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A VOL. XVII NO. I UNITED STATES NAVAL MEDICAL BULLETIN INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF INSTRUCTION AND PUBLICATIONS COMMANDER H. W. SMITH, MEDICAL CORPS, U. S. NAVY IN CHARGE EDITED BY LIEUTENANT COMMANDER W. M. KERR, MEDICAL CORPS, U. S. NAVY Compiled and published under authority of Naval Appropriation Act for 1922,approved July 12, 1921 PUBLISHED FOR THE ISSUED BY JULY, 1922 (MONTHLY) WASHINGTON GOVERNMENT PRINTING OFFICE 1922 VOL. XVII NO. I UNITED STATES NAVAL MEDICAL BULLETIN INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE ISSUED BY THE BUREAU OF MEDICINE AND SURGERY NAVY DEPARTMENT DIVISION OF INSTRUCTION AND PUBLICATIONS COMMANDER H. W. SMITH, MEDICAL CORPS, U. S. NAVY IN CHARGE EDITED BY LIEUTENANT COMMANDER W. M. KERR, MEDICAL CORPS, U. S. NAVY Compiled and published under authority of Naval Appropriation Act for 1932, approved July 12, 1921 PUBLISHED FOR THE 1922 (MONTHLY) WASHINGTON GOVERNMENT PRINTING OFFICE 1922 Navy Department, Washington, March 20, 1907. This United States Naval, Medical Bulletin is published by direction of the department for the timely information of the Medi cal and Hospital Corps of the Navy. . Truman H. Newberry, Acting Secretary. Owing to the exhaustion of certain numbers of the Bulletin and the fre quent demands from libraries, etc., for copies to complete their files, the return of any of the following issues will be greatly appreciated : Volume I, No. 1, April, 1907. Volume II, No. 1, January, 1908. Volume VII, No. 2, April, 1913. Volume VIII, No. 1, January, 1914. Volume VIII, No. 3, July, 1914. Volume VIII, No. 4, October, 1914. Volume X, No. 1, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1917. Volume XII, No. 1, January, 1918. Volume XII, No. 3, July, 1918. SUBSCRIPTION PniCE OF THE BULLETIN. Subscriptions should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning January 1, $1.50 ; for foreign subscription add $1.00 for postage. Single numbers, domestic, 15 cents; foreign, 24 cents, which includes foreign postage. Exchange of publications will be extended to medical and scientific organiza tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy, Washing ton, D. C. ii TABLE OF CONTENTS. Page. PREFACE v NOTICE TO SERVICE CONTRIBUTORS vi SPECIAL ARTICLES: Sanitary inspector of the community. By Capt. W. H. Bell, Medical Corps, United States Navy 1 Acid-base equilibrium. By Lieut. Commander C. W. O. Bunker, Medical Corps, United States Navy 21 Aviation medicine in the United States Navy. By Lieut. J. F. Neuberger, Medical Corps, United States Navy 34 Personal hygiene of aviators. By Col. C. M. Belli, Medical Corps, Royal Italian Navy 39 Gas warfare: Adoption, methods of use, protection of troops. By Maj. W. R. Galwey, Royal Army Medical Corps 47 Functions and organization of Medical Corps units serving with the Marine Corps in the field. By S. N. Raynor, major, United States Marine Corps 59 HISTORICAL: Jonathan Cowdery, surgeon in the United States Navy, 1767-1852, Part I : By Capt. F. L. Pleadweli and Lieut. Commander W. M. Kerr, Medical Corps, United States Navy 63 EDITORIAL : On investigations of the etiology of epidemic encephalitis. —A disser tation on soup.— On acute appendicitis. —Use of iodine as a skin disinfectant.—Removal of foreign bodies from the eye. —On kala nzar 89 IN MEMORIAM: Middleton Semmes Guest, 1869-1922 105 REPORTS : Report of the hospitalization of the veteran at Great Lakes. By Lieut. Commander R. G. Davis, Medical Corps, United States Navy 107 Report of the activities of the Medical Division of the United States Naval Hospital, San Diego, Calif. By Lieut. Commander W. D. Owens, Medical Corps, United States Navy 111 NOTES AND COMMENTS : Revision of form K, Dental. —Gallery at Wellcome Historical Medical Museum illustrating history of chemistry. —Public drinking foun tains.— Royal Air Medical Service rules to improve respiratory and circulatory efficiency. —The louse as a menace to man. —Color blindness in seamen. —Immediate surgery with the siege guns in France. —Sources of vltamlnes. —Mollere. —Dr. William Osier. —Erb and Nissl.—Yellow fever in West Africa.—Aniliu dyes 117 NURSE CORPS 137 BOOK NOTICES 141 QUERIES 149 PREVENTIVE MEDICINE STATISTICS, LETTERS, ORDERS, COM MENTS 158 in PREFACE. The United States Naval Medical Bulletin was first issued in April, 1907, as a means of supplying medical officers of the United States Navy with information regarding the advances which are continually being made in the medical sciences, and as a medium for the publication of accounts of special researches, observations, or experiences of individual medical officers. It is the aim of the Bureau of Medicine and Surgery to furnish in each issue special articles relating to naval medicine, descriptions of suggested devices, clinical notes on interesting cases, editorial com ments on current medical literature of special professional interest to the naval medical officer, reports from various sources, historical esays, notes and comments on topics of medical interest, and reviews or notices of the latest published medical books. The bureau extends an invitation to all medical officers to prepare and forward, with a view to publication, contributions on subjects of interest to naval medical officers. In order that each service contributor may receive due credit for his efforts in preparing matter for the Bulletin of distinct origi nality and special merit, the Surgeon General of the Navy will recom mend that a letter of commendation be forwarded to him upon the acceptance of his manuscript for publication, and that a copy of this letter be attached to his official record. The bureau does not necessarily undertake to indorse all views or opinions which may be expressed in the pages of this publication. E. R. Stitt, Surgeon General United States Navy. NOTICE TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing and wide margins are desirable. Fasteners which can not be removed without tearing the paper are an abomination. A large proportion of the articles submitted have an official form, such as letterheads, numbered paragraphs, and needless spacing be tween paragraphs, all of which require correction before going to press. The Bulletin endeavors to follow a uniform style in headings and captions, and the editor can be spared much time and trouble and unnecessary errors can be obviated if authors will follow in the above particulars the practice of recent issues. This is not only important in special articles, but still more so in reviews. The greatest accuracy and fullness should be employed In all citations, as it has sometimes been necessary to decline articles otherwise desirable because it was impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors in orthography in many contributions Is conclusive evidence that authors often fail to read over their manuscripts after they have been typewritten. Contributions must be received two mouths prior to the date of the Issue for which they are intended. The editor is not responsible for the safe return of manuscripts and pictures. All materials supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. The Bulletin intends to print only original articles, translations, in whole or in part, reviews, and reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assumption that they have not appeared previously and are not to be reprinted elsewhere without an understanding to that effect. VI U. S. NAVAL MEDICAL BULLETIN Voi. XVII. Jur.Y, 1922. No. 1. SPECIAL ARTICLES. THE SANITARY INSPECTOR OF THE COMMUNITY. By W. H. Bell, Captain, Medical Corps, United States Navy. " Without responsibility there can be no efficiency; Without efficiency success can only be accidental." It may be said without fear of contradiction that one indication of the spirit of the times is the mobilization of every form of science in an effort to contribute to human progress and efficiency. The tendency to reach into the realms of science for additional facts or the discovery of new principles has been stimulated by the assurance of their speedy application to the solution of various problems of everyday life. The recent war has given an impetus to this spirit of investigation, and by it alone may the world "ex pect ultimately to overcome the telling advantages, both in war and peace, which Germany long enjoyed because of the organization and development of her scientific resources." Every form of scientific research is important in building the firm foundation upon which enduring advances depwid. Thus, " Euclid, working out problems in pure mathematics in Alexandria, prepared the way for the calculations of the engineer. Galileo, discovering the satellites of Jupiter, convinced the world of the truth of the Co- pernican theory, broke down absurd medieval conceptions which prevented scientific progress, and stimulated exploration and ad vance in every field. Pasteur, studying the optical properties of certain crystals, with no thought of practical result, was led to his investigations of bacteria and his epoch-making discoveries for the benefit of mankind." Not only are scientific bodies organizing their educational and research resources in the interest of efficiency, but teaching and re search institutions are arranging their facilities along lines calcu lated to foster progress in a precise and effective fashion. Every where one notes the attempt to overcome the sluggishness with which the public receives and applies scientific information, and by the word "public" we mean the individuals who compose military as l 2 BELL SANITARY INSPECTOR OF THE COMMUNITY. Vol. XVII. well as civil communities. It has long been noted that whatever a military organization may be considered to gain by virtue of au thority is often lost in the persistence of a traditional conservatism, a conservatism which is often expressed as a resistance to reforms. This resistance is found in civil as well as military communities and is the factor which prompts reformers to exaggerate the conditions which are under consideration in order to emphasize the necessity of reform. It is difficult, however, to exaggerate the ill and far-reaching con sequences of a disregard to the dictates of health. Yet they are often so subtle and intangible to the average citizen who can not readily connect an obscure cause with possibly an unseen effect, that efforts to didactically impress the public with the necessity of precautions regarding public health are often futile. The mind is so constituted that unfortunately the value of experience derived from some public disaster is soon forgotten, and no matter how good the intention may be to continue preventive measures in the future, they often degen erate into a routine and then pass into oblivion. So discouraging an outlook does this suggest and so often has it been the stumblingblock to adequate and timely preparation for the prevention of public calamities, that the development of a pre ventable disaster is frequently a needed object lesson to arouse pub lic interest in matters pertaining to public health. It is particularly in connection with matters relating to hygiene and sanitation that cause and effect are not apparent to the average individual who at the present time has not been educated up to a satisfactory appreciation of the value of public-health measures. His education is a huge task, to be completed by various means, one of which forms the subject of this paper, namely, the sanitary in spector of the community. It may be interesting and helpful at this point to outline briefly the development of the science of sanitation from an educational view point and to review the facilities at present available to students who aim to make public health their life work. As early as 1865 the Medical College of the New York Infirmary for Women and Children made hygiene and public sanitation a com pulsory part of its curriculum. Even before this the Woman's Medical College of Pennsylvania had taught hygiene in connection with physiology. The University of Michigan, when its medical department was founded in 1850, taught the principles of the analysis of drinking water to its students, and in the early seventies lectures on hygiene were given not only to medical students but to others, including those taking the classical course. Later, in 1876, a course of lectures was established, with the professor of hygiene in charge. In connection with pathology or clinical subjects, as early as 1881, No. 1. BELL SANITARY INSPECTOR OF THE COMMUNITY. 3 Western Reserve, in Cleveland, Ohio, taught state, or as it is now termed, preventive medicine and hygiene. At Harvard, lectures on hygiene were instituted in 1876. In 1892 the Institute of Hygiene of the University of Pennsylvania was established. Foundations for the financing of instruction in hygiene were likewise provided in other medical schools, such as the University of California and Cooper Medical School, in San Francisco. The department of hygiene in the latter institution, now Leland Stanford, gave way to the depart ment of bacteriology. Not long ago Western Reserve recognized the importance of hygiene and appointed a full-time professor in this branch. A similar change took place at Yale and at the University of Chicago. With all this, hygiene as a major subject, with a trained scientist giving his entire time to studying its problems and teaching its principles, until recently existed in but 6 of the 38 reputable medical schools in the United States. This was not a highly creditable showing in comparison, for ex ample, with Germany, where all of the 22 universities teaching medicine had their hygiene institutes, or with Great Britain, where every graduate in medicine must have followed a course in public health, and passed an examination in it. This state of affairs in the United States was, perhaps, only a reflection of the apathetic public sentiment which seemed content that its interests in health require ments should be supervised in the main by so-called " part-time " health officers — often politicians, appointed without regard to fitness for the office they were expected to fill—and with such inadequate recompense as to inspire a primary interest in their original gainful occupation as a means to livelihood. This vicious practice is still too prevalent; but better things are coming to pass, though we are a long way from realizing practically all that our scientific knowl edge makes possible. The methods of handling health conditions are changing and they began to change with marked strides even before the World War gave such an impetus to the public-health movement. Strong and able men and women are behind this movement and the public is opening its eyes and its purse with the realization that there are grave facts to be faced with intelligence and honesty, and that there is much of an intangible nature and remote benefit that is worth paying for in advance of delivery. In preparation for the proper utilization of this awakened public understanding and the scientific economic disbursement of funds allotted, as a result of the growing confidence in public-health under takings, the idea of developing personnel to handle this tremendously important work is taking practical form. The study of disease and its prevention has always come within the province of the doctor of medicine, but in this new field of endeavor—the care of the health of a community—there is room 4 BELL SANITARY INSPECTOR OF THE COMMUNITY. Vol. XVII for other workers whose objective also is " the study of health and how to maintain it." Much is being done by various powerful agencies such as the United States Public Health Service, the Medical Departments of the Army and Navy, health departments of large cities, and educa tional institutions to lift our knowledge of preventive medicine out of the realm of the casual and to make the use of it the general prac tice of individuals and communities, to educate the public up to a full understanding of its responsibility regarding preventive medi cine, and to build up a body of public-health workers, men and women whose efforts are devoted to the prevention of disease. The requirements of the health official are to-day receiving most careful attention by such men as Sedgwich, Reinhardt, Whipple, Rosenau, and Overton, and out of a recognized necessity not only are books on the subject being written but special schools with graded courses are being established for instruction in this subject. In July, 1915, Rosenau stated that "hygiene is included as a major subject in the curriculum of only three medical schools in this country, namely, the University of Pennsylvania, the University of Michigan, and Harvard." On the other hand, Reinhardt in February, 1913, with regard to the division between preparation for preventive and cura tive medicine, stated : " The division has evidently come to stay, be cause it is recognized and provided for in some of the best institu tions of learning in our country; in Harvard, in the Universities of Pennsylvania, Wisconsin, and Michigan complete and separate courses are given to students who attain the degree of M. D. (doctor of medicine) and the degree of D. P. H. (doctor or diploma of pub lic health). Johns Hopkins University also has a school of hygiene and public health. Although the University of California has no degree in public health, nor as yet any definite course leading to the degree in public health, it is rapidly working to that end and has long supplied courses adequate for the need of general students. It will perhaps be interesting, and in connection with the development of schools of public health it is pertinent, to note that " what is vir tually a certificate of public health (based upon methodical and ap propriate courses) was established in Lyon, France, as early as 1905, and that, in 1919, 209 persons had received the certificate, 135 having been physicians or medical students and 74 nonmedical men—phar macists, chemists, architects, engineers, etc."1 In the United States the school for health officers conducted by Harvard University and the Massachusetts Institute of Technology represents the greatest and most substantial step in this direction, and ' Rosenau, Journal A. M. A., Vol. LXV, No. 4, p. 321 ; Reinhardt, Journal A. M. A.. Vol. LX, No. 6, p. 427; Sedgwich, W. T., Am. Jour, of Public Health, Vol. X, No. 4, P. 352. Ko. 1. BELL SANITARY INSPECTOR OF THE COMMUNITY. 5 at present awards a certificate of public health (C. P. H.). A doc torate of public health (D. P. H.) is conferred in connection with the training at this school of Harvard University as one of its highest degrees. "The primary object of the school for health officers is to provide the scientific groundwork in the sanitary sciences which un derlies efficient health administration,"2 for satisfactory practical work is done and economically done only " by those who have a secure scientific foundation." The school recognizes, it is understood, four general subdivisions of the field of public service for which it under takes to train, viz, the teacher, the research scholar, the technical ex pert, and the administrator. The scope of the training for the tech nical expert is perhaps comprehensive enough to include what may be termed the sanitary agent and the district health inspector, but the requirements for admission to, and the required period of study within, the school exacted of candidates for even its lowest award, the C. P. H., are such as to exclude the class from which are recruited the grade of public health servant at present so largely depended upon for the details of field inspection and work —the grade of public health servant which constitutes the sense bulb of the ultimate rami fication of public health organizations. I refer to the corps of field workers which comes in daily contact with the people of a commu nity as the representative of health departments in their effort to secure general recognition of health dictates and obedience to health laws. As above indicated, much has been and is being done to develop a competent personnel in the upper stratas of health organizations ; but it seems that little well-directed or systematic attention has been, or is being, given to the question of creating a high-toned, efficient, and dependable corps of sanitary inspectors, or of making the remunera tion sufficiently attractive to assist such creation. It has been esti mated by Farrell3 that fully 7,000 sanitary inspectors are required for work throughout the United States on the basis of a conservative minimum organization of public health units per 20,000 of popula tion. This would be independent of special problems and under takings. Little or nothing has been written in this country touching the peculiar requirements as to fitness, training, and service of those who would fill this office. I have looked almost in vain, outside of English publications, for anything except the most superficial outline of daily general routine duties.4 ■Rosenau, Journal A. M. A., Vol. L.XIV, No. 10, p. 795. ■Farrell, J. A., Jonrnal A. M. A., Vol. 77, No. 7, Aug. 13, 1921, p. 514. 