SPl::\A.L FE\·En. 509 In wme d1ronil· t•a:-cs no Huid can be withcl111\\ll. :111<1 this ~n!.!C'· is of :-;c1;ou:- import a.., it indicate;; occlu..,ion. Hemrn al of ccn~bro- ~Pinnl f111icl can he continued .f'afely until the flow i:- l'c111al to or e,·en lc...,s than normal. In the acute stage the appenraIH'C of the fluid is profoundly altered. " 1hen tir--t withclrawn it j, 1·louded or opaJe ... - cent. or it may contain fragments of flvcc11lent material. 'Yhen tillowcd to ... tantl the "ells to which cloncline::.s i::, 1lue -.iuk and the :-upernntnnt fluid is clear. In acute stnges a small ::unount of pu ... h, of fu mm ule, a lnrge amonnt of nnfn rnrnblc, import. Tu cu~e,.; "hich do nut respond to treatment pus increases. while in lnh·r :,la~e of fn' ornhll' cn::.es the f111i<l grad nally becomes clean•r. In chroni1· (';ise-. thE fl11id becomes denrN'. pn1ticularly i11 the t·hro11ie h~«lro­ cephalic· type. The chief alteration of constilueut:-. in solution c·nn- "j ... t::, in an increa,.,e of protein, mainly albumin. and <t di111i11utio11 of llf!lll'. "'ith improH'llH~nt in the clinirnl conc1ition the lattei· re- turn,... 'l'hl' cellnl;n· changes in cpidemil' meningitis arc char:1dl'rizecl h.'· till' pre,.;cnee of pol~·morphonuclcar leucocytcs. of ten in l .., ·111011;-. 11umb•r. and a re1atin•ly ~mall increase in lymphocyte:-.. The.--e conditions of the cerehro-spinal fluid are not pathognomu11ic of ccrebro--:pin<li fe,·er. ancl identification of the meningocoocul> i:- c:;.-.en- tml for n eomplete din:.,rnosi .... 1'crl111iquc.-,Yhen practicable a few cubic c:enti111ctcrs of the tluid .. iouhl he centrifuged and smears made of the sediment stained with methyknc blue or cal'liol-gcntian violet. arnl exnminecl 11ndc1· nil- immer-.ion ll'ns. It may be necessar~' to examine many field:- or e\·en many sliJes. If the organisms arc easily funnel in cn·r~ field, the outlook is gt'll\C and especially if many extracellulnr org:rni--111:- are pre:-enl. Staining by Gram's method should be done. The organisms are Gram-negative diplococci ancl they arc typi- rally fonml in polymo1·phonucleur cells, though in fnlminatin~. ' cry ~rn,·e. nnd in suppurating cases they are also extracellnhw. The cerclJro-spinal fluid should be placccl in tlw :31° incubator o\el'lli!!ht. m; a film from the sediment the nrxt morning will often show mcni11goeocci. mninly extrr..cellular, eYen when no11c we1e fouurl nt first. Cultures ~hould also he ma<le at 011C'C nnc1 for this purpo-~ many ml'din hnH' ueen recommended, all of \Yhich ha ,-c i-;orne body llnicl n- on e.":>ential eletrent. Tl1e fn.•e-.t growth. perhaps, may be obtai11c1l h~· !;CC1li11!! 011 n~ar plate:- on which about three drops of fresh blood hnrn Ul'Cn n1hled . • \medium which has been iound satisfactory i..; ma1le a,., follow;;;: To ;, part!; of n n11trient, 2 per cent neutral agar rnade of hcef i11fusion. with 1 per 1•cnt glucose, is added at 50"-:i~ 1 part of -,Jwep sernm wuter (shet•p -.ernm 1 to water 2). X cntrality i., te-.tl'I 1 agn in4 phenolphthn le in. 510 Cl'l\ll\IIXG-CEREBRO-SPIN AL FEVER. • The gluco:,c agar i:; :-lerilizcd for lt hours in streaming steam and the serum water i-. autoclan~tl for 15 minutes at 15 pounus pre::.::.ure. The serum water awl agar are mixeu shortly before using with nsep. tic technique aud tubed. The tubes·shoultl be incubated previou:; t-0 use and kept moist at all times. Thi-. medium is comparafo &ly clear and permit:; ca y recognition of colonies on the plate. It is well adapted to the growth of the meningococcus so that visible colonies appear in six to eight hours and de,·elop from 2 to 3 millimeters in diameter oYernight. In the absence of sheep serum an excellent medium can be maue by the addition of laked human or rabbit blood to the above-de.-;cribed agar. The blood is laked in distilled water and added to the meltt.'<l agar at 45°-50° in the proportion of 1 part of laked blood in 6 to 10 parts of agar. Rabbit blood agar (1 part blood in 20 parts agar) affords good growth, but is opaque ancl masks the color and structure of the colonies. The various serum agars are made by the additioh of animal fluid lo the agar in the proportions of from 1 to 5 to 1 to 20 . . Ascitic and hyclrocele fluid may be used and the organism will grow, though not so freely, on Loeffier's medium. Experience in England has demonstrated the Yalue of taking a swab of nasopharyngeal secretiou at the same time, as this secretion nt the onset always contains meningococci of the same agglutinating type as contained in the cerebro-spinal fluid, ancl at times they may be found in the nasopharyngeal fluid before they can be found by lumbar puncture. The flnid nnd secretion should be plated at once on plates which hnse been \Yarmecl and placed at once in an incubator kept at 35·-aT0 • • \.fter G to 12 hours plates should be examined under low power or with the naked eye for character~stic colonies, which can be recog- uized by lack of color, regularity o.f outline, homogeneous granular !-tructnre and ease of homogeneous suspension in salt solution. Occa- sionally colonies may not appear for 2-± hours or longer, but thi:; is infrequent if care has been taken to seed immediately on warm plnte::. . .A colony should be picked and specimens should be stained ior Gram-ncgntive cocci in which diplococci predominate, young cul- t nres exhibiting many ghost or involution forms. While very accurate differential descriptions have been made of the cultural characteristics of the meningococcus, further identifica- tion is necessary to distinguish the organism. Pending further identification, however, the finding of Gram-negative intracellular <liplococci in the cerebro-spinal fluid or in the nasopharyngeal :;wub fr.,m n patient with the cardinal clinical symptoms of meningitis justifies isolation and treatment of the patient with polyvalent scrum, nnd ii-:;olation of contacts. !'o. 4. cu:r.nu::rn-CEREBRO-SPINAL FEVER. 511 Ftu1her identification of the organism should be made by (n) ag!!lutinntion tests and (b) fermentation te::;ts. The colony in which Gnuu-ncgative cocci htiYe been found should be fished and heavily ,,..ecded on n :;erum nga1· slant tuLe which should be incubated for to 13 hours at 3i 0 • .\ su~pension of the growth should be mncle in :! to ;; cubic centimeters of 0.8 per cent saline solution, heated to 65° for 30 minutes to inactirnte autolysin, and saline shouhl be ucl!led to bring the solution to a suspension sufficiently heavy to facilitate the reading 0£ the test (as a minimum, the final suspension l::ihould be about equal to the turbidity of typhoid vaccine as made by the ,\r.my )ledical School or Hygienic Laboratory). The agglutination test should be made by the macroscopic method in small tubes, using equal parts of the saline suspension and the :.erum dilution to be tested. Agglutination tests should be carried out at ;,;, 0 for a period of 12 to 20 hours against normal serum, giYing no agglutination in an ultimate dilution of 1/ 50, and agglutination :-hould be obtained against polyvalent serum in ultimat~ dilutions 0£ 1/200 and 1/ 400, and also, preferably against univalent sera of ac- cepted ~tandard types, in order to determine the type to which the recoverd organism belongs. Such sera should have a titer 0£ at lea-.t 1; :300 for control meningoccocci of the various types. ~\gglutination with antimeningococcus serum in titer of 1/ 200 and fnilnre of agglutination in normal serum at one-fourth that titer is sufficient evidence on which to detain an individual as n carrier or to confirm a diagnosis . • \.s a result of their observations in England, Gordon and Hine hn n! fotrnd that practically all meningococci fall definitely into one of four serological types which breed true and preserve their clis- tinctiYe characters even when propagated on media for months. Tlw_v conclude that in spite of general similarity they behnYe as specificnlly distinct micro-organisms and not as transient varinnts. Of the four groups, the first two were found in o\·er 80 per c<.'nt of the English cases. Only one type of organisms is present in a cn~c. both in the nasopharynx and in the cerebro-spinal fluid. l\Ien- ingococci of the epidemic type are completely agglutinated b~· one or oth<'r of the standard sern. As a rule the differentiation is sharp, but in "ome cases an epidemic strain in addition to complete agglutinn- tion with its type serum is also partially agglutinated by certain other stnndnrd sera. The English found close agglutinative relations between types one and three and between types two and four. There is no ng-:?lntinn.tion with normal serum. Other variations nre possi- ble. but in most cases the type of coccus is indicated by the ~erum I\ ith which it shows most complete agglutination. Nasopharyngenl cocci resembling meningococci, but failing to qnnlify !:ierologicnlly may giYe one of three results: (a) Complete 51~ Cl.:')lMIXG-CEREBRO-SPIX.\L FEYER. \·01. XI. agglutina~ ion. by normal and all stand a rd !>.era in lo,~· di ~ution ; (b) no agglut mat10n by normal sermn. but partial ugglutmntton in dilu- tion:-: not c..-xceedinj! 1/100 by one or all ~tantlard sern (group " ng:rlu. tination "): (c) no agglutination by sem. normal or stundnrd. For further identification: a<h·antagl' mny be taken of the cliffer- eut·e;, hetwccn mcningococci and other Gntm-negatiYe diplococci in the fernw11tntion of the Yarious sugars. All of these other flrntn- ne:mti,·e cliplococci. except the gonococcus nncl )[. cutn rrhnlis. :fer- ment duco:se, maltose, mannose, lwn1lo:;e, and saccharo~e . Xone for- ml·nt hwL<>SC: galactose, mannite, clukite, dextrin. ancl inulin. ~1. fin n1.5 IJ I doe:-. not ferment saccharose. The gonococcus ferment... !!lucm;c only. The ~I. calarrhalis ferments none. The ml'11in!!ococ- c11:-; ferments gl 11eose and maltose ancl is negative for other Htgar~. Tht• USC' of glucose (dextrose) maltose, hP\'lllose, mnnno-.e and !'nccharose is sufiicient for differential 1rnrposes. One c. e. of n 10 per tt'llL ~.;olntion of et1ch sugar, previously sterilized by fractional UH.'thod. should be addccl to sugar-free n~nr meclinm with a rea<'tion of +O.:.! to +o .. ; ( phenolphathalein). to which jo.; ndded enough pur1• ;.terile litm11s solution to gi>e u decided blue tint. ThC' plnt<' or tube::- ::,houltl be obsen·ed for seYerul days for the production of ndd. The !!lul'o ... e re~\ction i<i usually thP most rapid. Gaskell and Fo ter prefer fluid media for these tests, and Yeal broth is excellent for the 1>1trpo-.c. Co11t rol of the disease may be cliscu~-.ed under menqures for the c:m·e of the patient and measures to prevent spread of the cli:;ea e. t '11rat i I'(' .-The most important an cl possibly essential nwn ure for the cnre of thr patient is the e11rly or immediate dia~nosi" with Jumhnr puncture and release of cerebro-spinal (luicl. with earl·· nd- mi11i:strntion of suitable nntimeningococcus thernpentic sernm. en- 1lo11bte<lly the high mortality and chronic nen·on:; seqnelre as:;nci11tecl with preYious epidemics have been the re~mlt largely of prolo11frecl pn's.-;nre, and theil' comparatiYe absence cluring recent outbreak~ ha!" hee11 dnc to the introduction of spinal puncture, as well ns to the introduction by Flexner of intrathecal uclministmtion o f a curntiYe ~t·rnm . Helie£ of pres.-;11re is in itself a curnti,·e measure, and it ~houhl be employed wlH•ne,·er clinical symptOlll'i of pre~snre. p'-'r- ,..istent fe,·er, or a sudden lapse into an nclynamic• stnp;t> appear. :t:::. well as when indientecl by hacteriolof!ical ohserrntions. Serum, either pol.n illent or the agglntinatin• for the infoctin!! type of organisms. l'honkl be used daily until the feY'-'l' tlisappc·nr-.. _\clminbtration of serum should follow the esc·ape of cerehro-'ipi11al fluid. ::,hould be of IC'ss quantity than the amount of ilui1l "ithdrnwn. nncl the serum :-ho111c1 lw ~iYcn ~Jo,rJy, l rt>frrahl,\ h,,. gn\\ it:-. .\n symptoms of vngnB inhibition, C'heynes-Stnkes lJI'<'nthing. ehan:.rt·~ in rhe pupil~ or fall in blood presure, thren<ly pnlsC'. or ~hallow n·spirn- ?'°0. 4. CU!\l:M:ING--CEREBRO-SPIN AL FEVER. 513 tion should be a signal to stop the injection of serum immediately. \bout 10 minutes :-hould be taken to inject 15 c. c. and from 30 c. c. ; 0 60 c. c. should be given. .After injection the puncture should be C<lYered with collotlion and gauze and the foot of the bed raised 011 ulocks 1:! inches or more to allow diffusion by gravity. :Morphin and hot bnths nre u~ful. Constipation, which i,, usually ob~tinate. ;,houl<l be treated with enemata, and the bladder should be cathe- terized when retention exists. Prol'eidion of spread fl'oui the 71atient.-The precautions to be ob:;errcd in nursing the cerebro-spinal fever patient are simple and are concerned mainly with discharges from the nose an<l throat. Cough is seldom present, but during active delirium the patient 111:\y "" l'pr:1y ·: the discharges. Attendants should therefore amid the patient":- breath when he is in such a stage and their throats and noses :-hould be sprayed daily with a mild antiseptic. The patient's bed :should be a reasonable distance from others to avoid •· llroplct" infection. He should be isolated if practicable. .Abuntlnnce of f:re.£h nir and ventilation are most important. All articles u,.ed in treating the patient, such as feeding utensils, all linen and other articles which m:1y htwe been infected, should be disinfected imme- diately by chemicals and later by boiling or by prolonged expo:;ure to direct sunlight. The urine sometimes contains the org·mism and incontinence is common. The foul discharges from the nt< nth arnl no ... e especially should be carefully disinfected. The risk of infec- tion to nurses and physicians is not great in a well-ventilated hos- pital. nnd there appears little evidence that such persons have c:lrried the , li · ;oase to others. The prevention of the spread of the disease should bo l..>a"l'cl upon know! ·il~c that the mcningococcus is short lived outsicle of the body: thnt infection occnrs only by direct conyeyance of the na~ophnryn­ geal secretion from a patient or from a carrier without clinical mnnife~tations of the disease; that a patient is simply n carrier who has. thrrmgh lack of resistance, deYeloped clinical symptom-.: anrl that ~udden changes in meteorological conditions, particularly in cold weather with lack of proper clothing, overcrowding-. nud h:ul ,·entilntion, as well as other acute diseases, are concluci,·e to bringing nbout the necessary lack of resistance . • \ o:ocm ns a case of cerebra-spinal fever has been disco,·erc.1. all contncb should be isolated and swabs made from the nn'-ophar~·nx. particularly the region in which :1clenoids are found. Salim i" nutagoni~tic to the meningococcus and also it cont:iins rnnfusing organi:-ms. therefore care is necessary to preYent touching the tongue or fnuces with the swab, which should be of stiff wire with one-half to three-fourths of nn inch of the end bent to nn angle of about 45°. 8:>51-17--G 514 CU::\r:\HNG-cEREBRO-SPIN AL FEVER. The pnrt oi the swab which hns been rubbed thoroughly on the proper region should be sown immediately on the serum agnr plate previou:-,ly described. Use of the West tube, a glass or metal tu~ containing the wire and swab: may facilitate the operation and lessen the risk of contamination. Contacts which show no menin- gococei on the first examination may be released if they have had no other e..~posure. In udrlition to the known contacts, as many possible contacts as practicable should be examined. The circumstances surroundin<7 each case must necessarily suggest the extent of such procedure. If a patient hns been received within two or three days and JllJ pre- vious cases have appeared in the vessel or on the station, manifestly the probable extent of contact would be more restricted than if he has been on the ship or station for several weeks. During convalescence the meningococcus is generally prl'sent in the nasopharynx in progressively decreasing numbers for from one to three weeks, bnt in a considerable number of convalescents the or- ganisms may persist for months. Such individuals are "clronic carrieri::." In addition to these persons, contncts and other c· rriers whose nasopharynges contain the meningococci may be divided into temporary and chronic carriers. Fortunately most carriers-per- haps 0 to 90 per cent-fall into the temporary class, the organism disappearing in from a few days to three weeks. Unfortunately there are others in whom the meningococcus persists for months. Despite the evidence that varying numbers of the population of communities free from cerebro-spinal fever are carriers, there is con- clusive evidence that carriers are responsible for the dissemination of the disease and they should be isolated until the organism disap- pears. They i::ho11ld be 1soh1ted, q1rnrte1·erl, messed, and rillowed in- door communication in small groups only, the smaller the better. of 9 if possible, and of not more than 25. There is bnt slight danger of transmission during drills or other contact under discipline in the open air. They should be kept in the open air, given exercise: and be well clothed and nourished. It would seem that an organism of ::;uch low vitality as the meningococcus, which is easily killed by desiccation, by weak disinfectants, and even by saliva, could be read- ily caused to disappear :from the nasopharynx of a chronic carrier. but the great number of remedies advocated in itself suggests failure. Of all the remedies tried by the British authorities and tried at Chicago as well as at other training stations, including the Gordon- Flack zinc sulphate spray, bicarbonate of soda, iodine, glycerin-and· iron mixture, Dobell solution, and menthol, none have given con- sh.tently good results. Vaccines and sera nJso have apparently failed. The use of chloramine in 1 to lt per cent solution has been encourag- ing to the British workers, and it is possibfo that dichloramine-T in ~o.4. BARBER-DENTAL PATIENTS ABOARD SHIP. 515 cblorinnted eucalyptol (1.5 to Z per cent solution) mny be of service. The difficulty appears to be the impossibility hitherto of reaching the crypts and recesses. The organism frequently temporarily disap· pears after treatment only to reappear after n day or two; hence no culture should be made until at least 48 hours after treatment. The proper procedure woulU appear to be to cleanse thoroughly the unsophnrynx daily with some disinfectant which will not inflame the mucuous membrane and to build up the general re:;i:;tance by plenty of nourishment, moderate exercise, and exposure to sunshine and fresh air. In military organizations it is important not only to detect an<l. isolate carriers to prevent spread of the disease, but to r.noid damage to tho service by unnecessary detention. It is proper to release all thoso who on first examination show no meningococci in their nnso· pharynges. ConYnlcscents and others who have yielded positive cnl· turcs should bo detained until four consecutive nega.tives hnve been !;(?cured nt intervals of five days each. The healthy cnrrier is the ~ource of greatest danger to the community, and medical officers mu,t be alert to detect cases promptly. Search for carriers amon~ con· tacts should be thorough. In the presence of the di!'ease the entire per5onni>l should be segregated in small groups. All personal contact should be reduced to the minimum, and possibility of mess gear and drinking utensils se1Ting as conveyances of moist secretions from the nose and throat should be borne in mind. SYSTEM IN HANDLING DENTAL l'ATIENTS ABOARD SHIP. Dy R. BAllBklR, Dental Surgeon, United Stales Nuvy. The many and varied activities necessary to sustain the li res of the thousand or more men and officers on board n. battleship, the work of upkeep of the ship, and the numerous all-important drills and eser· ci,es combine to make the organization of the ship highly complex. Lack of proper system in any one of the activities means that the efficiency of the ship as a whole is impaired to a certain extent. It j,, therefore necessary that all lines of work be systematized in such a manner that the highest efficiency be attained. The dental officer aboard ship finds that as yet no pro,·i!'ion has been made for the routine handling of dental patients. In planning such a l'y4em with a view to efficiency the following point~ are con· "'iden•d: First, that the system should enable the dental officer to rcn<ler the greatest amount of dental treatment pos:;ible. Bccam;e there are always more cases than he can treat properly the dental officer should not lose time except for the most urgent reasons. Second, that patients should be taken away from work and drills 516 BARBER-DENTAL PATIENTS ABOARD SIIIP. vo1. x1. no more than absolutely necessary in order to receive dental treat- ment. Third, that existing systems nnd cu. toms should be u,,e~l or purullelecl. It b better to use a modification of existing routine than to try to teach something entirely new. It, woulJ. not be in keeping "ith the aboYe if putieuh \H.'11.' per- mitted idly to wait their turn for treatment as seen in the ··waiting room·· of :mold-fashioned dental sunreon or physician. It would be equally La<l if the dental officer were to wait until it entirely ~nited the conYenience and pleasure of each patient to come for treatment. The dental oflicer can treat but one patient at a time, so no more thun one man need be taken away from work or drill at one titne except under C'ertnin conditions, as noted below. In order that tlen- tnl trentment may be cnrried through to completion in the proper manner and to insure the greatest return .from the dental ollict·r· cimc, <'ach patient must be available for treatment when wanted. To make this possible the following rule has been established bv certain commanding officers: "A man ha Ying an appointment fo 0r dentnl treatment is considered as though he were on the sick list and is therefore excused from all work and drill for the time of hi~ ap- pointment." This ruling may be objected to by division officers until it is explained that appointments are seldom mncle for a lonirer period of time than an hour, and that but one man out of the thousand or more is taken away from work or drill at one tirne. With this ruling as a basis the following system has been evoked. thorougl1lv tried out. and found satisfactory: ~fon desiring dental treatment report to the medical 0flicer at morning sick call. The health record for <'ach man is examined and in cnso it contains a dental record the latter is detached and sent to the dentn l officer. A printed form, as given below, is filled in with the patient's name and rate as shown on the health record, and should there be no dental record the fact is indicnteu by crossing out the proprr line. C. S. K C o x :>ECTrcrT. ~[EI>TCAL DF:P.\RTM E~ T. • --------------------· 101-- --------------------------------------- --------• rate ________ , (Lnst name. Ill-st name, middle Initial.) is l"<'C >mmC'IHletl for dental treatment. Dental recortl sent. Health re<'ortl contains no dental reco1·u. Sm·gcon, U. S. N. (Pnllcot will tl\ke this slip to tbe dental opcmtlog room nt once.) r;o. 4. BARBER-DEXTA.L PATIENTS ABOARD SHIP. 517 It is ne1..·c;o;::o:uy that the dental officer be gi>en the patient's name n:- it appears on the health record in order that the name on the dental reconl nnd health reconl be exactly the same. Frequently when a 111311 i:- a::;kl'd his name he does nut giYe it ns it appears on the health record. The patients come to the dental surgeon imme<lintely ancl each ca:- i::, examined. dental records are macle out ns necessary, urgent treatment is rendered and appointments are assigned. .\. half hour (S.30 to 9, if sick call is at 8.30) is usually sufficient time to reserve for this part of the work. This is the only time that more than one man may be away from ship's work for the purpO!m nf receiving dental treatment and it is at a time of day when work or dnll8 a1e Jen:;t apt to be interfered with. By the time sick call is O"ler, or very :-oon after, all new patients have been disposed of and sent back to their stations or duty. Should the number of men applying at sick call for permits to go to the dental officer be unusually forge on any one day. the·less urgent cases are held over by the medical officer until the following clay. This evens up the number received daily and makes it possible for the dental officer to dispose of all new cases be- fore the time of the first regular appointment for that day. )fore patiems can be examined during this half hour than can be com- pletely treated in several days . • \.ppointments are assigned in the order that men apply for dental treatment and further appointments are assigned in rotation, so that all men have nn equal opportunity to recci>e treatment. This is nec- ""!'ll ry on account of the large number requesting treatment. Before noon of each day appointment slips are made out on the form gi,·en below for men having appointments during the following day as shown on the nppointment book and delivered direct to the patients by messenger : U. S. S. " CoNNECTICUT." MEDICAL DEPARTMENT. ------------------------------· 19l __ To: Division Officer, ---------- Division. It ls recommended that --------------------· rate ----------· be sent to the dental operating room at -------- M, on _______ ...., ----------------· lOL_, for dental tt·entment. Dentai Surgco1i, U. S Y. (Patient will bring this slip to the dental operating room at tlm\' 11peclfled.) The man receiving such a slip takes it to his division officer, who nppro,·es it. The diYision officer is thus informed that the man hns 518 BARBER-DENTAL PATIENTS ABOARD SHIP. an appointment for dental treatment nncl, when nec~ary, nnnnge. ments may be mncle for his relief from duty for the time of his appointment. By not giYing the::c slip:; until a dny before the appointment there is n'ry little chance for slips to be lost nnd np- pointmentg forgotten. This appointment slip, signed by the dental officer and approYed by the diYision officer, is considered an order to the man to appear in clean clothes, at the dent!ll operating room at the time specified' and a man failing in this i_._, liable to disciplinary action. Dentai treatment is not compulsory: but when a man voluntarily applies for dental treatment he is required to haYe done such treatment as the dental officer prescribes and to continue to keep his appointments until discharged by the dental officer. Were it not for this rule mnny men would £ail to return for completion of treatment nft('r hay. ing been relieved of pain. One hour is the time usually allotte<l for nn appointment. A longer period is tiring to the patient, nnd '"ith shorte,. ones not enough permanent result can be accomplished in most cases. To make this plan the established system the commnnning officer bas issued the following order, which is printed on the reverse side of the nppointment slips an-i which is thus brought to the att~ntion of all patients: Dt:NTAL TREATMENT. Men ue,;:iring- <lentnl treatment must n11ply to the Medical OJ]icer nt morninu si<'k rail, in the Dispernmry, for n permit to go to the Dental Ollkc1·, who will make examinatlom:, treat urgent cases, nnd make np11olntmenls for further treatment. Before noon or ench day tlle Dental omecr will send n written notice to 1>nd1 paticmt ha Ying an UJJ})Oint mcnt during the followlni::- ,Iay. The pnUPnt shall take tl1is noti<'e to his Dii·ision Offlcc1·, who will sign It. This notice is au order to nppenr, in clean clothes, at the dental opera! Ing i·oom <1t the time speeiflcd. A mun haying an appointment for dentnl treatment ls conslllered as thouf!h he Wl'l'l' on the sick list autl is exeused from all work nn.J clrill for the time of his appointment. It is to be distinctly unuerstood that the Dental Officer shnll 1Je the sole judge us to what treatment ls nece~s1u·y (Art. R 2001), and men n1111J)·in~ :!or dental treatment will lJe requlrecl to have done such treatment as he prescribes. ApprO\'l'<l : OaJJtain, U. S. Navy, Oommanclino. A certain specified part of the day is set aside for treating office~ (nfternoon hours nre most con>enient). Officers are treated only xo . .J. CRANDALL-BARIUM FORMALIN METHOD FOR DISINFECTION. 519 during those hours, and enlisted men's appointments are thus not interfered with. It has been found unsatisfactory to make appoint- ments long in advunce for officers. The list of officers under treat- ment is ne,·cr \'cry lnrge. The officer whose name is nt the top of the list is notified by messenger about an hour in adrnnce that he js wanted by the dental officer at a certain time. If impo. ,;::ible for him to keep the appoil!tment the officer so st.lt :-, and the next officer on the list is notified for the same hour. Officers usuallv are nble to say positirnly whether or not they can keep an appointment within on hom or less. By continuing to make appointment;; by mes~enger the dental officer is able to get as many otliccr patient:> us he can treat during the officers' hours. After a dental ofliccr has been on a ship for some time the number oi ollkers re"c111iring dental treatment will be so reduced that the time set aside for officers may be shot tened and more hours assigned to enlisted men. The system of handling dental patients aboard ship n~ has been outlined has the following features: There is a certain definite time of dnv when men may recefre urgent treatment and htwe appoint- ments ar:signed and be returned to duty promptly. Records l'eceive their proper attention and a check can be made by the medical officer on the number of patients received each day. No time is lost by the dental officer nnd thus more patients can be treated. The activities of the ship are interfered with to a minimum degree. During the greater part of the day not more than one man is taken from his work and then only for an hour. It is hoped that those dental officers who are aL thi::; time having their first experience of ship life ma,y find some helpful suggestions m thl' above which will facilitate the organization of their work. BARIUM-FORMALIN METHOD OF DISINFECTION. By R. P. CRANDALL, Medical Director, United States Nnvy. When the prohibitive cost of potassium permanganate made th1: perm:mg·mate-formalin method of disinfection no longer available, the Medical Supply Depot, New York, communicated with various likely sources of information to ascertain the possibility of adopting other satisfactory means for liberating formaldehyde gas from its aqueous solution. From the replies received it was evident that no other all-chemical process was known to be as suitable as the per- manganate method. The lime-formalin and the Dixon methods both h:n·e supporters. However, it requires no exhaustive study to de- termine that the efficiency and adaptability of each are not to be eomparcd with those of the permanganate-formalin method, espe- cially nuder :-cnice conditions. 520 CRA:SOALL-BARIU:\1-FOR:\L.\LI:S ::\IETHOD 01'' Dll:il!U'ECTIOX. \'ot. XI. A nilable information on this subject being rather limited. the depot undertook an investigation with a view to finding n cheap ~fe, and efficient process for the rapid e,·olution of formnldehvde' together with n required degree of moisture. .As a result. the d~P<>t developed the "barium-formalin~· method, which is as follows: 1 pint snlutlon of fornialdehyde (U ~. P.). H (l<JUnus barium dioxide (technical) contninln~ not less than -;s per <:ent BnO.. (Required for each 1,000 cubic feet of space to be disinfected.) The barium dioxide is evenly distributed over the bottom of a wooden or metal bucket 1 of not less than lf-gallon capacity for the amounts stated above. The formaldehyde soluti->n is first transferred from its bottle to a pitcher or other suitable container, from which it is quickly poured over the barium dioxide. At 011ce close the room and keep closed for 6 to 12 hours. The method outlined above on repeated trials gave gratifying re- sults and showed conclusively that barium dioxide is in all respeets as efficient as potassium permanganate for liberating formaldehyde antl water vapor from formalin. An inexhn.ustible supply of barium dioxide is obtainable in the American market at n. price ranging from 30 to 50 cents per pound in pound bottles. In large quantities the price would be about 30 cents per pound, while potassium permangn.nate is aL present quoted at $5.uO per pound. The price of formaldehyde solution (U.S. P.) is about 25 to 30 cents per pound bottle. • The ataodard Medical Department bucket Is of 3·gallon capacity and may be em· ployed with amounts of material necessary to disinfect 2,000 cubic feet of space. ~o dllllculty will be experienced In washing real.Jue out of bucket. HISTORICAL. OSWALDO CRUZ, 1872-1917. By WILLIAM c. WELLS, Chief Stntistlcian, Pan American Unlf.n. To one who has seen Rio the old controversy, centuries ol<l, as to whether it is Naples or Constantinople which occupies the most beau- tiful site of nny city in the world loses most of its intt'rest an<l all of its point. Neither Naples, beautiful as it is, with its broad. sweeping bay, the islan<ls of Capri and Ischia, the :unphHheatcr of hills rising oYer the brightly colored crescent city; nor Constantinople, whether seen fr •m the south and through the early morning mist ncrcss the wnt~rs oi the Sea of l\farmora, an enchanted city oi blcudecl hills, minarets and towns rising above that domed glory of Byzantine art, Hagfa Sophia, the Church of the Holy \Yisdom, or from the north, a::. from the hills abo' e the Golden Horn, one sees a wonder stretch of city. harbor, and distance-fading waters that has charmed en~ry beholder since Constantine chose this site for the capit:tl of the world, nre either of them the most beautiful city site. It is Hio. blending of hill. mountain, and rnlleys clothed in tropical verdure on the shore of that n lmost landlocked, island-studded bay that the earlier navi- g.1tors imagined was a river's mouth, the River of J1muary- Rio de .Janeiro. 