'For example, Frank Stockman says In the chapter on "Duties of sanitary Inspectors In London," in his Practical Guide for Sanitary Inspectors : 1. Must obey and carry out Instructions and directions of sanitary authority. 2. Must attend meetings as required by sanitary authorities. Should report at these meetings all matters requiring action, etc. (Footnote continued on p. 6.) 6 BELL SANITARY INSPECTOR OF THE COMMUNITY. Vol. XVII. Yet these people bear the same relation to the doctor of preventive medicine as does the nurse to the doctor of curative medicine and are quite as important in the scheme of things. They represent adminis trative assistance reduced to its lowest possible equation, but which is none the less indispensable as a factor depended upon for results in the distal reaches of a health department's daily concerns. A sanitary inspector is anything but a theorist. His business is the observation of things as they are and the collection of information which shall reflect facts. The success of any system of sanitation or organization in the interest of public health, assuming it is well directed, will in the last analysis depend upon the type, training, and general efficiency of subordinates, the thoroughness with which they have been indoctrinated in the aims of the institution and their enthusiastic, persevering fidelity to the objective. The aim of all health organizations is, definitely and broadly, the physical and mental improvement of the human race—the pro gressive recognition, establishment, and observance of the utmost any given time in the interest of health, as a thing in itself, and as the basis of all that spells the best in life. Contributions to civic betterment in any and every direction should be one of the aspira tions in the breast of every worthy member of society. It is from such an element that we should seek to recruit sanitary inspectors. Unfortunately in the present state of our progress and facilities these are in the main without special training. Dependence for sanitary aides in civil life, by virture of inadequate compensation, has been upon a class of citizens less self-respecting and less conscious of its responsibilities than is desirable. This fact has suggested the very attractive proposition that the staff of visiting nurses which is a part of every properly organized health establishment be enlarged and given the additional duties of sanitary inspectors 5 or that sani- (Continued from p. 5.) 3. He Is to make systematic and periodical Inspections of his district to keep himself Informed as to its sanitary condition and especially to keep sharp lookont for those nuisances which require Immediate attention and abatement. 4. On receiving complaint of nuisance should immediately Inspect the place and take necessary action to remove the cause. u. Should report to sanitary authorities any damage done to any waterworks or other works belonging to them. Also any defects in water supply of any house. 6. He is to make from time to time inspections of slaughterhouses, and of shops, and markets where butchers' meat, poultry, fish, vegetables, In short, all articles of food are kept for sale ; and In case any article appears to be unfit for sale he shall cause It to be seized and dealt with by a Justice. 7. Shall procure samples ol food, drink, or drugs for analysis when required by sani tary authority to do so. 8. Should report overcrowding In any house and existence of any nuisance Injurious or dangerous to health. 9. Shall keep all books the sanitary authority requires him to keep. 10. Shall carry out instructions of medical officer of health and give him all informa tion In his power, and produce any books relative to his duties when required to do so. • Overton and Denno, The Health Officer, 1919, express themselves as of opinion that the public health nurse may also do much as a sanitary inspector. " She Is an Inspector and instructor of persons, while the sanitary inspector deals with their environ ment," but you can't, get away from the one in dealing with the other. No. 1. BELL —SANITARY INSPECTOB OF THE COMMUNITY. 7 tary inspectors be carefully selected from the female citizens of a community. In either case the services of those who by nature or early training are "housekeepers" are secured. In the first case the advantage of fortifying the duty of exacting, with the persuasive influence of service, would be realized as an asset in getting results. but whatever the source of personnel for this service, when there is combined with the general aspiration of good citizenship, an iden tification with a calling of vital moment to the welfare of society in one specific direction, nothing which will add to the mental equip ment, fire enthusiasm, and fix determination to devote the very best efforts to the work in hand, can be neglected by the individual in office. " He must be alive to conditions, awake to discoveries, and conversant with the success or failure of methods in other localities ; he can better afford to lag behind the science of which he is an ex ponent, but should be ambitious to hasten its advancement; this ho can accomplish if he will dignify his least undertaking as a definite problem in research." It is the small things that count in building up big results just as the wonderful creation represented by the liv ing body is made up of billions of little cells. Each sanitary inspec tor may be likened to an individual cell of an organ, and, as in the living body, the well-being of the whole depends upon the perfec tion with which the heart, liver, and kidneys perform their functions, both individually and in relation to one another, so the effectiveness of a given health department depends upon the perfection with which the corps of sanitary inspectors does its particular work in coopera tion with other divisions of the department concerned. It is the administrative possibilities in the make-up of a sanitary inspector that count so much in rating his efficiency, for he alone comes in daily contact with the individuals of a community. Before taking up the several points I have in mind let us analyze and give practical meaning to the term " sanitary inspector." In do ing so I will take the last word first and change its form from " in spector " to " inspection." " Inspector " is a designation of office, a title; "inspection" represents the execution —the function which is the realization of the office. What does it mean ? It means a routine periodic or a special investigation of operations or conditions to ascertain whether or not the subject of the inspection is as the best interests of all concerned dictate that it should be. And what is its purpose? Its purpose is to obtain periodically assurance that all is right, or to learn definitely what is wrong, and, in the first case, to commend and encourage the responsible parties to continue effort and, in the second case, to guide and urge to better effort and to cor 8 BELL—SANITAKY IKSPECTOK OF THE COMMUNITY. Vol. XVII rect the fault in one way or another, immediately if possible, but cer tainly by starting the necessary corrective machinery. The psychologic understanding with which the function of inspec tion is entered upon, or the lack of it, and the spirit with which it is carried out when human contacts are involved, spell success or failure. What are apt to be the results if the inspection is undertaken in a spirit of gruff destructive criticism with a crude display of au thority? In the first place we note resistance which essentially is opposed to one's best interests —opposed to the work in hand—to one's reputation as an official of the sanitary department. Every body within the field of the inspection will assume the defensive, and tenaciously withhold that information or cooperation so essen tial to success in securing the desired results. And thereafter will follow a long train of ill consequences in comparison with which failure, and the importance of it to one personally, fades into insig nificance. An insanitary condition and the spread of preventable disease entails far-reaching damage to the community. The benefit or damage, as the case may be, to the community and to oneself runs parallel and is effected by the same end result. What, on the other hand, are apt to be the results of the inspec tion if undertaken in a spirit of kindly constructive criticism and helpfulness with tactful firmness based on precise knowledge as the only show of force ? In the first place, respect for and sympathy with the aims of the office will be noted. The sanitary inspector comes in direct contact with the individuals of his field of responsi bility and must take their varying religious and racial susceptibili ties, customs of life, and temperamental and habit tendencies into account. He is the one who must carry the health propaganda tcy the home not only by word but by objective teaching. The secondary rewards earned by a proper spirit and bearing in carrying out the duty of inspection, and which are a direct product of the respect and sympathy thus won, are the helpful cooperation of the individ uals inspected, and their open and frank response to inquiry in all matters of concern to the inspector. Many inspectors fail because they promptly kill the goose that lays the golden egg—their source of information —by improper methods. The true criterion of efficient general sanitary inspection is not the number of reports of nuisances or violations of the law that are turned into headquarters, but the health of the district a given in spector may be assigned to supervise as shown by statistics from month to month, or, to take for example an inspection in which special training and experience is necessary, such as the inspection of a dairy farm, the criterion of efficient inspection is the maintenance of the required standard of the dairy product as shown by labora tory examination. Of course reports have to be made, and they serve the important purpose of showing conditions as they exist, and No. 1. BELL—SANITARY INSPECTOR OF THE COMMUNITY. 9 of bringing to one's assistance the power of higher authority, but I want to keep away from the idea that they are more than a small part of the full duty of the office. I want to avoid the possible false notion that the fulfillment of the obligation of the office is the sum total of unfavorable criticism and the unearthing of some culpable error or omission. It is the part of administrative wisdom, rather, to> loot for evidence of compliance with the sanitary code and general sanitary principles, taking careful note the while of those features in which there seems opportunity for improvement, and to look with surprise upon failure to render that measure of cooperation which is to be expected from those possessed of intelligence and honest purpose. Occasionally one will be called upon to exercise all the force resident in the office but, in general, the aim should be to- lead rather than to drive. When there are adequate laws and ade quate authority, force is the shortest road to a desired action, but. there are few laws perfect enough to admit the elimination of dis cretion or that do not present some loop hole of escape—some defect which can be taken advantage of for purposes of evasion. The work of the inspector, therefore, is in part a campaign of education, to convert a community to sanitary living and, as in religion or pol itics, it is impossible to convert by force. And now as to the word " sanitary," which precedes the word " in spector " and completes the title : It stands for that condition of our surroundings, immediate and remote, which conduces to physical well being, and brings contentment and happiness, not only as a re flection of a state of health1 but by preserving unstained and unmarred the native beauty of Gtfd's gifts. Furthermore, the word " sanitary " represents a conditjio^ upon which is based the possibilities of progress- and accomplishme$i;,)in all those enterprises wherein human energy is a determining factor. The title " sanitary inspector " is one of which to be proud, and it designates an office which is growing in importance. Indeed, it has become a specialty within a profession dignified by its identification with the great undertakings in tropical latitudes during recent years. Cuba would not be to-day the well-ordered, prosperous country that it is if the work of the sanitary inspector had been faulty. The Panama Canal would not be to-day accommodating the ocean traffic of the world if the sanitary inspector had been unequal to the task intrusted to him. Each of the 25 districts into which the Canal Zone was divided, as far as general sanitary work was concerned, was in charge of a sanitary inspector who had under his control a properly trained body of men, consisting of from 20 to 100 laborers, with as sistants and foremen as necessary.8 " No case of yellow fever, small pox, or plague originated in or was brought to the Isthmus during the • Gorgas, W. C, Sanitation in Panama, 1915. D. Appleton k Co., " The work of the unitary inspector," p. 182. 10 BELL—SANITARY INSPECTOR OF THE COMMUNITY. Vol. XVII month." This represented the usual statement of the chief sanitary officer in his monthly report upon health conditions during the con struction of the canal and reflected the work of the sanitary inspector. The obvious duties of the sanitary inspector will vary according to locality, season, and peoples. The difficulties in executing these duties will increase or decrease according to the temper of the com munity collectively, and that of the individual families composing it regardless of the personality of the inspector. In the Tropics, foi example, the duties are concerned, to a large extent, with the contro of protozoal diseases, whereas in northern climates, except in malarin districts, the bacterial diseases constitute the burden of concern Urban communities present quite different requirements from thost of rural settlements; manufacturing centers present sanitary prob lems distinct from those of business or purely residential districts and peoples of different races and religions present superstitions 01 habits or rites each of which, in its own way, imposes new and per haps peculiar duties, or the exercise of ingenuity, to the end that thi inherent violation of sanitary principles may be overcome with en tire deference to religious or ritual considerations.7 As an example of the general outline of duties which are formu lated and issued for the guidance of sanitary inspectors, I quote th prescription " by the local government board for sanitary inspector in the metropolis, in the sanitary officer's (London) order dated De cember 8, 1891." 1. He shall perform, either under the speclaj! directions of the sanitar; authority, or so far as authorized by the sanitary authority, under the dire< tions of the medical officer of health, or, in cases where no such directions ai required, without such directions, all the duties specially imposed upon a san tary inspector by any statute or statutes, or by the oWers issued by us, s far as the same apply to his office. (>*•)'' 2. He shall attend all meetings of the sanitary authority when so required. 3. He shall by Inspection of his district, both ■systematically at certal periods, and at Intervals as occasion may require, keep himself informed i respect of the nuisances existing therein that require abatement. 4. On receiving notice of the existence of any nuisance within his district, t of the breach of any by-laws or regulations made by the sanitary authority f< the suppression of nuisances, of any by-laws made by the London County Cou cil which it is the duty of the sanitary authority to enforce, he shall, as ear as practicable, visit the spot and inquire into such alleged nuisance or breai of by-laws or regulations. 5. He shall report to the sanitary authority any noxious or offensive bus nesses, trades, or manufactories established within his district, and the brea< or nonobservance of any by-laws or regulations made in respect of the same. 1 1n this connection it Is Interesting to note that in some parts of the Tropics the ho water fonts of Roman Catholic Churches, which were proline breeding places for t yellow-fever mosquito, have been transformed into inclosed receptacles, the preclc water being obtained by the devout through a device similar to the liquid soap d pensers in Pullman cars. No.l. BELL—SANITARY INSPECTOR OF THE COMMUNITY. 11 6. He shall from time to time, and forthwith upon complaint, visit and Inspect the shops and places in which is exposed for sale, or in which is deposited for the purpose of sale or of preparation for sale, any animal, or any article, whether solid or liquid, intended for the food of man, and examine any such animal or article which may be therein. If any such animal or article appears to him to be diseased or unsound or unwholesome or unfit for the food of man, he shall seize and carry away the same himself or by an assistant, in order to have the same dealt with by a justice according to the provisions of section 47 of the public health (London) act, 1891 : Provided, That, In any case of doubt arising under this clause, he shall report the matter to the medical officer of health, with the view of obtaining his advice thereon. 7. He shall, when and as directed by the sanitary authority, procure and submit samples of food, drink, or drugs suspected to be adulterated to be analyzed by the analyst appointed under the sale of food and drugs act, 1875, and upon receiving a certificate stating that the articles of food, drink, or drugs are adulterated, cause a complaint to be made, and take the other proceedings prescribed by the act. 8. Whenever it appears to him that the Intervention of the medical officer of health Is necessary in connection with any nuisance, he shall forthwith inform such officer thereof. He shall also, subject to the directions of the sanitary authority, attend to the instructions of the medical officer of health with respect to any measures which can be lawfully taken by a sanitary inspector Tinder the public health (London) act, 1891, or under any other statute or statutes. 9. He shall enter from day to day, in a book to be provided by the sanitary authority, particulars of his inspections and of the action taken by him in the execution of his duties. He shall also keep a book or books, to be provided by the sanitary authority, so arranged as to form, as far as possible, a continuous record of the sanitary condition of each of the premises in respect of which any action has been taken under the public health (London) net, 1891, or under any other statute or statutes, and shall keep any other systematic records that the sanitary authority may require. 10. He shall at all reasonable times, when applied to by the medical officer of ■health, produce to htm his books or any of them, and render to him such Information as he may be able to furnish with respect to any matter to which the duties of a sanitary inspector relate. 11. He shall, if directed by the sanitary authority to do so, superintend and see to the due execution of all works which may be undertaken under their direction for the suppression or removal of nuisances within his district. 12. In matters not specifically provided for in this order he shall observe and execute any instructions issued by us, and the lawful orders and directions of the sanitary authority, applicable to this office. Another example of later date is given by Porter.* These are prescribed in the order of 1910, which details the duties of the medical officer of health, which, in some respects, they resem ble. He is required— 1. To perform all duties imposed upon inspectors by the public health act, 1875, and other statutes. 2. To attend meetings of the sanitary authorities when required. ' Porter, Charles, Sanitary Law, London, 1920. Section 1, " Sanitary administra tion," p. 4. 103390—22 2 12 BELL—SANITARY INSPECTOR OF THE COMMUNITY. Yoi. XVII 3. To Inspect this district and keep himself informed as to nuisances calling for abatement. 4. To inquire on the spot into any complaint as to nuisance or breach of by-laws or regulations made for the suppression of nuisances. 5. To report to sanitary authority as to noxious or offensive businesses and breaches of by-laws or regulations relating thereto. 