'l'he volcanic hills of Naples rtre bnre alongside this riC'h outpouring of nature's wealth. Even Ilngia Sophia fade.-; frnm rnemory as one looks on Corcovado, and the mi1mrets of the ~fo,,que of the Conqueror, Mohammed II, are nothing in compnrison with Hio"s mol'O beautiful minarets, the stately royal palms thnt watrh oYcr the many-colored city. But for half a hundred years or more Rio was shunned. The voy- ni.rer who "onld fain gaze on its beauties threw a cast with Death. Plague :-lew its thousands, but fever, above all yellow feyer. slew its tens of thousands. Yellow fever was first recognized in Rio in 1 .J:9 inn C.'lSO said to have been brought from Bahia. For GO years there- after it rnvnged the city and the environs. "To go to Rio is to com- mit suicide'' was a saying among all shipping folk. Dr. Theophilos Torre~, \'ice president of the Brazilian Nntionnl Academy of Medi- <'i1w, in his work published in 1912 (in French). Ln Cnmpngne Sanitairc nn Brcsil, gives tables showing the number of deaths from yellow fl'\'Cr from the time of its first introduction into Rio. Decem- 521 522 WELLS-OSWALDO CRUZ, 18'72-1917. Vol. XI. her 27, 16-!!l, up to its extinction in 1908. These numbered :rn,OG3 :for the city proper, not counting the suburbs. In the epidemic which marked its first appearance, i. e., for the yenr 18:i0, the <leath::, were 4.lGO. This figure wns not again reached until the epidemic of isn with 4,456 death". In 1892 the number was 4,312 and in lS!lt 4.852 1 the highest number attniLeu in any one year. In 18.33 there were 5:{ deaths, which was considerably more than half the numLa for the precedin~ year. In the year following, 185±, there were only~~ fntnI case; and in 1855 only 3. This was a period of hope for Rio. hut in 1 :iG th<'re were over 100 deaths and in 1857 nearly 2,000. Again, in lSG:l, the fatalities fell to 12, in 1863 to 7, in 1864 to 5. In 1865 there were no fatalities and the disease apparently disappeared, for there were no reported cases until 1868, with 3 deaths. In 1870 there were oYer 1,100. An epidemic occurred in 1873 with 3)659 deaths. The interruption o.f three years, 1865 to 1868, was called by Brazilian physicians spontaneous extinction. It was certainly not due to any recogni'Zable sanitary measures. In the four years from 1891 to 1894, inclusive, there 'vere 14.44.) deaths from yellow fever, and this is the period of its greatest in- ten~ity. From 1894 until the adT"ent of Dr. Cruz the number of deaths rose above a thousand a year only twice, in 1896, 2,!l29. nnd in 1898. 1.078. During the 60-year period of the scourge the authori- ties were not inactive. The best medical nth ice, or whnt '•as believecl to be such, was taken and the then approved methods of sanitation were adopted and put into effect. Twice it was bclie,·ed that tlw yellow fever had been done away with-in 1855 and again some seven years later. But the outbreak in the seventies. contin- uing with unabated violence until and after 1900, proved the mist:lke. At the last it appeared that Rio had become almost callous and was reconciled to pay the Minotaur's tribute. What this tribute was in deaths alone we have seen, but only of deaths directly due t.o the disease. The indirect deaths, weakened constitutions, vital losses in every field are unmeasured. The property and ind I1'triul losses no one has attempted to enumerate. .A.nd what was goin~ on in Rio w11s only the same as in dozens of other places in centrnl and northern Brazil. The scourge of the yellow terror wns o,·er all the lund. So little was it believed in Brazil that this i:;conrge could be lifted that when the scheme for the improvement of thl? port and the beautification of the city of Rio began to take form. about 1890, proposals for the sanitation cut but a minor figure. Xot that sanitation was overlooked entirely; results prove lhe contr:iry: but o. hope that yellow fever could be driven from Rio did not exi"'t in the minds of President Rodriguez Ales and his associate;;. In the decree of September 18, 1903, the outlined plim for the rebuild- ing of the port and city was contained in nine proposals. in fur- No.f. WELLS--OSWALDO CRUZ, 1872-1917. 528 thernnC(l of which two loans of $40,000,000 and of $20,000,000 were secured. "X ot one of the nine proposals was directly in the line of sanitntion or closely touched the question of eradication of yellow fel"er. The fifth proposal! for the enlargement of the city water supply. and the sixth, for a revision of the sewnge system, bore indirectly upon sanitation. Gol"emment reports and new:;papers of this period are filled with the plans for reconstructing the port. building of quays, rectification of the canal known as Mangue. open- ing of new avenues, particularly the magnificent ..1.henida Central (now _\venida Rio Branco) and the Avenida Beirn ~for. but never a worcl of yellow fever or the mosquito. In 1 !lOO there was an outbreak of the plague in Rio. It hacl np- pl':ll'<'cl in October of the preceding year at Santos :rn l in Dccrmbcr nt Siio J>anlo. In 1900 there were 295; in rno1, mu; in l!l02. 215; und in 1003, :mo deaths from bubonic plugne in the city of Rio proper. In this Inst year the deaths from pl1lg11c wen~ nearly two- thirds a:-1 many as the deaths from yellow fever. On the outln'l'ak of the plnguc the municipality of Rio determined to create an estab- lishment for the preparation of antiplague serum and Prof. Baron Pedro Afl'onf:o. one of the bcc;t-known medical authorities in Brn.zil. undertook the inauguration of the enterprise. Prof. Pedro Affon,o went to Paris and consulted Prof. Roux, of the Pasteur ln!:>titute. n-- to the ehoice of a French specialist to whom should be giYen tl1e direction of the proposed establishment. The reply of Prof. Ronx wns that no French specialist was better equipped for undertaking thi" work than one of Prof. Pedro Affonso's own compatriots. u young Brazilian, Dr. Oswaldo Cruz, at that time e11gagcd in special lmC'tcriological work in the Pasteur Institute. Truly a prophet is not without honor save in his own country. o~waldo Gorn;nJes Cruz was born on August 5, 187~, ut Siio Luiz de P:1rahitingn, in the State of Sao Paulo, but removed to Rio in 1 'i2. He was the son of Dr. Benito Gon~ales Cruz, nt one time clir<:>ct< r genl.'ral of hygiene. Oswaldo Cruz obtainerl hi:- diploma in medicinP. in lSfl:? from the faculty of medicine of Rio. Immediately there!lfter he entered the X ationnl Institute of Hygiene. :founded by Prof. nochn Faria. and bPgan his studies in bacteriology. In 10::96 he 1'cnt to Paris anrl entered the Pasteur Institutl'. His \\Ork wn, mainly in the laboratory of toxicology and he became widel}' known to specialists through his experiments and studies in this field. He publi. he·l studies on the toxic properties of the castor-oil bean, n. method of discovering the· toxic properties of lighting gas. the Florence reaction and a pathologic history of poisoning by the cnstor-oil Lenn. The work of the American commission in Cuba in the sanitation of Ilnbana. "untiago, and other cities early attracted attention in 524 WELLS-OSWALDO CRUZ, 1812-1917. Vol.XL Paris. The ne\\ theol'y that the mo~quito was the yellow-fever con- Yeyiug agent, demon~trate<l by the work of the commission, had in O:swaldo Cruz one of its earliest belie\'ers. In Pnris he ha<l followed carefully the experiments of the American commission, and, as Dr. Torres says, he became absolutE>ly convinced that the stegomyia mosquito wa::. the agent in the propagation of yellow fe,·er. He l1<:lieved that what ba<l been accomplished in Habana might Le dupli- cated in Rio. On his return to Brazil he communicated the:-;.• ,·icw::; to President Rodrigues Ales and :found in him a sympathetic auditor. The matter of the manufacture of antiplague serum was Ill t lo~t sight of; on the contrary, the fight on the plague was the fir:,,t work undertaken. .Meanwhile Dr. Cruz was almost daily conferring with President Ales and urging a plan for the general sanitation ot Rio. and in particular a campaign against yellow fever, all of which wa:s to be undertaken in connection with the city and port impro\'(~­ ment plans. Pres-ident Ales heartily approved Dr. Cruz's plan:; au1l uppointed him director general of the office of public health. Thi:- was in 1!)03. Dr. Cruz,s connection with this office lasted fi>e years- until 1908. '·Give me the proper authority and a sufficient force and means to work with, and I will rid Rio of yellow fever in three years,,, he told President .Ales. To many this seemed a rash promise on the part of a young mnn just past 30 years of age, with no special reputation U" a yellow-fever specialist and no special knowledge of the disease or ib methods of propagation. But Cruz fervently believed in the re- sults obtained by the American commission in Cuba and in the theory that underlaid the work of this commission, and Ales believed in Cruz. Authority was given, new laws were enacted, money was pro- vicle<l and Dr. Cruz began the organization of his staff of workers. All of the old measures in force for controlling yellow fever were abandoned. Everythi11g was centered in one purpose, to exlerminate the mosquito and to prevent mosquitoes from having access to in- fected patients. On April 20, 1903, less than 30 days after Dr. Cruz's appointment as director general of the office of public health, the first case of yellow fever was rig-0rously isolated in Rio, based on the lines adopted by the American commission in Cuba. Dr. Cruz's stuff nt first consisted of 75 physicians, a number of students, and a large force of laborers. The brigade was scattered over the whole cily, but located especially at points where breeding places of m-0squitoes were known or suspected to be. All of these places were cleaned out and the larvre of the insects destroyed. Obligatory notification of all cases of yellow fever formed part of the existing sanitnry regulations of Rio, but, as has been pointed out by Dr. Torres, by Dr. Sampnio Vianna, chief of the demographic section of the office of public health. and others, this law had not proven effective. Dr. Cruz asked ~o • .f. WELLS-OSWALDO CRUZ, 18i:.!-l!ll7. 525 the Government to pass a law which would render such a cleclarntion compulsory and enforceable, under pains and pennltie:s for conceal- ment or prevention of notification. This law was passed 011 :\larch 8. 1904. The prophylactic procedure to be followed included n()tific~­ tion. isolation. disinfection. and medical vigilance or supervision. In addition to yellow fever. the following disens s were ad1led to the category of compulsory notification: Plague. cholera morbus. all choleriform seizures, smallpox, diphtheria, puerperal fcn•r. ophthal- mia in newly born infants, typhus, typhoid, leprosy. consumption. malarinl fever, beriberi, scarlatina and measles. In Hl03 there were 58-1: deaths from yellow fe,•et· in Rio. The clis- e:1se was stamped out entirely by 1908. In 1!)03 there were :1li0 cleaths from the plagne in 1908. 5±, and in 1912 nom1. \ Vh<'n Dr. Crnz in 1~0 resigned the position of director general of pulilic health to n:.:sumc the headship of the Institute of Tropicnl Disea!"es. now known n~ tl1e Oswaldo Cruz Institution for Experimental Pathology and -en mtherapeutics, at Manguinhos, Rio was freed from the ~<'ourge of ydlow fever nnd near to being free of the plngue. He had become a world figure, although perhaps better known in Europe than in the Cnited ~tates. It should ha>e been the other way. It is not nece~­ ~nry to make comparisons between the work done in Cnba nnd Pan- nmn and that in Ilio but it should not be lost sight of that Rio has a population much greater thnn the combined populations of Ilahann. Santiago, Pnnamn and Colon, and the work of Dr. Cruz wu::; not confin ·d to Rio, except in the beginning. It soon extended over n('nrly the whole of Brazil. His campaign against yellow fever was the 11101>t extended work of this kind that has yet been undertaken and it wns completely successful. When he did not himself personally supen ise tho work his assistants did or his methods were followed. The~e methods, as Dr. Vianna~ one of his chief coworkers has said, were tho-·e of the American commission in Cuba, modified hy condi- tions special to Brazilian localities. The O~wald Cruz Institute, so named by the Bra.zilian GoYernment in his honor, which was founded and organized by him and was until his death under his management, has acquired a reputation and a ~tnncling through its experiments and disco\·eries which has ex- tended to the whole scientific medical world. It is to he regretted. howen'r. that the work of this institute shonld be so much better known in London. Paris, Vienna and Berlin than it is in Xew York or 1Yn.;;Jiington. Dr. Cruz died in Rio, February 11, 1917, at the age of 44 years and Ci mouths. Truly a brilliant and useful life too early ended. .. EDITORIAL. TIIE )l:P.\OR ;\ILUENTS. It is doubtful if during the course of a long profcs:;ional career either the lawyer or the clergyman has such opportunities for observ- ing the vagaries of human nature as present themseh·es to the physi- • cian, and especially to the military doctor whose clientl>le is composeu almost exclusively of officers and men with whom he is in close con- tact and daily association. Civilian practitioners usually have social relations with but few of their patients. They see them in bed, on crutches, on the operating table but do not sit down to breakfast, lund1 and dinner with them, meet them at tennis ancl golf, nor con- tend "ith them for a high score at bridge. They do not live within a r ~tricted area where for weeks and months they see only the same faces and are able to watch and study their patients at play and at work as well as when stretched on the bed of languishing. In the case of the Navy doctor every one he meets in official and unofficial capacity among messmates and shipmates is a possible or prospecth·e patient or has been his patient. This is a feature of life on ship- board not without serious drawbacks from tho point of view of both physician and patient. That familiarity breeds contempt and that a prophet is not without honor save in his own country are old say- ings that can find no illustrations more apt than those constantly afforded by the conditions of life at sea. A former Surgeon General of the Navy, speaking at the final exer- cises of the medical school, urged on the graduates about to embark on their first cruise the importance of cultivating tact and circum- spection. a friendly spirit and a dignified bearing so a:; to invite rather than repel the confidence and good will of those with whom they were soon to consort in the restricted quarters of n seagoing vessel. In ciYil life even the most eminent practitioner can exercise but little selection as to whom he will treat and whom he 'vill not treat. .A specialist may restrict his labors to a certain field but can ill afford to discriminate in that field. The patient, on the other hand, is free to choose his attendant and often, if too poor to go to a great man's oflice, he can be treated in free dispensary or hospitnl ward by that 527 528 EDITORIAL. \ol XI same great mnn. On a ship the patient's situation is entirely differ- ent, and however obnoxious the surgeon ·s personality and whateYer be his reputation for professional skill the sick mun must commit himself to bis ministrations or go without attention. In spite of efforts to be nccommodating und the mo:-ot sedulous at- tention to cluty on hi::. part the ship·s surgeon will constantly be im- pressed by the frequency 'vith which both officers and men, from the captnin to the colored cook, seem to enjoy consnlting a pharnuu:isfs mate or one of the subordinates of the sick bay about details of health and minor ailments. There may be an element of pervcr:;enc-.s in !'Inch conduct but criticism should be reserved until all the feature;:: of the 8ituation have been considered . • \s a class we are prone to find anomalies of behavior in the sick uncl to ignore the fact that what an overwhelming mnjority of human Leings do under given conditions may be considered normal. .\t any rate, whatever the ethical aspect of an act may be, if it is in line with tmiYersal behavior, it must not be charged up us a pecu- 1 i:u·ity against any given individual. Doctors nre notoriously indifferent to the triYial complaints of patients. Business necessity and financial considerations lea l them to hide their contempt and many a man is described as taking "so much interst in his cases" because he has the acumen and the. self- control thnt go to bnjlcling up a good practice. Of a less circum- spect individual it is often disparagingly and unjustly remarked: ·· Y 011 ha Ye to be ha If dead before he will do anything for you."' To the practice of medicine in a military senice there is no b 1 ness !'ide in the ordinary sense of the term. ·when 30 days have cl 1pse<l :30 days' pay become due. This is an advantage to the physician. bnt it may sometimes he, and is invariably considered to Le, a dis;ul\'nn- tage to the patient, who inwardly contrasts the earnest solicitude of the ciYilian, who must in some way secure his fee out of the groundless ulnrm o,·er a pin scratch or the baby's sneeze, with the cusual aSS(>r- tion of the contract doctor that there is nothing the matter. From the surgeon's point of view there may be nothing the matter. but nlurm is always worth allaying, and the more grnunclless it · · the ~tronger the call for effort to that end. and if ignorance and prei 1dice appe;\l to his lmowledge and dispassionate jucl:;ment he rem r:- a rl'al $CrYice by dissipating them. How often we deceive ourselves! How prone we are to lay the flattering unction to our souls that because we do not coddle aml pet our patients l\S they magnify their trifling ills we ure hon~:;t and straightforward, maintaining a high ethical standard and scornina to make capital out of the meretricious devices of quackery. ~\s a matter of fact, the salaried surgeon, just because he is far remo,·ed from the suspicion of improper ends in view, is the one of all others • :-.o.4. EDITORIAL. 529 from whom n kindly manner and a gratifying ~how of interest may be expected and he is in honor bound to display the kindly manner nnd the interest. however little scientific n1lne the case may hold for him. Officer:. and men may sometimes hesitate to bother the doctor over n minor complaint through consideration for him. but oftener it i::. through consideration for themselve.s. The doctor may be ::.urly or facetiou .... whereas the Hospital Corpsman, grntifie<l at such a tribute to his abilities, lays himself out to satisfy his visitor and, of com·~. the milder the case the greater his opportunity. There is a happy mean between the fulsome, fawning attentions of the unsc1·upulo11s society doctor and the blunt dismissal of a surgeon who sees no importance in anything that does not invite the knife. Ji'amc as an operator is dearly bought if it is offset b~· a reputation for utter indifference to the ever-recurring petty ills of daily life. While not n fow men may go through their allotted three;core years and ten with little experience of se>ere illness or accident. until the hour and article of death never seriously requiring the good offices of surgeon or physician, the great bulk of mankind is more or les · con- :-tnntly acquainted with one form or another of physical discomfortr- catnrrh: sore throat, terrifying stomach aches, depressing <linrrheas. scratches, bruises, sprains, headaches, myalgias, etc. The.c;e things take up a goodly portion of the general pro.ctitioncr's time, and. how- e\'er commendable it may be for a young medical officer to desire to e.~ccl in some special branch, he should remember that in the Xavy he must be fil'st of all a good general practitioner. As the late ~1edi­ cal Director G. E. H. Harmon once remarked to an ambitious young associat.e: " When eYerybody in the :\Iedical Corps has a specialty, who will treat the bluejacket's tummy ache?" There is perhnps nothing more hopeless than the nttempt to cure a ~old in a young officer who alternates between an ill-Yentilated, over- l1eated 'tateroom when off duty and his watches in fog, rain and wind 011 the bridge; "ho insists on smoking, turns up his no:-;e at. the ~uggestion of a purge and would not forego attending n long-antici- pnh•cl party nshore though it hailed p:n·ing stone;-;. Io time the doc- tor inclines, ,-ery naturally, to take these cac;es as lightly as the patient's actions if not his demands warrant. but we should be big enough to pla~· 0111· worthiest role. regnrdJe...;s of the follie, of youth an<l inexperience. If a frontal sinus infection follows a cold in the hencl, if an arthritic process results from a :sore throat. the patient "ill be quick to recall his joking dismissal or the ussnrunce thut he would be all right in a day or two, and the doctor will luwe just cnu~ to reproach him:,elf if he was too indifferent or too hurried to mention dnngcrous pos:;ibilities, to offer n proper line of concl11ct. and at lea t to suggest prudence and overshoes. ~•fit-li-7 530 EDITORIAL. Vol Xl. One needs to have had but little experience of professional life to discover that a. patient's appreciation of the doctor's services are usually inversely proportioned to the intrinsic value of those service.5 as the doctor views them. You divide with the nurses the night watches over a case of pneumonia, you skillfully remove n gan- grenous appendix buried in old adhesions and when convalescence is established must listen to daily grumbling at the enforced confinement to bed or the restrictions imposed as to diet instead of the voluble thanks you expected. Per contra, a man who was long annoved bv a. few ~baceous cysts of the scalp-inconsequent, negligible .details in ~-our opinion-overwhelms you with gratitude nnd years after- wards when you meet him on another ship he comes to you smiling, hand outstretched nnd recalls with delight that he "has been ship- mate. ... with you before." It would be wrong to see perversity of human nature in these incidents. The pneumonia case was stupid from ab:;orbed toxins and did not recognize your presl'mce at his side. The ::tppendicitis was scented by your diagnostic acumen rather than through the patient's subjective sensations. The Yalue of your ministrations was seen as through a glass darkly and there were no anxious relatives at hand to advertise you after the fact. but the man whom a couple of incisions, a suture or two and a little cocaine relieved has occasion to bless you every time he comb~ his hair for the rest of his life. Such confidence and nfi'ection is not to be de..,pi,.ed, for it has an important bearing on ultimate professional succ·e::;.;, howeYcr indifferent one mu.y be to nny given individual's feelini:,r<:: nnrl opinions. If we repel a man with u. trifling nffection. we must not be surprised or ready to blame him if on some future occa- sion he is loath to report something lie deems unimportant but which is in reality the manifestation of a serious condition. It is the purt of wisdom to encourage officers and men to come to us with their mild complaints. The appendix where trouble is beginning will be no better for the apothecary's saline. The sore on lip or eyelid which the patient minimizes and scratches daily may be a chancre or epitheliomn, and there is no time to lose when these conditions appear. To tho:-c who are not too old or too deeply sunk in the ruts of long-estnbli ·hed hnbit and to the young who ha.Ye not yet fully reali7.ed the significance of the first aphorism of Hippocratc;; we 11ppeal for earnest study and sympathetic treatment of the minor ailments. In the renction from the complicated nnd highly em- pyricnl therapy of other days our medical schools pay less nncl le, attention to materiu. medica and many a recent graduate nff1..'Cts to despise scores of useful drugs because in reality he does not under- stand their physiological action or possess any conception of their ?\O. 4. EDITORIAL. 531 proper employment. And yet many of the·· :-hotgun ·· pre-:cription:; of the old-school clndor had real therapeutic Ynluc and nlforded a degree of comfort nn<l relief which the ~ingle nlknloid of to-dny does not irnpnrt. With onr ::triking ach·anccs in llrCYenthc medicine. with our progre ·;.:town rd seientific <lingno:-is nnd rationnl treatment, let us not forget that the physician's mission is not confined to $11\"ing life in l'mcrgencies by brilliant operations or to pr~cnting nn unu:,1.rnl nnd mrc ca:-,e with a high-flown diagnosi$ wherein blood pressure. blood count: refleXl':i, etc., are scientifically tabulated. but thnt hi:- mnin obligation is to administer relief from pain whether phy:;ical or mental, whether serious or trifling; to put his patient into lhnt stnte of rnmfort and case which usually contribute:' so lnrgt•ly to reco,·ery, if reco,·ery is possible. There are situations in life when negligible trifles ns ·1mH~ vast importance. Conceive of the exquisite mentnl fill flerin!!. the infinite cmbnl"l"assmcnt thnt an acute coryza, a boil, gaseous distention of the bowel. n black eye caused by stumbling against :m open door in the dnrk might occasion-to a bride, for example, to a man <lne to mnke his maiden effort at forensic oratory-:md consider whether with all your modern science you hnYe ready to hand a prompt remedy for the"c nwful cntnstrophies. That man would be an un .. ntisful'tory nttendnnt~ indeed, who limited himself to answering frantic nppeals for help in such critical situations by a laughing as:-;11rnnr.e thnt lifo wns uot in jeopnrcly. The old-fashioned poultice was alwnys n huge comfort and often <lid goocl. It was anything but aseptic nnd we hnve discnrded it iu fornr of the hot-water bag wrapped in :i towel or gauze "rung "llt in boric acid or bichlodde solution. It behooves ns to find up-to- datc substitutes for a host of other measures rejected b~· the 1111f<>el- i11~ scientist of to-dny. This cold creature 0£ accurate ralcnlntions is nncxcelled in the laboratory, but at the bedside we want some one \\ell tinctured with the milk of human h.rin<lness. When we arc sick oursch·es we do not abjure our modern divinities, but we welcome the r.d,·ent of the kindly ol<l gentleman made intensely hmnnu, intensely kind, by personal acq11!1int:mce with life's long chronicle of pnin. We Fhrink instincth-cly from the youth unacquainted with grief. whose ultrn-.cier tific Yiews, whose physicnl vigor, whose vast nppreci11tio11 of his high qunli.6.cations proclaim him, as he crosses the threshold, incapable of sympathy, incapable of applying his magna r.um lawlc attainments to an uninteresting case. 'For the young physician in all walks of life we ask of the gods a sensitive soul, a lively imagination and n keen physical susceptibility to pain. With these gifts he will not be a creature too exalted or too witless to condescend to study the relief of minor ailments. Pub- 532 EDITORIAL. Vol. XI. lished papers painstakingly prepared on the parasites of crustaceans may bring him fame to-day and lay the foundation for benefit to a futru·e age, but such pursuits are not for the general practitioner and the world wm always love best the man who lrnows some simple way to relieve itching, who disdains not to roll up his sleeves and ma&:;age your back when it is caught in the vise of lumbago, who comes un- complainingly at 4 a. m. to put a hot sponge on the larynx or force down a dose of ipecac when the first baby is hanng his first attack of spasmodic croup. Thomas-Vision· Testing Device. VISION-TESTING DEVICE IN USE AT NAVY RECRUITING STATION, NEW YORK CITY. 632- 2 SUGGESTED DEVICES. A CONVENIENT DEVICE FOR TESTING VISION. By W. S. THOMAS, Assistant Surgeon, M. R. C., United States Navy. The apparatus illustrated and described herewith, in use at the Navy recruiting station, New York City, has proved to be of con- venience in facilitating the use of the Snellen test-type cards. Its especial object is to permit the examiner, standing at a distance beside the candidate, to bring the different rows of letters on the Snellen card into view one at a time behind a slot and to conduct the test without an assistant. Standing out a few inches from the wall is a blackened wooden panel slotted horizontally so as to reveal one line of the test letters . . \hove and in front of this panel is an electric-light bulb illuminat- ing the type, but whose direct rays are shielded by a hood from the candidate's eyes. Behind the slot revolves a horizontal wooden cylinder about 2~ inehe8 in diameter, its surface coYered with a portion of an ordinary Snellen card, with an inch or so of the wood projecting from each end beyond the card. A piece of twine is tacked to the surface of this cylinder at one encl and, after passing several times around it, is led up through a pulley on the wall above. From thence it passes across the room at a height of about 6 feet from the floor and is fastened to the opposite wall. Another piece of twine is tacked to the opposite end of the cylinder and terminates in an elastic rubber band fastened below to the wall. When the overhead twine is pulled upon it unwinds from the cylinder causing the latter to revolve and revealing successively the several lines of type through the slot. At the same time the twine terminating in the rubber band winds up on the other end of the cylinder, and, with the stretching of the elastic, itcts as a spring, causing the cylinder to revolve back to its original position as soon as the examiner relaxes the tension upon the overhead twine. A SIMPLIFIED EYE-TESTING CASE. By R. B. HENRY, Passed Assistant Surgeon, United States Navy. ln order to simplify the test for acuteness of vision when examining recruits, as well as to furnish a conYenient and simple apparatus for this purpose, and one which can be tnrnecl out at a low cost, it is sng- 5HH 534 HENRY-SIMPLIFIED EYE-TESTING CASE. Vol.XI. gested that cardboard testing sets made according to the accompany- ing plan be adopted as a standard and furnished to all ships and re- cruiting stations. The affair consists of a cardboard disk, 1 foot in diameter, pivoted between two square or rectangular sheets of card- board in such a manner that the edge of the. disk protrudes suffi- ciently beyond the squares at one side to permit of readily turning by hand. Snellen test letters of the size to be read at 20 feet are printed on the front of tha disk in a circle so as to appear succes- sively behind a window cut in the anterior one of the two cardboard squares, and the latter are held in position by being glued to two strips of cardboard binding, each to its fellow along the upper and lower border!:Y-the strips being thick enough to allow free turning of the disk. Test cases constructed on this general plan, though of wood and brass, have been used with satisfaction at a number of sta- tions and on shipboard, and eliminate any question of the candidate's memorizing the letters, as only 'one appears at a time, and by spinning the wheel to right and left all possibility of learning which will appear at any particular time is prevented. Another simplification consists in omitting the useless 15 and 10-foot letters which appear on the present test cards. Brass eyelets should be inserted in the corners of the squares for fastening to the wall. If cardboard is not considered sufficiently durable, some such material as japanned tin might be employed without adding greatly to weight or bulk. .. No.4. TULLIDGE-MOTOR OPERATING .FIELD THEATER. 535 THE JlOTOB. OPEB.ATilfG PIELD THEATER. By E. K. TULLIDGS, Assistant Surgeon, United States :Savy. In an effort to overcome unsatisfactory operating surroundings und to insure early surgical attention under suitable conditions, with .,y I /ff ,ff';f I #. 1. Extei·lor. 2. Interior. proper provisions for the after treatment, the heads of many of the different army medical corps have decided that a motor operating 536 TULLIDGE-MOTOR OPERATING FIELD THEATER. Vol.XI. field theater is of the utmost value. These theaters can be equipped with all the modern conveniences necessary to perform the most intri- ..P/G 6 I" #fY " /, i ,1 # 11• __ / _ _.!' ·'- I - I ~ Interior: Side view. cate operation and taken immediately to the firing line, and such a theater as here shown should carry all its personnel, be compact. 0 1=====:1~ Rear view: Closed and open. thoroughly dust, dirt and wind proof, of reasonable size and weight, and of reasonable cost; in other words, a completely equipped operat- ing room upon wheels. ~ . .. TULLIDGE-MOTOR OPERATING FIELD THEATER. 537 ~ " ~ i ,, I G=a I IC:lil '/// / § ~ " ICIC I I ,{/" ,~Jf ,,;j --, I D r ~ • II' ~ I) !i l1 I / , ~~ ~ ,-#' /:,, , I ,_;-:///' / ~/Y/ /' / / , ~ l'.'. Interior: Front and rear . ~ r ~ 0 I~ ,, ' I 538 TULLIDGE-MOTOR OPERATING FIELD THEATER. \'ol. XI. To describe the pattern above: It contains two divisions or com- partment;:, namely, the cab and the theater, which are separated from each other by a thoroughly air, dust and gas proof partition contain- ing a sliding door for purposes of communication when it is not desired to go out into the air. The entire machine. inclu<ling two surgeons, a nurse and attendant weigh::; about 2 tons and has suitable arrangements as to steering facilities, water and gasoline supply, and a clear space of at least 2 feet 9 inches, and more if required, for a stretcher way. All washing and drying is done in the cab, which is also equipped with plenty of closet room for linen, etc. Cold sterile water is obtainable from the overhead tanks designed for th'lt pur- pose, either by tabloid hypochlorite in 15 minutes or by filling the >essels carried from the boiler. In addition to closets, 10 full-size drum shelves for sundries, a drum stool for plaster of Paris, :ind a folding side table are available for use. Ventilation is obtained by anterior and posterior overhead flaps, an electric fan and windows. Electric lights from the batteries can be used when desired. It is to be hoped that the necessity of these theaters will be realized and that they will soon be introduced into our own service. Prioleau- Shark bite. EFFECT OF SHARK B ITE. LATERAL VIEW. EFFECT OF SHARK BITE. ANTERIOR VIEW. 539 CLINICAL NOTES A DEATH FROM SHARK BITE. By P. F. P1uOLEAU, .\ssistant Surgeon, United States Navy. Some people have the erroneous idea that sharks will not attack man and as a general rule the noise or commotion of a crowd of individuals in swimming is sufficient to keep them aw3:Y· Since in tropical waters sharks are quite numerous it is important that none of the men should be allowed to go in bathing alone. Swimming in !;hallow water or, better, within the inclosure of a "shark net," as prodded on some of the naYal reservations, is to be ·encouraged. The U. S. S. Dale at the time of the accident waR anchored in Canacao Bay, P. I. About 5 p. m., May 31, 1917, E. E., water tender, attached to the U. S. S. Dale, started out for a long swim. nccompanied by one of his shipmates. E. E. was a most excellent swimmer and, after a time. his companion becoming tired and not wishing to go further left him, and he continued to swim alone in the rlirection of the open bay. About 5.45 p. m. a seaman on the U. S. S. '/If onte1·ey happened to notice E. E .. who was then some 200 yards from the ship. fall suddenly on hie: back and then give two or three dolent strokes in the water. At the same time the observer saw a shark in close proximity to the bather. It was not hard to conjecture that some accident had occurred, and a boat was rapidly lowered and rushed to the vicinity where the man had last heen seen. The body was recovered, but it was evident from the extensi,,eness of the "ound that the man was dead. Ile was then taken to the morgue of the rnited States Ka Yul Hospital, Canacao, P. I. . Nearly the entire abdominal cavity had heen torn a"·ay. lncleed, the wound extended from the ensiform cartilage nearly to the brim of the peh·is. Laterally, from the right mid-axillary line to the left mid-axillary line. The stomach, the small and large intestine, with the exception of a few feet. most of the liYer and bladder. hnlf of the left kidney and all of the large abdominal blood vessels were re- moved. The illustration shows the wound as it appeared a few hours after the accident. A portion of the ribs had heen taken out with the nicety of a costotome. Some of the skin along the edges of the wounn wus in ribbons and bore the imprint of the monster's li:eth. 540 YICKERY AXD ~lc:Ml:LLIX-AMCEBIASIS. \"ol. Xi E. E. was of large stature. He was about 5 feet 11 inche~ tall and weighed approximately ::wo pounds. Xo doubt if he had been of much smaller dimensions the force of the nttack might haYe hl•en sufficient to ha ,·e cut thC' body in two. DER!CATITIS PRODUCED BY MATCHES CARRIED IN THE POCKET. By W. E. EA'l'ON, Pas~ed Assistant Surgeon, United States Navy. With the onset of hot weather five cases of dermatitis were brought to the attention of the writer. With one exception the dermatitis first appeared on the front of the thigh upon the area covered by the side pocket of the trousers, the exception appearing on the chest beneath the ,pocket in the shirt or blouse. The area involved ap- pearer! pink-reel, with slightly raised yet diffused edges which tended to spread and seemed moderately infiltrated. At times there wns intolerable itching, and again this was entirely absent. Upon appli- cation of mild protective remedies the condition subsided, only to recur upon neglecting treatment. Upon inquiry it was learned that in each case the patient had been in the habit of carrying a box of safety matches in the pocket over- lying the area involved. Upon remornl of the matehes, washing of the garments, and application of soothing remedy the dermatitis at once disappeared. In three cases, upon the patient again return- ing the matches to the pocket ornrlying the previously affected region, the dermatitis recurred. In one case a dermatitis of the fingers of the hand and the eye on the same side of the body as the affected thigh was attributed to the handling of the matches and rubbing of the eye by the hand affected. The outbreak disappeared upon removal of the irritant. • In this connection attention is invited to the apparent impurities and poor qualities of the safety matclws now on the market. It seems probable that impurities were dissolved by the perspiration and in this way deposited upon the skin, resulting in an irritation and acute dermatitis. All cases became well promptly upon removal of the irritant. AMCEBIASIS WITH CONSTIPATION. By E. A. VrcKERY and J. J. A. l\Icl\luLLIN, Passed Assistant Surgcous, United States XaYy. In connection with amoobic infection in the Tropics it is interest- ing to note a symptom-complex which has received very little atten- tion in the literature. The symptom-complex so closely simulates that of chronic intestinal obstruction that a tentative diagnosis of ~o. J. BLOEDORX-GUXSIIOT WOt;XDS FROM DEFLECTED BULLETS. 541 intestinal stasis with autointoxication was made in the two cases herewith presented. The symptoms were practically identical in the two cases and were as follows: Marked and obstinate constipation, lasting for about a year: movement of the bowels heing obtained only with a cathartic for variable periods lasting from one to two weeks; rngue pains referred to the abdomen: with a little tenderness in the neighborhood of the crecum; loss of weight and appetite; lassitude; mild general malaise, with markedly sallow complexion. Both cases showed indicanuria. ~\.t no time was there any diarrhea. One case presented no history of acute attack, and symptoms were somewhat relieYed by the administration of Russian paraffin. It was impossible to obtain bismuth plates, owing to the lack of a suitable X-ray machine. The other case had a hi!'.tory of amrebiasis one year prior to symptoms and bismuth meal showed no intestinal stasis. It is interesting to note that amrebic infection can occur in its chronic stage with absolutely no diarrhea. a point not generally con- sidered in the diagnosis of the infection. The question of infectiYity from such a canier is an important one, as in one of the cases men- tioned the amoebre were found encysted, with but few motile forms. It seems probable that a symptom-complex of this kind in a patient returning from the Tropics would easily escape diagnosis and might well be treated surgically as a case of mechanical intestinal stasis, particularly as encysted nonmotile amrebre are not easily detected during a routine examination of the feces. We consider the adminis- tration of a saline purgatiYe as a necessary preliminary to microscopic examination in these chronic case~. as am<X'lxe were only founcl after such a procedure. Both these cases were extremely obstinate to the emetin-ipccac tn•atment. XULTIPLE GUNSHOT WOUNDS RESULTING FROM DEFLECTED BULLETS. Hy \Y. A. D1PJ:D•>n,;. l'MtiNI ,\sslstanl Surgeon, United States ~ary. The follo"ing cases may be of interest in showing the effect of bullets deflected and ricocheting after striking a steel plate. While practicing with a Benet-Mercier machine gun on the quarter-deck of the /{ cntuel~y the tripod supporting the gun gave way, allowing the muzzle of the gun to be lowered to such an extent that the bul- leb. in!'tead of clearing the deck: c:truck the water"\lay. It appears that from 9 to 12 hnllets struck the waterway in thif' manner. The muzzle of the gun "! s approximately 11) inche,; from the waterway during the firina and wa,., clirecte<l almost at a ri_ght 642 BLOEDOBN--OUNSHOT WOUNDS FROM DEFLECTED BULLETS. Vol. XI. angle against the waterway, which was slightly curved at this point with the convexity outboard. The waterway consisted of two steel plates riveted together and measuring in total thickne~ li inches. One bullet: striking at edge of rivet, penetrated both steel plates. The remainder of the bullets penetrated the ~teel to depths vary- ing from one-half to approximately 1 inch. It appears that these oullets were shattered into fragments varying in size from small bird :;hot to pieces about the bizc of a 2:2-('aliber rifle ball and with a few fr<lgmcnts ~ommvhat larger than :t :2:2-calibcr ball. Tht'se frag- ments ricocheted, striking three officers and nine men, including the man firi11g the gun. The injuries were confined to those men standing behind and at the sides of the gun at distances varying from 3 to 15 feet. The bullets used were 30-caliber and had a core of lead and tin com- position in a jacket of cupro-nickel. The weight of the bullet was 150 grains. The standard muzzle velocity of this ammunition in the rifle is 2,'700 feet per second. Case Xo. 1. Struck by small fragments in center of forehead, right leg and thigh. The majority of the wounds were superficial, one fragment p'netrating the deeper tissues of right leg. Ca!:c X o. :!. Struck by small fragments on both legs and thighs. one fragment penetrating the deeper tissues of left leg. Case X o. 3. Struck by small fragments on chin, left foot and leg~ all wounds being superficial. Case No. 4. Struck by numerous fragments on both legs and left thigh, one fragment lodging deeply in each leg. Cac:e ~o. 5. Struck by numerous fragments on left leg, left fore- arm, and right thigh, one fragment penetrating deeply in left forearm. Case X o. 6. Struck by numerous fragments in right leg, left fore- arm. left thigh, and occipital region of skull. The fragment striking the occipital region penetrated the bone and lodged in the brain. This patient fell to the deck, but immediately got up and walked tc sick bay. He complained of no discomfort . . Exnminu.tion showed penetrating wound of occipital bone in median line about one-fourth inch in dinmeter. Pupils \Yere widely dilated, but reacted to light and accommodation. and examination revenled some dimness of vision. Case No. 7. Showed numerous wounds of legs, thighs and back. He was literally sprayed with fragments of bullets, the majority of the wounds being superficial. Case No. 8. Showed wounds of both legs and penetrating wound of right forearm caused by small fragment. Mann and Conklin-M ultilocular Cyst. MULTILOCULAR CYST . One sac Is here invaginated into the large one. In this picture the t umor Is pinned up by t he pedicle, conseq uently it is "up- side down.' 543 J r;o. f. MANN AND CONKLIN-A MULTILOCULAR CYST. 543 Case No. 9. Showed wounds of both legs, both thighs and right forearm, several of the fragments being embedded in deep muscle. Case No. 10. Showed wounds of both legs, both thighs, left side abdomen and left arm, the majority being 1:mperficial. Case :No. 11. Showed slight wounds of nose and left side of face anrl a small fragment in left buttock. This man was firing the gun and being directly back of the steel plates struck by the bullets, was more slightly injured than any of the others. Case No.12. Struck by a fragment which lodged in the deep muscles of left forearm. First-aid dressings were applied to all the wounds and then each case was examined at length to determine the extent of injury. Owing to the fact that the injured were wearing blue clothes and that bits of clothing were remoYed from the \YounJs, all oflicers and men injured reccivecl l,:300 units of tetanus antitoxin. A MULTILOCULAR CYST. By W. L. MAllN, Pnsscd Assistant Surgeon, United Stntea Navy, nnd F. L. COllKLl"<, Assistant Surgeon, United States Navy. A multilocular cyst, in a congenital hernial sac simulating, by physical and clinical symptoms, a reducible hernia. Patient, nati>e of Guam, age 22. life-term prisoner for murrler, first seen October 16, 1916, complaining of pain in left inguinal region, duration two months. Physical examination revealed what was then thought to be a moderately large hernia, easily reducible. Operation two weeks later, under ether anresthesia. Sac easily lo- cated and incised. Inside of sac was a pedicle of tissue, traction upon which caused a mass of cysts to literally flop out of abdominal cavity through internal abdominal ring. The two larger cysts were so arranged that abdominal pressure would cause the upper cyst to invaginate into lower one, while scrotal pressure caused evagination into the abdominal cavity. The pedicle and sac were carefolly dissected toward testicle; here the condition was so obscured by adhesions that it was impossible to state exact origin of tumor. In addition to the cysts, there existed a small piece of omentum adherent to fundus of sac, thus causing it to be a bona fide hernial condition. The sacs were filled with clear, straw-colored fluid. Careful ex- amination of the tissue by two pathological laboratories fails to clear up the etiology of same. For a better idea of the tumor, see illustra- tion. The recovery from the operation was uneventful. 544 TOUSEY-METHOD OF LOCATING BULLETS BY X-RAY. Vol.XI. llll'ERJOABLE DRESSINGS IN THE TREATllENT OF BURNS. Dy J. J. A. MclluLLB11, Pasded AsRlstant Surgeon, Unlted States Navy. Skin grafts are usually covered with rubber tissue or some other impermeable material. Is it not probable that the satisfactory results are sometimes wholly due to the retentive fabric placed oYer them? The uniYersal interest aroused by De Sandfort's ambrine recalls to mind the following case, treated in the naval hospital, Olongapo, P. I.: C. P., native fireman, first class, admitted April 18, 1916, scalded with live steam from a burst steam pipe while working in the fire- room of the "G. S. S. Pompey. Both lower extremities, scrotum, penis and lower abdomen involved in burns of the first, second and third degrees (Dupuytren's classification). Worst burns on inner and anterior sides of thighs. Picric acid was applled upon admission and morphine given to relieve pain. At the end of four weeks skin grafting was contemplated, as there was no sign of epithelial regeneration anywhere. Instead of apply- ing skin grafts, however, the burned regions were cleansed with warm salt solution and the affected parts covered with rubber tissue. Each morning the rubber tissue was removed, the burns were washed with salt solution, covered with freshly sterilized rubber tissue and bandaged with muslin. ~\.fter four days islands of epithelium were apparent everywhere, and the burns rapidly healed without scar tissue, except on the inner surfaces of the thighs. A small area on the inner surface of the right thigh did not heal after three weeks of treatment. There the granulations were exuberant. Silver nitrate was applied and healing promptly ensued. Too much enthusiasm should not be aroused by a single case, but it seems to me that in warm salt solution and impermeable dressings we may have an effective substitute for ambrine. A lllETHOD OF LOCATING BULLETS AND OTHER FOREIGN BODIES BY THE X-RAY. By Dr. SI~CLAIR 'l'Ot::SEL I ham made a careful study of the 57 methods of X-ray localiza- tion of bullets and other foreign bodies which the European war has brought forth. Such a large number of remedies naturally sug- ge ... ts the possibility that none of them is a specific. including 1me of , .. No. 4. TOUSEY-METHOD OF LOCATING BULLETS BY X-RAY. 545 my own published a number of years ago. I have therefore made a new attempt to solve the problem, with the following result: As with all other methods, facilities are required for placing the X-ray tube at a measured distance from the plane of the photo- graphic plate, and, after the first exposure, displacing the tube a measured distance in a plane parallel to the plane of the photographic plate and making a second exposure upon the same or another photo- graphic plate. The only special apparatus required for my new method is an 8 by 10-inch piece of galvanized-iron wire netting, one-eighth inch mesh and with the thickness of wire such that there are seven meshes to the linear inch. This is laid upon the photographic plate while the exposures are made, and the squares show unchanged in the finished picture. If the displacement of the tube is one-seventh of the distance from the anticathode to the plane of the photographic plate, then the number of squares that the image of the foreign body is dis- placed in the second picture will show the number of half inches that the foreign body is distant from the plane of the wire netting. For the thigh or any part of the trunk the distance from the anticathode to the plate might, for example, be 21 inches and the lateral displace- ment of the tube 3 inches; while for the leg or arm the distance might be 14 inches and the displacement 2 inches. Here again each (one- seventh inch) square over which the image of the foreign body is displaced in the second picture will represent a distance of one-half inch between the plate and the foreign body. In addition to the sheet of wire netting, a small lead marker of a uniform and distinctive character, like a small ring, for exmaple, should be fastened to the skin with adhesive plaster at a place where the skin will be in contact with about the middle of the wire netting when the exposure is made. Before this marker has a chance to hecome displaced its exact position should be indelibly marked upon the skin. A lead serial number should be laid upon the plate in- variably at its lower external corner. This is very important for identifying the picture and avoiding any uncertainty which might result from the plate being film side up or glass side up. The letters "R " and "L" (right and le!t) in connection with the serial number will be of occasional value, but the essential thing is to mark the number on the lower outer corner. The same serial number had better be indelibly marked upon the patient's skin. As a rule the two exposures had bette1' be upon the same plate and each exposure had better be of the duration and intensity which would be required if only one picture were to be made. If for any reason separate plates are used, a stereoscopic plate holder is an inexpensiYc and nonbulky apparatus. The lead marker near the middle of the wire netting, 8551-17--8 546 TOUSEY-METHOD OF LOCATING BULLETS BY X-RAY. Vol. XI. the serial number in the lower outer corner and the wire netting itself should not be displaced, ns they are to identify the position of the image of the foreign body upon both plates. Of course the patient's position is unchanged. The advantage of my new method lies in the small space required for the apparatus and especially in the absence of any mathematical calculations. It would be of great advantage for the X-ray operators to acquire practical experience beforehand with this method upon different parts of the human body employing the X-ray apparatus that they are to use in actual service, so that the pictures may be perfect from the start (of course this applies to any method). PROGRESS IN MEDICAL SCIENCE.5. REVIEWERS. Medical Inspector J. C. PRYOR, United States Navy. Surgeon C. N. FISKE, United States Navy. Surgeon C. FOX, United States Public Health Servl~e. Surgeon H. F. STRINE, United States Navy. GENERAL MEDICINE. HAI.DWIN, E. R. Latent tuberculosis: Its importance in military preparation. Cleveland Med. Jour., xvi, June, 1917, No. 6. The author defines latent tuberculosis as, first, "any and all old or recent tuberculous infections that are capable of producing clinical disease, bnt have never caused recognizable symptoms"; second. "cases whose symptoms were recognizable but nnnoticecl and tran- sient and now ceased." · Ho states that infection usually in the tracl1eu-l.mmchial lymph nodes occurs in from 75 to 90 per cent of ~'Olmg adults. These lymph nodes and mesenteric glands arc "storage places for the tubercle bacillus." The author reminds us that living tubercle bacilli have been found in the most calcareous remains of tubercle. The period of incubation of tuberculosis appears to be not longer than three months, during which time the organisms produce tubercles and remain encysted indefinitely or die. The author believes that no one is immune to primary tuberculosis infection if a sufficient number of virulent bacilli enter the body fre- quently and considers that the disease in the young adult!i usually is metastatic and the result of infection in childhood or youth. Physical, mental and occupational strains play their role in favor- ing the development of the disease. Mechanical factors tend to spread the disease from foci where living organisms have been en- cysted, "but do not act in causing fresh invasions from the· outside." The bearing of latent tuberculosis upon military preparedness is considered very important. The inability to recognize some cases, as well as failure to detect recognizable ones upon examination for enlistment, may result in the development of clinical tuberculosis in these latent cases, many of whom might almost be rejected upon his- tory alone. 547 548 GENERAL MEDICINE. Vol. Xl. The British and German reports concerning tuberculosis are stated to concur in the fact that little tuberculosis is acquired from infection in army service. " The germ enlists with the man " (Osler) and is merely reactivated. "\Vetting, cold, overstrain, trauma and hemorrhage are considered ('auses for the lighting up of latent infections. Chest wounds do not appear to predispose to any unusual degree. It is thought that care- ful, candid history and thorough examination of the chest and glandu- lar system would have excluded a large percentage of those who already have broken down in military service. The value of the various diagnostic methods in common use is discussed briefly and the author concludes that "the serum reaction with complement fixation" is of greater value than the tuberculin test. Those upon whom responsibility rests for sifting out the latent tuberculous at recruiting stations may gain a measure of comfort from the following pronouncement: "It is impossible for sanitorium physicians after prolonged observation to confirm or disprove a con- sidernble percentage of suspected cases." (J.C. P.) COLE, H. Suggestions concerning the prevention and cure of acute lobar pneu- monia. Am. J our. Pub. Ileultb, June 1917, Yii, No. 6. The author reports briefly some of the late observations and con- ceptions concerning prevention and cure of acute lobar pneumonia and includes a resume of some work done at the hospital of the Rockefeller Institute. He emphasize$ the fact that over half the cases of acute lobar pneu- monia occur between the ages of 20 and 50 years, " the period of greatest activity." Many laymen and physicians are prone to regard pneumonia as a disease of the very young and the aged. In discussing the recent observations concerning pneumococci, he calls attention to the several groups which until recently have been classified under the general term " pneumococci " and shows that acute lobar pneumonia may be caused by any one of several groups or types of organisms having definite immunological and less de.finite morphological differences. About 65 per cent of the cases of acute lobar pneumonia are caused by pneumococci of types I and II, types which are "immunologically quite distinct and have definite, specific characters." The mortality rate among cases infected by these or- ganisms is 25 to 35 per cent. The organisms constituting type III are those having very large capsules, forming sticky exudates, and are known as pneumococcus mucosus. This organism causes pneu- monia in only about 10 per cent of the cases, but of the cases caused No.4. GENERAL MEDICINE. 549 by type III the mortality rate is at least 50 per cent. Group IV em- braces different strains of pneumococci not falling in any of the aboYe-mentioned three groups. About 25 per cent of ca,,e.c; of acute lobar pneumonia are produced by this group~ and its rate of mortal- ity is low compared with the other groups, namely. 10 to 15 per cent. "Most of the pneumococci found in mouths during health belong to group IV." Of 942 normal individuals studied in the ho,-pital of the Rockefeller Institute, 450, 47 per cent, were found to harbor pneumococci, and group IV claimed 345 out of the total. Types I and II appeared in 56 instr.nces. In all but three of the case::. in which types I or II were isolated from normal incfo·iduab. the healthy individuals had been in close association with a per~on. sick of pneumonia caused by the same type of pneumococcus. In study- ing the length of time convalescents or healthy carrier::; might harbor organisms belonging to types I or II it was found that in mo.c;t cases the organisms belonging to these types die out in the mouths of con- valescents within a few weeks. The longest time in which any organ- isms have been observed in the mouth of a convalescent has been 83 days. The same facts hold good concerning the persistence of ty~,. I and II in the mouths of healthy carriers. Study of dust in houses where pneumonia was present and in houses where no known cases of pneumonia had occurred showed the following interesting results: From 175 specimens of dust from houses which had contained pneumonia due to type I or II. 73 spec:- mens showed pneumococci, and o:f this number 47 belonged to type.s I or II. In only two cases did the type of pneumococcus :found in the dust fail to correspond with the type isolated :from the patient. Sixty-two specimens of dust from houses where no cases of pneu- monia were known to have existed were studied. Of these specimens 18 showed pneumococcus and only 1 was o:f type I or II and in this case the "known carrier of the corresponding fixed type was found to be visiting at the time." Two small epidemics were inwstigated and it was shown that a fixed type organism was responsible, car- riers of the same type of organism were found and the same type of organism was found in the dust. This evidence all tends to indicate that infection occurs either directly or through healthy carriers. Concerning group IV the author remarks that the cases produced by this group, which is commonly carried in the normal mouth, may be autogenous, as all infections with pneumococcus originally were belieYed to be. Infections from type III, which causes the most severe pneumonill l\re somewhat baffiing in the effort to discover their source. In an examination o:f 450 healthy carriers group III appeared 8:J time5: "and in practically none of these persons could any association with cases of pneumonia due to the same type o:f organism be discovered.'t 650 GENERAL MEDICINE. \'ol. XL It has been proved that these healthy carriers may harbor group III organisms even for years, and as yet no difference of any character has been found between the type III organisms found in disease and those found in the mouths of healthy carriers. 'Vith reference to preventi•e inoculation the author appears to think that ··among troops pre,·cnti•e inoculation might be tried with considerable hope of success," although the results of its use in ci,·il population hitherto ha•e been disappointing. Concerning serum treatment the author notes the difficulties in determining the type of organism present before administration of the specific serum. He states that a diagnostic method has been devised which "is sufficiently simple to be carried out as a routine measure in any well-equipped laboratory," but does not describe the method. Against pneumococci of type I a serum of a high potency has been obtained; against type II a .serum of " considerably less power"; against type III a serum of very slight protective power. Since group IV is a group containing pneulnococci which can not yet be placed in fixed types according to present laboratory methods, it has been impossible to prepare specific protective sera. The serum treatment of acute lobar pneumonia appears to be most satisfac- tory in treating the diseases caused by pneumococci of type I. '' In the ho:opital of the Rockefeller Institute 103 cases of this type have now been treated with but 8 deaths." The New York City and State Health Departments are now determining the "type of pneu- mococci present in specimens of sputum sent to them for examina- tion." The author recommends: 1. That pneumonia be made a reportable disease. 2. That patients be isolated, sputum sterilized and that the rooms O<'cnpied by pneumonia patients be thoroughly cleansed " at least with soap and water" (if not disinfected). 3. That for statistical purposes health departments should deter- mine the type of pneumococci in pneumonia cases. 4. That utmost speed be exercised in indentification of the type of pneumococcus in a given case when it is intended to employ serum treatment, the greatest benefit being obtained by the earliest possible administration of the serum in appropriate cases. In cases treated with serum the author states 250 c. c. have been nece.'-sary in the average case. This large amount causes the manu- facture to be very expensi•e. No established standard of potency for this serum exists at present. Effort is being made to establish :mch. The author states that in his opinion a. thorough washin!? with soap and water is "Yery much more efficacious" than fumiga- tion in the matter of prophylaxis, and states that knowledge conceru- No.4. GENERAL MEDICINE. 551 ing per:::.istence of the organism in dust is insufficient. Type I dis- appears from the dust within three or four weeks. (J. C. P.) SJlITH, A. L. Perleche. Its bacteriology, symptoms, and treatment in 223 cases. Arch. Pediatrics, xxxiv, No. 4, April, 1917. "Perleche is an infection of the labial commissures, manifesting itself, first, by ii. maceration of the epithelium; secondly, by a desqua- mation of this tissue, and, thirdly, by a formation of shallow ulcers and cracks." While occurring chiefly among children the contagion is frequently conveyed to adults ( 16 cases, 7 being dispensary attendants). An anaerobic streptococcus was isolated from 135 cases, although other common pyogenic organisms may be present, and, in causing second- ary infection, starve out the anaerobe. Six times the author in- fected his own labial commissures with the anaerobe. Cold weather favors infection through chapping and fissures: buccal and nasopharyngeal conditions which favor increased ~aliva formation are secondary or contributing etiological factors. Treatment for this otherwise obstinate affection consists in relieY- ing conditions causing salivation, painting lesions with 50 per cent solution of silver nitrate and when dry the application of Lassar's zinc oxide paste. Spirits of camphor locally and tincture of bella- donna internally may be required. For secondary pus infections soaking crusts with 1-1,000 solution of bichloride of mercury fol- lowed by 5 per cent ammoniated mercury ointment will prove efficacious. (c. N. F.) CoPEMAX, A. l\1. The prevention and arrest of certain epidemic diseases in war time. Jour. State l\!ed., xxv, 1917, Vol. 4-5. In connection with cerebro-spinal meningitis the article states that in the early spring of 1916 it was decided, in Yiew of the possibility of wide extension of the disease, not only to isolate cases, but to segregate contacts and examine bacteriologically for carriers by swabbing the nasopharynx. Under this arrangement it wa:::. possible to release about 70 per cent of the contacts within 2-1 to -18 hours and the majority of the remainder within 2 to 4 days later. Those found to harbor the or.ganism were isolated until positive results were no long.er obtained. To perform the work a central cerebro-spinal laboratory was equipped and 37 district laboratories started or coopted for the purpose. 