6. To report any damage done to water supply, works, or fittings and any case of waste or fouling of water. 7. To visit butcher's and other food shops and inspect the meat, etc., and seize and deal with it if it is unsound ; in doubtful cases to consult the M. O. H. (medical officer of health). 8. To take samples under the sale of food and drugs act, submit them to the public analyst, and if they are reported adulterated, take proceedings. 9. To notify the M. O. H. of outbreaks of disease, and any cases of overcrowd ing or nuisance injurious to health. 10. To attend to the instructions of the M. O. H. (so far as the sanitary authorities direct) as to the taking of measures which an inspector may take under the public health acts for the prevention of disease. 11. To keep a daily journal and books recording the action taken under the public health acts. 12. To produce his books to the M. O. H. and furnish him with any informa tion relating to his work. 13. To superintend work undertaken by the sanitary authority for the sup pression or removal of nuisances. 14. To act, if required, as officer under the diseases (animals) acts, and orders and regulations thereunder. 15. To obey the orders and directions of the sanitary authority and L. G. B. (local government board). It makes little difference from where the examples are derived. Such formulations of duties will vary according to the conception of the prescribing authority. It frequently happens, of course, that sanitary inspectors are assigned to special fields which absorb their whole time, at the expense of attention to the duties of the general inspection above indicated, and in which the}' must become experts. This brings me to the character and peculiar fitness requirements of the office, and as an introduction to this section of my paper I quote from The Sanitary Inspector's Handbook, by Albert Taylor (London, 1914). 9 In general terms, a person to be fully competent to perform the duties of a sanitary inspector should have the following qualifications : He should be the owner of a good, sound constitution and be able to follow the rules laid down to preserve it, including temperance. He should be able to write legibly, spell correctly, and have a fair knowledge of arithmetic. » The preface to the last edition Bays that this book was compiled with the desire of furnishing to the sanitary inspector and those seeking to qualify for such appointment a useful vade mecum upon the subjects pertaining to the office. The book aims to supply practical Information on the various matters which come dally under the notice of the sanitary Inspector, and not at being an exhaustive work of scientific reference. As it la> In Its fifth edition, it would seem that the book has met a demand and filled a useful purpose. No.1. 13 BELL—SANITAKY INSPECTOR OF THE COMMUNITY. He should have a thorough knowledge of building construction, including plumbing, and the methods of water supply and drainage; also the proper principles of ventilation of rooms, and should know the best and most suitable sanitary appliances to use under varied circumstances. He should have an observant eye, a quick ear, and a sensitive nose, and be able to detect any defective or faulty sanitary arrangements of dwellings and other buildings. He should be thoroughly acquainted with the provisions of the various public health acts and model by-laws relative to the duties of sanitary inspectors. He must make himself acquainted with the various kinds of infectious dis eases and know the best means to adopt for preventing the spread of such diseases. He should acquire a knowledge of the different kinds of disinfectants in use and know those best fitted for safely and effectually disinfecting bouses and fever localities. He should have a thorough knowledge as to the different methods adopted for the collection and disposal of house and other refuse. ' He should be of pleasing address, and in ids dealing with the public he should be calm and collected, learn to restrain his temper, and to endure hard speeches. He should bear himself with a sympathetic aspect to the many bereaved widows, mothers, and orphan children he so frequently meets in the per formance of his duties. Civility and kindness must characterize all his actions, and rude behavior or supercilious officialism should find no place In his conduct. He should at all times attend promptly to any special complaints, and frequent inspections at irregular periods are necessary as regards slaughterhouses and other similar businesses. Sanitary authorities are sometimes disposed to disregard anonymous com plaints, but it Is the duty of the authority to investigate every specific com plaint made to them without regard to the means by which it comes to their knowledge; and, if satisfied, upon Inquiry, that such complaints are justified, they should direct that measures be taken to remove the ground of complaint. It is essential, however, to exercise the greatest care when inquiring into such complaints, otherwise the authority and its inspector may be made the victim of ill-will or spite. Speaking from the Engish point of view again, and in a rather quaint vein, as indicating great expectations and the extremely large order that some in authority were wont to impose upon the occupant of a hitherto miserably compensated office, it has been said, " That in order to carry out the multifarious duties of his office, an inspector should be partially educated in the following trades and professions, viz, that of a plumber, in order to detect bad work and be able to fill in his notices how the bad work is to be rectified ; that of a butcher, in order to detect and intercept bad meat; that of a veteri nary surgeon, in order to observe animals that may be suffering under the contagious diseases (animals) act, and also in connection with his visits to slaughterhouses ; that of a lawyer, in order that he may he well cognizant with all the acts and regulations under which he carries out his duties, and to enable him to form a judicial opinion upon all statements of facts; that of an architect, in order that he •Day understand plans, and, if necessary, make sketches of anything 14 BELL—SANITARY INSPECTOR OF THE COMMUNITY. Vol. XVII. that comes under his notice in connection -with his duties; that of a clergyman, in order that he may preach the good tidings of sanita tion, and may by his precept and example further the good work he is engaged upon, and also that he may be able to patiently bear the abuse which he may sometimes receive for what is called his ' prying interference.' Lastly, he must try to educate himself in common sense —that most valuable commodity without which book learning availeth not much." Discussing the character and temperament of the sanitary inspec tor, Taylor 10 says : " To carry out his duties efficiently, the sanitary inspector must exercise great forbearance, tact, and good temper ; sometimes technical objections will be raised to his proceedings; vexations, delays, and evasions will often occur in the fulfillment of his notices ; nuisances, which the officer is anxious to suppress, may elude his authority; when he would force one person to refrain from tainting the atmos phere with the result that his tenants were better housed than cattle, he will often be reminded of the rights of property and of an Eng lishman's inviolable claim to do as he will with his own. " With private affairs he should interfere only when they become of public import, and with private liberty only when it becomes a public encroachment. " Thus neither the personality nor the office should be magnified. To do this is to court the contempt of ordinary men and women. Officialdom is the curse of any administrative body. Therefore, the man who goes about his duties in a way that compels respect, and whose tactful demeanor impresses others that the thing he is asking for can not be denied, is the one who will win his way to the front Owners and occupiers are but human, and they like to feel they are receiving the attention of a friend although an official." And again, on page 38 of his book, Taylor says under the heading " Qualifications " : " Sanitary authorities do not and have not always sought to ap point the person best fitted for the post of inspector. They have too frequently appointed the man who could command the greatest influence with its members without the slightest regard to his qualifi cations. The important duties which sanitary inspectors are now called upon to discharge, and the large discretionary power that must be vested in them, demand that only qualified persons should receive these appointments, and experience has undoubtedly rendered it necessary to establish some mode of testing the competency and qualifications of persons offering themselves as candidates to fill such appointments. Some assurance should be given to the public that "Taylor, Albert, Sanitary Inspector's Handbook, London, 1914, p. 38. No. 1. 15 BELL—SANITARY INSPECTOR OF THE COMMUNITY. the persons entrusted with these responsible duties are properly qualified. " Evidence of special training and of potential efficiency as repre sented by character and temperament ought to be regarded as basic, and when the question of qualifications has been thus determined and appointment has been made, a fixity of tenure should obtain. " Every sanitary inspector is entitled to security of office, for he it is who is brought into personal conflict with property owners more than any other officer appointed by the local authority." The Secretary of Health and Charities in Cuba, speaking of his local chief sanitary officers, said: "They can all feel perfectly sure that they will not be removed from their offices while they comply with their duties in a satisfactory manner, because I sustain the view that the employee who fulfills his obligations competently should be respected, defended, and protected." Needless to say, definite knowledge on a variety of subjects is of the utmost importance, but the best professional equipment may be a total loss if its possessor lacks a personality which is considered essential to the effective application of such knowledge. In seeking to outline the right personality I am conscious of dealing with the main factor in success. Indeed, so clearly is this the case, that if something in one or the other qualifications must be sacrificed in the candidate it had better be in the direction of technical training. Professional shortcomings can be more easily corrected than defects in personality. The difficulties and perplexities which beset a conscientious in spector are rarely mentioned or are insufficiently dwelt upon by the instructors in sanitary science who are primarily interested in the technicalities of this or that particular subject, and who may be merely preparing students for examination. This fact the inspector may be sure of, namely, that to frame requirements is one thing, and to see that they are carried out is quite another. There is no doubt many who, through luck of serious intention, through laziness, men tal or physical, or through sheer lack of ability and perception, skim along lightly over things and avoid annoyance and difficulties but effect nothing. Others fail for want of adequate training; for want of a sanitary point of view, a sanitary interest and ambition, sanitary ideal, and a sufficient acquaintance with sanitary problems or satis factory practical methods of solving them. Ingenuity and resource fulness, which are so imperative, are to such a group total strangers. But the vast majority who find employment as sanitary inspectors, and are appointed without regard to their qualifications, fail to do more than to keep their own skirts clean —fail to realize the reward of perhaps an honest ambition and purpose because they are not tem peramentally constituted to be a telling figure in that field of work. 16 BELL SANITARY INSPECTOR OF THE COMMUNITY. Vol. XVII What sort of personality fits the job and makes for its utmost possi bilities ? It is impossible to lay down any bard and fast rules or to treat this phase of the subject briefly. It finds concentrated expres sion in the thought that once an inspector succeeds in persuading the people to accept him as a friend, working as much in their inter est individually as in the public welfare—even though a friend who tells home truths— the battle is largely won. Difficulties there will always be under the best of circumstances, difficulties which may have been increased by want of wisdom or tact on the part of a prede cessor, but the gratification of a victory in spite of them is great, and the self-satisfying consciousness that something positive is really being accomplished —that progress is being made through one's personal effects—is a large reward. A number of contributors to the literature of public-health work have touched upon the element of personality in the make-up of sanitary inspectors, but the one giving most systematic and sym pathetic consideration to it is Edith L. Maynard in her book entitled " Women in the Public Health Service." It is written from the English point of view, as is the case of most of the literature on the subject, but it is not the less applicable to either men or women in field work anywhere, and so nearly expresses my own views tbat in the following paragraphs I have drawn largely upon it. " It must be borne in mind that public-health work of whatever sort consists mainly in trying to make people do what, if left to themselves, they would not do." The bringing about of a new order of things, then, is the real crux of the task, and it should appeal to one's sporting nature. It is a contest as to which shall win —the exponent of progress or of the obsolete — and its very difficulties and tenacity of purpose is a characteristic of women which men will do well to imitate, and it is particularly necessary to the reformer in the guise of a sanitary inspector, for he can not afford to compromise with principle. He can do so only as a means to an end. In other words, if a thing can't be done one way, it can be done in another way, and it is the inspector's duty to be practical —to familiarize himself with all the details involved in a given problem and to find reasonable means for meeting reasonable objections. It is a matter of managing people, of exerting and proving oneself in the most inter esting game imaginable, and " it is not everyone who can deal satis factorily with others." Owing to the variety of classes and racial peculiarities or habits and shades of self-conscious social caste that will be met in the course of the day's work, the background of the inspector, in other than the mere matter of education, is not an inconsiderable item in the total making for potential efficiency. The environment from which he is No. 1. BELL—SANITARY INSPECTOR OF THE COMMUNITY. 17 drawn is important and should be such as to give promise that he possesses that savoir faire which will make it possible for him to dis cern both the nature of a situation and its opportunities or impedi ments. He should entertain a sense of the importance of his work and assume the quiet dignity and full measure of responsibility which properly attaches to his office, but he should be 'one who has found himself, in a worldly-wise sense, and is not disposed either to take himself too seriously or to patronize those with whom he comes in contact. There must be a nice appreciation of ethical relation ships as shown in his bearings and intercourse. "But this, obvi ously, is not enough, for there are people of all classes who have the (unhappy) knack of rubbing others up the wrong way, and such an one is of no use in the Public Health Service." "To whatever class the public-health officer belongs, he must possess tact. The tactful official will quickly ascertain the frame of mind of those whom he visits, will know when to praise and when to blame, when to be firm and when to use persuasion only. Many un pleasant truths will have to be told if the work is to be effective, but he will know how to take the sting out of them. He will possess that true sympathy which understands the greatest difficulties which are in the way of those who would endeavor to rise above their often debasing surroundings. But weakness is quite another thing, and there is no place in public-health work for such a characteristic. It is uphill work all the time, and the worker must possess the strength of mind which will enable him to persevere in spite of the most dis heartening results of his efforts." Determination and patience therefore are also essential. In the exercise of these qualities the inspector should know whereof he speaks: he should be sure that the knowledge of his subject is pre cise. Glittering generalities sound well, but they do not leave as deep an impression on those he seeks to guide as do simple instructions given in a manner at once kindly and convincing, which seems to invite rather than compel cooperation. In this connection too much stress can not be laid upon the importance of demonstration and memoranda. Whenever possible, resort should be made to object les sons, and written instruction expressed in the simplest phrases should be given, because, however well intentioned, people will forget, and the mere fact that they are being called upon to do something strange or unusual fosters that unfortunate trick of the mind— forgetful- ness. The need of patient repetition will be realized when the well- nigh universal resistance to any change from an old order of things which has become the habit of life is taken into account. People get into a groove and the older they grow the deeper that groove be comes and the harder it is to get them out of it. Because they have 18 BELL—SANITARY INSPECTOR OF THE COMMUNITY. Vol. XVIt done a particular thing a certain way for years they rebel against having a new way of doing that same thing imposed upon them. For this and other reasons the credulous person will not accom plish much. Deception will be met with daily in almost every branch, of the work, and the inspector must be observant, critical, accurate, and thorough. Nor does the " cocksure," self-opinionated individual usually go very far. It is necessary for the inspector "to keep an open mind as to the methods of work and to look out for opportuni ties of learning from those engaged in the various branches of social service as well as from others in his own profession. A constant effort will have to be made against becoming stereotyped in either methods or ideas, and the public-health worker, above all others, needs to remind himself frequently that the work of his department, important though it is, is only part of a great endeavor which is: being made in many directions, by multifarious agencies, toward social amelioration. If, therefore, the inspector is to be saved from- isolation and incompetency, he must contrive to keep in touch with other agencies, learn their aims and methods, and look out for every opportunity to cooperate." Furthermore, the inspector must be self-controlled. An " easy-go- ing" person will never make progress, but a bad-tempered person will always be getting into difficulties and stultifying the effect of work which otherwise might have been valuable. There i& ample cause for annoyance and irritation. Indeed, "the inspector may look for any sort of treatment —quiet patronage, insolent opposition^, irritable impatience at disturbance, a quiet acceptance of inspection as one of the ills of life, or a marked anxiety to please." His tem per must be controlled throughout, and an endeavor to see the point of view of the one responsible for the condition or property under inspection will make compliance with this injunction easier. "It is: by no means a pleasant thing to be inspected. The interruption alone is a serious annoyance to a busy person and the very fact of possess ing the right of entry should make the official all the more careful to treat the occupier courteously and respectfully. This is quite com patible with a quiet dignity. In most cases the work can be car ried out without friction if this is borne in mind. It is not always- easy for an employer to keep discipline among workers, and the dif ficulty will be increased if an inspector walks into a premises as if' it belonged to him and speaks autocratically to the occupier before the workpeople. It is always best to act as if it were taken for granted that everything would be found in due order. The major ity of occupiers err through ignorance, or carelessness, or press of " work, and are often quite unable to grasp the necessity of the legal-: standard." No. 1. BELL—SANITARY INSPECTOR OF THE COMMUNITY. 