552 GENERAL MEDICINE. Vol. XL The culture material invariably employed was trypagar. The work of media preparation was performed in the central laboratory and supplied to the district laboratories as needed. For rapid trans- portation a motor laboratory was fitted up. Four specifically distinct types of the organism have been isolated from cerebro-spinal fluid, the serum prepared from one type being useless as a means of treatment in outbreaks associated with other types. Encouraging results have followed the use of a polyvalent serum. If the organism is isolated from the throat as well as the cerebro- spinal fluid, it will be of the same type. This also holds good for cultures from the nasopharynx of positive contacts of the case. This fact can be made use of in tracing possibly unsuspected carriers. The trend of opinion is that the disease is spread through contact with healthy carriers. As a prophylactic measure and in the treatment of carriers good results are claimed by nasal insuffiation of 0.5 to' l per cent of a solu- tion of chloramine or of 1 in 5,000 permanganate dissolved in normal saline. On a large scale promising, results have been obtained by requiring the men to remain for five minutes in an inhaling room the air of which is charged with steam and fine droplets of either a 1 per cent zinc sulphate solution in normal saline or, in the case of chronic carriers, 1 to 2 per cent of chloramine. Under beriberi mention is made of a "savory" tablet which is both antiberiberic and antiscorbutic. It is made up of a basis of steam-cooked pea flour with which are incorporated extracts of yeast and also of certain vegetables extracted at a low tempernture, to- gether with certain other flavoring constituents. These tablets are quite palatable and weigh one-half ounce, which is the prophylactic dose for one week, the two halves being taken at intervals of three days. (c. F.) AULD, A. G. New treatment for bronchial asthma. Brit. Med. Jour., l\fay 5, 1917. In a preliminary note the author refers to his belief, uttered in 1908, that a pure asthmatic attack is a reaction on the part of the lungs to a toxic substance, " either of distinctly pathological origin or else a product of normal metabolism which gradually accumulates in the blood." In the following year Auer and Lewis, of the Rockefeller Jnstitute, showed that the lung of the guinea pig in anaphylaxis presented conditions identical with those of bronchial asthma. They found the pulmonary distention to be due to imprisonment of the air in the alveoli from an intense bronchial construction which was No.~. SURGERY. 553 exclusi>ely of peripheral origin. The symptoms could be relieved or a>erted by atropine. The anaphylactic nature of bronchial asthma has since been expounded by Meltzer and many others. The author desired to use 'Vitte peptone in the treatment of selected cases of pure bronchial asthma with or without bronchial catarrh or t:mphysema. The '\Vitte peptone being unprocurable, .Armour's was u"ed. He began with one-third gram of peptone dissolved in about 5 c. c. distilled water at blood heat, injecting this (with due precau- tions) subcutaneously at an interval of three or four days during the fin;t week. The next week two injections of two-thirds gram were gi>en at similar intervals, and during the third week two injections of 1 gram in 7 to 10 c. c. water. This sufficed in !'Orne cases. In others 1-gmm injections weekly or biweekly were indicated for three weeks more. No apparent constitutional reaction followed. The author concludes: "In the limited number of cases tried the results have surpassed expectation. In several cases of moderate asthma the symptoms have become perfectly quiescent, while other:-: have greatly benefited. In one case three months have elapsed without recurrence. Sometimes the relief is very rapid, the patient experiencing relief after one injection. Where attacks of great severity occurred every two or three months, a few weeks' treatment beforehand has caused the attack to abort." (ED.) SUB.GERY. Huoo1::o;s, G. N. The surgery of amputation of stumps (an experience of 2,000 consecutive cases). Lancet, London, April 28, 1917. Until the outbreak of the war modern aseptic methods have meant a negligible number of amputa.tions in this generation. The experience of an earlier race of surgeons is not applicable to present circumstances, because they planned their operations for speed and the eventual use of peg limbs. The classical operations for the foot were devised before artificial joints had been introduced. Amputa- tions must now be done with the idea of ultimately employing a deli- cate and complicated artificial limb. Primary amputations are done to arrest infection, and ~o to save life. Further operation or radical treatment has commonly been necessary in England to prepare or improve the stump for the fitting of an artificial limb. The author aims to elucidate this secondary treatment and at the same time give the basis for action in the case of primary amputations. The cases seen at the Pavilion Hospital, Brighton, had experienced amputation at periods varying from two months to two years before coming under the writer's care. He makes this rough classification: (1) Good stumps not ready for arti- 554 SURGERY. Vol.XI. ficial limb; (2) stumps that have not healed after primary amputa- tion; ( 3) sequestrum formation : ( 4) sinus; ( 5) bad scars and ecze- mas; (6) pain or tenderness; and (7) joint contractures. Three months is the minimum time in which an amputation stump can be made ready for an artificial limb, and then only if a tight bandage has been worn and massage given daily. These measures accelerate the shrinking of the stump. Unhealed i::.tumps are usually the result of so-called guillotine amputations, or those in which the flaps have not been stitched up. These should be treated with continuous skin extension from the earliest possible moment until healed or operated on again; continu- ous extension for a few weeks will almost cover such a stump. Every infected stump, after healing is well advanced, suddenly shrinks and skin becomes loose. This is the time to refashion the stump. The time for this varies, but two or three months or longer are required for the thigh. It is sometimes possible to remove the scar and bring the skin edges together without shortening the bone. The importance of a few inches of bone can not be overestimated, and it is hardly ever neces::;ary to remove more lhan one-half to ll inches. Other rP-asons for waiting are the improvement in general health and the higher resistance to infection developed by the patient. Many bad results are due to operating on guillotine stumps in le:;::; than two months after the original amputation. Mmy of the cases of necrosis of bone occurred in guillotine <tmputations that had been shortened too soon. X o stump is ready to go to the instrument maker until it has been radiographed. as a stump may heal and yet contain a sequestrum. with the result that as soon as the artificial limb is worn an absces:s forms, with resulting sinus. If the sequestrum is small, at least two pictures should be taken, so that it can be removed with :east pos- sible damage to the stump. Sequestra in stumps are generally buried in new bone thrown out from the end of the shaft. New bone which is cancellons can be chiseled away freely. but the shaft must on no account be injured, as there would be danger of further necrosis. Sinuses in stumps are due to: (1) Silk ligature; (2) necrosis of bone; (3) foreign matter, such as metal, or, ( 4) long septic tracks in scar tissue which are unable to close through imperfect drainage nnd low vitality. The writer uses a crochet hook instead of a probe in examining a sinus, and often removes "·ith it ligatures or small seqncstra. A sinus should not be operated on for removal of liga- ture!:> 1 nless repeated attempts have failed. When silk is the cause of a sinus there are often several pieces. In one thigh stump 17 silk ligatures were discharged in three months. Four or fiye is a more usual number. ~luch harm is done to a stump by exploring for silk. ~ilk should neYer be used for ligatures on amputation stumps. It SURGERY. 555 caused 40 per cent of the sinuses treated by the author and prolongs and increases pain. X ecrosis and foreign matter are localized by the aid of X-rays and the remarks under;, Sequestrum" apply. The Jong septic track in scar tissue is hard to diagnose, and can only be demonstrated by exploration. "\\hen no foreign body is found, excise the skin around the sinus, remoYe deep portion of scar, sew up wound. Packing the wound and attempting to obtain healing from the bottom often leads to a bad puckered scar. Pain and tenderness of stump is due to: (1) :Xerves adherent to ='car; (2) bulbous nerves; (3) sequestrum in new bone; (4) spurs of new bone ; or, ( 5) chronic abscess . • \.dherent nerves (result of not shortening the nerves at time of amputation) always have to be removed. As bulbous nenes vd1ich no not adhere to the scar as a rule become painless in three or four months, wait that long before removing. On the other hand, bulbous nenes which are not tender or painful may become so after three or four months. Bulbous nerves may cause extensive symptoms such as large areas of hyperrosthesia. In one case it caused epileptiform fits. Spurs of new bone are common and every now and then cau~c pain and require removal. The large amount of new bone formation in stumps that have been infected is striking and it often takes ,;n fan- tastic shapes and follows muscular attachments and sinu&'s. It is important to be sure that pain apparently due to a spur is not caused by a bulbous nerve, as the spur alone does not often cause pain. Often where a diagnosis of bulbous nene is made a small abscPss will be found instead. It may be' around a ligature or han~ no ap- parent cause. Fic:lrs in stumps that have been infected are clue to insufficient coY- er:ing of bone or to too much co-\ering. If the scar is very large and liahle to ulcerate, in the case of insufficient covering, use skin exten- :':ion and then excise the scar. In the second group, if the edges are 'er.\' puckered or turned in~ the scar is liable to eczema, and after wearing an artificial limb is apt to break down through the softening induced by decomposition of sweat. In excising a scar refashion the deep parts as well as the skin, or the condition will relapse. The commoner contractures are: (1) Flexed knee. (2) flexed and nbducted hip, and (3) adducted shoulder. These deformities are ,•orrected by massage, splints, forced movements, plaster of Paris dressings and, if necessary, tenolomy. In shortening a stump the author uses only skin flaps and makes them shorter than usually recommended in the text books. Exces~ive :-kin flaps are never well nonrished. He does not nc:c mnsclc in the flaps. 556 SURGERY. >ol. XI. For foot amputations the writer finds that as a rule the stump of a Chopart becomes deformed ; a Pirogoff is too short to use as a peg and too long to take an artificial foot. He prefers the Syme ampu- tation with section of bone a quarter of an inch above joint surface of the tibia~ rounding off all bony projections. This stump is end hearing and short enough to fit an artificial ankle. For the leg amputation in the middle third at the lower end of the prominence of the calf, use a long anterior and a short posterior flap. Unless two fingers can be placed side by side on the inner side of the posterior surface of a leg stump when flexed, the stump is too short to use a below-knee artificial leg and a kneeling leg will have to be worn. It is unusual for enough skin to be available for a good amputa- tion through the knee, and if there is enough skin a short below- knee stump can as a rule be obtained. RemoYe the patella. The Lt>st amputation is through the top of the condyles, rounding off all hony projections. The Gritti-Stokes amputation is an unnecessary refine- ment unless the bone section has to be made above the cancellons p: rt of the femur, and then it should be used to make an end-bearing stump. EYery inch of the femur above the condylcs is of the utmost 'alue until the upper third is reached. In that situation, unless 2t inches of bone below the lesser trochanter can be saved, a thigh bucket can not be used. Therefore when this amount of bone is not available it is Lest to amputate through tho neck of the femur, thongh an equally satisfactory and less severe operation is to go through at the junction of the great trochanter and shaft. The artificial leg for a hip-joint amputation is a sound practical appliance and can be fitted to a subtrochanteric amputation. The conical stump is often satis- factory and must not be regarded as unnecessarily bad. For the wrist and forearm it may be said that one movable finger is better than any artificial device. Every inch of bone from the lower end of the ulna to within 3 inches of the upper end of the ulna is of value. Less than 3 inches can not be utilized, and in such a case amputate above the condyles, removing the supracondylar ridges. Every mch of humerqs above the condyles is useful. The shoulder joint can not be used unless 11 inches of bone can be saved below the anterior fold of the axilla. (ED.) BERNHEIM, B. M. The limits of bleeding considered from the clinical star.d- point. Am. Jour. Mecl. Sc., Ap1il, 1917. Bernheim believes that there has been a tendency to overemphasize the importance of blood transfusion methods when in reality there is greater need for fl more thorough understanding by the medical SURGERY. 557 profession at large of the indications for this procedure. It goes without saying, of coursei that to achieve the best results one must be prepared to use the method best suited to the case in hand: since no device answers equally well in every instance. The question to be determined is, 'Vhen has the limit of bleeding been reached 1 The author is convinced of the utter futility of having a specific rule by which to be governed, each case being a rule unto itself. Yet one must have some tentative plans by which to be guided, and there are, after all, certain fundamental features which are true to a degree in all cases. For instance, a sudden loss of blood is a more serious matter than a gradual depletion . .A rapidly falling blood pressure is always a warning of rnlue, although it must be remembered that nausea of the slightest degree will send the pressure down. In severe cases, it matters not what the cause, a good working rule is to transfuse if the blood pressure falls as low as 70 mm. of me1·cury, since life is hardly possible with anything below this level. Pallor, sweaty skin, the anxious counte- nance, are all danger signals that come to mind at once and air hnn~er when present is always of true diagnostic import. Curiously enough, the blood picture itself is of little avail in severe accidental hemorrhage. A patient apparently exsanguinated ma:y hnxe a hemoglobin estimate around 50 per cent, with a red-cell count of onr 2,000,000, figures well within the limits of safety. E-rnn in cases of actual air hunger blood counts alone do not indicate the dire need for fresh blood. In fact, so constantly has this state of affairs been found in cases of this sort that the nuthor now entirely ignores this feature. Terrific loss of blood apparently gives rise to the tighten- ing up at first of the vascular apparatus, a narrowing of the >essel lumen, thus causing a concentration of the blood remaining in the peripheral system, and at the same time preserving a blood pressure sufficient to sustain life. The true anemia does not become apparent until later on, when the vessels have relaxed and taken up a renewed supply of plasma with resultant blood dilution. In chronic bleedings and the anemias the hemoglobin is the safest guide. Drugs are of little aid in acute bleeding, morphin, judiciously giYen. excepted. It is human nature to try to help, but drug therapy in acute bleeding is misdirected aid. The author thjnks <' quartc>r of a grain of morphin seems to be indicated at the start of any hemor- rhage to quiet restlessness; after that the doses h~d better be smaller. because of the depressant effect of this dru!Y on re,.piration and the blood pressure. He believes in liquids of any and all sorts. bY mouth. per rectum, subcutaneous infusions, intravenously, coffee, tea. water: ice-any- thing at all that will quench the intolerable thirst and keep up the bulk of the circulating medium-nll within reason. Many patients 558 HYGIENE AXD SAXITATION. Yol. Xl. have been actually water-logged by overadministration of salt solu- tion-a heart can be overdistended and the blood can be made too dilute. If 1.000 c. c. or 1.500 c. c. of salt solution do no good, a greater amount will be equally rnlueless and may do harm. In case:::; of severe hemorrhage, if 1:200 c. c. do not steady a falling hlood pre.~­ sure or cause a slight rise. its introduction had better be discontinued. When the bleeding has been excessive a transfusion is indicated. be- cause it has been conclusively shown that blood alone can raise a pressure and sustain it. Salt solution has no sustaining power per se, and when the fall comes after a rise :from this means it usually por- tends the end, for added salt solution is useless. It never raises a pressure twice. (H.F. S.) HYGIENE AND SANITATION. DAKIN, II. D., and Duxu.nr. K K. Disinfection of drinking water. Hrit. Med. Jour., May 26, 1917. Sterilization 1 of drinking water by use of bleaching powder or Rimilar hypochlorite or chlorine preparation has been used with the greatest success for relatively large volumes of water when troops are practically stationary. The problem of sterilizing small indi- ,·idual quantities of water, such as are needed by cavalry or rapidl~ moving troops is much more difficult. For such purposes the insta- bility of small tnblets containing the minute quantity of active disinfectant required led the writers to make a number of experi- ments. which are summarized here. The first experiment was made with chloramine--T. It was un- satisfactory. If waters were heavily contaminated and hard and alkaline, the concentration required was too great, though this could be reduced by use of citric, tartaric and other organic acids. The next attempt was with preformed toluene-sulphondichlora- mines: and first results were encouraging, but when put up in tablet form too much time was required for solution to bring about prompt ~terilization. Greater solubility and stability were obtained with p-sulphondi- chloraminobenzoic acid. This can be prepared from cheap, readily available material. The formula is Cl2N.02S.C6H 4.COOH. The presence of the COOR group confers a slight but definite solubility in water, which is increased by dispensing it with alkaline salts, such as sodium carbonate, sodium bicarbonate, borax, etc. The writer:. propose for convenience that the designation "halazone" be used for this substance. 1 Halazone Is now on sale In the United States, con>enlently put up In ~mall vials of a hundred tablets each. One to two tablets sterilize a quart of water in 30 minutes. ~o.4. HYGIEXE AND SANITATION. 559 Tests of the efficacy of this .. halazone,:· both in powder and tablet form, were made. using tap water and B. coli: hard water and feces suspension; hard 'Tater and 10 per cent city sewage; tap water and 5 per cent city sewage; hard water and B. coli. The "halazone" was in Yarying degrees of concentration, as 1 : 250,000, 1 : 500.000. 1: 1,000,000. The ordinary routine was to take ,) or 10 drops of the treated water, place on agar to count surYiving organi:;rus and use suitable controls. The experiments appeared to show that in a concentration of 1: 300,000 an ordinarily heaYily contaminated water was sterilized in 30 minutes. This concentration could be relied on to remove coli, typhoid, or cholera organisms. The tablets were efficacious when acting on water in aluminum· containers, though if the tablets were allowed to remain undisturbed for a long time in contact with the metal a negligible action on the latter resulted. In the concentration prescribed the water acquires a o::light taste but is not unpalatable. The active chlorine is used up slowly, and the disin- fection continues for a longer time than when most hypochlorite preparations are used. The starting point in the preparation of "halazone ., is p-toluene- sulphonamide, which is readily obtained by the action of ammonia on p-toluenesulphonic chloride, a cheap waste product in the manu- facture of saccharine, and is available in relatively large quantities. It is now used in the manufacture of chloramine-T. Toluenesulphonamide is oxidized to p-sulphonamidobenzoic acid, and the latter substance on treatment with chlorine giYe" the desired dichloramino acid. A\.dcl 250 grams commercial sodium dichromate t.o a mixture of 200 c. c. concentrated sulphuric acid and 600 c. c. water contained in 2-liter round flask. Then add 100 grams crude toluene-p-sul- phonamide and heat on a sand bath with reflux condenser for one hour. using a small flame at first, as the reaction is vigorous. On cooling, wash separated crystals with cold water and dissoh·e them in hot dilute sodium hyroxide in slight excess. Filter hot and add excess of hydrochloric acid. When cold filter off precipitated acid und wash well with water and dry. Twenty grams of p-sulphona- midobenzoic acid thus obtained are dissolved in 200 c. c. normal ~odium hyroxide (2 vols), warming if necessary. Then add 200 grams crushed ice and saturate the mixture with a rapid current of chlorine. The reaction is best conducted in a wide-mouthed flask, which is shaken as the gas is introduced. More ice can be added if necessary. A white, chalky precipitate of the dichloramino acid is at once obtained. Filter off the acid by suction, wash in cold water, dry in vacuo on a porous plate. The dry substance is prac- tically pure, may be powdered and will apparently keep indefi- 560 HYGIENE AND SANITATION. Vol. Xl. nitely. It is spariugly soluble in water and in chloroform and in- soluble in petroleum. It readily dissolves in glacial acetic acid crystallizing in stout prisms, which melt at 213 C. When rapid!; heated on platinum foil it explodes feebly, but is remarkably stable when compared with most members of this group. The sulphondichloraminobenzoic acid behaves equally well whether made into a tablet with salt and either sodium carbonate, sodium bicarbonate, dry crystallized borax or sodium phosphate, but the crystallized salts are undesirable if the tablets are exposed to high temperatures. A convenient formula for tablets weighing 100 to 105 mg. is: Sulphondichloraminobenzoic acid, 4 per cent; sodium carbonate, 4 per cent (or dried borax, 8 per cent) ; pure sodium chloride 92 per cent. Grind the acid with the dry salt and then add the sodium carbonate. Pass mixture through a 40-mesh sieve. No lubricant or other addition is necessary. Tablets must be stored in small amber-colored bottles. One tablet prepared as above sterilizes one liter of moderately contaminated water. H contamination is excessive, use two tablets to liter or quart. Sufficient time has not yet elapsed for final reports on the stability of the tablets, but under ordinary conditions no decomposition was noted after two months. Bright sunlight acting on tablets in clear- glass bottles did cause decomposition. The estimated cost in England of disinfecting water by the use of halazone is 2 cents per 100 gallons water. (ED.) GUNN, J. A. Note on prevention of pediculosis. Brit. Med. Jour., May 5, 11>17. The writer gives very favorable reports on the use of thin under- shirts made of muslin (so cheap that the original intention wa~ to throw them away after using once) soaked in the following solu- tion: Naphthalene and sulphur, each, 1! ounces; benzol or gasoline, 1 gallon. :N'o inconvenience results from the use of undergarments so treated. The effect on pediculi is not immediate. The writer quotes from a letter from France, in which it was stated that 200 dead pediculi were counted on a shirt that had been treated with the above solution. The solution has been applied under a plaster cast without irritation to the skin. [ED.] BELLI, C. M. Food ration of the Italian Navy. Office Internatlon11l D'Hygil!ne Publique, Ix, No. 5. This is a resume of a brochure published in Naples giving the • results of a royal commission's inquiry into the subject of the navy ration. HYGIENE AND SANITATION. 561 Belli notes that the navy is recruited from a sober, thrifty ele- ment of the population, and that, thanks to the influence of German ideas in recent years, a ration has been constructed not only in excess of physiological requirements but unconformable to the' previous habits of the men. He quotes Chittenden and his school and the work of the Italian investigators in support of the postulate that man can live and work on less food, especially of proteid character, than has generally been considered necessary. Since 1912 Tenente-Generale Medico Rho, R. M. I., has contended for this idea. In 1915 he published his views and asserted that all so-called war rations were wrong, in that when more labor is re- quired the ration is supplemented by proteid increase instead of starch increase, which is better calculated to contribute to restora- tion of strength. No attention was paid to his researches and recom- mendations because of the unfavorable impression likely to be pro- duced by a reduction of the ration. During the past year the necessity for economy has triumphed over political considerations. One by one various reductions have been made in the Italian Navy ration. The following tables show the allowance for a period of a week, column I being the issue for men on duty ashore. column II for men at sea: I VinPgar -------------------------Centiliters__ 3 Coffee ______________________________ grams__ 105 Beef _________________________________ do ____ 1, 200 Beans--------------------------------do____ 235 Cheese _______________________________ do____ 335 Olive oil _________________________ centlliters__ 30 Bread ______________________________ grams __ 4,270 Farinaceous material (macaroni, etc.) __ ao____ 600 Rice _________________________________ do____ 380 Salt ---------------------------------do____ 78 Wine ---------------------------Centiliters__ 25 Sugar ------------------------------grams__ 140 Biscuit------------------------------~do____ 140 'runny preserved in oil ________________ do____ 140 The above yields per day : Proteids ____________________________ grams__ 99.8 Fats ---------------------------------do____ 15. 3 Carbohydrates ________________________ do____ 524.3 Or, expressed in calories-- Calories from proteld sources________________ 409. 1 Calories froni fats-------------------------- 142.2 Calories troni carbohydrates ________________ 2, 149. 2 II 3 105 1,650 340 190 50 3,360 640 4-.?() 96 175 140 700 50 106.7 18.9 545.3 437.5 174 8 2,224. 7 2,700.5 2,837.0 In actual practice the ration differs distinctly from that of the tables. In addition to the provisions indicated above the navy depart- ment allows a varying cash amount for purchase of fresh stores re- 8551-17-9 562 HYGIENE AND SANITATION. Vol.XI. quired for preparing and improving the ration. Furthermore, the commanding officer is authorized to substitute other articles for any or all of those enumerated. This privilege is taken advantage of to a considerable extent among the personnel on shore. The tables are therefore misleading, except where it can be ascertained that there has been no waste and no commuting. Belli, under orders of the minister of marine, examined 15,000 men, both in barracks ashore and on board ship. He has determined that the ration has a value of over 3,000 calories, which he considers in excess of physiological requirements and entaHing a tax on the digestive and assimilative organs of the body. The daily proteid consumption, though actually below that shown in the tables, is. he believes, greater than the bodily requirements, which he fixes at 90 grams per diem. While the fats furnished are low and derived wholly from oil, the cash allowance permits the purchase of other fats, principally lard, so that column I should actually read 22, and column II, 30 to 35. The average carbohydrate intake is, column I, 500 grams; column II, 540 grams. An interesting control test is furnished by a study of the not in- considerable number of groups who by reason of military necessity are not rationed by the Government but allowed cash for the pur- chase of an exact equivalent of the ration and permitted to consult their individual tastes and preferences. Two important points are to be noted-first, the money issue is proved to be liberal by the fact that a majority of the organizations thus subsisted are actually able to save on the allowance; secondly, much greater variety in diet is made possible. The energy obtained from the diet thus selected and bought is represented by 2,700 to 2,800 calories, which is approximately the yield of the Government ration. The average daily proteid ingestion is 90 grams, about what the official ration calls for, but the proportion derived from animal sources is much less. The fats selected yield 25 to 28 grams a day, but, on the other hand, carbohydrates in the diet of election reach 500 to 600 grams. In a word, where there is an option the diet tends to be principally vegetarian, thus conforming to the popular basis of sustenance in the Italian of the working classes. The ration seems to the writer to he adequate except for a lack of variety. His recommendation is to have but one column or table which shall be mandatory for pro' iding a total of 2,600 calories from the morning and midday meal. The remaining 200 calories required are to be obtained by the evening meal, which shall be largely vegetable in character, selected and pre- nared according to the wishes of the messes concerned. (ED.) REPORTS. A REPORT OF 112 CASES. OF CEREBB.0-SPINAL FEVER. By J. T. MILLER, l'assed Assistant Surgeon, United States Navy, and D. D. MARTIN, Assistant Surgeon, United States Nnvy. It is so seldom that medical officers of the Navy ha,·e the oppor- tunity of studying a series of 100 or more cases of cerebro-spinal fever that the following report is submitted, with the hope that it may assist others in caring for and treating this most trying and treach- erous disease. It is not our aim to attempt a scientific discussion of cerebro-spinal fever, but, rather, to bring to the attention of medical officers the more important facts as they presented themselYes to us during this epidemic. While the first case was admitted to this hospital in March: Hl17, it was not until April that the disease began to assume epidemic pro- portions. The fact that this first case was admitted before the first draft from the Chicago training station arrived throws some doubt upon the prevailing belief that that station was the original focus of the disease and that all subsequent cases can be traced to men coming from there or to contact with these men, but it must be ad- mitted that there is considerable evidence in support of this belief. Etiology.-It is, of course, universally accepted now that the causa- tive organism is Weichselbaum's meningococcus and in all of the cases in this report this diplococcus was found in the spinal fluid. Also cultures from the nasopharynx were positive for the menin- gococcus in practically all cases, and, as has been reported by Eng- lish army surgeons as well as others, in the few cases in which it has been possible to follow up this line of work the mcningococcus has" run true to type," i. e., the meningococcus found in the naso- pharynx of a. given case is always the same type as that found in the spinal fluid. Mode of transmission.