1$ Again, no one who is dependent upon direct orders as a basis for his activities will ever "get through more than 'jog-trot' routine work." Success in the office demands initiative and resourcefulness for situations constantly arise requiring action without opportunity for reference to higher authority, and the inspector can not afford to appear incompetent in emergencies. Serious trouble can often be averted through quick decision and rapid action, and failure in this direction may also lower the service in the eyes of the public. Not only are the requirements exacting as regards the tempera mental make-up of the individual, but the need " for good health must be emphatically emphasized. The work is extremely hard ; it involves a mental as well as a physical strain and makes demands upon the strongest." Mere freedom from organized disorder is not enough. Finally the disposition of the inspector should be such as to teach by example as well as precept. The development of a health con science in the public is a progression hoped for as an asset to public- health organizations—to the inspector in facilitating his work— and every sanitary inspector should be a nucleus of enthusiasm for the health propaganda and spread an understanding of its principles throughout his district. But in doing so he must remember that acts speak louder and carry greater force and conviction than words. His own personal appearance and the conduct of his own life and surroundings must therefore illustrate his advice. As regards general education and special training, others have spoken and will speak. This phase of the question of fitness was not contemplated in the discussion planned for this paper other than to touch upon the need, as has already been done, for a wider insist ence upon the degree of fitness represented by a certificate or diploma on sanitary sciences. It is perhaps sufficient to say here that, both in general and technical education, the highest is none too good if the inspector is to be able to enter intelligently into the wider aspects of his work and is to perform satisfactorily the various duties that may be properly imposed upon him, to say nothing about the im portance of well-written letters and reports, an understanding of statistics and usefulness of a working knowledge of languages other than his own. " It is certain also that every public-health worker will be called upon sooner or later to speak in public. It may be only to give a 'friendly talk' to a mothers' meeting, but even this is no simple matter if it is to be given well, for simplicity and conciseness are rarely combined with a limited capacity." It is incumbent upon all sanitary inspectors to see to it that the possibilities of their profession do not fail of realization because of 20 BELL—SANITARY INSPECTOR OF THE COMMUNITY. Vol. XVII. their neglect to inform themselves of the advances made in sanita tion.. They must always do the best they can. Well enough is not sufficient. A mere show of enthusiasm and energy will not satisfy. To have no deeper interest, no higher ambition, than the accomplish ment of that which suffices to save him from censure by his superiors, exhibits an attitude of mind toward his profession which is bound to be barren of anything worth while and which in the long run will make his work a dull occupation. It is a safeguard to his own per sonal contentment and essential to his success that he thoroughly acquaint himself with both the theoretical and practical sides of his job and discern all the possibilities in his field of work. Probably the large majority of those men and women who are serving as sanitary inspectors in this country to-day have not had a practical course in sanitary science, but that handicap is not, and need not be, a serious impediment to success, nor should it have any other effect than to inspire a determination to learn by reading, ob servation, and otherwise, anything and everything that bears upon the profession. All those thus situated are in the same position as doctors and lawyers who, in the early days when there were few if any schools and many students, simply read medicine or law under the direction of a preceptor. At a certain period of the world's progress some of these men of the old order, so to speak, had, of course, to measure themselves with the product of scientific schools, and they did it creditably by just the process that is open to the sani tary inspector of the old order, or what is hoped will soon become an ohi order. In other words, it is the urgent duty of the sanitary inspector of this class to readjust his ideas to the fast-coming new order of things, and to place his services on the substantial basis of scientific knowledge. The need that all persons occupying the posi tion of sanitary inspector shall, by every available means and an un flagging acquisitiveness, improve their fitness for office is, of course, imperative ; but, on the reasoning that the process of rusting is more reprehensible than the failure to develop, the obligation to keep in touch with progress which rests upon those who are happy pos sessors of scientific training as a background, is as vital as self- preservation. As intimated above, in the last analysis the tell-tale of the efficiency of the sanitary inspector is the health of his district. By this I wish to be understood as referring to the relation of his work to that of the doctor. The sanitary officer precedes in the field, and it is only where his failures crop out in relation to preventable diseases that the doctor steps into the breach. The sanitary inspector should be and is coming to be, more and more, a valuable accessory for the dissemination of sanitary gospel and, in addition, he stands ready Xo. 1. 21 BUNKER ACID-BASE EQUILIBRIUM. to ameliorate the situation where preventive efforts have failed, but the sanitary inspector must square himself with his conscience and with the public and with his chief that he has honestly and faithfully done everything that was humanly possible in the circum stances to prevent the demand for the doctor's healing assistance. ACID-BASE EaiJILIBRITJM. By C. W. O. Bunkeu, Lieutenant Commander, Medical Corps, United States Navy. Fourteen years ago Ewing reviewed the question of acidosis. Since that time our conceptions have undergone profound modifications, and Haldane, Haggard, Henderson, and Van Slyke have figured prominently in this development. I have drawn largely upon their writings for this article. At that time acidosis meant conditions showing increased amounts of acetone bodies in the blood (ketosis) or in the urine (ketonuria), usually accompanied by increased ex cretion of ammonia. We now, however, recognize the deeper sig nificance of this ketosis, i. e., that the body is robbed of its bases, and extend the term acidosis to include conditions in which other factors produce such a result. Moreover, we now realize that acidosis is but a particular phase of disturbance of the acid-base equilibrium of the body. Van Slyke restricts acidosis to a condition caused by acid retention sufficient to lower either the bicarbonate or the pH of the blood below normal limits. Work of the past five years has demonstrated the necessity for a broader vision, and we must conceive nine clinical phases of acid-base equilibrium, determined by high, low, or normal bicar bonate in the presence of a high, low, or normal pH. The pH of the blood may be considered the danger signal—as long as it is normal the acid-base equilibrium is normal or compensated ; otherwise, it is uncompensated and life is seriously threatened. The normal pH of the blood may be given as 7.3 to 7.5, each individual, however, having narrower limits. That of blood serum is about 0.2 higher, and that of the other body fluids (not the excretions) prob ably closely approximates and promptly follows any change in that of the blood plasma. Variations to the acid side may, for a short time at least, be as low as 7, although not much lower without fatal results; 7 is considered as the point where coma occurs. Variations to the alkaline side {alkalosis) beyond 7.8 are accompanied by symp toms of tetany, although one is not at present justified in assuming that all tetany is either caused or accompanied by alkalosis. So the extreme range of reaction compatible with life probably lies ap proximately between pH of 7 and 7.8. 22 Vol. XVII. BUNKER ACID-BASE EQUILIBRIUM. The hydrogen-ion concentration (or its derivative, pH) of the blood varies as the ratio between the concentrations of dissolved carbonic acid and bicarbonate (generally indicated by rfflJQQ 1 in which B represents the metal, such as Na, K, etc., in the bicarbon ate), i. e., a relative increase in the H2C03 increases the hydrogen-ion o o o ▼ n t* — *03%sinmoA concentration (CH+) and lowers the pH, and vice versa. A full ap preciation of the significance of this ratio is the basis of an intelli gent comprehension of acid-base equilibrium. The accompanying chart (modified from Peters, Barr, and Rule, and Van Slyke) is a graphic representation of essential facts in acid No. 1. 23 BUNKER—ACID-BASE EQUILIBRIUM. base equilibrium. Ordinates represent total C02 (content, which com prises that in simple solution and that as bicarbonate) of whole blood in volumes per cent, and abscissae the millimeters C02 tension in the blood as withdrawn. The line OT gives the proportion of total C02 present in simple solution. pH values are shown by the lines OL, OM. etc. The extreme normals for carbon-dioxide-absorption curves are OP and OE. These curves are obtained by plotting the total C02 of whole blood after being drawn and equilibrated with dif ferent percentages (tensions) of C02. The intersection of such a tune with total C02 value of the blood as drawn would give the C02 tension in the blood and also the pH. The actual state of the acid-base balance can only be determined by the use of any two of a number of interdependent variables, such as total C02, C02 tension, pH, H2C03 concentration, other buffers than bicarbonate, plasma chloride, ratio of oxyhemoglobin to hemoglobin, etc. Findings that fall within -ABCD and at about 40 millimeters tension indicate a normal equilibrium for the resting individual at ordinary altitudes ; or, such a normal would be a total C02 of about 49 (43-56) volumes per cent for whole blood, and 50-65 volumes per cent for plasma. The normal for the individual falls within nar rower limits. The C02 tension of alveolar air may be the same or vary as much as 20 millimeters below, while that of venous blood will be about 6 (0.8-10) millimeters higher than that of arterial blood. So, although the C02 tension in alveolar air is usually approximately that in arterial blood, it is not an accurate measure of the latter, being dependent upon the extent to which pathological processes may influence ventilation of alveoli or alter their walls so as to impair diffusion, etc. The "C02 capacity (combining power)" of plasma may be as much as 15 volumes per cent more than the total C02 of whole blood. The ratio, , is influenced by many factors, of which the following is an analysis. To increase or protect bicarbonate : 1. Administration of same. 2. Loss of gastric HC1 caused by obstructing the pylorus, and regularly washing out the stomach for some days. 3. Processes indicated by increased excretion via the urine of ammonia (probably diverted from urea formation) and titrable acid (including buffer acids, such as acid phos phates) . 4. Possibly a shift of HC1 to the tissue cells from the plasma like that from the plasma to blood cells. 24 Vol. XVII BUNKER ACID-BASE EQUILIBRIUM. To decrease bicarbonate: 5. Acid substances. (a) Increased production. (b) Decreased elimination. (<?) Administration of same. 6. Diuresis, and elimination via the urine. 7. Lack of factor three above. 8. The hyperpncea of oxygen want. To increase carbonic acid: 9. Administration of same. 10. Impaired diffusion in the alveoli of the lungs. 11. Slowing of respiration. To decrease carbonic acid: 12. Hyperpnoea. (a) Voluntary. (6) Due to disease processes. (c) Due to low oxygen content of air. (d) Emersion from warm water. 13. Low atmospheric content of C02. If either the H,CO, or bicarbonate vary from normal values, there is apparently an effort on the part of the body to adjust the other so as to maintain at least a normal pH (compensation). This is ac complished by respiration, or by diverting alkali from, or recalling it to, the blood stream. In the chemical complex presented by the body fluids, the C02, or H2C03, is the easily variable factor, at the same time activating and being itself regulattd by the respiratory center. The latter is extraordinarily sensitive to the slightest altera tion in the reaction of the blood toward the acid side. C -f- is, so to speak, the hormone of respiration. Normally, the bicarbonate (represented in the ratio by BHCOs) is maintained at a definite level, so much so as to be a physiological constant (more so than temperature or osmotic pressure). In case the respiratory control of H2C03 is inadequate to maintain a normal pH, some bicarbonate will disappear from the blood stream if the [ILC03] is diminished. A relative increase in [H2C03] recalls bicarbonate to the blood stream, or an increase of the latter is effected by the hemoglobin as noted below. Such is the normal mechanism by means of which the constancy of the ratio, and, consequently, the pH, is preserved. Another powerful factor, however, also aids in the control of the pH of the blood, i. e., the buffers. Such substances in solution afford a high resistance to change in reaction —they tend to minimize the effect of added acid or alkali so that the pH is but little affected. The body fluids contain a mixture of such chemical substances that is probably as satisfactory as could be devised, being effective in colloidal as well as aqueous solution. The important blood buffers No. 1. 25 BUNKER—ACID-BASE EQUILIBRIUM. are bicarbonates in plasma and cells, proteins (especially hemo globin), and phosphates in the cells. The hemoglobin, in addition to its general buffer effect as a pro tein, is especially important since, by virtue of it and the reversible reaction H2C03+NaCl=HCl+NaHCOs, the erythrocytes not only control the [BHCO„] but also transport SO to 95 per cent (sometimes possibly all) of the C02 to the lungs. The HC1 passes into the cell and is probably held by the hemoglobin, although, when .the latter is overburdened, another buffer may be called into play, i. e. HCl+Na.HPO^Nall.PO.+NaCl. The relatively slight remainder of alkali necessary for transporta tion of the rest of the CG2 is supplied by the other buffers, i. e., cell phosphates, plasma proteins, and bicarbonate. In the lungs, the C02 is excreted and NaCl reformed. The acid phosphate would be ex creted in the urine. This ability of the hemoglobin to form bicarbonate is important, inasmuch as it not only aids in the regulation of the [HX'O,] : [HHC03] ratio, but also because the corpuscles can thus conceal 5 to 10 times as much acid as the plasma bicarbonate can ordinarily neutralize. Moreover, by so controlling the acid, H2C03, itself, the hemoglobin enables the cells to use their reserves of buffer alkali to maintain a constant pH in the plasma. The numbered regions of the chart are associated with various clinical conditions, e. g., tetany from 1, 2, and 3 ; the acidosis of dia betes mellitus. nephritis, or infantile marasmus with 6 or 9; pneu monia, morphine narcosis, and breathing of air containing 3 to 5 per cent C02 with 7 or 8; emphysema with 4: some cardiac cases with 9; overdose of bicarbonate with 1 or 4; fever with 2; as the re sult of high altitudes, 2 or 3, or, when acclimated, 6: shock (handling of the intestines), deep ether anesthesia, and carbon-monoxide as phyxia with lowered bicarbonate. Relative to these areas, I will further brief a recent article by Van Slyke, and refer to the factors influencing the [H2C03] : [BHC03] by their numbers in the analysis above. Area 1 is uncompensated alkali excess. Factors 1 (overdose) and 2 will produce it. It will be accompanied by compensatory factors, such as 6 (may excrete several grams bicarbonate per hour), 7 (titrable acid may become a negative quantity), and 11. Areas 3 (partial compensation) and 2 cover uncompensated carbon- dioxide deficit, 2 representing the first result of lowering the [H2C03] in the blood by a respiratory stimulus other than either the blood hydrion or the [H2C03]. Genesis, factors 12 a, c, or d. Compen 26 Vol. XVII. BUNKER ACID-BASE EQUILIBRIUM. satory, factor 6 (only a fraction of a gram of bicarbonate excreted per hour) , and retention of acid metabolites as shown by factor 7. Area 4 is compensated alkali excess or carbon-dioxide excess. Genesis of former, factor 1 (the moderate overdose orally adminis tered, which usually is not absorbed rapidly), and as entire compen sation for area 1. Genesis of compensated carbon-dioxide excess, factors 10, possibly 4, and as entire compensation for area 7. Differ ential diagnosis, compensated carbon-dioxide excess is associated with cyanosis, either permanent or caused by slight exertion. Area 5 is the normal for the resting individual in health at ordi nary altitudes. May be final compensatory result from adjacent areas. Area 6 is compensated alkali deficit or carbon-dioxide deficit. Genesis of former, factors 5 a or b. Compensatory for former, fac tors 3 or 12 b. Genesis of latter, factors 12, 13, and as entire com pensation for area 3. Compensatory for compensated carbon-dioxide deficit, factor 8. Areas 7 (partial compensation) and 8 are uncompensated carbon- dioxide excess. Genesis, factors 9 (air with 3 to 5 per cent CO,), 10, and 11. Compensatory, factors 3, 12, and probably 4. Area 9 is the premortal uncompensated alkali deficit. Genesis, from area 6. Normal metabolism results in the constant formation of acids (H2C03, H2S04, H3P04, etc.). H2CO„ is probably the most im portant, being one of the chief end-products of catabolism of car bohydrates, proteins, and fats. Fats and amino acids give rise to fatty acids, the process normally terminating in butyric acid. These acids react with the alkali (fixed bases) of the tissues, and are ex creted as salts of Na, K, Ca, Mg, etc. The animal body furnishes the curious anomaly of alkaline tissues eliminating acid excretions (principally C02 from the lungs and acid phosphates from the kid neys). So beneath all metabolism is a constant diminution of alkali, notably blood bicarbonate. Unless this depletion is repaired, acidosis develops. Normally, of course, the alkalis are restored by the food. This, however, is not the entire story of the blood alkali. Haggard and Henderson call such a diminution, i. e., as the result of acids, the acidotic process. They have also demonstrated that the bicarbonate may be varied in another manner, by the acapnial process. In the latter, variations in [H2C03] automatically divert bicarbonate from, or recall it to, the blood stream, as noted previously, in the apparent attempt to preserve the [H2C03] : [BHCO„] ratio and thus a normal pH. " Various influences and conditions excite the respiratory center through agencies other than increase of hydrogen-ion concentration. This results in overbreathing and an excessive elimination of carbon dioxide which leaves the blood abnormally alkaline. A gradual com No.1. 27 BUNKEK—ACID-BASE EQUILIBRIUM. pensatory disappearance of alkali from the blood follows." Slowing of respiration will tend to produce an acidosis by reason of retention of HjC03, and alkali will be recalled. So, an alkalosis may be a com pensatory effort, just as, under such conditions, an acidosis may be a restorative process. The acidotic process above may become accentuated in disease by reason of the presence of acid substances in increased amount. This is due to increased production (or ingestion) or to decreased elimina tion. Ketosis is the important example of acidosis due to abnormal formation of acid substances, while retention of acid phosphates is that of decreased elimination. In both cases, the body is robbed of its alkali. As regards lactic acid, it is very ineffective in the pro duction of acidosis, and Haggard and Henderson say, "It is im probable that such a condition as 'lactic acid acidosis' ever occurs in life. An increase of lactates in the blood or urine is probably an indication, not of acidosis, but of low ratio of H2C03 : NaHC03 ; that is, alkalosis." Fats normally are oxidized to butyric acid. When, however, there is a deficiency of, or lack of proper tolerance for, carbohydrates this oxidation is incomplete and defective, and acetone bodies (acetone, diacetic acid, and fi-hydroxybutyric acid) are formed in increased quantity. Normally there is a slight but definite produc tion of acetone bodies. To prevent ketosis, one molecule of carbo hydrate must undergo combustion for every three molecules of higher fatty acids. Acid neutralization normally results in the production of acid phosphates (such as NaH2POJ from basic phosphates (such as Na2HP04). The former are then excreted by the kidney, and consti tute about 90 per cent of the phosphates in the urine. Pathologically and probably as the result of impaired kidney function the acid phosphates are retained. I have indicated above the means by which the organism meets the attack of acids upon its alkali, viz, respiratory control of C02, hemo globin control of bicarbonate, the action of buffer substances, and ingestion of alkali in food. The average total alkali of normal human blood available for the neutralization of invading acids is equivalent to 63 volume per cent of bicarbonate C02, of which 46 volume per cent belongs to bicarbonate alkali and 17 volume per cent to the other buffers (mostly hemoglobin). Buffers from the tissues or other body fluids also become available in extreme cases. The bicarbonate first meets the onslaught, and it will maintain a normal pH until reduced to one-fourth (perhaps even to one-eighth) of its normal value. If, nevertheless, the pH falls (and only then), the other buffers are used; and if it reaches 7 most of the remaining bicarbonate becomes available. 103390—22 3 28 Vol. XVII BUNKER ACID-BASE EQUILIBRIUM. In connection with this defensive mechanism, ammonia must be mentioned. Nash and Benedict present strong evidence to the effect that there is probably less NH3 in the blood than usually believed, and also that it, as well as the urinary NH3, is the product of an active synthetic function of the kidneys themselves. They believe that the " kidney, instead of excreting NHf from the blood, forms the NH3 Avhich it excretes, while at the same time it contributes a small amount of NH3 to the blood." The source of the NH3 may be the blood urea, or, possibly, from deamination of amino acids. Such NH3 is available for the neutralization of acid radicles only as they are excreted, and, in such neutralization, alkali is preserved for the blood. With impaired kidney function the result might be a reten tion of acid radicles or defective NH2 formation. The former would deplete the alkali reserve; the latter would permit excessive loss of base during excretion of the acid. The acid-base equilibrium of the body, then, is controlled by a mar- velously sensitive mechanism that constantly and automatically en deavors to preserve a normal alkali reserve and a normal pH. Fail ing in the former, it at least functions to maintain compensation (a normal pH). if possible. In dealing with pH values, one usually does not appreciate the extremely small magnitudes in question. It might be well to place the extreme range of reaction compatible with life (pH of 7 to 7.8) —not the lesser normal range of 7.3 to 7.5—in other terms. Thus, if life is to be preserved, the weight of hydrogen ion per liter of blood must not be more than one ten-millionth of a gram, nor can it be so little as one one-hundred-millionth of a gram. The appearance of acidosis in disease constitutes a serious compli cation demanding immediate attention. This is especially true for females and infants and children, because their plasma bicarbonate is normally lower than in men. This difference amounts to about 8 volume per cent CO, with women, and about 10 volume per cent C02 with children. I have already called attention to several clinical conditions asso ciated with disturbance of some phase of acid-base equilibrium. The acidosis in the cases of carbon monoxide asphyxia and deep ether anesthesia is the result of acapnial processes. We must also be pre pared for acidosis in terminal malignancy, starvation (whether the result of ulcer, malignancy, or otherwise), severe eclampisia, wood- alcohol poisoning, salicylate poisoning, and following chloroform anesthesia. Acidosis is usually present at time of death, and may be its immediate cause. The surgeon is particularly concerned with the influence of anes thesia upon acid-base equilibrium, as well as with the detrimental effect of acidosis upon convelescence. Ether causes a decrease Xo. 1. 29 BUNKER—ACID-BASE EQUILIBRIUM. of 4 to 17 volume per cent in plasma C02 capacity, and chloro form has an even more pronounced effect. In spinal or gas-oxygen anesthesia, the fall is but slight. Hemorrhage and shock accentuate the danger. The acidosis of diabetes mellitus is characterized by a ketosis, keto- nuria (as long as kidney function for acetone bodies is not markedly impaired), and increased ammonia quotient of the urine. The blood phosphates are not increased. Kidney function is commonly impaired in nephritis, and then there may be decreased elimination of acid radicles, and interference with the ammonia function. This change in function does not necessarily parallel that for chlorides or urea. The acidosis is largely due to retention of acid phosphates, figures as high as 23 mg. per 100 ml. blood serum being obtained for inorganic phosphates. There is also probably an increased production of acid radicles, although there is no ketosis nor material increase of lactic acid. The NH3 quotient is variable, as one would expect, and is of little clinical significance. Generally there is not even a moderately severe acidosis without con siderable nitrogen retention (a blood urea nitrogen of over 30 mg. per 100 ml. demands examination for acidosis) . All fatal cases with marked nitrogen retention show severe acidosis, sufficient to be the immediate cause of death. Acute nephritis may show a pronounced acidosis but no nitrogen retention. Acidosis is usual with a two- hour phthalein test of under 30 per cent ; with over 30 per cent, how ever, it is only found if there is severe toxemia, such as occurs in active parenchymatous types and in infections. Infants and children are especially susceptible to acidosis by reason of their normally low level of C02 tension and plasma bicarbonate, and, with them, it constitutes a very fatal complication. It may occur alone, or as the result of improper diet, or be a feature of other dieases, especially alimentary tract disturbances (diarrheas, cyclical vomiting, etc.), and pneumonia. It is said that infantile diarrhea with ileocolitis shows a marked ketosis. but, lacking the ileocolitis, the ketosis is only moderate and the acidosis is then due to phosphate retention. The acidosis resulting from ether is not only acapnial in origin l>ut often shows a ketosis. Ketosis may also occur in fever, malignancy, psychoses, and le sions of the central nervous system, delayed chloroform poisoning, liyperemesis gravidarum, inanition, cachexia, starvation, etc. Tiie symptomatology of disturbances of the acid-base equilibrium is well known. Alkalosis accompanied by tetany may be expected to present the symptoms of the latter, including carpopedal spasm, Chvostek's sign, Erb's sign. Trousseau's sign, etc. The classic evi 30 Vol. XVII BUXKEH ACID-BASE EQUILIBRIUM. dence of acidosis is Kusselmaul's air hunger—a respiratory disturb ance manifesting hyperpnoeic dyspnoea without cyanosis, perhaps even with an abnormally bright color of the mucous membranes. This hyperpncea is the best of all the signs of acidosis to be obtained by physical examination alone. Such symptoms, however, occur only with the severer degrees of disturbance of the acid-base equilibrium, and earlier evidence must be sought in the blood and secretions by laboratory procedures if timely intervention is to be secured. Van Slyke's resume above relative to different areas of the chart indi cates some points in diagnosis. Dyspnoea on exertion may precede the true hyperpncea. Van Slyke also calls attention to the fact that two variables are necessary for an exact estimate of the status of acid-base equilib rium, as noted above. But he furthermore states that the conditions (diabetes mellitus, nephritis, metabolic disturbances of infants, and most other pathological as well as normal conditions) most com monly examined in this respect usually present a normal pH, and, when only one determination is made, either the carbon-dioxide ten sion or the carbon-dioxide combining power of whole blood (pref erably) or plasma will suffice. With an abnormal pH, however, de termination of only one variable will be inadequate to accurately define the condition. Clinical methods comprise tests for whole blood or plasma C02 or bicarbonate, alveolar CO, tension, bicarbonate (soda) tolerance, pH of blood or urine, Sellard's test, NH3 quotient of urine, or presence of abnormal acids (particularly acetone bodies) in blood or urine. The first two methods are the ones of choice, particularly the first, as by it one can estimate the reserve of the very important blood buf fer, bicarbonate, and its result closely indicates the total buffers. Free H2C03 is present in the body fluids in such concentration that it automatically converts into bicarbonate all bases not bound by other acids. The bicarbonate, therefore, represents the excess of base which is left after all the nonvolatile acids have been neutralized, and it is available for the immediate neutralization of further acids. In this sense, it constitutes the alkali reserve of the body. The en trance of free acids reduces bicarbonate "to an extent proportionate to their amount. The determination of plasma bicarbonate (C02 capacity, or C02 combining power) by either the gas or titration method of Van Slyke is not difficult. It may be considered the standard method, and the cooperation of the patient is not needed. Normal values for men were given as 77 to 53 volume per cent; 53 to 40 means mild acidosis without symptoms; 40 to 30, a moderate to severe acidosis, possibly with symptoms; less than 30, severe with symptoms; 20 is osually fatal. Xo. 1. 31 BUXKER—ACID-BASE EQUILJBKIUM. The alveolar C02 tension is a practical measure of the blood bicar bonate, but the cooperation of the patient is desirable. The sample of expired air obtained at the end of a full expiration after a normal inspiration should approximate the C02 tension in the arterial blood, although, as already noted, it may be on occasion as much as 20 millimeters lower. One obtained by rebreathing is closer to that of venous blood. Results are affected by manjT conditions, e. g., pathological processes, especially pulmonary and advanced cardiac disease, drugs, emotion, atmospheric conditions, position of the body, digestion, etc. The tensions in infants is 3 to 5 millimeters lower than in adults. For the latter, 40 to 45 millimeters is normal, 30 to 35 in dicative of mild acidosis, 20 millimeters means imminent danger, and 8 to 10 may be observed in coma. The tolerance for bicarbonate is a very convenient and practical measure of acidosis, and means the dose of sodium bicarbonate re quired to produce a urine alkaline or amphoteric to litmus. A normal finding is 5 to 10 grams ; 20 is required with a mild ; 30 to 40 with a more severe ; and more than 40 grams with extreme degrees of acidosis. In coma, it is usually impossible to produce an alkaline urine. Kidney function does not interfere with bicarbonate excre tion, and tolerance is the result of a need for fixed bases. Determination of the pH is clinically unsatisfactory, especially in the urine where it is particularly unreliable. In the blood, the change is small and late, and results lack uniformity by reason of the technic. Titration does not measure hydrion, and is unsatis factory as the proteins interfere with a clear end point. Certain changes in the urine are recognized and acceptable as indi rect evidence of acidosis, but they are not synonymous and are de pendent upon renal integrity and other factors for constancy. These comprise acetone bodies, NH3 quotient, and titrable acidity. The last is of no real service clinically, and it must be borne in mind that acetone bodies are not necessarily present in, nor is the NHS quotient necessarily affected by, acidosis. The changes neither parallel the severity of acidosis, nor measure the efficiency of compensatory processes. They have diagnostic value, but are not safe clinical guides otherwise. tennined and upon a mixed diet, is normally about 5 per cent. Values of 10 to 40 per cent occur in acidosis. It may be increased by diet, disturbances of protein metabolism, ammoniacal fermentation, etc., and there may be no increase in certain diseases with acidosis. It is said that the NH, parallels the acetone bodies, and is a better measure of ketosis. The ammonia of urine, as usually de- 32 BUNKER ACID-BASE EQUILIBRIUM. Vol. XVII Acetone and diacetic acid have the same clinical significance: a progressive increase gives a grave prognosis, and it is generally con sidered that the presence of (3-hydroxybutyric acid indicates greater severity. It is well to bear in mind that the sodium nitroprusside tests for acetone are really delicate tests for diacetic acid. But as these substances have the same significance, it is wasted effort to attempt to clinically differentiate them. It is said that the kidneys do not excrete acetone but do diacetic acid, the latter changing into the former in the urine, which, when freshly passed, contains about 10 times as much diacetic acid as acetone. More acetone forms as the urine stands. The qualitative test for acetone bodies in the breath is sensitive, and yields positive results earlier than Gerhardt's test on urine. Moreover, it is useful when impaired kidney function pre vents excretion of acetone bodies via the kidneys. One might men tion in passing that the sweetish odor in such a breath is not due to acetone, but to some associated unidentified substance. Intelligent treatment demands a recognition of the etiological factors involved. With acidosis, is it acapnial or acidotic in origin '( In general, the former calls for administration of CO„. and the latter for bicarbonate ; the use of the wrong one is dangerous. The former is employed as a 6 to 10 per cent mixture in oxygen. Mar riott and Haessler call attention to a point that may have therapeutic bearing. With phosphate retention, the calcium in serum may be decreased to 1.5 mg. per 100 mils. Administration of phosphate causes an increased elimination of calcium via the feces, and the converse is also true. Bicarbonate (sodium bicarbonate) seems especially efficacious in conditions associated with phosphate reten tion. It is now about a decade since Sellards obtained his brilliant results in the acute nephritis of cholera, and since Fischer advised alkalinization in similar conditions. Bicarbonate is less effective in the presence of ketosis. Glucose is indicated in conditions with ketosis due to carbohydrate deficiency, providing the organism can assimilate it. The administration of bicarbonate is best controlled by estimations of the plasma C02 capacity; 0.5 gram NaHCO., per 19 kilograms body weight will raise it 1 volume per cent. Palmer, Salvesen, and Jackson recommend its oral administration (nausea is a contra indication) in 100 mils of water every 30 minutes, using 2, 5, and 10 grams as the dose in cases showing plasma C02 capacities of over 50, 40 to 50, and less than 40 vplume per cent, respectively. For more severe acidosis they advise administration every hour. The effect is determined by blood examinations, the frequency of which they lessen by following the pH of the urine colorimetrically before each dose. An increase of 0.3 to 0.4 in the pH calls for a determination of plasma bicarbonate. The more usual procedure, however, is to No. 1. 33 BUNKER ACID-BASE EQUILIBRIUM. stop the bicarbonate when the urine is alkaline or amphoteric to litmus. Methyl red is a better indicator for the urine than litmus in that, by ceasing administration when the urine produces a yellow color with methyl red, one lessens the danger of overdosage. Relative to the administration of bicarbonate in treatment, there is now a decided reaction against the use of injudicious amounts, by reason of the danger of alkalosis. There is a tendency to employ it only in decompensated acidosis, and certainly to control it by estimations of the plasma C02 capacity. It is distinctly contra- indicated in conditions with a low plasma C02 capacity due to acapnial processes. L. J. Henderson states that any attempt to treat a disease like nephritis by the indiscriminate administration of large amounts of alkali is malpractice. Small amounts over a long period are justifiable and make acidosis impossible. In most pathological cases, the urine does not become more alkaline than the blood until the plasma bicarbonate is above normal. Therefore, reliance upon a urine alkaline to litmus may involve the use of unnecessary and possibly injurious amounts of bicarbonate, and erroneous deductions as regards the severity of the acidosis. In surgery, as noted above, evidence of even slight acidosis should be corrected prior to operation by the administration of bicarbonate. Frank states that the patient is not in the best possible condition to undergo any surgical procedure when he has a blood pH of below 7.35, an alveolar C02 tension below 35 millimeters, or a soda tolerance test above 15 grams. One should add a plasma bicarbonate under 53 volume per cent C02. Women and children should be especially considered in view of their normally low alkali reserve. For the very depressed condition following prolonged etherization, Haggard and Henderson recommend the use of the C02 mixture noted above, as it induces hyperpnoea, helps remove the anesthetic, and restores the plasma C02 and bicarbonate. Alkali is of only minor value in the acidosis of diabetes mellitus Its effect is temporary, being often lost in a few hours, and heroic injections are often required. It is of definite value only in long and stubborn acidosis, or to combat coma in certain severe cases. Twenty-five grams in 5 per cent solution may be used intravenously for impending coma. Death is not necessarily caused by the reac tion of the blood, for alkalinization may keep it normal, but the patient may die in coma with typical ketosis. The ketosis is better controlled by other methods, especially periods of fasting alternating with periods of properly adjusted diet, combined with rest and warmth. Fasting is more apt to be followed by acidosis in a normal person than in a diabetic. The ketosis is not necessarily due to lack of carbohydrates, but, perhaps, they do the most to control it by insuring proper oxidation of fats, and the rates of protein 34 NEUBERGER —AVIATION MEDICINE IN TJ. S. NAVY. Vol. XVH. and fat metabolism must be lowered to meet that of carbohydrate. It must not be forgotten that proteins yield 48 to 80 per cent glucose in metabolism, depending upon the variety. As with all methods of treatment, acidosis is more to be feared than hyperglycemia, but especially with the Allen method. The plasma bicarbonate should be closely followed, and, with the Allen treatment, a certain drop is permissible before interruption of the fast. With an initial plasma C02 capacity of 77 to 53 volume per cent CO., a drop to 45 is allow able : with 53 to 40, a further drop of 5 to 10 volume per cent ; with 40 to 31, a drop of 2 to 3; with less than 31, interrupt the fast in 6 to 12 hours unless the value rises by reason of the fast and alka linization. Alkali is of real value in nephritis, especially in acute types. Even in the chronic or in the uremic cases, it affords at least much symp tomatic relief. Sellards separates the frankly parenchymatous types as having a very low bicarbonate tolerance, small doses often pro ducing an alkaline urine ; and one should be careful in any attempts at alkalinization in such cases, as they may react violently. With the other types, the effect of a course of bicarbonate lasts for a com paratively long time, a normal response occurring after possibly even weesk. Acidosis itself is not infrequently the immediate cause of death in the nephropathies. As regards infants and children, restortaion of bases may produce a normal blood bicarbonate and alleviate hyperpncea, but the child dies nevertheless. Alkali gives good results with older children, but an acidosis once established in infants may result in death despite it. It is, therefore, desirable to begin alkalinization even before acidosis is demonstrable. Rapid action should be sought, and any method may be used, although a 4 per cent solution intravenously is considered preferable ; the alkali is administered until the usual urine reaction is obtained, and even 10 grams per 24 hours has been given to an infant aged less than one year. With ketosis, no glycuresis, and a normal blood sugar, give glucose. One should also administer much water. AVIATION MEDICINE IN THE UNITED STATES NAVY. By