-While Flcxner's experiments have proYed that the meningococcus may gain entrance through the nasal cavity~ Pizzini has recently incriminated the body louse and reports a series of 77 cases in which all cultures from the nasopharynx were ncgatiYe and enltnrcs from the blood of the patients positi•e in every case, remaining so (with occasional intervals of ll<'f!atiYc cnltttr<'s) ln.te fiG3 564 REPORTS. Yo!. XI. into conYalescence. The experience of the writers has also been that blood cultures (at least those taken early and during the Yery acute stage of the disease) have pro,·en positi,·e for the meningococcus, and it doe:; not seem reasonable to suppose. although we have no direct evidence to submit, that the disease may be transmitted by some parasite such as the body louse or bedbug. ~\..n interesting fact in support of the former mode of entrance is that the disease fre- quently complicates or follows measles. It, indeed, would seem that a person in normal health and with an uninf!amed nasal mucous membrane is naturally immune to the disease, otherwise jt is hard to explain the fact that, with the large number of Hospital Corpsmen, nurses and medical officers who have come in such very close contact with the cases now reported, not one has become infected. It mav also be noted that, so far as these cases are concerned, all vermin hav~ been excluded by daily inspection, sterilization of clothing, etc. Under this heading must be mentioned carriers, those who show no evidence of disease and yet who harbor the meningococcus in the nasopharynx. It probably is not generally known what a large per- centage of these exist. Research along this line shows a considerable percentage of noncontacts to be carriers. Pathology.-It is much to be regretted that no report of the path- ology of this disease can be made, as it was impossible to obtain a complete autopsy in any case. DiagMsis.-This is not difficult in a fully developed typical cage, when we find stupor or delirium, stiff neck muscles with retraction of the head: positive Kernig's sign, etc., but in the very early stages all of the symptoms mentioned may be absent. However, there are se,·_ eral symptoms that will invariably be present even in the >ery early stage before there is any turbidity of the spinal fluid. These are elevation of temperature, perhaps of only 100 F. or 101 F.: head- ache, generally occipital in type but perhaps described as'· all OYer 1'; increased leucocyte count. This latter has been found to be over 30,000 per cm. when there was no backache, no stiffness of neck muscles, negative Kernig, and perfectly clear spinal fluid. Finally the lumbar puncture determines the presence or absence of the disease. It is particularly difficult to diagnose cerebro-spinal fever from other forms of cerebro-spinal meningitis; for instance, that of streptococcic origin, and this can be done only from the bacteriology of the spinal fluid. During an epidemic one must be on his guard not to be de- ceived by hysteria. The following interesting case was recently seen. The patient was in attendance on cases of cerebro-spinal fever, and, when seen by one of the writers, fear and dread of meningitis was most marked; this is practically never seen in a true case and is a good diagnostic point. Kemig's sign was positive in both legs; intense headaches (occipital) and pain in the lumbar spine were Vol. XI. has also been t hut fog the Yery acute he meningococcus. iough we have no be transmitted bv t\n interesting fa;t at the disease fre- d, "\\ould seem that med nasal mucous erwise it is hn,rd to Iospital Corpsmen, i very close contact ~ infected. It may ed, all vermin haYe clothing, etc. those who show no mingococcus in the n what a large per- hows a considerable report of the path- possible to obtain a ·eloped typical case, ~s with retraction of very early stages all ivever, there are sev- en in the very early al fluid. These are F. or 101 F.; head- :ribed as " all oYer "; .n found to be OYer no stiffness of neck pinal fluid. Finally bsence of the disease. ·inal feyer from other that of streptococcic riology of the spinal guard not to be de- !l.Se was recently seen. >ro-spinal fever, an<l, td of meningitis was a true case and is a )Sitive in both legs; e lumbar spine were =-o. •· REPORTS. 565 present. There "·as hihlory of nausea and Yo1mtmg: ,.tiffness of neck muscles with marked retraction of the head, so much so that patient had to lie on the side and head was almost between £capulc.c. But temperature was normal and the leucocyte count was i .000. Lumbar puncture was not done. During an epidemic cases of meningism or meningismus will al~ be seen. The.--e consist of cases, clinically, of apparent cerebro-spinal fenr but quickly clearing up without treatment. The spinal fluid is normal and there is no increased leucocyte count. These cases are said by some to be due to the invasion of the nasopharynx by the meningococcns. Symptoms.-The period of incubation is uncertain: probably within 10 days. 1. Fever is constant, possibly only 100 F. if the case is seen early, but it may quickly mount to 104 F., or even 105 F. It generally falls by lysis, but there may be a. sudden drop to normal, to be fol- lowed by an intermittent course. 2. Headache, generally occipital in character, is a constant and most persistent symptom. Backache (lumbar) is generally present. Insomnia is a constant and distres.c;ing symptom. 3. Vomiting, which may be projectile, or history of rnmiting is quite usual. 4. Kernig's sign may or may not be present in the early stage, but is generally positive at some period of the disease. Babinski's sign was found in a few cases and Brudzinski's in only one or two. 5. Apathy was found in all cases, and generally stupor or delirium occurred during the height of the disea!'El. Profound coma, with abolition of all reflexes, was noted in a few cases of the seYere type. 6. Leucocytosis is constant and may be high e•en in the early stage, ranging from 20,000 to 35,000 cm. 7. Spinal fluid: Always under increased pressure. If obtained early, it was frequently found clear, but quickly became turbid, this turbidity ranging from slight haze to marked purulence. The cell count was always increased, in some cases only 20 cm. on the first count, with a steady increase as the disease progressed. These cells were found to consist chiefly of polymorphonuclears, and as improve- ment occurred were replaced by 1ymphocyte5:. The meningococcus was invariably found, and in some cases before the spinal fluid showed any turbidity. The albumen and globulin content were in- creased. The reduction of Fehling's solution was not tested with regularity. 8. Posture, etc.: On account of retraction of head the patient gen- erally lies on his side; the legs and thighs are generally flexed. }i'ace is generally flushed, but this may change from time to time and is later followed by pallor. 566 REPORTS. Vol.XI. 9. Pulse is accelerated, but when pressure is marked it may be below normal. The lack of relation of pulse and temperature was quite marked. The pulse rate is of great value in the later stages of the disease when the spinal fluid has become clear and apparently convalescence has commenced. A persistently high pulse rate under these conditions is a warning, and treatment must not be discon- tinued or a so-called recrudescence will result; pressure symptQms will appear, and a lumbar puncture will show a return of turbidity. 10. Cutanecus: A prodromal rash was noted in a number of cases seen very early. This consisted of discrete maculo-papular spots varying in size from minute points to half an inch in diameter, found on the dorsum of hands and feet and also on forearms and legs. This rash was very evanescent, disappearing in a few hours and was seen only in cases that had not developed well-marked symptoms. In fact lumbar puncture was done on a.number of cases when this rash was the only symptom, and diagnosis was confirmed. The nearest ap- proach to mention of this rash that the writers have been able to find in the literature of the subject is made by Horder of the British Army, who describes "large rose spots appearing during the first three or four days, scattered discreetly over the body and involving the arms and legs as well as the trunk." The rash described above does not appear on the trunk or face. Petechial and purpuric rashes were rather the exception, occurring only in the very acute or the fulminant forms. In a few cases these spots were very extensive, appearing over entire body, face, and limbs, including palms of hands and soles of feet and at times attaining the size of a thumb- nail. These change color, becoming black and persist far into convalescence. 11. Urine: Albuminuria was rarely found. Polyuria was the rule. Hematuria was not seen, even with marked purpura. Incontinence of urine was frequent and retention was sometimes encountered. 12. Constipation occurred in practically all cases and persisted into convalescence. Prognosis.-This should always be guarded and depends upon the stage in which diagnosis is made and treatment instituted. The mortality in this series has been 26.7 per cent. This includes not only cases reaching hospital in moribund state, but also one case dying in transit and one case of cerebro-spinal meningitis of strep- tococcic origin in the spinal fluid of which a few Gram-negative diplococci were found. Another case included was one in which all meningeal symptoms had disappeared and which developed lobar pneumonia, followed by suppurative pleurisy-and was operated upon. Complications.-ConjunctiYitis was very common. Strabismus occurred in a number of cases: but always disappeared during con- No.f. REPORTS. 567 valescence. Panophthalmitis result.ed in three cases. Nystagrous was not noted. Pneumonia developed in three cases and in one was followed by empyema. Deafness occurred in several cases, but disap- peared during convalescence. Otitis media was quite common, and in one case resulted in acute mastoiditis and was operated on. Joint affections were rare and became troublesome in only one case ( ar- thritis of shoulder). Treatment.-(a) Prophylactic: Avoidance of overcrowding and dark, damp living quarters and prompt attention to colds and coryza. are important. Swabbing with weak solution of iodine in glycerine of the nasopharynx of not only contacts but all persons in the epidemic area is a good practice and has been carried out at this hospital. All persons should be examined for carriers and whelf found to be such should be treated. A 2 per cent solution of chlora- min in oil of eucalyptol has been found efficacious. Prophylaxis by means of vaccines was not attempted. Isolation was strictly prac- ticed. (b) Curative: Diet should be light but nourishing during the acute stage, but should be increased as soon as appetite returns, as emacia- tion and prostration tend to become extreme. Lumbar puncture: This is put down as a treatment in itself and not merely as preparatory to the administration of serum, for it is the opinion of the writers that it is very important, if not th~ most important, part of the treatment. The relief is frequently instan- taneous, and cases in active delirium have become rational in a few hours. Several cases received early were treated by this method only and convalesced quickly and uneventfully. Early diagnosis is most important, as a few hours delay may change a mild case easily handled into a most grave or even fatal one. In all cases of doubt a lumbar puncture should be done immedi.ately. Evidently a number of medi- cal officers do not appreciate the necessity for prompt action, as cases are sometimes kept aboard ship without lumbar puncture but "under observation" for 24 hours or more when cerebro-spinal fever is sus- pected. Certainly every ship should be furnished at least the needles necessary for a lumbar puncture. General anresthesia was not used, but ethyl chloride as local an- resthetic was used as a routine measure and gave satisfaction. All spinal punctures were performed with patient lying on right or left side. The following position was found most convenient and satis- factory: Patient on side with back well over edge of bed, and an attendant with his back well up to abdomen of patient and with one arm firmly grasping patient's knees and the other under patient's shoulders, carefully avoiding head and neck. This effectually pre- vents the struggling of a delirious patient and possible injury by breaking of needle. 568 REPORTS. Vol. XI. Tincture of iodine painted over site of puncture was used as a routine measure and no local infection resulted in any case. The third lumbar interspace was the point of election, but the fourth and second were used in a few cases for irrigating purposes. Administration of antimeningococci serum, when of sufficient de- gree of polyvalence, has given good results. Undoubtedly the dis- appointment experienced by some has resulted from the use of a serum in preparing which too few strains of the meningococcus have been used. A polyvalent serum made from about 80 different strains of meningococci by the Rockefeller Institute is used in this hospital and has given good results. It is given in this manner: In very acute cases from 20 to 40 c. c., according to the amount of spinal fluid with- drawn, are given every 12 hours until three doses have been injected, then every 24 hours, not only until the fluid is negative for meningo- cocci, but for at least several days longer or until there is marked im- provement in the patient's condition. It is most important to give this serum in less quantity than the fluid withdrawn; also to obtain the best results the canal should be drained thoroughly, i. e., until the fluid ceases to run faster than normal (one drop every 4 seconds). It is equally important not to drain too rapidly, as this causes intense headache and increases the tendency to hemorrhage. From this time lumbar puncture is done daily until the fluid be- comes clear and there is no pressure. Frequently after active treat- ment has stopped it becomes necessary in a few days or even a week or more to tap to relieve pressure. Irrigation of the spinal canal with normal saline solution has been found of benefit in those cases with purulent fluid and in the long-continued cases. Morphia for the relief of pain and insomnia is required. Careful watch on the excretions is necessary, as retention of urine may occur. CONCLUSIONS. 1. The necessity of an early diagnosis with prompt institution of treatment. 2. Importance of thorough drainage of canal, done slowly and of the introduction of serum, being careful not to administer as much and never more serum than fluid withdrawn. 3. Proper position of patient in bed must be obtained. 4. Always administer serum at body temperature. 5. Irrigate canal thoroughly with normal salt solution in cases whose spinal fluid is markedly purulent and those that have a recrudescence. 6. Employ careful swabbing of all contacts. 7. Watch for retention of urine. 8. Institute prompt treatment on the return of symptoms. 9. Watch for complications. 10. Isolate all cases. Anal118i11 of 11! casei; of cercl>ro-apinai meningitis. case. Rate. Dato or Mlmfs. alon. Via hosplt.al ship. Name or ship. -1 I I 1--- 1017. Trafnlng camp. Followed other dl8ca8ca. 1 A. S ............ May 1 I Solace ... Arizona ........ . 2 A. B.. ...... .. .. May O .. . .. . .. . . Montgomery . •.• 3 A. S ............ May 13 Solll('e ... Baltimore ....... 1 .................................... . 4 F., 2d cl.. ...... May 6 1 ... do .... Rownu . .. ........................ ! Measles .•....•. • 5 A. S ............ May 10 ... do.... Florida . . ....... Great Lakes ••.. 8 A. S ............ May 12 .......... .................. Norlolk .... .... . 7 A. S ......... ... Apr. 24 .......... Delaware ....... Great Lakes ........... .. 8 A. S ......... ... Apr. 27 Solace .•. Arizona .... .......... do . ....... .. ~ n:++ ~ii: ~ -:1r-::::n:::0: :::-~:: +: H Sea., 2d cl. .. .. . May 6 • • • • • • • • • . Prometheus ..................... .. 15 F., 3d cl.. ...... May o Soloce ... Vestal.. ... .............. ......... . 16 A. S ............ May 4 . .. do .. .. Now York .. .... Great Lakes . . •. 17 A. S ..... ...... . May 1 ... do .. . . Connertlcut . ..................... . 18 A. 8 ............ Apr. 23 .......... New York ....................... . 10 A. 8 ............ Apr. 15 . . ...... .. Great Lakes Groat Lakes ... . dralt. 20 Sea., 2d cl. ..... May 6 Solace .. Seattle .......... Newport ....... . 21 A. 8 ........... . May 13 ............................ Norlolk ... .... .. 22 Sea., 2d cl. ..... Apr. 27 SoJBce •. Michigan ........................................... . 23 Sea., 2d cl.. ...... . do ....... do .... Wvomlng ....... Great Lakes ... ··1 ................. . 24 Sea., 2d cl. ........ do .... . .. do . ... C'onnectlcut ........................................ . 25 Soo., 2d cl. ..... . \pr. 21 ... do .•.. New York ..... . ................................... . 26 A. 8 ............ llay 1 ... do ......... do .......... Great Lakes ..................... . 27 A. 8 ............ Apr. 23 ... do ••.• Connecticut ... ....... do . . ........ Measles ....... .. 2R A. 8 ............ Apr. 21 ... do ...... ... do ............................ ;··--............. . 20 PYt ............ May 13 ... do .... Ut.ah ............ Great Lekes .... Measles ........ . ~ ~~l:·.~.~~:::: ~:;: ~ :::::::~:: :~~'t:,;a:::::::: ::::::::::::::::::::::::::::::::::::: 32 A. 8 ............ May 6 ............................ Norlolk ......... ' :Measles ........ . 33 Sea., 2d cl...... May 1 Solace.. . • .. .. . .. . . .. .. .. .. Greet Lakes ....• 34 Sea., 2d cl ...... Apr. 17 ... do ........................... do ......... . 36 A. 8 ............ May 10 ... do.... Delaware ............ do .. ....... . 36 Sea;; 2d cl...... May 21 ... do.... Florida .............. do ••.•.•.... 37 A.:; ............ Moy 16 ............................ Norlolk ....... .. 38 Sea;; 2d cl...... May 4 8016<'8... Baltimore ........................ . 30 A.:; ............ Apr. 27 .•• do •... Connecticut ...................... . 40 A. S ............ May 16 ............................ Norfolk .•.•••... · ................. . llrat c. c. bar given Date of I No. I Lum· 1 Senim puno- with· puno- In tore. drawn. tures. c. o. 1017. Apr. 28 May 11 May 8 May 6 May 6 May 12 Apr. 21 Apr. 24 May 7 Apr. 27 May 8 Apr. 23 Apr. 17 May 6 May O May 4 Apr. 27 Apr. 23 Apr. 16 May 4 May 16 Apr. 24 Apr. 23 Apr. 25 Apr. 18 Apr. 28 Apr. 23 Apr. 21 Kay 12 Mar. 26 May 1 May 6 Apr. 28 Apr. 17 May 6 May 12 May 16 1 May 2 Apr. 25 May 16 245 60 56 105 ~ 240 110 70 246 640 125 220 lQO 160 205 106 136 260 250 116 05 236 253 170 270 320 300 350 :m 245 308 309 356 210 370 300 225 110 125 176 8 1 21 6 10 5 3 3 6 20 4 6 6 4 6 6 5 6 7 4 3 7 8 4 7 7 7 16 6 7 7 8 8 6 7 8 6 3 4 4 125 30 115 60 165 60 60 20 90 300 76 100 140 30 60 90 75 35 105 110 40 110 110 85 120 175 95 90 70 110 00 70 1115 00 120 185 flO 76 70 30 Complications. Died (day orl Re. dis- co very. cue). 8 2 6 13 6 6 Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. · .Aitiiiiii;::::::::::::: :· · · · · · · · · Yes. Yes. Yes. Orchltls . ..•....•••.... , ........ Yes. ·p-n,;·oi>iii&1iDiiiS::::::: :::::::: ~=: .. ...... Yes. .. ...... Yes. ........ Yes. . ....... Yes. . ............................... Yes. ................................ Yes. .. .............................. Yes. ................................ Yes. Malaria....... ........ •• . • . . • . Yes. ................................ Yes. Mea~les ....................... Yes. Mumps ...................... . Yes. ................................ Yee. Otltls media .................. Yes. .................. .............. Yes. .................. .............. Yes. Ery!lpelas ............ 1 ........ Yes. ................................ Yes. ~ f" ~ 0 ~ fll C1l 0) c.o Analysts of 11! cases of ccrebro-spinal mc11i1igftiR-Contlnued. Rate. Date or admU. slon. Via hospital ship. Name or ship. Training camp. Followed other dlseaaea. --- 1 I 1----1 1- - ----- 1917. 41 Soo.:1 2d cl...... May 6 . . • . . . . . . . . . . . . . . . . . . . . . . . . . Norro!k ......••• 42 A."'· ........... Apr. 27 Solace ... Arkansas •....... Great Lakes .•... 43 Sea,,., 2d cl..... . Apr. 24 • • •• • . • • •• Mlchlgnn ...•.•..... .......•.•..••. 44 A. "'·........... Mny 19 . . • . . . . . . . Connecticut . ........ .........•.•• ·1 ·. -........ ·. -... . 45 A. S . ........... Mar. 16 ...•.................•...... Norfolk ......•.. Maasles .. ..•...• 46 A. S .. ..••...... Apr. 23 ..•....... 47 A. S ...........•... do.... Solace ... 48 A. S............ lilly 4 ... do •..• 49 A.$ .......... .. Apr. 30 oo ~-A., 3d cl.... May 6 51 A. S ....•....... May 9 52 Sea., 2d cl.. . . . . A pr. 24 53 Sea., 2d cl. . . . . . May 1 54 Sea., 2d cl...... Apr. 27 6/i A. S ...........• Mny 20 M Sea., 2d cl.. .... May 16 67 II. A., 2d cl..... May 6 68 A.S .......... . . Mny 26 69 A. S ..••...•..•• May 1 00 A. S ............ Mny 21 . . . . . . . • . • Prometheus ..... Solace .. Nebrnska •..•... .......... Montana .•..............••.•.. .••• ..•.....•.•.•..•............ Norfolk •.. .....•.................. Solace... Arkansas..... ... . . . • . . . • . . . . . . . .. . Mumps .•.... ... Solace ...•.... do...... .... . Groot Lakes..... Measles •........ Alabama • . •.•.. .•... do ..... ...................... . 61 A. S .........•.• Apr. 28 62 A. S ...•...•...• ?.fay 6 63 1:1ea, 2d cl....... May 281 Solace .•. 64 F, 2d cl.. ....... June 1 ... do . .. . Delaware .•.•..•.•... do ...•...•.. Mumps •......•. W~onsin ............•....•....•.. .•.•......... ..... Michigan ........ Newport ............•............. 6S A. S ............ May 29 66 A. S ............ lfoy 9 67 A. S...... ...... May 29 OS A. S. ........ . .. June 14 69 A. S .•.........• 70 A.S ........... . 71 A.$ ........... . 72 A.$ ....•....... 73 A.$ ........... . June 16 June 4 Mny 28 May 1 June 3 Norfolk ....•.•.• Mumps ••••.•... ..... do ..••....•............•...... . .•. . do .••.....•• Measles ........ . ..... do .•••...... Lobar p nou· monla. Orchitls ..•.... . Measles ....•...• 74 A. S .••.• ••....• 75 A. S ....... •. . .• ~~ ~ns~~~~::::::: 78 A. S ........... . 79 ~Sea ,2d cl.. .... . June I Solace .•. Seattle .......... Newport ....... . ~~~ ~, - - --- -i- May 29 ............................ Norfolk ......••. June 6 1 •••••••••• Kentucky •...••• ! ..... do •...••.•.•••••.•••.••.••....• May 26 ••••••••••••••••••••••••••••••••• do ••.•..•••• Dato or llrst punc- ture. 1917. May 6 Apr. 26 Apr. 24 May 18 Mar. 16 Apr. 23 No. I Lum-1 Berum c. c. bar gt von with· unc- In drawn. f urcs. o. o. <'ompllcatlons. Died (day orj Ro- dis- covery. onse). 120 4 301························1········1 Yes. 135 4 80 Orchltls............... . . • . . . . • Yes. 115 3 .•......•.....•••...•..••..•..••••.•..•• Yes. 120 8 76 Pleur. ac. fib........ . . . . . . . . . . Yes. ········ ········ -···-·· 60 1 30 ······-· ········ 60 1 30 110 8 100 ··-· ········ ........ ························ 2 .... ········ ····-··· ························ 8 .... ............... ............ ..... ........................ 10 iii)" . i.i~iciici .. ac". .• "(s;;pp:. 1 Apr. 13 5 76 ········ Yes. arth.) May 21 423 12 160 .......................... ........ YM. May 9 310 6 100 Mumps .... ...•.•..... ........ Yes. May 6 325 8 40 .......................... Yes. May 26 330 7 60 ························ ........ Yes. May 1 290 6 95 .................... ~ ...... ........... Yes. May 26 258 8 30 ......................... ········ Yes. ~r. 28 3:0 9 2.'.i Bronchitis Ill' ••••• ••• •• ........ Yes. ay 13 269 9 00 .............................. ........ Yes. May 25 496 12 123 ························ ......... Yes. May 29 596 14 155 . .... ....................... .......... Yes. May 27 411 13 .......... ........................... . ....... Yes. May 9 900 30 200 .......................... ......... Yes. June 9 380 9 140 .......................... ......... Yes . June 14 255 5 110 ........................... ········ Yes . June 16 160 3 60 ························ ········ Yes. June-13 300 7 200 D . pan opthalmltls .... ········ Yes. May 2ll 376 10 45 ........................ Yes. Apr. 28 610 17 2[,Q Mumps .. ....•....•... ········ Yes. June 3 435 11 105 ......................... Yes. June 1 327 11 85 · ii8i&;1;1:::: :.: : : : : : : : : : ····t·· Yes. May 24 40~ 12 0 Yes. May 28 1 416 10 135 ......................... ........ Yes. May 29 210 7 0 ············· ··•········ . .......... Yes. May 26 435 10 136 . .............................. ........... Yes. 1une 6 480 11 100 ••••••••• •••••• •• ••••••• . ........ Yes. C11 -l 0 ~ ~ ~ ~ r.l !le6, 2d cl ••••••• May 21 Solace •.• :-lortb Dakota •.. Great Lakee . •. •• ••.• ••••.•.•.•••. . May 17 81 See ••••••••••••• June 1 . • • •• • •••• Florida .••.•..•....•....••.••.•••• Measles •...••••• June 2 112 A. S ..••..•••.. . May 6 Solace •••. \rkansas ••••.••. Great Lake., .••.•....••• ...•.. ••.•. May 6 83 A. 8 .••.••••• •. • June 4 . •••••.••. . . ... . ..••.•••.. Norfolk .. .•••• .•.••. . ••• .•.• .••... June 4 84 F, 3d cl.. . . ..... June 18 Solace .•. Mkhlgan .••..... ...•....••••.•... . Mumps •..•..•.• June 24 86 Sea. 2d cl. ..•... June 26 . •. do • ••• Arizona .•••••... . ..•.•. .•.••••...• ••••••••• . •.••••.• 1une 16 86 A. s ............ July 1 .....•..........•...•...•.. Norrolk ....••. · ..•........ ..•..•... July 1 87 Sea, 2d cl.. ..... June 30 .••• •• . ••. Rhode Island .•. Newport . .•.• ••. Mumps ••....... June 30 88 Soo, 2d cl....... June 26 Sollll'e... 'ifornda......... • . . • . . . . . • . • . . . . . . • • • . . • . • . • . • • • . . . . June 21 89 Sea, 2d cl.. ........ do ....... do ••.. Michigan ........ Newport .......•.•.•.....•........ June 7 00 W. '!' •.•.....•.••.. do •... .•• do .•.. Wvomlng ......• Nortolk . . •....•................. . • June 14 01 Sea, 2d cl.. . . ... June 15 .......... Utah .•...................•...•......•........•...... June 16 02 Soo, 2d cl. ...... June 26 Solace ..• Vosl111..... .. .•.. Groat Lakes .•..................... June 4 ~~ l:~~- 0 !::::::::: ·j;S~·-5· :::~~:.-.:: -~~~:::::::::::: -~~~~~~::::::::: :::::::::::::::::: ·i;;~·T 95 y_,3dcL . ...... June 14 Solace .•. Nevada ..•..•... Utah ..•••.•...•. Mea,les •...•.... June 23 96 lll.. M., 2d cl. ••. July 4 •• •••••.••.. ••• do •..•..•... Norfolk ....... .• Mumps •........ July 4 725 140 895 400 030 6.'15 3-'lO 500 425 476 470 170 195 405 2:IO 566 240 17 7 21 12 19 19 g 12 12 10 10 7 7 10 8 20 7 ra \::::::::::::::::::::::::·:::::::: 156 ••••••••••••· •· ••••••··. ••• ••• •• 2ro ··•···•·•·••·•·•·•·••••· ·••••·•• ml:::::::::::::::::::::::::::::::: 160 .• ·• ··· ·•·•••· •·•· ..•..• ····••·• 140 ••·•••••••·••·••••••·••· ·••• ••·· 30 •••·•••••··•••·••··••••· ·••••••• 195 60 00 00 00 285 100 26 4 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 Sea, 2d cl.. ..... June 26 .•........ :Y:lcblgan .....•.. Newport •.•. ..••.•... .•........... June 26 670 I 12 136 . . . . . . . .. •. .. .. • . ..••... 11 F,3dcl.. .. ..... July 6 ............................ Norrolk ......... Mumps ••.•••••. July 11 140 6 100 . . .............•....• . ..•...... 1~ I~~~~~~~~~~~~ .~L~. ~~~~~~~~~ ~ ~~~:;~~~~ ~~~~~~~~~~~~~~~~~~ ~~~~~~~~~~~~~~~~~~ t~~~?: ::::~~: :::::~~: ::::~~: ~~~~~~~~~~~~~~~~~~~~~~~~ if ~. 3 ~c1·~i::::::: ·i;~~-2i· :::::::::: .~:.~~~~::::::: ·:Norrouc::::::::: :::::::::::::::::: ·iw;ti·2i· ····295· ······5· · ·· ··so · : :::::: :::: :: :::::: : : :: :··-- -~~- ......... . . . . . . . . May 21 . • . • . . . . . . Minnc.,ota....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 :f !~~······· ~ ~ ·l~j::: ·~········ :~~f •••• •ti~!••·······~~·~:'.····~·,•····~· ····~·1•~;,;~~UJl:·:::·.: ::::::: N. B ... Jn case.<1 where data is missing, death had occurred and all papers heen !orwnrdod to bureau before the writers assumed charge. YGll. Yes. Yes. Yes. Y8s. Yes. Ye~. Yes. Yes. Yllll. Yes. Yllll. Ye.,. Yes. Yes. Ye.,. Yos. Ye.1. Yes. '.I. ? !'" ~ 0 ~ 01 ~ '""' 572 REPORTS. Vol XI. SPINAL IRRIGATIONS IN EPIDEMIC MENINGITIS. By J. J. O'liALLEY, PaRRed Assistant Surgeon, United States Navy. In treating patients with meningitis during the recent epidemic in the fleet the idea of irrigating the spinal canal with normal salt solution was suggested by the rngue which irrigations of pm; caYities ha,·e reached in the present European war, and from an ac- quaintance with the original observation of Flexner 1 that salt solu- tion is toxic to the meningococcus. Experiments by Shearer 2 showed that the action of sodium chloride is most toxic when the conce'ntration of the salt is not much below 0.85 per cent or above 0.9 per cent and that freshly isolated menin- gococci were more yulnerable than older cultures, the former sel<lom resisting its action longer than 20 minutes, while the latter might remain nable for two or more hours. In our experience with four different 24-hour cultures, emulsion'S in 0.85 salt solution failed to show a growth after 25 minutes ex- posure. In meningitis an increase in the quantity of spinal fluid is present in most cases, with pus cells, meningococci and products of bacterial invasion in varying quantities. Whatever properties the spinal fluid may have normally as a serum in preventing the infection from occurring, as it must do in an epidemic of meningitis where carriers are so frequent, certainly after its resistant properties ham been re- duced or destroyed and infection has taken place, the fluid becomes an excellent culture medium. In our laboratory we used fluid obtained from patients as one of our media on an agar-dextrose base and found that the meningococci were more prolific on it than on human blood, horse serum, or horse blood on the agar-dextrose base. The growth appeared about the same time on all our media, but after its appearance it grew much faster on the spinal fluid medium. That this infected fluid should be entirely removed by irrig:1tion and drainage, leaving the canal clean for the injection of seruu, is the strongest argument for irrigation. :N" ormal salt solution is the irrigating fluid of choice because of its toxicity to the meningi- coccus and its nonirritating qualities on the cord and membranes. In doing the irrigations normal salt solution (38-40 C.) is used and kept at the required temperature in a container. A graduated burette, holding about 100 mils, with a hose attachment and a nozzle to fit the lumbar puncture needle and a medicine graduate to measure the return fl.ow is all the apparatus needed. 1 Flexner: Jour. Ex. Ml'd., 1907, 9, 10:>. •Shearer: Lancet, London, Noyemt>er, 1916. !\o. 4. REPORTS. 573 Lumbar puncture is made low down between the fourth and fifth lumbar vetebrre, with the idea of using the lower part of the canal as a reservoir. The head of the bed is elernted and the canal drained of all fluid that will return. ~.\s the fluid is generally under pressure, the quantity obtained can not Le used as an index for the amount of salt solution in irrigating or the quantity of serum to be injected afterwards. In one of our cases we obtained 96 mils of fluid and could use only 56 mils of salt solution in irrigating, and in only a few instances could we irrigate with a quantity equal to that ob- tained in drainage. The irrigating fluid or the serum should never be put into the canal in quantities to cause pressure symptoms. For complete drainage and proper irrigations the position of the patient is very important and provisions should be made for lower- ing the upper part of the body while fluid is going in and elevating it while draining. Dlocks inserted under the legs of the bed will answer this purpose very well. When primary drainage of spinal fluid is complete the burette is filled and the nozzle inserted into the needle, the burette being held on a plane slightly higher than the needle and from 15 to 20 mils of salt solution are allowed to flow in slowly. The solution is immediately allowed to return, measuring it with the graduate to insure a full return of the solution. The irrigations are repeated at least three times to clean out the lower portions of the canal, or, as sometimes happens, the spinal fluid is quite thick with pus cells arnl flows very slowly through the needle, and a few prelimi- nary irrigations will tend to dilute this and allow it to drain more freely. Then "·ith the hips elernted the solution is allo,Yed to flow in until the capacity of the canal is reached. The nozzle is detached, the stylet in~rted into the needle, and the solution allowed to re- main in the canal for 20 minutes to allow for diffusion of the liquid and for its toxic effect npon the organism. The irrigations are repeated until the return flow has become clear or until it is much clearer than the fluid obtained from the puncture. The capacity of the canal is judged by the pressure symptoms dem- onstrated by the patient, and these are always referred to the sacral region, hips and lower extremities. 