J. F. N'euberger, Lieutenant, Medical Corps, United States Nary. HYGIENE OF THE AVIATOR. As has been repeatedly stated, aviation medicine has as a primary function the task of keeping the flier physically and mentally fit. When the United States entered the war medical officers had had little opportunity to study the effects of continuous flying on the airman. It was soon realized that the ordinary standards of fitness Xo. 1. NEUBERGER —AVIATION MEDICINE IN U. S. NAVY. 35 for the regular officers of the line and staff of the Army and Navy were not applicable to the aviator. The first aim of the leaders in aviation medicine was to determine standards of fitness required in air work and to find an explanation for the physical and mental deterioration observed among aviators. The Army early recognized the necessity of keeping their fliers in the pink of condition and physical directors were provided for the various training fields of the air service. These physical direc tors cooperated with the flight surgeons not only in keeping the men in the best condition possible, but also in teaching them how to in crease their natural strength and endurance, to sharpen their powers of alertness and to obtain quick, cool action, and muscular and mental coordination. These physical directors did wonderful work during the war and were in no small way responsible for the excellent work of the air service in the armies of the Allies. In the Army's publication, Aviation Medicine in the A. E. F., it is stated that experience has shown that in sports, in which the sub ject is undergoing great physical and nervous strain, the period of efficiency is limited. It is impossible to fix the exact duration of this period. It depends upon the physical endowment of the subject and the care he gives his body. However, each athlete has his day, some lasting only a short period, some for months or even years. The strain in aviation, especially in war times, demands more of the human mechanism than any other sport. It also follows, therefrom, that the period of efficiency is limited. The exact duration of this period will depend upon the effort demanded from the subject, the condition under which flights are made, and above all, upon the mode of life of the aviator. The necessity for health comes from the fact that the aviator has need of all his physical energy and intelligence. Flying is a question of an active- well-balanced, decisive mind, and of quick reflex actions. Not a thing can be left to chance. Every flier must quickly recognize the slightest difficulty with his machine. His senses must give him accurate information of changes in the rhythm of his motor, of the sing of the air across the wires of his machine, and of his position in space. He must be master of his impressions and be ready to make prompt decisions in a calm, cool manner. His correcting movements should be made with precision and without exaggeration. It is clearly recognized that the aviator's reaction to stimuli are disturbed by disease, worry, fatigue or after excesses. A delay of a second or a part of a second in correcting an error in the air or in landing mean all the difference between a crash and safety. Excellent physical condition permits the body to react with more adequate compensation to altitude and cold. Hygienic living is necessary to keep the body and mind in good condition. 36 NEUBERGER AVIATION MEDICINE IN U. S. NAVY. Vol. XVII Sleep is most important. Firm-nerved men become vacillating and irritable on account of lack of sleep, and are quick to take offense. Troubles that would be laughed away by rested men are magnified by sluggish brains. Eight hours of sleep is a good average. A few men seem to be able to do efficient work with seven hours or less. Edison is one of these. It is said Napoleon was another. But it is known that Napoleon in his later years showed a loss of energy due to accumulated fatigue, as he often dropped asleep in the midst of important matters. To get the sleep one needs, often takes courage, the courage to refuse the invitations of pleasure. It is believed that lack of sleep is responsible for many minor illnesses, because it lowers the vitality or resistance of the body, thereby increasing its susceptibility to infection. Alcohol. —The alcohol problem, despite prohibition and many opinions to the contrary, is still a grave one. The consequences of drinking are too well known to every one to even be discussed, except to show that too much indulgence in alcohol has been the cause of the loss of many a good flier to the service. It is often claimed, however, by aviators that a man can fly better when slightly under the influence of alcohol. The writer's experience, however, does not confirm the above statement. Excessive alcohol will remove the sense of fear so that the flier becomes reckless and careless and does not use his best judgment in case of difficulty. Major Dunlap at the research laboratory, Mineola, has shown by experience that alcohol produces the same effect as high altitude or low oxygen. It is very easy for a pilot to lower his physical condition to the point of useless- ness by the constant use of alcohol. He may be able to fly, but he is not flying at his best. Clouded brains prove dangerous and are not fit to direct an air or sea plane. Smoking.— Smoking when carried on to such an extent as to cause nervousness, palpitation of the heart, faintness. or impair ment of vision must be curtailed. Most aviators smoke too much, and in talking to them about it they will all admit it. yet they keep on smoking. Excessive smoking makes the flier turn out of bed heavy of head and this in turn, together with lowered vitality, causes loss of enthusiasm in his work and has a tendency to break down his morale. Underwood and Reeves, in writing on " The ef fects of smoking on the visual acuity," state that one of the great est difficulities encountered in their work was that most of the workers are habitual smokers and^are never free from any such effects as smoking may have. This makes a control test, in the strict sense of the word, almost impossible. Such clinical disturb ances, both in vision and of other bodily functions, as have been ascribed by medical men to the use of tobacco have been held to be the result of long-continued use. Apart from the graver func No. I. NECBERGER —-AVIATION MEDICINE IN TJ. S. NAVY. 37 tional and anatomical disturbances there is a possibility that func tional depression, short of anything that might be held to threaten permanent disability, could result from continued smoking and be come fatal to the flier by reason of the exacting requirements of his work. Drugs. —Many fliers come to the hospital and ask for aspirin. It gives the medical officer a clue to the fact that the flier is not feeling well. Drugs do not render one fit, but only temporarily hide the symptoms of fatigue and illness. When the flier comes to the sick bay and asks for medicine, the medical officer has to handle him with a great deal of tact. If the medical officer uses his au thority and immediately places the flier on the sick list, the aviators will not report to the sick bay. being afraid that the medical officer will not allow them to fly. I have always made it a point to enter into a personal conversation with the flier and talk his case over with him and specifically ask him whether he thinks himself capable under his present condition to fly as well as he does on other days when he feels normal. He, usually, answers " No." By talking it over with him in this manner, he feels that one is only doing what is best for him and he himself usually suggests a relief from flying. Overeating. —It is a known fact that work in the air produces a very keen appetite and there is a great tendency to overeat. Over eating produces a sense of fullness and general sluggishness, con ditions which are not desirable in flying. The effects of overeating are particularly manifect after lunch, as a great deal of flying is carried on in the afternoon. The midday meal or lunch should con sist of a very light repast, sufficient, however, to supply the desired amount of energy. Eating between meals, as well as the constant or frequent eating of confectionery is not advisable. Physical exercises. —In the Army's publication. Aviation Medicine in the A. E. F., it is stated that physical exercise, judiciously em ployed will do much to secure physical fitness and serves to arrest the onset of staleness ; it will also put the body in condition to sus tain the compensations needed when flying at high altitudes. A man in good physical condition is much more resistant to altitude sickness than the physically " soft " man. The ability to endure high alti tudes is dependent upon adaptive changes in respiration, circulation, and the blood itself. The untrained individual breathes more fre quently and shallowly than the trained man whose breathing is low and deep. Shallow breathing does not ventilate the lungs effectively. The habit of deep breathing can be cultivated by ex ercise, but not so satisfactorily by voluntary effort. It is also known that at high altitudes, physical exertion makes a greater demand upon the heart than the same amount of work does at sea level. 38 NEUBEKGER AVIATION MEDICINE IN U. S. NAVY. Vol. XVII. Men in good physical condition can stand the strain on the heart better than individuals weakened by dissipation and fatigue. Con sistent physical work increases the percentage of hemoglobin in the blood. Capt. William L. Culpepper, United States Army, has shown that the hemoglobin and the red blood cells are temporarily increased in the aviator during flight, which is very advantageous at high altitudes. Exercises must necessarily be arranged according to the tempera ture and the weather. Mass athletics are very much desired, as foot ball, soccer, baseball, pushball, and basketball. Tennis, handball, and calisthenics are beneficial. General hygienic principles. —The general h\7giene of the airman scarcely differs from that of other sportsmen. As in the case of all other forms of exercise, the younger he is the better he will be able to adapt himself to it. Training in flying after the age of 32 is not recommended, although some men above this age have developed into good flyers. Airmen need regular intervals of rest. Some writers recommend three weeks' rest after four months' flying. It is believed a better method would be to give a rest after so many hours of continuous flying. At most air stations it is necessary for the pilots to stand officer of the day's duty. This necessitates making frequent inspec tions at night and being subject to call at all hours, and oftentimes the flier does not obtain the necessary amount of sleep. I can not too strongly recommend that any flying officer standing officer of the day's duty should be excused not only from flying but from all other duties the day following, in order to enable him to make up for the loss of sleep, thereby regaining his energy and putting him back to his nor mal physical condition. The writer knows of several instances in which crashes followed such a tour of duty and could only attribute them to a lack of the proper amount of sleep. The commanding officers of air stations should be made to realize the above facts. After all, for the flier, the danger is personal. His life is in his own hands. It is he who pays the penalty, irrespective of where the re sponsibility lies. Another point of importance in connection with the hygiene of the aviator is the attention to the needs of nature. It is desirable to move one's bowels and void urine before going up in an airplane in order to avoid, in case of fall, the rupture which may result from a loaded intestine or bladder. The cold of high altitudes leads to an increased formation of urine, and this causes distress unless relieved. Certain appliances for aviators have been designed with this point in view, which will be described in a later article. Clothing worn while flying should not fit too tightly. Clothing next to the skin should be made of wool, as this material counteracts No. 1. 39 BELLI—PERSONAL HYGIENE OF AVIATORS. most advantageously the loss of heat. A combination suit, fur lined, and fur-lined gloves and boots are very satisfactory as an outer cov ering. Frostbites, parching, and chapping of the skin, cracking of the lips, and dryness of the nose are often the result of flying in high alti tudes. These conditions can be prevented by applying an ointment of petrolatum. REFERENCES. Aviation Medicine in A. E. F. War Department, Document No. 1004, Office of the Adjutant General. Underwood, H. L. and Reeves, P. The effects of smoking on the visual acuity. Air Service Information Circular. Washington, D. C. Vol. I, No. 3, March 15, 1920. Culpepper, W. L. Blood changes in the Aviator. Mil. Surg., Vol. XLVIII,, page 180, February, 1921. PERSONAL HYGIENE OP AVIATORS. By Prof. C. M. Bnxi, Colonel, Medical Corps, Royal Italian Navy; Director Psycho physiological Division of Aviation, Royal School of Naval Military Hygiene, " A. Pas- qnale," of Naples. [Translated and condensed by Capt. J. S. Taylor, Medical Corps, United States Navy.] Aviation is comparable to no other form of endeavor and only partially resembles mountain climbing. The human organism is unlike that of birds and is not designed by nature for flight. Eagles and vultures have been observed at altitudes of 7,000 meters. Cigna, over a century ago, reported a swallow that resisted for more than half an hour a pressure of 229 milimeters, which is greater than would be endured at the summit of Mount Everest —a height of S.840 meters. The high development of the semicircular canals in birds ; and the air spaces in their bones and feathers, are features which enable them to confront the chemico-physical conditions of flight. Man's state is abnormal from the moment he leaves the ground until his return. There is diminished oxygen and low temperature at high altitudes, and the aviator experiences a change from stable to unstable equi librium as soon as he leaves the ground. He is aided by certain com pensatory actions on the part of the respiratory and circulatory organs. The respiratory rate is reduced; breathing is deeper and intermittent. There is an increase of blood pressure and the cardiac systole becomes more frequent. In no other form of human effort is the personal equation so strik ing as in aviation. The weak, cachectic, abnormal, those in a state of exhaustion can not support the variations of external physical agents encountered and must be prevented from flying. But even individuals who are sound in a psychic and physical sense show 40 BELLI PERSONAL HYGIENE OF AVIATORS. Vol. XVII. differences of reaction during flight : There are all shades of dif ference between the bird man and the one who can not rise a few meters above the earth without experiencing all the torments of hell. Psychophysiological examination usually helps to exclude those less fitted for aviation and liable to fatal accidents, but does not posi tively determine the individual reaction. A man's behavior under atmospheric rarefaction is only forecast by the pneumatic chamber. Somewhat as we judge our Alpine troops, the Americans attempt to classify aviators by the altitudes they can safely negotiate. 1. Those who can go to the highest altitudes. 2. Those who should not ascend above 5,000 meters. 3. Those who should not ascend above 2,500 meters. Intolerance of aerial flight presents itself in two distinct forms. One resembles the picture of the disturbances common to going to sea and develops at low levels —malaise, vertigo, nausea, and vomit ing. The second form, called altitude sickness, or aviator's sickness, appears at high altitudes, and the phenomena are serious and com plicated—headache, vertigo, cyanosis, roaring in the ears, impair ment of vision, respiratory distress, cardiac palpitation, syncope, somnolence, and sleep. The most pronounced symptoms concern the nervous system. The muscle sense is obtunded : muscular contractions are feeble and the psychic control of muscular movements is impaired. Visual acuity is reduced: likewise the peripheral field of vision. The shape and distance of objects is imperfectly perceived. Con centration of attention is reduced ; the will is enfeebled and absolute intellectual inertia develops. This impairment of the psychic powers acquires special significance from the fact that the subjects thereof give no warning of the change from a physiological to a pathological condition and go forth entirely unconscious of it to meet the dangers that threaten. The type of symptoms varies with the individual. Altitude sickness and mountain sickness differ in that the latter appears at lower altitudes, owing to increased oxygen requirements following muscular exertion. The sense of equilibrium, as in the case of sea goers, readily adapts itself after a few flights to the new positions of the body with reference to the outside world and disturbances of equilibrium grad ually cease to develop. But on the contrary man does not possess the power to become accustomed to altitude sickness in the sense of recognizing the symptoms, though there is some increase of toler ation for them. The statistics of the World War show that out of 100 milder casualties in the air, 2 were due to circumstances of battle, 8 to de fects of apparatus and motors. 90 to causes inherent in man. This Xo. 1. 41 BELLI PERSONAL HYGIENE OF AVIATORS. proves that the most important factor in successful flight is a per sonnel not only trained technically but, above all, physically adapted thereto. Flight must be restricted as far as possible to men physically perfect and endowed with the best psychic and physical qualities. Every government requires a severe test for the personnel of avia tion. The Italian Navy conducts its examinations through the psychophysiological bureau attached to the Royal Naval Medical School, Naples. Aviation, like athletics, involves great expenditure of nervous energy and, as in the case of sports, the capacity therefor is limited. Aviators after a continuous service of months or years show signs of incapacity and must temporarily or permanently be excused from further flight. The incapacity shows in a technical way by less able handling of the machine, especially in landings. In a medical way the incapacity is evidenced by tremor of the hands and eyelids, • insomnia, deficient muscular control, increased reflexes and psychic irritability. Nervous exhaustion is a not unusual cause of casualties, many of which may be ascribed to the fact that through false pride the exhausted ones have insisted in continuing a flight and paid dearly for their imprudence. Guynemer in his later period was nervous and irritable, in spite of which and despite advice to the contrary, he insisted on starting on that, last flight. The individual's constitution and his habits of life determine full capacity for flight. Incapacity' results from loss of sleep, excessive fatigue, sickness, and abovfl'till from nervous exhaustion following excesses. Such excesses —smoking, gambling, drink, and sexual in dulgence^—flow in part from a certain fatalism imposed by the . aviator's very calling. The authorities are not in a position to regu late the minor details of an individual aviator's private life. Hence the necessity that all concerned should appreciate the scientific basis for rules of health bearing on flight and the importance of a maxi mum of efficiency and a maximum of service. For successful flight, apparatus and motors must be in good order ; on his side the aviator must have a maximum of physical and moral energy. The human machine is fully as complicated and requires just as minute care as the airplane. HYGIENIC RULES. The function of preventive medicine is not fully accomplished by the mere selection of the fit and the elimination of the unfit ; but it must include preservation of forces. The cardinal rule is : Modera tion in all things. 