'Then the solution starts to flow in there will be tingling sensations about the thighs and legs or there may be complaints of warmth at the site of injection. Twitch- ing of the superficial muscles about the buttocks and thighs may be seen, and as the canal fills there will be sensation of fullness in the bladder and rectum, with pains about the hips and thighs and usually shooting pains down the legs. \Then these pains become quite severe the flow is stopped and a few mils are allowed to return to avoid any pressure. The quantity used is noted, and this will be 574 REPORTS. Yol. XI. the guide for the next irrigation and also for the amount of serum that can be injected. Experience with irrigations will quickly acquaint one with the amount of solution to be used, and neither the salt solution nor the serum should be allowed to remain in the canal under such pressure us to cause discomfort. The capacity of the canal will rnry in different indh-iduals. The largest quantity we used was 56 mils; the least 26 mils. The average capacity in 15 patients who were irrigated a total of 78 times was 32 mils. If the fluid obtained from the puncture is very cloudy, it is quite impossible to get it to return entirely clear, even with a number of irrigations; but if it contains only a moderat{I amount of pus, then persistence in irrigation will produce a clear return flow. In two patients the spinal fluid was so thick that the flow wa:; Yery slow through the needle and in each case a second puncture was made between the second and third vertebrre. The salt solution was allowed to flow in slowly through the lower needle and, by diluting the fluid, the drainage was much faster through the upper needle. As drainage is the slow process in irrigation, the use of two needles is a timesaver. The principal objection is the fact that it requires two punctures in patients who in the early stages of the disease are hypersensitive and complain very ~t.rongly oI a procedure that involves any pain; and as they have to be punctured seYeral times during their illness and have considerable tenderness in the tissues surrounding the puncture, it is hardly justifiable in every case to make two punctures at each operation just to save time. There were 51 patients in our series, and before they were trans- ferred to the base hospital ashore lumbar puncture was performed 211 times, and in each case the canal was drained of all the fluid that would return. Of the 51 patients the last 15 were irrigated and completely drained 78 times, and in not one instance in the entire series was there an untoward symptom associated with the drainage or the irrigation. Following up the patients to the termination of their illness, it was found that in the 36 cases of the series who were treated by drainage and injection of serum there were 12 deaths, a mortality rate of 33 per cent. In the 15 patients who were drained, irrigated and injected with serum there were 2 deaths, a mortality of 13 per cent. Besides this marked decrease in the death rate, the irrigated cases were more comfortable, rested better and suffered less from headache and other symptoms of the disease. No. 4. REPORTS. 575 SANITARY WORK AT CAPE HAITIEN, HAITI. By R. B. IIBXBY, Passed Assistant Surgeon, United States Navy. On the arrival of the United States forces in Haiti in August, 1915, the country was found in a. most deplorable condition. The city of Cape Haitien, on the north coast of the Republic, a place of about 30,000 inhabitants, was typical of the other towns through- out the country. Abounding in ill-smelling filth, its streets littered with decomposing refuse and the broken-down gutters widening at intervals into little pools covered with a green scum and swimming with mosquito larvre and water bugs, the town was an object lesson in the futility of negro management. Passed Assistant Surgeon J. R. Phelps, of the U.S. S. Connecticut, was detailed as sanitary or public health officer on September 1, 1915, and given full charge of all matters pertaining to this position. His first work was to organize a much-needed street-cleaning force and, securing the services of a foreman of the long-defunct street-cleaning department as native manager, an English-speaking negro boy as interpreter and a native clerk as timekeeper, together with a force of about 60 laborers, divided into half a dozen gangs under subfore- men, he started out to clean the city. A few carts with mules were obtained, and before long a marked change in the appearance of the streets took place. The writer relieved Dr. Phelps on October 1, continuing, in addition, the duties of regimental surgeon and Dr. Phelps returned to his ship after having accomplished much in the short space of one month. It soon became evident that the street-cleaning force required con- siderable augmentation in order to bring the town to anything like an American standard of cleanliness. Eventually the main body consisted of 8 street gangs, each with 1 foreman, 12 sweepers, and 3 shovel men with wheelbarrows. In addition, there was a mule-cart gang equipped with 8 carts and with brooms and shovels, who carted to various dumps the refuse collected by the street gangs. Part of this was burned in an incinerator which had been constructed by Dr. Phelps. A dozen men with machetes and rakes were placed in a number of public squares or small parks to keep these places in order. Most of the streets were paved with large cobblestones, which would catch all sorts of dirt in the interspaces, making them par- ticularly difficult to clean; and as the people live largely on fruit and sugar cane, the skins and leavings from these foods would be thrown about everywhere and, falling between the stones, would soon rot in the heat, attracting great swarms of flies, the sugar cane being espe- cially attractive to them. To meet this difficulty 120 boxes 3 by 2 576 REPORTS. Vol.XI. by 2 feet, with handles for carrying like a sedan chair, were placed in convenient places about the city and two dozen men were employed emptying these as they were filled up. Another gang was kept busy in cleaning about 20 concrete canals which emptied into the bay and drained nearly all the gutters of the city. Vacant lots scattered about the town had been used as dump- ing grounds for refuse from the neighborhood, and these were cleaned up and, in some instances, fenced in and wooden refuse boxes placed close by. Special sanitary guards had to be stationed at a. number of the largest of these places to prevent their immediately being used for the same purpose. A difficulty encountered at first was in the distribution of street areas to be cleaned daily by the various gangs. In the beginning the chief foreman laid out the work and the names of the streets cleaned each day were reported to the public health officer the follow- ing morning, but this system did not work well. Mitny of the streets were infrequently cleaned and the men were evidently shirking. A competitive system was then tried. a bonus being paid to the foremen whose gangs cleaned not less than a selected minimum of blocks each day during the whole week and, while this was an improvement over the older arrangement, the plan was still not satisfactory. Con- stant watching was required to prevent foremen from claiming they had cleaned more blocks than was really the case. The next arrange- ment tried proved entirely satisfactory and solved the problem. The city was divided into sections and each gang given a section and required to clean from end to end every street in that section running north and south on one day and every one running east and west on the following day, thus insuring that all the streets and the whole city were cleaned each two days. The main street, a long and wide thor- oughfare, was given to one gang and cleaned throughout its length e•ery day. An extra gang, called the" utility gang," was maintained to handle special jobs coming up all the time. The streets in Cape Haitien ha•e long and cumbersome names, such as Rue des Trois Chandeliers, Rue de la Marmousette, and the like, sometimes changing their names once or twice as they come to different sections of the town. This caused difficulty and delay in giving instructions as to localities, and so the streets were given new designations, those paralleling the water front being lettered, and those at right angles to the lettered streets numbered. The letters and numbers were painted . on all eight walls of houses on every corner in the city and, as the place is laid out with great regularity, matters were much simplified. Instead of saying, "The corner of Rue de la Providence and Rue du Petit Diable," one simply said, "p 21." No.L REPORTS. 577 The condition of the paving in different portions of the city had become so bad from years of neglect that to prevent the continuance of stagnant mosquito-breeding pools in the principal streets it became necessary to rebuild many portions of the latter. At first this was done by simply relaying the cobblestone paving, retaining the central gutter characteristic of the place (instead of two side gutters as with us), but later the paving was replaced by crowned streets of a sort of macadam ha "ring cemented side gutter:-:. Street, road and culvert construction was gradually taken up in different parts of the city and later extended into the outlying country for 8 or 10 miles. The work outside the city limits was carried on directly by Captain W.W. Low, United States Marine Corps, public works officer, until relieved by the writer in May, 1916. The engineering features were supervised by Mr. Charles Martin, a Haitian engineer in the employ of the department of public works. The street work in the city was for several months carried on by the department of public health but, as fund requirements demanded its transfer to that of public works, the public health officer was appointed assistant public works officer (and subsequently public works officer) and the work continued under public works without change of organization or personnel. There is no sewerage system in Cape Haitien and only the better classes have privies, the poorer people passing their evacuations on the water front, in vacant lots, in the near-by ravine and especially in spaces overgrown with vegetation and affording some measure of privacy, though this is by no means deemed essential. The result was that many foul-smelling places likely to become sources of dis- ease existed close to inhabited districts. The vegetation in these places was cut down and burned and the grounds cleaned and, in order to provide for the wants of the population, several wooden privies with corrugated iron roofs were built over the water and two in the town over concrete vaults. At first these were provided with seats after the customary fashion, but these were soon in such con- dition that no one would sit on them and they were replaced by little compartments, 3 by 3 feet, in which the central plank had been re- moved from the floor, leaving an opening 1 by 3 feet, over which the occupant squatted after the manner of the Japanese. The arrange- ment worked very well. The water supply of Cape Haitien is maintained by means of an excellent hydraulic system built by the French in the eighteenth cen- tury. This was thoroughly overhauled and put in first-class condi- tion by Captain Low and the daily supply of water, which is pure and wholesome, much increased thereby. The general health conditions about the town were excellent except for malaria and filariasis which 8551-17-10 578 BEl'ORTS. Vol. XI. flourished extensively on account of the swarms of mosquitoes. The breeding places of these pests were numerous and in a house-to-house inspection of premises many were found and destroyed. Great num- bers of large iron bowls 4 or 5 feet in diameter at the top, relics of ancient sugar mills, were standing in different places about the city generally filled with stagnant water containing larvre. These were turned bottom up by a sanitary squad sent around for the purpose. Handbills, in French, were printed and circulated, instructing the population with regard to steps necessary to maintain sanitary con- ditions, including the destruction of mosquito and fly breeding places. Close to the north end of the town was a space on the water front, about two city squares in extent, which was covered by a jungle of cactus and other vegetation. Pools alive with mosquito larvro were scattered about in different situations and cleared areas inside were used by the natives to pass th~ir discharges. Owing to its proximity to habitations, this locality was a distinct menace to the neighborhood, so a gang was put to work to cut down all vegetation; the ground was then graded, the pools filled in or drained and the land subse- quently raked and put in order. An ancient stone rampart several hundred yards in length was cleared out in this space and stone steps were built at the ends. Iron settees were procured from the United States and placed on the top and the whole area, which :formerly was very generally shunned, has since become a kind of public recreation ground where persons of all classes gather in the evening to walk about and enjoy the breeze and sunset. The main source of mosquitoes was a large pond situated on low- lying ground about a quarter of a mile north of the town in a dis- trict known as the Carenage. In order to abate this nuisance the public health department secured a mile or so of portable track and six steel dump cars and set about to fill the pond up, hauling dirt from different available hillsides during the process. The work re- quired about three months to complete and several thousand car· loads of dirt were thrown in the fill, successfully completing the ob- ject sought. In this job and the one mentioned immediately before it was necessary to employ some sort of drainage and for this pur- pose a number of trenches 2 to 3 feet deep were dug and filled with i:.tones, the surface being covered with small stones and pebbles. The plan worked satisfactorily, the trenches carrying off the water as it accumulated. Much of the land near the water front was infested with land crabs and, their holes becoming filled with water, they were prolific causes of mosquitoes. Various methods of combating them were tried but none with much success. There is a fairly large hospital, the Hospice J ustinien, run by French Catholic sisters, but there was no regular medical staff and ... Tullidge-War Injuries. I SHRAPNEL WOUND, FEMUR. T etanus developed. 30,000 units used. Recovered from tetanus. Amputation and recovery. (Russian prisoner.) 678-1 f '• 2,. , \ Tullidge-War Injuries. SH RAPNEL WOUND. ( Cl I 0: Compound comminuted fracture both bones leg, followed by infection of joint. (Russian front.) 678-2 ' Tullidge- War Injuries. GAS GANGRENE IN SHRAPNEL WOUND, ELBOW. 578-3 Tullidge-War Injuries. COMPOUND COMMINUTED FRACTURE OF TIBIA AND FIBULA, SHOWING SHRAPNEL I N TlSSUES. Recovery after removal of loose bone splinters and foreign bodies. (Russo-Austrian front.) 678-4 Tullidge-War Injuries. / FRACTURE OF LEFT PARIETAL BONE BY BULLET. (1895 RUSSIAN SHARP-POINTED AMMUNITION.) Extensive fracture. 678·6 SHRAPNEL WOUND. Two operations (trephlning). Survived 8 days. ments of bone driven into brain. Infection. Fine frag- Tullldge-W ar I njuries. SHRAPNEL WOUND. Fracture of last two lumbar vertebra;,. Paralysis of both lower limbs. Incontinence of fmces and urine. Ana;,sthesia. Wound cleaned of foreign bodies and bony spicules removed. When last seen was up and about, being taught to wal k again after two months dorsal decubitus In plaster. 578-6 !\o. 4. REPORTS. 579 only a meager surgicn1 equipment. A native physician was ap- pointed city physician under the department and his duties em- braced attendance at the hospice as well as on employees of the city injured in the course of their work. He was also employed by the gendarmerie and the prison, under their respective heads. A sum sufficient to purchase a general operating set, with a metal and glass case, was allotted for this institution and the articles were obtained from New York. Among other work handled by the public health department was the maintenance of the market, including scraping, red leading and painting the market building, an iron structure imported from France and covering four blocks. A minor work, but not without value, was that of repairing and painting the city band stand and cleaning out the surrounding square which had become oYergrown till the weeds stood about 'l feet high. Flowers and shrubs which were contributed by the sisters and other public-spirited persons were planted within. The port quarantine was under the public health officer, who ex- ercised a general supervision in the matter by authority of the dis- trict commander, Colonel Cole, United States Marine Corps. The ordinary routine business was handled by a native physician, Dr. Doucet, holding a Haitian Government appointment as port phy- sician. The Haitian quarantine regulations are excellent and ample. In July, 1916, there was a definite separation of the activities car- ried on under public health and public work, respectively, Dr. E. U. Reed, surgeon of the Second Regiment, taking the former, and Captain F. B. Garrett, United States Marine Corps, the latter. X-RAY PICTURES OF WAR INJURIES. By E. K. TULLIDGE, Assistant Surgeon, United States Navy. When the war broke out I was a postgraduate student in Vienna, and offered my services for the relief of the sick and wounded of the Austrian Army. During the short but interesting period of my connection with that org,anization I obtained many souvenirs of my service. The accompanying illustrations are of interest as show- ing the severe traumatism caused by shrapnel on the Russo-Austrian front and also as demonstrating the character of the work accom- plished with the portable field X-ray machine used in the Austrian service. The apparatus is transported on a horse-drawn vehicle and can be set up at the dressing station. 580 REPORTS. Vol. XI. CIVIL HOSPITALS AND OTHER AIDS TO THE 11.ECll.UITING SURGEON. By w. G. FARWELL, Surgeon, United States Navy, and E. W. GOt:Ln, Assistant Surgeon, United States Naval Re~erve Force. In the four months following the declaration of war recruiting was extremely acti,·e, 10,848 men h3ving been examined at the New York recruiting office, and the class of applicants was far abo•e the average in quality as well as in numbers. Intensive recruiting neces- sitated a larger staff and the department assigned to duty at this station several members of the Medical Reserve Corps and Reserve Force. Fortunately these men were residents of New York and in close touch with many of the hospitals, dispensaries and research institutions of the city and one was a member of the mayor's com- mittee on national defense. It was realized that problems of diagnosis and treatment were constantly arising in connection with the examination of the recruits which made it advisable to have the expert opinions of specialists in order to pass more intelligently upon the physical and mental eligibility of applicants. Furthermore, many of these volunteers who were desirable except for minor defects such as hernia, vari- cocele, varicose veins, etc., welcomed opportunities to submit to oper- ation and thus make themselves acceptable. An appeal to the civilian hospitals and dispensaries met with a most enthusiastic response and unusual facilities for diagnosis and treatment were at once placed at our disposal. The Cornell Uni- versity :\fedical College and the New York Eye and Ear Infirmary and the University and Bellevue Medical College placed their dis- pensaries at the service of the recruiting station. They arranged to have all men sent by the Navy surgeons examined promptly and without charge and on request sent back sealed opinions as to diag- nosis and prognosis. They have been of great help in the diagnosis and treatment of mild disabilities of the ears and throat, of suspected trachoma and other diseases of the eye, of skin diseases and gonor- rhea and the medical clinic at Cornell has made a careful study with X-ray plates of all tuberculous suspects. Most valuable information and advice was derived from consulta- tion hours held at our statio1~ by the eminent specialists, Dr. Col- man W'. Cutler, oculist, and Dr. Bryson Delavan, laryngologist. Dr. A. S. Knight, the medical director of the Metropolitan Insurance Co., offered all the facilities of his excellent laboratory situated directly across the street from us. During the past four months Dr. Knight and his assistants have removed impacted cerumen from over 200 cases, thus allowing us to complete an examination almo!d immediately which would otherwise be impossible, as neither the time nor the facilities for doing this work were present at this sta- No.<i. REPORTS. 581 tion. They have also made urine examinations upon all our candi- <lates for aviation. A very large number of applicants have required dental treat- ment. At first the urgent cases were treated by volunteer members of the Dental Preparedness League at Bellevue Hospital and later at their offices. More recently men requiring even a small amount of work have been sent to the New York College of Dentistry, where they have received splendid treatment at the hands of the students. The Dental Preparedness League has now furnished equipment and supplies so that a dental chair may soon be installed in our station, and hopes to furnish competent dentists so that we may have each day the benefit of their advice and may secure prompt treatment for the applicants. One of the most interesting branches of the work has been the special heart clinic conducted by Dr. Alfred E. Cohn and his as- sistants at the Rockefeller Institute for Medical Research. Since :May 1 almost all of the doubtful heart cases have been referred to him for X-ray and electrocardiographic examination and special exercise tests. In addition he has made a very careful physical ex- amination in each case. Practically no applicants with appreciable enlargement of the heart have been sent, so that the X-ray findings have been largely negative. Curiously enough, cardiac irregulari- ties have been extraordinarily rare, if one excludes the mild cases of sinus arrhythmia, which are of no importance. Among the appli- cants there have been, perhaps, a couple of dozen with an occasional premature systole and less than a half dozen with any marked irregu- larity. No cases of heart block, fibrillation, paroxysmal tachycardia, or pulsus alternans have been seen. For this reason the electro- cardiographic results have been largely negative also. The chief reliance has been placed upon clinical judgment and the use of the stethoscope, and in certain cases the use of the naked ear. Within one week two cases appeared, both presenting well-marked diastolic murmurs heard clearly with the ear but absolutely inaudible with the four different types of stetho~cope used at the station. Every heart that is overacting or at all enlarged should be examined with the naked ear to detect this important and elusive murmur. The rnlue of a special cardiac clinic c.:tn not be o>erestimated as a means of raising the standard of cardiac examinations. It is always a matter of keen interest to see if one can in a necessarily hasty examination grasp the essential features of the case. The New York, Harlem and Bellevue Hospitals have received and, without charge, operated upon many of our applicants who have since been accepted and enlisted. St. Luke's Hospital generously opened a ward of 30 beds and placed it entirely at the disposal of the recruit- ing surgeons. Since May 21 they have operated upon 72 cases and 582 REPORTS. Vol.XI. of these 35 have since been accepted and 22 have already enlisted. The United States army and British recruiting surgeons are now l also sendi.ng many defective cases to this military ward. The con- -valescence of these operative cases frequently becomes a difficult social problem, but most valuable assistance has been received from the Burke Foundation, a convalescent home located in the suburbs, where many of these men were most comfortably housed, fed and entertained for periods of two or three weeks. In order that we might have a convenient and accurate record of these cases which have been referred to various hospitals, a card catalogue system has been instituted and is being maintained by the mayor's committee on national defense, who have kindly fur- 11ished the services of a competent civilian clerk. A cross index under the heading of the defect or cause of rejection serves as a ready refer- ence. Entries are made on the name cards whenever the applicant 1·eturns to report or is accepted or enlisted. It was intended, further- more that, by means of these records, a" follow-up" system could be instituted by which we could, by civilian help, keep in personal touch with the recruits at the hospitals and during their convalescence. Their final return for acceptance and enlistment would thus be more easily insured. In this card catalogue were filed under proper head- ings the records of cases which were, after complete examination, found desirable except for defects which might later be remedied, such as underweight, undeveloped, underage, defective teeth and thus a list of excellent volunteer material exists from which we might later draw should the occasion arise. The custom of having all surgeons working together in the same quiet room has proved to be of great mutual advantage for, instead of causing interference and confusion, each surgeon ha~ benefited by frequent consultations with others and has thus personally ob- served the salient and interesting points noted in more than 6,000 cases. In all this work where the applicant is referred to civilian doctors the final decision in all cases rests with the Navy surgeon. Civilians can not understand service conditions, though their help is often invaluable. Whenever an applicant is sent out for treatment he is given a note made out on a special form and he is required to sign a statement releasing the Government from any financial or moral responsibility. Copies of these special forms and a picture of the military ward at St. Luke's Hospital are shown. 682 ...: en 0 Ct: < 3:: >- 0: < f- -' LL 0 I 0.. < Ct: 0 0 f- 0 I 0.. 11 No.!. REPORTS. I have been rejected for enlistment in the U. S. Navy on account of ----------------------------• und have been a<lvh;ed to have treatment for the ~ume in .order to enlist. I unde1·stand that the U. S. Navy a~~umes no re:;pon!':ibility for the results or expense and can not guarantee to enlist me unless found physically qualified in all respects. Signed, ---------------------------------------- "\Vitness,---------------------------------------- Date, ___________________ _ ------------------------------------------· an applicant for enlistment in the U. S. Navy, has been rejected on account of ------------------------------------------------------· and Is referred tO---------------------------~--- -----------------for Surgeon, U. S. N. (Kindly return this card in sealed envelope by applicant.) VENEREAL PROPHYLAXIS IN SANTO DOMINGO.' By P. E. GARRISON, Passed Assistant Surgeon, United States Nayy. 583 Every endeavor was made to secure faithful use of prophylactic measures against venereal infections. Prophylactic stations, in charge of a hospital steward or apprentice, were maintained at Fort Ozama, the Receptoria Camp and the field hospital. Every oppor- tnnity was taken to impress upon the men the necessity of taking prophylactic treatment early after exposure, if possible within one hour. It is believed that the results were as good as could have been expected without authority to inflict punishment for nonobservance of rules. Records for the last three months of 1916 show that from one- :fourth to one-half of the men took prophylactic treatment within one hour after exposure, the proportion varying in different organi- 1 Extract from Annual Sanitary Report, 1916, Field Hospital, Fourth Provilllonal Regi- ment Marines, Santiago, Dominican Republic. 584 REPORTS. Vol. XI. zations and different months. No case of ve;nereal disease developed from exposure when prophylaxis was taken within one hour. From one-fourth to one-third took prophylaxis during the second hour after exposure. Among these there occurred eight infections. The remainder managed to get their treatment from two to three hours after exposure, and these appeared to acquire as many infections as those who took no prophylaxis. The 'TO venereal infections acquired during October, November and December were distributed as follows with reference to the interval between exposure and prophylactic treatment: Time Interval. 1 hour ......•...•.•••....•••.•••••••••••••.•••••••••.•.••••.•.••.•.•••.•.•.•....••... 1 to 2 hours •.•..•.•••.•.•••••••••.••••..•.••••.............•.................•.•.... 2 to 5 hours ..•.•.••..••.•••••••..••••..••••••.••.••.•.••....•.•.•.•.•.....•....•.... ~ 1 ~o~b~taii8::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::: Total .•••.••••.... ••...•.•....•..•• : .•...••.••..............••••.•••.•••...... Number of cases. Percent. age of total number of cases. 0 0 8 11 14 20 Z1 39 21 30 70 100 Gonorrheal and chancroid infections were about equally prevalent. Many of the latter are undoubtedly mixed infections, 8 out of 35 having developed secondary symptoms by the last of December. ADDITIONAL BORDER-LINE CASES AT THE RECRUITING OFFICE. By W. G. FARWELL, Surgeon, United States Navy, and E. F. Du BOIS, Assistant Surgeon, United States Naval Reserve Force. In the preceding number of this BULLETIN one of the writers 1 has published a series of photographs of cases in which it was difficult to decide whether or not the applicant should be accepted. Through the generosity of the Russell Sage Institute of Pathology it has been possible to increase this series and make an extensive collection. From the large number of photographs available a few have been selected for this publication. Others are being used by the Army Medical Corps for the instruction of surgeons on recruiting duty. An effort has been made to gather the disabilities of a grade so mild that they are not usually photographed for publication. The text- books are full of pictures of marked cases, but these are the very ones that present no difficulties to the examining surgeon. These photographs were made with the cooperation of Assistant Surgeons W. S. Thomas, of the Medical Reserve Corps, and E. W. Gould, of the United States Naval Reserve Force. Our thanks are due to Mr. A. Tennyson Beals for his care and skill in making the photographs. 1 Farwell, W. G. Border-llne cases at the recruiting office. NAVAL MEDICAL BULLETIN, 1917, xi No. S. Farwell and Du Bois-Borderline Cases. NO. 35.-DEFORMED THORAX. Age, 19 years, 7 months; height, 69; weight, 133 pounds. Chest measure, 33 inches. Chest expansion 3)1 inches. General condition good. His color Is rather pasty but the hoomoglobin Is 85 per cent. Rejected on account of prominence of middle of sternum, which has been found to be a frequent cause of rejection at this station. 584-1 Farwell and Du Bois- Borderline Cases. NO. 41.- SCOLIOSIS. A&e, 19; hei&ht, 64; weight. 121 pounds. Chest measure 32~ Inches. Expansion, 2~ inches. H istory negative. General cond ition good. Rejected on account of marked curvature of spine. 584- 2 NO. SOB.-FLAT FEET. Shows one of the functional tests for flat feet In use at this office. Function is best tested by making candidate hop 70 yards on each foot. Accepted. NO. 47.-CLUBBED FINGERS. Age, 22; height, 68; weijl'.ht, 145 pounds. General condition excellent. Finger tips show marked clubbing. Faint systolic murmur at apex of heart believed to be functional. No cardiac enlargement. Lungs and bones normal. Rejected and referred to a clinic for further study, but did not report. Cause of clubbing could not be ascertained. Farwell and Du Bois-Borderline Cases. No. 53.- KNOCK-KNEES. No. 51.-SCOLIOSIS, KYPHOSIS, LORDOSIS. No. 53.-Age, 18years, 8 months; height, 67; weight, 119 pounds. General condition, aood. When knees are just touching, the feet are 2~ Inches apart. Unable to place Inner sides feet in contact without advancing one knee. Undesirable on account unmllltary attitude. Rejected. No. 51.-Ago, 30; holght, 66; weight, 135 poundo. General condition, good. Note tilting of pelvis. Rejected. 5 84-4 Farwell and Du Bois-Borderline Cases. 82 - No. 82.-0LD FRACTURE OF RIGHT CLAVICLE. Age, 27; height, 65; weight. 141 pounds. Chest measure, 36 Inches. Chest expansion, 3 inches. General condition, excel- lent. Right clavicle fractured while in Naval Service, 1915. Proper treatment was not available until fragments had already united In malposition. Operation, January, 1917. Discharged, March, 1917, by medical survey. Has worked as fireman; func- tion of arm perfect. X-ray showed bony union. Request tor waiver (accompanied by photographs). Accepted as fireman. Would not be acceptable as a marine as he might have diffi- culty carrying a rifle on his right shoulder. Farwell and Du Bois-Borderline Cases. No. 82.-0LD FRACTURE OF RIGHT CLAVICLE. No. 62.-SCOLIOSIS AND KYPHOSIS. No. 82.-Exerclsing to show normal power In deformed clavicle. 584-6 Farwell and Du Bois-Borderline Cases. NO. 83.-RETARDED SEXUAL DEVELOPMENT. NO. 62.-SCOLIOSIS AND KYPHOSIS. No. 83.-Age, 21; height, 64; weight, 122 pounds. Chest measure, 32. Chest expan- sion, 2)1. The genitalia were extremely small and the male secondary sexual char- acteristics were absent except that the voice was of masculine type. Rejected. No. 62.- Age, 17; height, 63; weight, 122 pounds. General condition falr. Showed marked lateral curvature of spine with tilting of pelvis. There was an apparent short- ening of the right leg and marked atrophy of the muscles. Rejected. 584-7 , Farwell and Du Bois-Borderl ine Cases. No. 91.-LARGE BIRTHMARK. Age, 21 ; height, 65; weight, 150 pounds. General condition, good. Whole right leg, thigh, and lower abdomen were bright red color. Cutaneous blood vessels were so distended that they wou ld bleed profu sely with slight abrasions. RIQ:ht leg was slight ly swollen. Extensive nevi are listed as special disqualifications in Circular for Physical Examination of Recruits. Re jected . 684-8 Borderline Cases. NO. 54.-H ARELIP. Age, 23; heli:ht, 66; wei~ht, 140 pounds. Th e deformity of the lip is a cause for reject ion in conformity with Article 2068, Cir- cular of Physical Examination for Recruits. 584-9 FOR THE HOSPITAL CORPS. At a time when economy is being indoctrinated, studied and in- creasingly practiced in all departments of business and in the home, it behooves every individual in the service of the Government to prac- tice economy in every way possible, not only in his private life, but in the performance of his official duties. There is a disposition on the part of most individuals in times of great stress and in acute emer- gencies to feel that it is unnecessary to consider expense, provided only the needs of the moment are promptly and adequately met. This is well illustrated on a small scale when an important accident case has to be treated on board ship or when there is a hurry call in a hospital for an urgent operation at some unusual hour. Disturb- ance of the usual routine leads to haste and confusion and as a result of commendable desire to help on the one hand, but, on the other, of defective training surgical dressings are wasted, bandages, towels, sheets are soiled unnecessarily, and various articles are injured or broken. Upon the advent of war the necessity always arises for a large expenditure of funds, and some waste of money is perhaps the unavoidable result of habitual unpreparedness. This fact, however, should not justify a given individual in wastefulness, but rather make it all the more incumbent upon him to save for the Government in every possible way. Here and there throughout the service are to be found medical officers who appreciate the necessity of economy in surgical dressings nnd who not only instruct the Hospital Corps in this matter but pains- takingly supervise the expenditure of supplies. This instruction and supervision sometimes provokes antagonism or excites ridicule, but such would not be the case if every nurse and every member of the Hospital Corps were made to feel that economy and care in the handling of surgical dressings is just as much an essential part of his qualifications as is a knowledge of bandaging, bed making, steril- ization, etc. At a time when the Nation is preparing to bend all its energies to carrying on a successful war the patriotism of members of the Hospital Corps should show itself by saving eYery possible penny for the Government. However generous appropriations may be, they are necessarily limited, and waste in any department to-day, even 1n trivial matters, may involve want in important ones to-morrow. 585 586 FOR THE HOSPITAL COBPS. Voi.:X:I. Here is a simple illustration of the way cotton, for example, is wasted every day in hospitals and aboard ship: The doctor is opening a sty or lancing a small boil. He wants to wipe away a minute drop of pus and, intent upon what he is doing, calls on the nurse for a little cotton. The nurse tears off from the roll a whole handful and hands it to the doctor, who removes and uses the small wisp which is all he requires. The rest can not well be put back on the roll and c;oon finds its way to the slop pail. A. Hospital Corpsman is told to dress a finger or toe presenting a minute and trifling scratch. Yery often, if not watched by the doctor, he will use for this purpose a sterilized gauze pad big enough to cover the entire hand and enough bandage to go halfway up the forearm. The chief pharmacist's mate or the surgical nurse himself should have the forethought to see that the dressing room where minor cases are treated is always well stocked with small-sized dressings for this class of cases. The importance of economy in surgical dressings is thoroughly ap- preciated in civilian institutions. For example, the superintendent of the Pennsy!Yania Hospital, Philadelphia, writing in the Modern Hospital for July about surgical dressings, says: We are realizing a saving of 65 per cent, an<l this, at the present time, means a han1lsomc sum every month. For instance, we uRe<l only 55,000 yarclR of gauze lai;t year, whereas, without reclaiming. 200,000 yai·ds would be a small estimate. In this institution it is found that having gauze examined, trimmed and prepared by the nurses seems to have many advantages over the method of having this work done by maids or by the laundry people. The soiled dressings are collected at the bedside, in low-priced, 20-pound, 'lutomatic paper bags, held in position by homemade frames. Immediately after the :-;urgical dressings are completed the bags are taken to the laundry. where the dressings are transferred to net bags and placed In cold water in the soak- ing tank. This water Is changed three or four times during the day. The fol- iowin~ morning the net bags containing the dressings are transferred to the sterilizing washer and wnRhed by the following process: 1. Two cold-water washes, without soap or alkali, for 10 minutes each. 2. Forty-five minutes' washing in hot water and soap solution. 3. Two rinsinp;s In hot water for 10 minutes each. 4. After a small amount of hot water Is placed in washer the cylinder ls run for 45 minutes under steam pressure of 12 pounds. After the dressings are put through the extractor they are taken, while r.ioii;t, to the gauze room, where they are stretched, trimmed, and prepared for final sterilization by the probation class of the training school under the class supervisor. Preparation and sterilization of dressings Is taught at same time. The class hour is sufficient. The trimmings, worn-out pieces and pieces of gauze bandages are saved until a considerable quantity has been coliected and are then sent away to be I•lcked and carded for absorbent cotton. The amount of gauze cotton thus &PCurecl nearly equals the amount of absorbent cotton required. Dressings properly washed are entirely aseptic before the final sterilization In the gauze room and, after final sterilization, could be used for any purpose, ~o.4. FOR THE HOSPITAL CORPS. 587 tiut n<1 a matter of convenience the new gauze Is first used In the operating r{l(l!llS. 'l'he dressings are first cut large and of uniform size, and as they become ~mailer, as a reRult of washing and trimming, they are placed in the next l-maller size. Four sizes are convenient for nearly all dressings. Where the gauze is to be reclaimed a cheaper quality than a heavy 24 by 28 count is not economical. ~luslin bandages are washed and ironed, but it does not seem practicable to iron gauze bandages; hence they are used as waste. Most manufacturers of cotton waste do carding; but if location makes this impracticable a picker may be purchased and the waste used without carding. While carding is very desirable, a carding machine is expensive. From the periodical quoted above we cull the following notice po::;ted in the New York Hospital for Ruptured and Crippled: "\\'AR Eco:rnY1Es. SUPPLIES OF ALL KINDS ABE COSTLY. DO NOT WASTE. 1. The good will and cooperation of the physlclnns and surgeons, both attend- ing and house, Is requested to bring about economic use of urugs, appliances and supplies. 2. Xurses and attendants will collect all gauze and bandages from ward dress- ing, operating rooms, and out-patient department In bags set for that purpose. 3. To whom It may concern: Do not use two pounds of plaster where one pountl only Is necessary. 4. Do not use an appliance or a surgical instrument except for the purpose for which it Is Intended. 5. Save the worn-out article or the broken In order to obt:1ln n new one on requisition. G. Do not light an electric lamp when not uece.--sary. To do otherwise Is wasting money. 7. All lights not actuall~· nec-essary must be extinguished b~· 9 p. m. ~- Do not use the printed blanks of the hospital for any other purpose than that for which they are designed. Illnnk forms cost money. 9. Oltl rubber is Yaluable. Don't throw any away. Keep rubber in a cool place. Don't allow any form of grease on rubber, as it causes it to rot. 10. Do not take the elevator to go up or down one or two flights of stairs. VmoIL P. Gm:-(EY, M. D .. Surgeon in Chief. Miss Catherine C. McGrath, chief surgical supel'\·isor, Grace Hos- pital, Detroit, writing in the same number of the Modern Hospital on "Economy in the cutting of surgical dressings,"' and the impor- tance of eliminating all waste by standardizing preparation of dre::;s- ings, and the need for practical training of pupil nurses and Red Cross aids, says: Training in the preparation of cotton surgical Rupplies and dre.<>sings shoultl begin with the pupil nurse, who at the start has little Idea of the cost of supplies or the economies of their preparation. It is therefore nece."'sary, first, to present to the pupil nurse a frank statement as to the cost of gauze, cotton, and other accessories that enter into common surgical dressings. The pupil !lhould learn that all waste ends and cuttings in the manufacture of dressings • 588 FOR THE HOSPITAL CORPS. have a vnlue. even though that value be represented by clean white mg,;, which are a marketable commodity. The next general prindple to be taught is to the effect that the cutting ot gauze for dressings, cornpre,,ses, sponges, etc., should be arrau~ed on definite geometrlcnl lines so as to fully a•old waste. The pupil should learn that fanciful dres,,ings and surgeons' hobbies In supplies should be dl!':coura~ed and that compresses, sponges, bandages and all dressing units should be fuily standardized and approved by the entire surgical staff. • • • It should be stated that the majority of these surgical units can be systematically washed and used again. It is the practice of this hospital to wash all gauze dressings and bandages and utilize the washed gauze after proper sterilization and culture for secondary dressings in the surgical depart- ment. ·This has been carried out here for 10 years and in many other large hospitals for a like period. It has been demonstrated that washed dressings ure softer in texture and more desirable for redressing wounds than unwashed mill gauze. The adoption of certain standard types of surgical dressings for ships and hospitals of the Navy is already under way. This will not preclude the employment by surgeons of dressings of special patterns preferred by them, but will greatly simplify the work of preparing dressings for routine cases and, as diagram and specifica- tions can be prepared so as to get the maximum yield from rolls of cotton and gauze of standard size, a marked saving should result. Here is a simple practical suggestion for the sick bay of a ship: Ha•e a muslin bag hanging near the dressing table and collect in it all the fairly clean odds and ends of cotton and gauze from the outer layers of dressings as they are removed from the patients. When the bag is full the contents can be sorted, some becoming available for resterilization, while the rest can be used for cleaning purposes and thrown away after use, for wiping up a drop of blood from the clean deck, for drying the leakage around steam pipes, etc. The usual practice is to use a towel, and when this article is em- ployed in the dispensary to wipe up the prescription counter it soon becomes unsightly with stains of silver nitrate, picric acid, etc. The Supply Depot is now prepared to furnish on requisition a sort of rough dish toweling to be used for such purposes in the dispensary instead of the regular high-grade, expensive towel. It will be issued in bolts, to be cut up into proper lengths and hemmed aboard ship. (ED.] CONSERVATION OF LINEN AND BLANKETS IN NAVAL HOSPITALS. By SARA B. MYllR, Chief Nurse, United States Navy. Recent experience in naval hospitals has shown that in order to prevent as far as possible wasteful destruction of linen, one person. preferably a member of the Nurse Corps (who by reason of possess- ing the woman's instinct for the careful use of household supplies. inherited from generations of housekeepers, is naturally better fitted No. 4. FOR THE HOSPITAL CORPS. 589 than a man for this duty), should have entire responsibility for all linen from the time it is received on requisition until it is con- demned and turned over to her to be torn up and issued for cleaning rags. She should have charge of the linen storeroom, keep an inventory, receive and store the new linen. Being familiar with the stock, she should recommend the items for each requisition in order that the hospital shall not run short of pillowcases, for instance, while dozens of extra spreads and nightshirts lie on the shelves year after year, being carelessly added to with each requisition, only to go to pieces from old age when finally issued for use. She should receive and pass upon all linen turned in for survey, list and store it for the board, mark and issue new in exchange. She should have full supervision of the laundry to insure that no destructive methods are in use there. In the laundry she will be able to observe the condition of linen from different parts of the hospital and run down various careless habits of destruction, i. e., articles put to uses never intended, wet linen stuffed into hampers and allowed to mildew instead of being dried, nightshirt sleeves cut instead of being slipped off, patients allowed to write on their beds and upset ink bottles, etc. She will also see that worn linen returning from the laundry is sent to the mending room and that the badly worn is turned in for survey instead of being used for rags and appearing minus at inventory time. She should keep the ward inventory books and count the linen in use at regular intervals. She will be able by word and example to teach those using linen the value of its conservation, and through constant care and interest the life of each article will be greatly prolonged. The provision of suitably constructed places for keeping soiled linen before sending to laundry, preferably a porch furnished with a wire hamper, also a drying cupboard for wet towels and sheets, which could be used as well to dry cleaning rags and swabs in bad weather, would fill a long-felt want and prevent much deterioration and waste. It is a question worthy of consideration whether the custom in naval hospitals of using condemned linen and blankets for cleaning rags does not off er too great a temptation to the willing cleaner (on occasions when rags may happen to be scarce and" inspection" very near) to tear up partly worn or even perfectly good articles. H it were possible to exchange the rags for a cheap substitute to be issued for cleaning, it might be found to eliminate one source of needless destruction.1 •Rough toweling for cleaning purposes is now procurable by r equisition on navnl medical supply depots. 590 FOR THE HOSPITAL CORPS. NEW ISSUES BY SUPPLY DEPOTS. In order t-0 avoid the possibility of error in interpreting the value of the various preparations which may be issued, it has been deemed advisable to adopt the following general (class) designations, which will appear on the labels of respecth'e containers in addition to the commercial or registered title: " Colloidal silyer "-to co,-er a elm<~ of preparation containing al>out 20 per cent silver. with chewlcal, bactericidal and clinical properties equlrnlent to those of argyrol. "Protein silYer "-to cover a class of preparation containing about 8 per rent silver. with chemicnl, bactericidal and clinical properties equil ale11t to tho,.:e of protargol. " Sulphonated oil "-to cover a class of organic sulphur compounds with a sul11hur combination and properties similar to Jchthyol. N"otwithstanding the relatively lower silver content (8 per cent) of protein silver, protein silver can not be used in solutions anywhere approximating the strength of those in which colloidal silver can be employed. This is readily understood when it is remembered that argyrol, which is of the colloidal silver type, is often employed in 25 per cent to 50 per cent solutions, while protargol, which is of the protein silver type, is probably seldom employed in solutions exceed- ing 3 per cent strength. Therefore any preparation issued by naval medical supply depots bearing a colloidal silver label is to be used in solutions of the same percentage strength as argyrol, likewise any preparation bearing a protein silver label is to be used in the same percentage strength solutions as protargol. Rough toweling for cleaning purposes, etc., will be issued in bolts. It will be torn into proper lengths and hemmed aboard ship. THE ROUGH FORM F CARD. By J. R. PHELPS, Passed Assistant Surgeon, United States Navy. Form F cards contain an important part of the data upon which vital statistics of the :N" avy are based. It is necessary that every itcn. called for on the face of the card be furnished as accurately as pos- sible. Each and every item is essential, but nothing should be entered on the face of the card except the information demanded by the in- structions for numbered lines, which instructions are printed in red on the back of the detachable card designated "Original." Upon disposal of the case, as soon as the proper indicator has been entered after "Disposition," on line 7, the card should be forwarded to the bureau at once. As a rule, it is practicable for all stations and ships in United States ports to forward cards the day they are released. ]S'o.4. FOR THE HOSPITAL CORPS. 591 It is remarkable that in spite of clear and definite instructions many cards are received with errors or omissions and in many cases with both. The name of the patient must be entered, surname first, with the Christian name in full. Frequently, where enlistment rec- ords or health records have not been available at the time, cards have been sent in with the line for the date and place of birth blank. Those items are particularly necessary for statistical purposes and, inasmuch as the man himself has furnished the information in the first place, it is suggested that it be obtained from him when the card is filled out instead of waiting for his health record. In filling line 5, "Diagnosis," the official nomenclature must be adhered to strictly. That is very generally realized and yet it is surprising to note the number of cards in which the diagnosis is misspelled and in which other terms have been used. A key letter must be given in the case of each and every injury. When the term "Diagnosis undeter- mined " is used in the case of an injury, the proper key letter should be given anyway. Frequently line 8 is overlooked. Whenever a patient is transferred as a patient, even though the diagnosis may be "No disease," there should be entered on line 8 the name of the hos- pital, dispensary, place, or ship to which he has been transferred. Line 9 is the continuation of line 8, and is to be used only when there is not sufficient space on line 8. It is not to be used as a convenience for the filing of notes at the place where the card is prepared, al- though there is no objection to making such notes," Typhoid prophy- laxis completed,"" Contagious influences," etc., separately on the re- tained duplicate copy after the original has been detached. If line 10 is not filled in properly it is difficult to trace the card. Several hundred cards are received each day and in order to file them it is necessary that each shall plainly indicate the ship, station, or hospital in which the card was prepared. In the bureau the cards are sorted and all of the data they contain is taken from them on separate punching-machine cards. The latter are sorted and tabulated by an accounting machine under the various classifications required for the preparation of the Surgeon General's report and for the compilation of various special statistical reports from time to time. Form F cards are also used each day as notifica- tion cards for communicable diseases. When a case of measles, for instance, is admitted to the sick list at a station or on board a vessel and is transferred to hospital the same day, if it happens to be on the Atlantic coast, in the ordinary course of events the card reaches the bureau the fol1owing day, and by means of an appropriately colored spotting pin on a map kept for the purpose the case is imme- diately recorded as being in the hospital to which it was transferred. For the purpose of keeping track of infective areas the case is also 592 FOB THE HOSPITAL CORPS. Vol. XI. charged to the vessel or station where admission to the sick list occurred. As a notice of communicable disease, the card is deficient in only one respect. A certain percentage of acute cases are sent to hospital with the diagnosis undetermined or with the diagnosis in error, as with German measles, when later it may be clear that the correct diagnosis is measles. When the diagnosis is changed by the hospital there is no line on the face of the card for a statement of the new diagnosis. In order to facilitate the work of the bureau, in all cases when the diagnosis is changed it is requested that a memorandum be made on the back of the card, typewriting across the red printed instructions, giving the new diagnosis and stating whether the change was made on account of error, complication, or intercurrent disease. For example, "Changed to measles on account of error." At the same time, because the new card will indicate the patient as received from the hospital or place where the diagnosis was changed, a memo- randum should be made on the back of the new card giving the former diagnosis and stating the name of the ship or station in which the infection was acquired, as taken from line 4 of the old card, so that eventually when the new card is received in the bureau both can be filed together without trouble. l J~DEX TO U~ITED STATES :L\AVAL MEDICAL BCLLETIN, VOLCME Xl. 1:-IDEX TO SUBJECTS. [.\ r tlclcs not appearing In full in the BULLETIN are marked (ab).] A Page. Abdomen, gunshot wounds of_ ____________________________ (ab) __ 3()5, 307, 400 Absce;,-s of liver, nmclJie __ ------- - -·-------------------------- (ab) __ 25U Abscess of lung _______________________________________________ (ab )__ 255 Absorbent cotton, tests for___________________________________________ 435 Abstract, syphilitic record____________________________________________ 358 Acicl, lactic, in treatment of corneal ulcer _______________________ (nh >-- 103 Aci<lo>;is _____ --· ------------------------------- ------------------ - 99 Addiction to <lrnp;s -------------- ------- ------- --- ------------------- 305 Addiction, narcotic _____ -------------------------------------------- 6-!, 305 Ailments, minor------------------------ ------------------------------ 527 .Air renewal on t he Balill:L------------------------------------------- 156 Ambler, J ames lllarkham, private journal oL_________________________ 183 Amebic abscess of liYer ________________________________________ (ah) __ 25!) Ammoni:1 in l!l"ine _____________________________________________ (ab)__ 101 Amebiasis, with constipation__________________________________________ 540 Amputation stumps---------------------- ------- --------------- (ah )__ :)53 Anaphylactic skin reaction to diphtheria bacilli_ _________________ (uh)__ 97 Anaphylaxis, ocular ____________________________________________ (ab) __ 266 Anesthesia , strych ni n-s to~a in ________ --·· _____ ----------------_________ 34 Angina, Yincent'S------ ---- - - ------------- ------- - ------------- (ab )__ 413 Animal parns ito l o~·, r eviews of literature on _____________________ !H, 260, 410 Apparatus for moving sick ______ -- ------- --- - ------------------------ 371 Appendicitis, chronic, Bastedo sign in ____________________________ (ah) __ 6!> Argyrol and Wrigbt"s solution in gonorrhea____________________________ 170 Arseniurette<l hydrop;en. poifi'oning by_________________________ 342 Arteriosclerosis, <·erehn I. dementia of_ __________________________ (>th >- - 74 Asphyxiation, gas_··---------------- ---- ----------- ------------- (ah) __ 388 Asthma, treatment of ____________________________________ _ ____ (ah)__ 5ii2 Atmospheric comlition:,:-effect upon res11iratory lrnct_ ___________ (ab)__ 8-! Kata-thermometer in ______________________________ ------ ___ (ab ) _ 85 Aviation, naval _____ --------------------- - - ------------------------- 273 B Bacilli- diphthel'ia, annph~·J actic skin reaction to ________________ (ah) __ 97 Tubercle, isolation of, from discharging ear _________________ (ab)__ 104 Bacteria-adaptation of, to tensions of oxygen __________________ (alJ) __ 04 In etiology of cholecystitis _________________________________ ( nh) __ 71 In milk destruction of. hy electricity ______________________ (ah) __ 255 Bacterial infection of fresh eggs _______________________________ (ab)__ 256 Bacteriology-general. pathological. and intei;tinaL ______________ (ab) __ 04 Of pemphip;us nconatorum __________________________________ (ab)__ 263 Of swimrninp; pools in 1\Ianila ______________________________ (ab )__ 83 Of the bubble fountain _____________________________________ (ab) __ 82 R eviews of literature on ------- ------ ---- -------------------- 94, 260, 410 Balilla, ventilation on________________________________________________ 156 Burinm-f ormn l i 11 <lisi nfcction_ ----------------------------------- 519 855:1- 17- 11 593 594 SUBJECT INDEX. Pap_ Bnrrncks, tempornry, Brooklyn. X. Y- -------------------------------- 479 Bnstedo sic:n in chronic appendicitis ____________________________ (ah)__ G9 Bnttleshlp in action_ - ----------------------------------------< ub >-- :!4U Bichlorid of mercur~· poisonin~------------------------------ --------- 226 Bile nnd cholera----------------------------------------------------- 411 Bleeding, limits oL-------------------------------------------------- 556 Bone tli:sense~. Hoent;.:en diac:no:<e;o; in _____________________ ------ (ab)__ 249 Border-line cnses in recruiting ______________________________________ 346, 584 Bones, suJ1Crn11mernrr in foot______________________ _ __________ (ah)__ 40-1 Botulism _________________________________________ ------------ (ab) __ 407 Box ratiou,; ust'<I by French troops _____________________________ (ab)__ 2:5.S Brcud, !ilalin~ oL------------------ ------ - ------------ -------- (ab>-- :!57 B ronchosroplt• trNllment -------- ------- ------------. --· _ __ (ah)__ '.2i0 Bubble fountuin, bncteriology oL------------------------------- (ab)__ 82 Building,; for Tropic;; ----------------------------------------------- - 425 Bullets, locutln~ by X r·tY-------------------------------------------- r).14 Burn!;, treatment of---------------------------------- - -------------- 338 Impermc:ihll' dre.,sings for________________________________________ ;-144 c. Canacno. improvements aL ------------------ ------------------------- 426 Cape Haitlcn, sanitary work aL-- - --------------------------- -------- 575 Cardiovnsculur renal problems---------------------------------------- 430 Cnrrell-Dukin, treatment-------- -------------------- ------ -- ----- __ &:iS Carrell method of wound sterilization _______________ ------- -----(ab)__ 253 Ca tu met. t•xtrnction oL------- - --------------------- ----------(ah)__ 266 Cati:ut, iodized______________________________________________________ 210 C<>rebro-s11Inal fever, pre,ent status oL________________________________ 504 C<>rehro-,;pinal fever. report of treatment of (112 ca~e.-;) _________________ :;r.3 Cerehro;minnl meulnc:itb; _____________________________________ (ab) __ 3G;>. 3Si Epidl'mle;;; of, in w111·--------------------------------------------- :i:il S\pinal lrri~tion;; in_____________________________________________ 572 Chemistry, reviews of literature on___________________________________ 99 Chloricls In body tluids-----------------------------------------(ab)__ 100 Chol eeystceto1n~·, indications and contraindications fpr ___________ (ab)__ !!:l~ Cholecystlti~, etiolo~· oL--------------------------------------< nh) __ 71 Cholera culture ancl hile _______________________________________ (ah l __ 411 Chol em, gnll-hlm\1ler infections in ______________________________ (ab)__ 261 Civil hospitals :ts aids to re1.:ruiting___________________________________ 580 Clinical notes ------------------------------------- ------------ :!:!3, 373, 58:> Clinicul thennomf'ters, cultures from ____________________________ ( :1b) __ 90 Co]() nml infl'ction -------------------------------------------- (ab)__ 410 Colon, i;iurirery of, in Intestinal stm:is---------------- ----------- (ah)__ 80 Color bllndnes'<, Jennings's tcsL----------------------------------- --- 334 Complcmcut-flxntion reaction on board ship___________________ ____ _ __ 15 Com11lement-1lxntion test for s~·philis------------------------ --- ------- 17;') Conclensc<l milk--- ------ - --- ---------------------------------- (ah)__ 40G Conjunctlvnl coverln~. value of in war __________________________ (ab>-- 10~ Cornrol ulcer treated with lactic acid ___________________________ (ab) __ 103 Cruz, Oswaldo-------------------------- - - --------------------------- ;:;~1 Cnltn, hookworm infedion in_____________________________________ ___ 00 Cyst, multllocular --------------------------------------------------- 54~ D. Deafness nnd 111M1l Infection><----------------- - ----------------< nb) _ :!69 Dl'tlcctcd Imllets, wounds from_______________________________________ 541 Dementla--eplll'plic - - -----------------------------------------(ab) __ 1.J In dementln paralytlcn ------------------------------------(ab)__ 73 01'. cerebral arteriosclerosis _________________________________ ( nb) __ 7 4 Pn rn lytlcu ________________________________________________ (ab)__ 75 Precox, i;tuclies ____________________________________________ (ah) __ ~41 Schlzophr1>nic__________________________________________ (ah)__ 76 Dental pntlents. "r"tem in lrnndlin~ oL________________________________ :i1;; Dermatitis 11n1l eczema _______________________________________ ( nh) __ 2.'H. ~3;1 Dermntltls from rnatche.~-------------------------------- ---- --- ---- :.40 De,1ecs, suggested------------------------------------------ r,1;, 2Hl, 371, ;:;33 SUBJECT INDEX. 