42 BELLI —PERSONAL HYGIENE OF AVIATORS. Vol. XVII. FOOD. Food is important both as to quality and quantity. Abnormal digestion and constipation weaken both the physical and mental powers and predispose to altitude sickness. Flight sharpens the appetite and predisposes the aviator to eat heavily which is in jurious. The hours for meals are matters of importance. One should not eat heavily just prior to flight. (Less blood to brain; more to stom ach, predisposition to vomiting, nausea, etc.) The morning meal should be light and taken about noon, after the morning exercises. These exercises should not be resumed before 4 p. m. The principal meal of the day is best taken at night, when the work of the day is over. During flight, hot drinks from a thermos bottle (e. g., chocolate) and sweets are best. Between flights a sandwich, coffee, or a light ' broth containing a farinaceous ingredient (noodles, etc.) are bene ficial. REST AND SLEEP. Flights should not be too prolonged and should alternate with suitable periods of rest. When the aviator returns to camp, showing unusual fatigue, the rest period must be correspondingly prolonged, eight hours being the minimum period of sleep to restore him. CLOTHING. --• Clothing must be warm to protect against the cold of high alti tudes which favors discomfort and aggravates symptoms due to high altitude. But garments must not constrict the body. Under garments next to the skin should be woolen ; outer garments should be fur lined throughout. Fur-lined gloves for the hands and linen shoes lined with fur for feet add to the aviator's comfort. PERSONAL CLEANLINESS. Personal cleanliness is of special importance in the event of in jury so as to lessen chances of infection. A tepid shower or tepid bath is favored ; warm baths if prolonged and oft repeated are de pressing to the nervous system. EXERCISE. Physical exercise of a kind agreeable to the individual and not entailing unusual expenditure of nervous and physical energy is highly desirable. Stunts, athletic meets, and the like are objection able. Mountain climbing, sailing, swimming, and polo are the best pastimes. JfeL BELLI PERSONAL HYGIENE OF AVIATORS. 43 In the United States the training of aviators includes physical drills calculated to promote muscular coordination rather than mus cular strength, 'and to develop visual, acoustic, and static control. VISION. Perfect vision is as important to the aviator as to the mountain climber. Aviation involves ocular strain and in bright weather the ucess of solar rays dazzles the eyes and reduces vision. The high velocity of flight causes a current of air which tends to dry the con junctiva and cornea and all minute foreign bodies impinge on the eye with force and favor trauma and infection. The wearing of goggles is imperative. Usually, aviators dislike wearing them. Still the benefits of goggles largely compensate for some reduction of the field of vision and acuity of vision. Mica lenses have been recommended, through dread of possible injuries if crystal lenses should be broken. Mica is far less trans parent than glass and the danger of injury to the globe from broken eyeglasses is much exaggerated. Wilmer and Berens, during two years on the American front in France, saw only one case of eye injury due to broken glasses, but it was accompanied by general lesions serious enough to cause the death of the victim on the day following. The best goggles are made of crystals having at least 2 millimeters of thickness. The surfaces are plain and parallel. A pure white glass capable of transmitting 90 to 100 per cent of incident rays is commonly used, but it is better to use glasses with a slight yellow- 2reen tint to absorb short-wave actinic rays. These do not affect color perception and are a comfort in traversing snow fields, large bodies of water, and cloud strata. The lenses should be round or slightly ovoid, set in a metal frame, and retained by metal rods. They must be easily removable during flight, and the aviator should have spare lenses. The spectacles must be strongly made and easily taken off, with one hand only. All metal parts must be sheathed in leather or cloth to avoid frostbite. In order to protect the eye from frostbites the goggles must close hermetically over the orbits, even at the sides. This results in con densation of moisture and when temperature is below freezing a fine frost collects on the glasses which interferes seriously with vision. In some models the full protection is obtained by metal gauze at the sides to favor the escape of water vapor. It must be admitted that, to date, all types leave much to be desired from this point of view. 108390—22 4 44 BELLI —PERSONAL HYGIENE OF AVIATORS. Vol. XVII. THE EAR. Hearing and equilibrium are of the greatest importance in flight. The aviator must be able to determine by its rhythm the regularity of operation and the number of turns of his propeller. Also he must be able to estimate his position relative to the medium in which he is immersed. The care of the ear is therefore of immense importance. Accumu lations of wax must be prevented, since they interfere with vibrations of the tympanum. Further, there must be a balance between the outside air and the contents of the tympanum to prevent vertigo, subjective sounds, and pain, occurring when communication is inter rupted. The closure of the Eustachian tube becomes specially serious in connection with the rapid and powerful disturbance of balance between the inside and outside air as in hurried landings from high altitudes. Gradenigo, the high authority serving as consultant to the psychophysiological bureau at Naples, insists on full and constant patency of the Eustachian tube. He advises frequent acts of degluti tion during recompression, and even the Valsalva method of deep •expiration with mouth and nostrils closed. RESPIRATION. While respiration is automatic, still, within limits, it can be modi- tied by the will. This is not recommended. Aviators should be required to breathe through the nose, with the mouth closed, in order to moisten, warm, and filter the inspired air and reduce the pressure of the strong air current due to the velocity of the machine. This is also essential because the teeth are sensitive to cold. Mouth breath ing under these conditions parches the pharynx. Agazzotti advises holding a swallow of water in the mouth at frequent intervals. The nostrils must be kept clean. Flights should be forbidden if the nasal passages are obstructed. MENTAL STATE. Intellectual faculties and special senses are under a great strain during flight. When the psychic state is in good balance, flying is a source of pleasure. With the nervous system in perfect equilibrium, resistance to high altitudes is greatest; the reverse holds when the aviator is dispirited, fatigued, etc. Every sort of entanglement caus ing mental preoccupation and worry makes for casualties. Three seconds give time for irreparable disaster. ALCOHOL. Aviators commonly hold that a moderate dose of alcohol raises the courage in the face of danger. Experience and physiology teach the very opposite of this. .Vo. 1. 45 BELLI—PERSONAL HYGIENE OF AVIATORS. When alcohol is used, after a fleeting period of excitation, there is a paralyzing effect on the nervous system and especially on the higher centers —in the psychic faculties. The abuse of alcohol suspends inhibition; if persisted in alcohol wholly incapacitat«s a pilot for handling his machine. Casualties among troops on high mountains during the war showed corresponding disadvantages of alcohol. According to Mosso, mountain troops should not go into action on the day following holiday celebrations, etc., and I consider this still more important in the matter of flying. Italian aviators are noted for their sobriety. Neverthless caution may properly be enjoined regarding use of alcohol prior to flight. Of course the ordinary wine with meals is not harmful. TOBACCO. Usually aviators smoke too much. Tobacco damages the system partly through the action of pyridine bases, partly through the tollidine, carbon monoxide, and other substances formed during com bustion of cigars and cigarettes. Tobacco has local action— irrita tive and congestive —on the mucous membranes of the mouth, pharynx, Eustachian tubes, and even on the tympanic cavities—also a general toxic and depressing effect on the central nervous system, nerves of special sense, and particularly on the optic nerve. During the war numerous casualties were attributed to tobacco, hence aviators should be most abstemious in the matter of smoking. DRUGS. Aviators very commonly resort to drugs like aspirin, phenacetin, and to secret remedies against seasickness to avoid discomforts of high altitudes. This is a bad habit which only masks the real situa tion and often leads to casualties. Narcotics such as cocaine, mor phine, and opium are of course the most dangerous. It is imprudent to fly after generous doses of quinine. PREPARATION FOR FLIGHT. The aviator who feels indisposed and is lacking in confidence should refrain from flight and consult the doctor because ailments that are negligible on the ground may seriously handicap the physi cal and psychic side of the aviator and seriously reduce his capacity for flight. After sickness or accident the aviator should always be reexamined by a physician. According to Guilbert the old precept " head cool, feet warm, belly clear " is as valuable in aviation as in any other contingency of life. The intestinal functions should be carefully regulated. Symptoms of intoxication may arise from constipation and destroy 46 BELLI PERSONAL HYGIENE OF AVIATORS. Vol. XVII. the fineness of perceptions. Kidney functions should also receive attention. Aviators should always empty the bladder before climb ing into the machine. At high altitude ultra-violet rays combined with the cold lead to erythemas and chilblains. Mosso has shown experimentally that the best protection for the skin is to smear it with burnt cork. This method has never become popular. Instead most aviators prefer vaseline, lanoline, or cold cream. These agents protect the skin from rapid evaporation, but not from the ultra-violet rays. PROPHYLAXIS OF HIGH-ALTITUDE SICKNESS. The first symptoms, confined to the sphere of the vegetative func tions, are usually well tolerated by most men. Very few, however, can withstand the later developments involving the neuro-psychic feature. Of these, sleepiness is the most constant sign and indicates depression of the nervous centers. When it develops the aviator should come to the ground. The primary cause of these disturbances is reduced atmospheric pressure. This is not the place to discuss the details of etiology ; whether it is due to insufficient exchange of oxygen between the air and the blood or to diminished tension of carbon dioxide in the blood. Mosso thought the administration of oxygen useless in mountain sickness, but admitted that it had some value when taken at an ele vation above 7,000 meters. English and American physicians be lieve that oxygen saved the lives of many aviators during the war. Oxygen can not be employed by the apparatus commonly used in medicine. Special apparatus is necessary for aviators. It must be easy to handle and not interfere with movement. The aviator's hands must be free. The inhalation must be by means of a mask and entirely automatic, that is to say, the oxygen feed must accom modate itself automatically to the requirements of changing eleva tions. The apparatus devised by Colonel Dreyer has been used with satisfaction in the American Aviation Corps. Mosso insists that carbon dioxide should be distributed along with the oxygen. Agazzotti has shown by experiments with the pneu matic chamber that the proportion giving the best results is 15 to 20 parts carbon dioxide and 85 to 80 parts oxygen. As the effects of oxygen persist for four to six minutes after inhalation has ceased, the gas should be repeated at intervals of not more than six minutes. Administration of oxygen should be the rule, not the exception, when the aviator has reached the height of 3.000 or 4.000 meters. Oxygen may be used to advantage when the aviator lands after a long flight to overcome as quickly as possible his sensations of fatigue. No. 1. 47 GALWEY —GAS WARFARE. GAS WARFARE: ADOPTION, METHOD OF USE, PROTECTION OF TROOPS.1 By Maj. W. R. Galwey, O. B. E., M. C, Royal Army Medical Corps. The legitimacy of the employment of noxious gas as a weapon of warfare has recently been much discussed in both the public and scientific press. At the meeting of the British Association in Edinburgh in Sep tember, the president in his opening address, called upon the asso ciation to use its every endeavor to persuade scientists to cease research into chemical methods of destruction as derogatory to the high call of science. Much might be said regarding the humanity of inflicting casual ties by gas rather than by high explosive, of the high percentage of permanent recoveries after the former as against the latter and the low percentage of deaths, but it seems to me that two fundamental facts are ignored by those who write and speak against gas war fare: (1) That, in the highest sense, all weapons in war are inhuman; and (2) That the use of gas in warfare is an accomplished fact. It has proved a most effective weapon, so that any nation fighting in the future for its existence must be prepared to combat it and use it. Research into new compounds capable of overcoming exist ing methods of defense can be carried out in secrecy in the laboratory without attracting the attention of foreigners—many of the poison ous compounds are intimately connected with the chemical indus tries. Therefore it appears that so long as war remains the ultimate means of settlement of international strife, and until the League of Nations can enforce its mandates, so long must each nation continue to prepare for gas warfare. Two facts are significant: (1) During the inquiry into German methods of making mustard gas which followed the armistice one of the respondents asked: "Why are you worrying about this, when you know perfectly well that this is not the gas we shall use in the next war." (2) Of the total American casualties, about 30 per cent were due to gas, and of these about 90 per cent were due to skin burns ; of the gas casualties 3 to 4 per cent died and about 95 per cent recovered completely. The Americans have laid to heart the lesson taught by these figures and have established a Chemical Warfare Service on a peace footing with a personnel numbering about 1,600 and have budgeted for an annual expenditure of $4,500,000 for research into this branch of warfare. 1Reprinted from the Journal of the Royal Army Medical Corps, January, 1922. 48 GALWEY GAS WARFARE. Vol. XVII. Adoption. —In ancient times the Spartans in the fourth century before Christ, used gas in the form of sulphur and pitch fumes against the Athenians. Greek fire, which is of the same nature, was employed by the Byzantine (ireeks against the Saracens and by the latter in turn against the Crusaders. In modern times the' first suggestion to employ this method of offense was made by Lord Dundonald. It was seriousty advocated by the chemist, Lord Playfair, at the time of the Crimean War, as a humane method of overpowering the enemy, and the use of sulphur fumes was suggested as an aid in the reduction of the Redan redoubt. The suggestion was considered by experts and dismissed as in human. Later The Hague Convention, to which German}' was a signa tory, practically forbade its use. It was the treachery of Germany in this case as much as the nature of the weapon she employed which raised the storm of execration against her in April, 1915. At the end of the last century poisonous gases were investigated in Germany by Lehmann and his pupils with the ostensible purpose of making dangerous trades safe; but in England, although many of the compounds afterwards used had been met with in chemical research, practically nothing was known of their production on a large scale or of their action on the human organism. It is true, however, that useful work had been done prior to the war in South Africa by medical officers to mines in investigating cases of poison ing from nitrous fumes given off after the discharge of explosives in blasting operations. The first German gas attack was made against the French and our second army in the Langemarcke sector on April 22, 1915. The surprise was absolute and our line simply ceased to exist, since those who did not retire were either killed or incapacitated. The Germans captured 60 guns and a large extent of territory. A second cloud gas attack was delivered in the same sector on April 24. and was chiefly directed against the Canadians. The Germans did not realize the power of the new weapon and neither used it over a sufficient extent of front nor followed up their initial success. Had they done so the war might have ended in a German vic tory by the summer of 1915. The first attacks were quickly followed by others, some of which were on a large scale, during the months of April and May; all were in the Ypres sector. The gas used in the early attacks appears to have been pure chlorine, though later phosgene was combined with it. It was deliv ered from steel cylinders, each of which contained some 45 pounds of compressed chlorine. No. 1. 49 GALWEY GAS WARFARE. Gas attacks followed each other rapidly until May 24, and then there was a lull until December. 1915. The last cloud gas attack was on August 8, 1916. Various statements have been made as to when the Germans first began to use lethal gas in projectiles. The earliest certain date is July, 1916, when lethal gas shells were used, and from that time the enemy developed this mode of attack more and more. In all he used no less than 18 different gases against us and our Allies. It is unnecessary to detail these, and in my next paper I hope to put be fore my readers a classification of war gases according to their pathological effects. It will suffice to say here that the three main types of gas shell were known as green cross, blue cross, and yellow cross. The green cross contained phosgene alone, or combined with such substances as chlorpicrin and chlorarsines. Green cross 3 con tained various arsenic compounds. Blue cross contained chlorar sines, cyanarsines, and N. ethyl carbazol. Yellow cross contained dichlorethyl sulphide or mustard gas. At first gas shells were fairly easily distinguished from others, owing to the small bursting charge they contained, but later they were mixed with bombardments of high explosives, and the gas shells themselves contained large quan tities of high explosives; so that it became difficult to say whether a bombardment was simple or mixed, and a constant outlook had to be kept for gas. Gas warfare reached its zenith in 1917 when the Germans intro duced mustard gas—a weapon, which although of minor importance from the point of view of death, causes a great number of casualties from its insidiousness and persistence and which can be used to render ground untenable by troops for considerable periods. The last development was the use of large projectors which dis charged by means of bombs enormous quantities of gas over small areas, so that concentrations were arrived at when one breath in capacitated if it did not kill a man. The projector attack was in troduced by the British in April, 1917, and adopted by the Germans in December of the same year. I may mention that toward the end of the war our use of gas far surpassed that of the Germans, as our defense was better; so that they were very literally hoisted with their own petard, and must have bitterly regretted their treachery in introducing this weapon. Methods of use.—As the science of gas warfare was developed, three definite purposes emerged for which this weapon is effective : (1) To inflict casualties; (2) to reduce the fighting efficiency of troops by compelling them to wear respirators; (3) to render posi tions temporarily untenable. 1. The best substance to employ is that which answers the par ticular purpose of the general staff, and the fact that a substance is 50 Vol. XVII. GALWEY GAS WARFARE. lethal need not necessarily give it preference over one whose effects are only temporary and do not permanently incapacitate, but which quickly puts men out of action. Thus a lachrymator might in par ticular circumstances be more effective than phosgene. The first gas attacks caused very numerous casualties but it is impossible to estimate numbers with any great degree of accuracy as so many men were killed outright or died before they reached medical units. But as our defense developed the casualties dimin ished, so that in the last cloud attacks they were confined to units, and individuals, where gas discipline was slack or defensive ap paratus was not properly cared for or adjusted. With the advent of mustard gas the casualty list lengthened until the troops had again learned how to combat this new evil. 2. The second purpose for which gas is employed —to diminish the fighting efficiency of troops—is more difficult to combat. The respirator is uncomfortable to wear, and if worn for any length of time the resistance to breathing and general discomfort diminishes the fighting and working power. The greatest sources of discomfort are the mouthpiece and nose clip, but, so far, it has been impossible to dispense with them. In tercommunication and accuracy in handling delicate instruments also suffer. Two examples will illustrate how efficiency is impaired : (a) It was noted that if, when shelled by the enemy, our batteries replied with gas shell, in 20 to 30 minutes the accuracy of the enemy's shooting, as indicated by " qvers," " duds," etc., was greatly dimin ished. (b) The French experimented to see how long men could wear respirators. An area was chosen in the rear, where men were made to carry out light work or left at rest wearing respirators continu ously and not even removing them for food or drink. The men were exposed to a gas, nonlethal, but causing intense lachrymation with the least dose. Forty-eight hours' leave was given to each man for every two hours he could stick it over six hours, but though a certain number of men managed to accumulate a considerable spell of leave, the best result that could be obtained was that 70 per cent were effi cient at the end of 24 hours. The French mask is more comfortable than ours. 3. The third purpose for which gas is used is to render posi tions untenable. Mustard gas has so far given the best results on ac count of its persistence. It is therefore imperative when occupying a position which has been shelled to make certain whether gas has been used and to warn troops against handling objects which might be contaminated, and against drinking water contaminated by gas. Numerous casualties were caused in France by neglect of these pre cautions. No. 1. 