595 Page. Diet and metabolism ___________________________________________ (ab)__ 388 Digestibility of Yery young veaL _______________________________ (ab>-- 89 Diphtheria bacilli, anaphylactic skin reaction to _________________ (ab)__ 97 Diphtheria toxiu in Schick tesL-------------------------------- (ab)__ 96 Disease, ear, in the service___________________________________________ 53 Disease---nasal sinus------------------------------------------(ab)__ 105 Weil's, in army in Flanders ________________________________ (ab)__ 93 Diseases incident to submarine dutY---------------------------------- 44 Mental and nervous, reviews of literature on __________________ 73, 241, 300 Diseases, ;enereal, prevention of______________________________________ 1 Disinfection-barium-formalin __________________________ r------------ 519 Of drinking water_ ________________________________________ (ab)__ 558 Of swimming pools---------------------------------------- (ab)__ 258 Dressings, surgical, economy in use of_________________________________ 585 Drug addiction------------------------------------------------------ 305 Drum membrane, trephining of _________________________________ (ab)__ 103 Duodenal indigestion in children ________________________________ (ab)__ 240 Duodenal ulcer, Sippy treatment of _____________________________ (ab)__ 236 Dysentery, gall-bladder infections in ____________________________ (ab)__ 261 Ear-disease in the service___________________________________________ 53 Reviews of literature on ____________________________________ 102, 266, 415 Eczema and dermatitis--------------------------------------- (ab) __ 234, 235 Eggs, bacterial infection oL-----------------------------------(ab) __ 256 Ehler's method in treatment of scabies __________________________ (ab)__ 233 Empyema, encapsulated ________________________________________ (ab)__ 255 Enucleation of tonsils, bloodless method oL _____________________ (ab)__ 104 Epidemic jaunuice in Europe----------------------------------------- 364 Epidemics in war, prevention of_ _______________________________ (ab)__ 551 Epidemiology of lobar pneumonia ______________________________ (ab)__ 231 Epidemiology of pertussis-------------------------------------- (ab)__ 69 Epileptic dementia-------------------------------------------- (ab)__ 75 Eustachian tube, obstruction of ________________________________ (ab)__ 267 Explosion of 6-pounder ________________________ :______________________ 224 Experimental surgical studies---------------------------------- (ab)__ 402 Exposure to cold anc1 infection _________________________________ (ab)__ 410 Eye---reviews of literature on ___________________________________ 10~, 266, 415 Testing case, simplified------------------------------------------ 533 Testing device--------------------------------------------------- 533 Femur, fractures of ___________________________________________ (ab)__ 78 Fcver-llemoglobinuric, quiniu in_____________________________________ 135 Trench ___________________________________________________ (nb)__ 02 Field hospital, Port au Prince, HaitL ____ .:_____________________________ 107 Field-operating theater, motor________________________________________ 535 Filtration planL----------------------------------------------------- 422 Fixation of thorax-------------------------------------------------- 220 Formalclehy<l fumigation ______________________________________ (ab) __ 80, 519 Form F card, rough-------------------------------------------------- 590 For the II0R1)ital Corps---------------------------------------·---- 435, 585 Fountain, bubble, bacteriology of _______________________________ (nb) __ 82 Fractures of the femur ________________________________________ (ab>-- 78 France, surgical observations in ______________ ·---------------- (ab)__ 393 Froin and ::\onne. ~vina l fluid syndromes 0L _____________________ (~1h >-- 243 Fumigation, formaldehyd-------------------------------------- (ab)__ 89 Functional neuroses------------------------------------------- (ab)__ 241 G. Gall hlad<ler infectious in typhoid, cholera, and dysentery ________ (ab)__ 261 Gallstones, etiology oL---------------------------------------- (ab)__ 71 GangTene, gas--------- ------------------------------------- (ah)__ 95 Garbage bin for battleships__________________________________________ 67 Gas asphyxiation --------------------------------------------- (ah)__ 388 Gas gangrene-------------------------------------------------(~>)__ 05 Gastric ulcP-r, Sippy treatment of _______________________________ (ab)__ 236 Gastric ulcer, treatment oL----------------------------------------- 58 Gastroenterostomy, mechanics of stomach after _________________ (ab)__ 251 SUBJECT INDEX. ~~1:~!: ~~dT~~~~~o================================:=========~====== ~Ialaria, quinin in __________________________________________________ _ Malal'ia, tnrtar emetic in ______________________________________ (ah) __ Malingering, psycholog~· oL ____________________________________ (ab) __ :Mare I sland, Yenereal conditions aL------------------------------- --- 1\Iarines in Santo Domingo __________________________________________ _ l\Iarines wounded in Santo Domingo _________________________________ _ ~latches causing dermatitis------------------------------------------- :'llaxillnr~· sinus _______________________________________________ (ab) __ liedical department at occupation of Santiago, Santo Domingo _________ _ liedical science,;, progre,:s in- 597 Page. 150 421 135 2GO 241 128 117 2!) 5-10 415 114 Chemistry ancl pharmaCY----------------------------------------- !)!) Eye, ear, nose, and throat_ _________________________________ 102, 2GG, 415 General medicine -------------------------------------- GO, 231. 385, 547 Hygien<> and sanitation _________________________________ 82, 255, 403, 038 Mental and nervous diseases _________________________________ 73, 241, 390 Pathology, bacteriology, and animal parasitology ______________ 94, 2GO, 410 Surgery ________________________________________________ 7G, 2·16, 393, 533 Tropical medicine ______________________________________________ 01, 259 ::\Iedicine-gcneml, reviews of literature on ___________________ GO, 231. 385, 547 Tropical, reviews of literature on ________________________________ !)l, 259 Megacolon, a ease oL------------------------------------------------ 223 l\Ielnnoma -------- ------------------------------------------ (ab)__ 411 Membrana t~·mpani, trephining oL _____________________________ (ab)__ 103 l\Ieningitls, acute syphilitic------------------------------------ (ab)__ 239 Mental diseases, reviews of literature on _________________________ 73, 241, 390 :'I font al h~·p:iene, un<lerl~·iug concepts in __________________________ (ab)__ 391 l\Iental tests for recruits--------------------------------------------- 325 l\Iercm·~·. bichloritl of, IJOisoning bY----------------------------------- 226 Metabolism and <lieL------------------------------------------ (ah)__ 388 liexico, the west eoast of, f<anitary notes on___________________________ 430 :\Iilita1·y organization, tuherculosis and________________________________ 430 lfilk-h:~eterial eounL _________________________________________ (ah)__ 409 Bacteria in, dcstrnction of, by electricity ___________________ (ah>-- 255 :'IIortalit)' of 011r pnhlic men ___________________________________ ( nb) __ 87 l\Iotor-operating fiel<l theater----------------------------------------- '>35 N. Nails in joint surfaces _________________________________________ (nh) __ 78 Narcotic ad<liction, pathology oL_____________________________________ G4 Nasal infections an<l deafness __________________________________ (ah)__ 260 Xasal sinus cliHease ___________________________________________ (ah)__ 105 Xasopharynµ:eal hemorrhage controL _____________________ ------ (ah) ·- 416 Nasophar:rn:::eal infections, relations to generaL _________________ (ab l-- 268 Naval aviation ------------------------------------------------------ 273 Naval district-medical organization oL _________________________ ---- 497 Training camp in________________________________________________ 470 Ka ml medical school laboratories______________________________ ·- 63, 437 N er,·es. peripheral, war injuries to _____________________________ (ah)__ 73 NerYom; tliseases, reviews of literature on ________________________ 73, 241, 300 Neuroses, functional ___________________________________________ (ah)__ 241 New issues from supply depot_ _____________________________________ 308, 500 Xonne nrnl Froin. :<11inai J!ui<l s~·mlromes oL ____________________ (ah)_. 243 No~e. reviews of li!Nuture on __________________________________ 102. 266, 415 Notc,;;-clinienl ------------------------------------------------ 22:3. :373. 539 Sanitary- From- Rr<'<>h·ing ship New York _________________________ ---- _ 130 U. ~- S. HnnnibaL______________________________________ 274 IT. S. S. Ne\Y York-------------------------------------- 133 U. S. S. Saratoga________________________________________ 125 On- Liberia ------------------------------------------------- 429 Ti1e west coast of Mexico________________________________ 430 598 SUBJECT INDEX. o. Pan. Oc·ul:1r ::rnaph)·luxi:< ----------------------------------------- __ (ab)__ 266 Operating theater field motor_________________________________________ 53.) Omentum. i::tudies and U!='es oL ______________________________ -------- 402 Operations In HaitL------------------------------------------------- 374 Organizntion-111C11ical, !='ixth nnval dbtrict________________________ ___ 4!>7 ~Illita~·-tuherculosil' nnd -------------------------- _ __ _____ 43!) Otltls me<lln-trephinin~ of <lrum membrane in _________________ (ab)__ 103 Tubercle bacilli Jn ______________________________________ __ (ah)__ 104 Oxygen-lntrnvascular injection oL__________________________________ 181 Pnrtinl tensions of, in culturing ____________________________ (ah)__ 94 P. Pnrafl1n treatment of burns------------------------------------------ 358 Para:sitolO.!Z3". animal, re,·iews of literature on _____________________ !>-!. 260. 410 Patlwlo;:ical <'Ollcction. Xaval ~Iedical SchooL ________________________ 65, 437 Patholo;r)·-of nar<"otir addiction _____________________________________ G4. 305 ReYlew:s of literature on ____________________________________ 04. 260, 410 Patients-f'n>hilitic duty to_______________________________________ ___ 3:i5 Trnn,;fcr of------ ----------------------------------------------- 3G2 Pedkulosls, pre,·ention oL-------··--------~------------------- (ab)__ 560 Pemphi~'Us neonatorum, bacteriology oL ________________________ (ab)__ 263 Perli!cbe ------------------------------------------------------ (ab)__ 551 Person::lit~·-unemplo~·ment nnd ------------------------------- ( nh) __ 302 Pertussis. epi<lemioloi!)" oL ____________________________________ rah)__ G9 Pharmney reYlew,.; of literature on___________________________________ 9!) Pneumonla--epille111iolol?)· of ____ ------------------------------ I ah)__ 231 Prevention oL_ ---------------------------------------- --(ab>-- 548 Polsonin:!-hy hkblorl1l of mercury----------------------------------- :.!:.!() .\rsenluretted hydro~en ------------------------------------------ 342 Poliomyelitis, acute epitlemic. etiology oL ______________________ (ah)__ 263 Pool«, swlnunin~. 11islnfection oL_ ·----------------------------- (ab)__ 25.S Port nu PrlnC'e. llnitl. fiel1l hospital at________________________________ 107 Prevention of venereal di<:enses______________________________________ 1 l'roditis, gonorrheal_----------------------------------------------- 22S Pro;!I'cs,.; In medical srience!='. (See ~fedical sciences.) Prophylactic sern In Turki,;:h Army___________________________________ 271 Protein for maintenance _______________________________________ ( nh) __ 4-0S Prilritus nni, treatment of ______________________________________ (ab)__ 237 P,.;ycholo:..')· of malln~ering _____________________________________ (ah)__ 241 PsyclV>P:l thic lnhor:itory of the ~Iunicipal Court of Cbicn~o ______ t ah)__ 244 Public men. mortality of our ___________________________________ (:ib) __ 87 Q. Quinin and ninlnria__________________________________________________ 1'50 Qulnin in mnlarln and hemoglobinuric fever___________________________ 135 R. Ration. Italian XaYY------------------------------------------ (ab)__ 560 Rations, box, used hy French troops ____________________________ ( nh) __ 2;-13 Heaction-the complement fixation on board shiP---------------------- U Recelvlni:: ship Xew York, sanitary notes from____________________ ____ 130 Recor<l-the s~·phili<:_ ________________________________________________ 21 Recrniting'-llor<ll'r line. cases in ____________________________________ 346, fiS-1 Civil hnspltnls :1 ·· nids in_________________________________________ i1SO Greater cnre in__________________________________________________ 318 Recruits at Xewport. R. !_------------------------------------------- 421 HeJectio11 . •f----------------------------------------------------- 427 Recruits, meIJtal tests for____________________________________________ 325 Rejection of recruits _______________________________________________ ·- 427 Renal i::l~· co,.;uriu ---------------------------------------------- ( nlJ) __ 236 Reports------------------------------------------------ - - - 107.271.41!>,5G3 Re,.;plratory t1:nct. atmospheric influences on ____________________ ( nh) __ 84 Reviews of lit<'rature. (See :\Iedicnl sciences; Sanitation.) noentg-en dln~noses in bone diseases _____________ --------- ____ (ab) __ 249 SUBJECT INDEX. s. Sanatorium. naval, Las Animas, ('oJo _________________________ _ Sanitary notes- From- Receiving ship New York-----------------------~------_ U. S. S. HannibaL __________________________________________ _ U. S. S. New York _____________________________________ . U. S. S. Saratoga ______________________________________ _ On- 599 Page. 120 130 274 133 125 Liberia ----------------------------------------------- _ __ _ 429 The west coast of l\lexico______________________________ __ _ 430 Sanitary work, Cape Hatien _____________________________________ ----- !i75 Sanitation, reviews of literature on __________________________ 8~. 2r>5, ·l05, 558 Santo Domingo, marines wounded in drive on_________________________ 29 Santiago, Santo Domingo, occupation oL______________________ ___ 114 Santo Domingo, with marines in__________________ _ ________ --· __ __ 117 Scabies cured by Ehler's method------------------------------- (ab)__ 233 Schick test, diptberia toxin in ________________ ---------------- (ah) _ 96 Schizophrenic dementia --------------------------------------- (all)__ 76 Screws in joint surfaces _________________________ ------------- (ah) ·- 78 S!'ra, Pl'OJlhylactic, in Turkish ArmY--------------------------·--------- 271 Serum, use of, in tetanus _____________________________________ (ab) _ 385 In cPrebro-spinnl menin.~itis ________________________________ (ab)--. 387 S<'rum therapy, locaL----------------------------------------- (ab)__ 232 Shark bite, Canacao BaY-------------------------------------------- !i39 Shell shock, etiolO!!:Y oL _______________________________________ (ab)__ 2-!2 Ship, rccei\•iug, :New York, sanitary notes from_______________________ 130 Shock, shell, etiology oL-------------------------------------- (ab)__ 242 Sippy treatment of gastric and duodenal ulcer __________________ (nh) __ 236 Six-pounder explosion -------------------------------------------··--- 224 Skin lesions, X-ray treatment oL------------------------------------ 373 Slop chute for battleships____________________________________________ 67 Soda, p;yuocardate of, in leprosy _______________________________ (ah)__ 91 Sphenoid sinus ________________________________________________ (ah)__ 417 Spinal anesthesia____________________________________________________ 34 Spinal fluid syndromes of Nonne and Froin ____________________ (ab)__ 243 Spirocheta ictero-hemorrha.~ica in rats-------------------------- (ah)__ 410 Spirochetosis ictero-hemonhagica ------------------------------(ab)__ 93 Staling of hread _______________________________________________ (ah)__ 257 Stasis, Intestinal, surgery of colon in ___________________________ (ab>-- 80 Station, naval, Norfolk, venereal diseases at__________________________ 1 Stomach, mechanics of after p;astroeuterostomy _________________ (ab)__ 251 Stovaln and stryclmin in spinul anesthesia___________________________ 34 Streptococci-in water supplies-------------------------------- (ab)__ 86 Specificity of---------·------------------------------------ (ab)__ 98 Streptococcus-dassification -----------------------------------(ab)__ 414 Lesions, study of ----------------------------------------- (ab)__ 265 Stl"ychnin-stovain spinal anesthesia__________________________________ 34 Submucous resection followed by ·septic arthritis ________________ (ab)__ 416 Submarines, poisoning on ·board of___________________________________ 342 Ventilation on___________________________________________________ 156 Submarine duty, diseases incident to_________________________________ 44 Sugar in urine------------------------------------------------(nb) __ 101 Suggested devices------------------------------------------ 66, 219, 371, 533 Supernumerary bones of foot---------------------------------- (ab>-- 404 Supply tlepot, Navy MeclicaL_________________________________________ 337 Supply depots, new issues bY----------------------------------------- 500 Surgery, reviews of literature on ____________________________ 76, 246. 393, 553 Surgical dressings, economy in_______________________________________ f>85 Surgical observations in France------------------------------- (ab)__ 393 Surgical studies, experimentaL _________________________________ (ab)__ 402 Sm;pcmdon laryngoSCOPY--------------------------------------- (ab)__ 269 Swimming pools-bacteriology oL------------------------------ (ab>-- 83 Disinfection of------------------------------------------- (ab)__ 258 Syphilis, complement-fixation test for_________________________________ 175 Syphills record----------------------------------------------------- 15.358 600 SlIBJECT INDEX. Page Syphilitks-(lut~· to-------------------------------·-------------- :r;;; Abstract --------------------------------------------------- --- 3~8 RN·ord of____________________________________ ---------- -- 3::;s Syphilitic meningitis, acute__________________________________ (:.h) __ :!:\!) T. Tampico, malaria in--------------------------------------------- 4::!1 Tartar emetic in malaria ______________________________________ (ab)__ 260 Test-complement-fixation. for srphifo;________________________________ 115 Schick, diphtheria toxin in --------------------- ---------- (ab)__ 96 \Vassermnnn, more general ·u"'c oL_____________________________ __ 177 Tests for absorbent cotton _____________________________ ----- --------- 435 Testing-vision ----------------------------------------------------- 53:: Devices for ------------------------------------------------- ---- ;;:~3 Tetanus :rn<l antitoxin _________________________________________ ( nh) _ 3S:i 'l'hcrmometers, clinical, cultures from _________________________ (ah)__ !}O Thermometer, kata -------------------------------------------<ah)__ S:i Thoraeotomy, exvloratory --------------------------------. - (ah)__ 253 Thorax, fixation of------·--------------------------------------_ ---- 220 Throat, reviewR of literature 01i_ __________________________ • - --- 102, 266, 41ii Tonsillar infections, relations to genemL _______________________ ( :i b) __ 2GS Tonsils, bloodless enucleation oL _______________________________ (ab)__ 104 Toxin, diphtheria, in Schick test_ ______________________________ (ah)__ 9G Trachoma, specific treatment for_ ___________________________ . (ab)__ 103 Training camp, second naval district__________________________________ 47!i Transfers from shiJ)s ___________ ------------------ • 36'.! Trench fever------------------------------------------------- ( :ih) __ 9'.! Trephiniug of drum membrane _________________________________ ( nh) __ 103 Tropical medicine, reviews of literature on ___________________________ m. 25!l Trtl(leau. B. L. (historical sketch)____________________________ 349 Tr.vpnnosowinsis. chemotherapy of experimentaL _______________ (ah)__ 264 Tubercle bacilli, isolntion of, from discharging ear ______________ (ah)__ 104 TuherC'ulosis-aml military organization______________________________ 439 And military preparation___________________________________ ____ !i4'i In Xa vy ------------------------------------------------ -------- 289 And l)·mphoi!l tissue ______________________________________ (ah) 41:? Latent --------------------------------------------------<ah l __ ;;47 Navnl sanatorium for-------------------------------------------- 120 Turkish Army, 1n·onhylactic sera in___________________________________ 271 Typhoi1l, r:nl 1-hln<ldN infections in _____________________________ ( n h) __ 261 Trentment b)' stock vaccines_________________________ __ (ah l __ 262 Wi<lal's reaction for--------·------------------------------- (ah) __ 260 Typhus viru:>. ·------------------------------------------ ( :ih) __ 414 "C". Ulc!'r-<:orneal, treated with lactic acid____________________ _ • (ah) __ rn:i Gastric. tre:1 tment oL___________________________________________ 58 • _Ga~~ri<' and <lno<lenal, Sippy treatment of______________ .(ah)__ 23G l 11Clll:ll'laf::IS --------------- ----------------------------------------- 3SO l-nclPrlrin1t <'Olll't'Jlts in mental hy~iene _____ --------------- _ _ _ 391 rnemployment ancl per:::onalit~·-------------------------------- ( :ih) __ :m2 Uri<· aci<I, solrnnt power of urine _______________________________ (ah) _ 101 rrine-nmmonia in--------------------------------------· ---- (ah)__ 101 Rugar in------------------------------------------------- (:: b) __ 101 Fri;; a cl cl, solvent power oL ___ ----------------------- --- l nil)__ 101 rrotropin. solvent properties of, in urine _________ _______________ (ah)__ 101 r. H. S. Haunibal-snnitary notes from_______________________________ 274 Jeannette, loss of the-------------------------------------------- 183 Maine, sanitary notes from_______________________________________ 130 N<'w York, Ranitary notes from _______________________ ------------ 133 ~arntoga, sanitary notes from------------------------------------ 125 v. Vaccination --------------------------------------------------<ab)__ 40:1 Vaccines, Rtock, in treatment of typhoid______________________ _ ( nh) __ 262 Veal, digestibility of very young _______________________________ (ab) __ 89 SUBJECT INDEX. 601 Venereal conditions at- Page. Mare Island------------------------------------------- ---------- 128 :N'orfolk_________________________________________________________ 1 Venereal diseases, prevent ion of-______________________________________ 1 Venereal prophylaxis _______________ ---------------------------------- 428 In Santo Domingo_______________________________________________ 583 Ventilation on the submarine Balllla__________________________________ 156 Vincent's angina- ---------- ------··-- -------------------------- (ab) __ 413 Virgin I slands, impressions oL--------------------------- -------- - - - - 465 Vision-testing deYice----------------------------------------------- - 533 W. W ar injuries, :X ra~·,,; oL_____________________________________________ 579 Warfare, intelligence in _____________ -- ------------------------------- 283 Wassermann test. moi:e general use oL________________________________ 177 Water, filtt-ation plant_______________________________________________ 422 Water supplies, streptococci in _________________________________ (ab>-- 86 Weil's disease in l<'landen;_ ___________________________________ (ab) __ 93 West coast of Mexico, sanitary notes on_______________________________ 430 Widal's reaction for typhoid ___________________________________ (ab) __ 260 Wounded mar ines during the drive on Santiago, Santo Domingo________ 29 Wound sterilization. Cnrrel method oL __________________________ (ab)__ 253 Wounds-gunshot, iodin vapors in treatment oL _________________ (ab)__ 247 Magnesium sulphate in t reatment of_ _______________________ (ab) __ 248 Wright's solu tion in gonorrhea________________________________________ 179 X, Y, Z. X -ruy for f'kin k•i.,H:< - ------- -------- ---------------- ------------- 373 Locating bullets br- - - --------------- ---------- ----- --------- - - - - 544 X-rays of war in.iurics- - - --- --- ----- --------------------------------- 679 INDEX TO AUTHORS. (Articles not appearing in run in the Bt:LLETIX are marked (ab).] :\(lier, H. )I_ ___________ (ah) _ Alfred. A. R _________________ _ .\lien. D. G------------------- Andrewi::. C. F __________ (ah) __ Ai::hurst, .\.. P. C ________ (11hL_ Auld, A. a _____________ (ah) __ l'nge. :m2 426 4:.':l 40::? 2:t:i ;);)2 Pase. Copeman, A. )L ________ (ab)__ 551 Cords. R ---------------(ab)__ 102 Cottle, G. F ------------------ 21, 273 Cowie, D. :\L ___________ (ab)-- 96 Craiir. C. B _____________ (ab)__ 73 Crandall, R. p ______________ 337, 519 Bal<lwin. E. R __________ (ah)__ ;-147 Ores,;, W. "'----------------- 15, 228 Barber. G. H ________________ 120, 280 Crowe. S. J _____________ (ab)__ 268 Barber. R ---------------- --- :i 1.1 Cunnninir. H. S---------------- 5Q.1 BarthCllOw. p ___________ (ah)-- 4041 Dakin, H. D ____________ (ab)__ 558 Bell. W. H____________________ 67 Depping, C. W ---------------- 223 Belli. C. ){_ ____________ (ah)__ fi()O Dick;:Cln, E. a ___________ (ab)__ 407 Benton. F. L__________________ 114 Dobell, a _______________ (ab)__ 2..'19 I~crnheiln, B. :\! _________ (ah)__ 5:lG Don, A_ ________________ ( nb) __ 400 Bishop, L. F ------------ (ab)__ 3SS D1·a1wo. C. H------------------ 179 Blake. F. G _____________ (au)__ 414 DrummonrL II __________ (ab)__ 397 Bloeuorn. w. A _____________ 30:i, :;41 Dn Boi". E. F ----------------- 584 Bloomhnrdt. S. L _______ (ah)__ 402 Dunham. E. K __________ (ab)-- r;;-,g Bogart. F. B ___________ (ab) __ 82. 406 Dwyer, J. G ____________ (nb) __ 104 Bo!!~><. R H------------ (ah)__ 240 Eaton. W. E------------------ 540 Bonnema, A. ,L _________ (ah)__ 102 Espach, W. 0----------------- 421 Bowman, F. H___________ __ _ __ 141 Este;:. W. L ____________ (ab>-- 78 Dram;:. W. ,\._ ________________ :>s, 220 Falls. P. H _____________ (nb >-- 263 Bro1i;:tein. B ____________ f ah)__ :!30 Farenholt. A------------------ 318 nrmrn. E. W -------- 90, 3 :i, 400-410 : Farrar, C. B ____________ (ab)__ 76 Brown, )I. A ___________ (ah)__ 2:l0 I Farwell. W. G ___________ 346, 580, 584 Rntler, C. S------------------- 46:) Fi!:her, !_ ______________ (ab)__ 87 Caldwell. D. W--------- (nb) __ 2:>6 Fiske, C. X _____________ 128, 447, 551 Cal Yer, G. W ------------------ 407 Foote. J ________________ (ab>-- 240 Camerer, C. B _____________ _ 221. 430 Fox, 0---------------------- 547, 552 Campbell, C. )L ________ (ab)__ 7:t Fraser. J_ ______________ (ab)__ 397 Campbell, H. c __________ (ab)__ 400 Gabel, C. E _____________ (ab)__ 83 Carpenter, D. N _____________ 421, 475 Garrison, P. E---------------- 583 Cecil. R. L ______________ ( nb) __ 265 Gatewood, J. D---------------- 183 Chantemesse, • .\.. ________ (ab)__ 261 Giorcl:mo. :\I------------------ 342 Chnrle,;, S. F. A ________ (ah)__ 305 Godclnrd, H. H________________ 283 Chm<seynnt_ ____________ (ab)__ 388 Gouhl, E. "'------------------ 580 Cark, G. F ______ 177, 385, 413, 414. 415 Graham, l\I. p ___________ (ab)__ 236 Clark. P. F ____________ (ab)-- 82, 406 Grimherir. A ____________ (ab)__ 261 Cocks. G. H-----------(ab) __ 84, 104 Grow. E. J_ _________________ 102, 266 Gile, R _________________ (ab)__ 548 Gunn, J. A _____________ (ab)__ 560 «'oles. A. c _____________ (nb)__ !!GO Guthrie, D ______________ (ub)__ 2..'12 CoJ~·er. J. F ____________ (ab)__ 76 Guttman, J_ ____________ (ab>-- 103 Conklin, F. L_________________ '343 HucllPy. P. B ____________ (ab)__ 256 003 604 AUTHOR INDEX. Ilnlrnnssou. E. G-------------- IIanes, F. l\L ___________ (ab)-- Ilnre, H. A-------------------- Hnrgra ve, "\V. W -------------- Hnselberg, A ____________ (ab) __ Haskins, H. D __________ (ab) __ Heimann, W. J _________ (ab) __ Hemici, A. T ___________ (ab) __ Page. 465 243 459 274 103 101 235 98 Pai:e. :\Iartin. D. D. _____ ------------ ;;03 :\lather>:, G _____________ (ab)__ ~63 :\Ian rel, E ______________ (ab)__ 23S :\kDowell, R W --------------- 44 :\IcFle, R. B ____________ (ab)__ 3!l:; :\IcKimitry, W. H _______ (ab)__ 413 :\IcLean, A. D_________________ 13:; :\IcLean, F. a ___________ (ab)__ 100 Henry, R. B ________________ 533, 575 "\lcl\1ullin, J. J. A ___ 181, 380, 540, 544 Herrman _______________ (ab)__ 103 :Melhorn, K. Q_________________ 117 Hetherington, R. R____________ 402 l\Ien<lel, L. B ___________ (ab)__ 403 Hirlen, :M. B------------------ 428 Michael, W. H_________________ 150 Hill, H. W ______________ (ab)-- 405 Miller, J. A ____________ (ab) __ 84,410 Hoch, A ________________ (ab>-- 74 ~\Iiller, J. F------------------- 563 Ilolmes, A. D ___________ (ab)-- 89 :\!orison, A. E ___________ (ab)__ 248 Ilolmes, B ______________ (ab) __ 241 :\loshage, E. L __________ (ab)__ 97 Huff, E. p _______________ 34, 224, 271 l\Iurphy, J. B ___________ (ab)__ 412 Huggins, G. N __________ (ab)__ 553 :\Iurpby, J. T ___________ (ab)__ 251 Ilurst, A. F ------------(ab)__ 92 :\lj·er, S. B __________________ 175, 588 Ide, C. E--------------- (ab)__ 267 ~ngasaki, S ------------ (ab)__ 101 Imperatori, C. J ________ (ab)__ 416 Natale, ]] _______________ (ab)__ 232 Ionnescu, T------------------- 34 ~ichols , H. J -----------(ab)__ 261 ,Jacobson, J. IL ________ (ab) __ .J um;en, R ____________________ _ Johnnesco, T _________________ _ 2f:il 479 34 .Johnson, L. W ----------------- 223 .Tolles, A ________________ ( nb) __ 100 .Judd, c. c. w __________ (ab)__ 411 Kutz, J. R ______________ (nb) __ 257 K<>ndall, A. !_ __________ (ah)__ 94 Kennedy. C. :\L _________ (ab)__ 395 Kleh>;, A. 0-------------------- 439 Klien berg, S------------ (ab) __ 404 Knapp, A -------------- (ab)__ 266 Knowles, F. Q __________ (ab) __ 234 Kolmer, J. A __________ (ab)__ 97, 264 K~·Ie. J. J ______________ (ah) _ 103 Lnng, R. :\L ____________ (nh) _ 99 L:mg,Yorthy, C. F ------- (nb) __ 89 Laning, R. II---- 94, 385, 411, 412, 413 Leishman, W. B ________ (ab) -- 385 J.ewis, F. Q _____________ (ab)__ 255 Lockwood, A. L _________ (ab)__ 395 Low. G. Q ______________ (ab)__ 259 Lowenstein, ]] __________ (ab) -- 103 Lumsden, T ------------ (ab)__ 241 Luttinger, P ------------(ab)__ 69 Lynch, R. Q ____________ (nb) __ 269 l\IacCurdy, J. T _________ (ab)__ 75 l\Innheimer, W. A _______ (ab)-- 258 :\1ann, A. J_ ____________ (ab)__ 78 Mann, W. L----------------- 425. 543 l\1a rantonio, R_________________ 156 ~oble, W. Q ____________ (ab)__ 410 Noguchi, H _____________ (ab)__ 410 ~Oland, L ______________ (ab)__ 253 Ochsner, A. J ___________ (ab)__ 80 Oliver, W. W ___________ (ab)__ 94 Osborne, T. B ___________ (ab)__ 408 Olitsky, P. K ___________ (ab)__ 414 O'l\!alley, J. J _________________ 57!! Pnrk, W. H _____________ (ab)__ 406 Peck, A. E-------------------- 410 Penfold, E. A ___________ (ab)__ 246 Pettibone, D. F -------- (ab) __ 82, 406 Phelps, J. R___________________ 590 Prioleau, P. F ----------------- 539 Pryor, J. Q ______________ 547, 548, 551 Pugh, W. S------------------- 470 Rnlziss, G. D ___________ (ab)-- 264 Ramsey, W. B __________ (ab)__ 90 Randall, J. A --------------- 385, 390 Read, w. J _____________ (ab)__ 8G Richnrtls. T. W---------------- 130 Ridpath. R. F ----------(ab)__ 270 Riggs, C. E-- ----------------- 1 Risley, E. H ____________ (ab)__ 253 Robb, A. Q _____________ (ab)__ 387 Rollinson, l\f. M_______________ 219 RogerR, L ______________ (ab) __ 91, 260 Rosenbloom, J __________ (ab)__ GO Rosenow, E. Q __________ (ab)__ 71 Ruge, 0. G-------------------- 99 Hothholz, A. S __________ (ab)-- AUTHOR INDEX. 60& p~ ft~ Ryder, C. E___________________ 422 Syme, W. S------ -------(ab)__ 269 Ryle, J. A ______________ (ab) __ 93 Tallman, l\f. H __________ (ab) - - 252 Savage, W. Q ___________ (ab) __ 86 Tanganelli, E ___________ (ab)__ 233 Scharnberg, J. F ________ (at/)-- 264 Taylor , IJ'. E ____________ (ab)__ 413 Schier, A. R___________________ 325 Taylor, H. D ___________ (ab)__ 412 Schoberg, H. M _________ (ab)__ 90 Ta~·Jor, J. s _________________ . 156, 371 ScbObl, 0 ______________ (ab) __ 411 Taylor, K ______________ (ab)__ 95 Schroeder, M. c ________ (ab) __ 406 Thomas, W. s_________________ 533 Shi1tert, H. Q_________________ 133 Torrance, R. A________________ 141 Skillern, R. H __________ (ab) __ 417 Tousey, S-- ------------------- 544 Smallman, H. B ________ (ab)__ 385 Trible. G. B___________________ 53, Smith, A. L _____________ (ab)__ 551 102, 266, 334, 385, 415, 416, 417, 418 Smith. E. T _____________ (ab) __ 104 Tullidge, E. K ______________ 535, 579 Soiland, A------------- --- ---- 373 Tulloch, w. J ___________ (ab) __ 248 Solomon, H. Q __________ (ab)__ 390 Vnn Slyke. D. D ________ (ab)__ 100 Southard, E. E __________ (ab) __ 300 Vickery, E. A----------------- 540 Spear, R______________________ 50 Watkins, S. S __________ (ab) __ 268 Speed, K _______________ (ab)__ 393 Weinstein, J ____________ (ab)__ 416 Sterzi, L _______________ (ab) __ 247 Wells, W. 0---- --------------- 521 Stillman, E . Q __________ (ab) __ 231 Whel'ry, W. B __________ (ab)__ 94• Stitt, E. R-------------------- 259 White, W. A ____________ (ab)__ 391 Stokes, A _______________ (ab) __ 93 Whittington, T. H ______ (ab)__ 262 Stokes, C. F ---------- --- - ---- 64 Wieber, F. W. F -------------- 226 Stone, H. B ____________ (ab) __ 237 Wiltshire, H ____________ (ab)__ 242 Strine, H. F ______ 29, 385, 405, '547, 558 Williams, R. B ______________ 107, 374 Strouse, S-------------- (ab) -- 236 Winslow, 0 .-E. A ________ (ab)__ 85 Sullivan, J. J, jr ________ (ab) __ 415 Woods, A. a ____________ (ab)__ 266 Rutton, D. Q ____________ 385, 391, 392 ! Zalesky, \V. J_________________ 125 0 ,