51 GALWEY —GAS WARFARE. Though the means by which an enemy attains his object in a gat attack, i. e., gas tactics, is primarily the business of the general staff and gas services, it is important that all troops, officers, and men alike, should understand the general idea in the use of gas. Cloud gas is used to inflict casualties and as a preliminary to an infantry attack. The gases used must have the following properties: (1) Must be heavier than air; (2) must be easy to liquefy; (3) must be lethal in fairly low concentration. Not man}7 substances fulfill these conditions, and for this reason and because our protective measures had become almost perfect against it, the Germans abandoned the cloud attack. Weather conditions must be closely considered with all kinds of gas warfare but they are particularly important in cloud attacks. The best wind is a steady breeze from 4 to 9 miles per hour, but attacks have been made with winds from 2 to 20 miles per hour. The effects of cloud attacks has been felt as far back as 20 miles from the point of liberation, but the usual distances for serious casualties is 5 to 6 miles. Heavy rain is unfavorable, but slight dampness keeps the gas low —fog gives opportunity for surprise. Nighttime is most favorable both on account of surprise and be cause cold currents coming downward keep the gas low. The usual number of cylinders employed was one per yard of frontage and the front attacked was about 3,000 yards. An attack can be recognized by the hissing noise as the gas emerges from the cylinders and by the greenish color (becoming white in damp weather) of the cloud in the case of chlorine. Gas shells are used both for surprise attacks and to inflict casual ties, and also to harass communications and prevent arrival of re inforcements. The news of a cloud attack can be quickly passed to the rear, but the gas shell is its own herald. In the last stages of the war the only way of recognizing gas shells was by the smell of the compounds they contained. The projector attack combines the advantage of both cloud and shell and is more deadly because of the enormous concentration which it can give. The projector discharge can be recognized by: — (1) Noise on dis charge— like an ammunition dump going up, (2) flash along the line, (3) whining noise of the drums in flight, (4) sight of drums flying, (5) at night by the trail of sparks emitted from the drums. For a big projector attack as many as 1,500 drums, each containing some 31 pounds of liquid, were used, one drum being sufficient to overcome the German respirator at the point of impact. 52 Vol. XVII. GALWEY —GAS WARFARE. It has been well said that " Gas warfare resolves itself into a con test between offensive materials and protectice devices, and there is no finality in regard to either; so that the chemical substances em ployed must necessarily vary from time to time, as well as the tactics adopted to using them." Protection of troops. —Though the first attack found us totally un prepared, efforts were at once made to counteract this new weapon. On April 23, under telephone instructions from the Director General Medical Services, General Headquarters, the Director of Medical Services, First Army, issued a circular recommending the use of a solution of bicarbonate of soda, which should be kept in buckets, etc., and that men should be instructed to use handkerchiefs or cloths dipped in the solution to cover the nose and mouth. On the following days various other appliances were improvised : for instance, on 27th and 29th, Professors Haldane and Baker visited France, and the latter recommended the use of cloths, etc., moistened with urine, or of earth folded in cloth or inclosed in a bottle from which the base had been removed. A German respirator captured at this time proved to be a pad of cotton-waste soaked in hyposulphite solution and contained in a gauze bag which was provided with tapes for tying over the face. In the meantime the War Office authorities at home had turned to the Army Medical Service, and it was very largely due to the scientific knowledge and unfailing resource and energy in organiza tion of Col. Sir William Horrocks and Colonel Lelan that the menace to our troops was met and disaster averted. It was known that for the moment chlorine was the gas to be dealt with, and the chemical problem was therefore simple, though the pro vision of the appliances for making pads within a few hours was far otherwise. However, so nobly was the call met that within 60 hours 98,000 pads of cotton waste in muslin containers, dipped in hyposulphite solution and dried, were available at the front; 300.000 were avail able in a week, and 2,000,000 within a month. It was, of course, recognized that this provision was at most a tem porary expedient, the life of the pads was short, and they were not effective in high concentrations ; if a heavier charge of gas absorbent were added the obstruction to breathing became serious. Moreover, they were only effective against chlorine gas, and, once gas warfare had been established, it was obvious that the enemy could and would use higher concentrations and different and more potent substances. A research laboratory was therefore started in the Royal Army Medical College. The history of the evolution of our present pro tective apparatus records a story of untiring zeal, energy, and dogged pluck not surpassed in the story of scientific research. GALWEY— GAS WARFARE. 53 At the same time a research laboratory was organized in France and the closest liaison was maintained between workers at home and abroad. Every development in the use of gas was foreseen and pro vided for, so that our gas defense in a short time equalled and then surpassed that of the enemy. A brief account of the various types of protection evolved will serve to illustrate the problems which must be met and solved in chemical warfare. The original cotton-waste respirator was soon superseded by those of black veiling-cotton waste impregnated with hyposulphite of soda and glycerine. Two problems called for immediate solution : L To make the filtering area greater ; and 2. To make the absorbent substance such as would withstand not only chlorine but other gases which, it was recognized, might be used. The filtering area was increased by substituting a helmet for a pad. thus providing an area of 3£ to 4 square feet through which the air could enter and reducing the resistance to between 0.3 and 0.5 inch of water. The air current was also slowed so that the absorb ent had more time to neutralize the noxious gas. Suitable materials had to be found and in sufficient quantities. After a few days of testing on individuals a manometric device was devised for rapid testing at a definite standard pressure. The color of materials used in making helmets was also important, for if light colors were used men wearing the helmet's would furnish an easy target for enemy fire. The question of sight when wearing the helmet was also a knotty problem. At first mica windows were used, but these proved too brittle: cellulose acetate and chromicized gelatine were also unsuc cessfully tried. Finally nonsplintering triplex glass disks fixed in tin rims that clamped the textile of the helmet firmly by being screwed into flanged collars were adopted and proved most suc cessful. Polyvalency of the absorbent was first secured by adding sodium carbonate to the thiosulphate of soda and glycerol. This helmet could be donned in four to six seconds, gave 10 times as great pro tection as the pad, while its effective life against chlorine at a con centration of 1 in 1,000 was five hours. A new solution was made necessary by the fact that the absorbent afforded no protection against phosgene (carbonyl chloride) or hydrocyanic acid, and sev eral other gases. An effective absorbent was, however, found after many trials in sodium phenate, but it was found that the solution rotted the woolen fabric of which the helmets were made. This difficulty was met by adopting a cotton material which took up more alkali, and for a double thickness of cotton gave a resistance of 0.2 54 Vol. XVII GALWEY— GAS WARFARE. to 0.3 inch of water, as against 0.5 inch for a single thickness of wool. The problem was further complicated by the discovery that the CO> given off in expiration neutralized the protective alkali, so that after a time it ceased to protect against HCN. It therefore became neces sary to provide a valve through which the wearer could expire and so get rid of his CO* outside the helmet. The simple and effective respiratory valve still in use was the outcome of this research. One more addition to the absorbent impregnating the helmet was made in January, 1916, i. e., hexamin—suggested by Russia —this substance removed the remaining phosgene (carbonyl chloride) which had escaped the sodium phenate. With this final improvement the P. H. helmet, as it was called, removed 100 per cent of 1 in 1,000 phosgene and HCN. Of these helmets, from the first issue in July, 1915, until the final withdrawal in February, 1918, in favor of the box respirator as the sole issue, nearly 27,000,000 were made —many were supplied to our allies as well as to our own troops. In addition to protection against lethal gases of the asphyxiant type, protection had to be afforded against a group of substances known as lachrymators whose chief action is on the eyes. The majority act in minute proportions so that as small a quantity as one part per million causes intense lachrymation which throws the victim out of action. These lachrymators were first used against us in the autumn of 1915, and the first protection against them sent to France was a goggle of rubber with glass eyepieces similar to motor goggles. This failed in many cases owing to the difficulty of obtaining close adjustment over the bridge of the nose. To obviate that trouble the French pattern was next adopted. This was of impervious cloth with flannelette lining and celluloid eyepieces, the fit over the bridge of the nose being obtained by malleable wire sewn into the lower edge of the fabric. These were found service able against low concentrations, but against higher concentrations the best fitting results were obtained with rubber sponge. In a final pattern the base was of stiff impervious fabric (gelatine for malin impregnation) lined with soft material to which were cemented and sewn the two halves of an oval sponge —holes being cut in the sponge and the base into which were fitted screwed metal and glass (helmet) eyepieces. Elastics were provided for attachment. The P. H. helmet was also fitted with rubber sponge round the eye pieces and was issued as the P. H. G. helmet. Goggles were finally withdrawn after the issue of the box respira tor, since they tempted a man to put on his goggles rather than his respirator, and so continue to inhale small quantities of gas which would have a cumulative effect. No. 1. GALWEY GAS WARFARE. 55 No helmet could ever be completely polyvalent. For one thing it is impossible to impregnate so thin a layer of material with both oxidizing and reducing substances. The realization of this fact led to the research which culminated in the production of the present box respirator. The object was to produce a container filled with strata of different absorbents, through which air could be drawn —each group of noxious gases being removed or neutralized in its appro priate stratum. The box respirator was issued only one montli be fore the enemy attacked with gases which the helmet could not have withstood. Very extensive and exhaustive trials were made by Lieutenant Colonel Harrison and his colleagues before a granule was made which was sufficiently active, and at the same time hard enough to with stand the shaking and general rough usage which the respirator must necessarily undergo and yet remain active. The box respirator was originally charged with successive layers of: Sodium sulphite (reducing) ; soda lime manganate (neutralizing and oxidizing) : animal charcoal (absorbing and condensing) ; each layer being separated by plaques of cellulose. This was found to be completely polyvalent against every gas which the enemy had then used against us, and to give very slight resistance to respiration. It was efficient against carbonyl chloride for three hours, against chlorine for eight hours, and withstood a sequence of six gases run through it in succession, each for one hour. But it was found that gas tended to pass up the smooth interior against the side of the box so that this channel became ineffective, whilst the remainder of the box remained effective. This defect was remedied by corrugat ing the sides of the box and so lengthening this route, leaving large air spaces above and below the absorbent layers to equalize the flow and by arching the base of the lowest absorbent layer so as to divert the flow from the sides. Two valves were necessary —an inspiratory flap valve in the base of the box and an expiratory valve, like that in the helmet, between the mouthpiece and the box, so as to prevent ex pired COj, neutralizing the soda-lime-alkali. A closely fitting face piece with eyeglasses and nose clips was added. The whole ap paratus could be adjusted in 25 seconds [since reduced to 10 seconds]. There were several slight modifications of the box respirator, and the small box respirator as at present in use replaced all other gas protection appliances in February, 1918. Work is still being carried out on it to make it more perfect and to decrease its resistance to the passage of air to the lowest possible amount. The resistance of the present pattern is equivalent to about 3 inches of water. 56 Vol. XVIL GALWEY —GAS WARFARE. The above sketch of the evolution of the methods of individual protection against lethal gases will show you the essentials to be aimed at in devising such apparatus: 1. The apparatus must be capable of very rapid adjustment. 2. It must be able to neutralize all forms of noxious gases and clouds and vapors which may be used against the troops wearing it for a reasonable length of time. 3. It must offer as little resistance to breathing as possible so as to avoid diminution of the working powers of troops. 4. It must be strong and light. The box respirator has, so far, resisted all gases used against us, but it will be readily understood that constant research in defensive measures must proceed pari passu with new discoveries of substances which may be used in chemical warfare. The soldier must be taught that if his respirator is kept in good condition, and he has learned to adjust it with the necessary quick ness, he can place complete reliance upon it. Very frequent inspection of respirators is necessary to see that they are in good condition. Periodical inspections are carried out by the antigas officer with the formation concerned, but it is the duty of all officers commanding units or sections of units to see that their men's gas equipment is thoroughly effective. The most serious causes of damage to the respirator are : (1) Water entering the container and damaging the chemicals, (2) injury to the mask, (3) injury to one or both valves. It is of the utmost importance in reference to (2) and (3) to see that nothing is carried in the satchel but the respirator and anti- dimming outfit for cleaning the eyepieces. I hope to deal with the question of the disinfection of respirators in my last paper. The container, as finally issued, should be replaced after it has been breathed through for 40 hours. A record card is therefore issued with each container, and on this should be entered the time during which the apparatus has been worn during cloud gas attacks or gas shell bombardments. The number of hours during which the respirator has been breathed through for training are entered in the bottom three rows under shell gas. The date of issue is also stamped on the card. A fresh card is issued with each container. I have dealt above with the apparatus supplied for the protection of troops, and it is unnecessary to do more than remind you that in gas warfare everything depends upon the quickness and efficiency with which troops apply their protection. It is, therefore, necessary in preparation for war. to train all troops thoroughly in gas drill, i. e., in systems adopted for spreading gas alarms, in recognizing conditions whether of weather or environment when gas may be used, Xo. 1. 57 GALWEY GAS WARFARE. and in recognizing when gas shell is being used and the type, and in circulating information to all who may come into a gassed area. In conclusion, therefore, I will refer briefly to the secondary means of protection against gas attacks. ,1. When cloud gas attacks were made, various methods were adopted to disperse the gas, e. g., firing and throwing bombs in the gas; lighting fires in the trenches. Fans were also supplied for re moving gas from dugouts and trenches. 2. Solutions of hyposulphite and hexamine with sprayers were also issued for spraying the air in trenches, dugouts, etc. 3. With the development of gas warfare and the use of lethal gas shells these methods had to be revised, and additional measures taken for the protection of important dugouts, pill boxes, and aid posts. It was recognized that if possible the dugout should be evacuated until the gas had dissipated, but short of this it was found that an effective measure was to light a fire in the middle of a dugout after a gas bombardment. It was necessary to take care that the ground outside the dugout was free from gas before the fire was lighted, otherwise the fire merely drew the gas into the dugout. In the case of dugouts which could not be evacuated —e. g., aid posts, advanced dressing stations, headquarters —a gas-proof curtain was devised as a method of protection. One method of applying this curtain is as follows: A frame of 4 inches by 1 inch timber covered with blanket material is fixed flush with the wall, sloping outwards at an angle of 20° from the vertical. Antigas material — i. e., a special cloth to be treated with a solution of sodium thiosul- phate and sodium carbonate in water—is cut to the required size, so that when fastened to the top of the frame it will close the en trance completely and leave about 9 inches resting on the ground. Three pairs of laths are nailed horizontally to the curtain to keep it stretched. The lath on the underside must be left shorter than those in front so as to clear the frame. The lowest of the laths should be 4 inches from the ground but must not touch it. Two curtains should be provided, the upper as near the top of the stair case as possible (otherwise a pocket of gas may lodge and be carried into the dugout). The frame for the inner curtain should, if pos sible, slope inward. A similar contrivance was used to protect pill boxes. When mustard gas came into use it became necessary to protect men handling objects contaminated with it and to find some means of removing it from clothing. For men specially liable to contamination—e. g., gunners and stretcher bearers —in addition to their respirators special gloves were provided. After trial of various substances leather gloves treated 58 Vol. XVII GALWEY —GAS WARFARE. with unboiled linseed oil were found efficient. With them two pairs of cotton gloves were issued to be worn over the leather. Although efficient in preventing burns, these gloves were large and clumsy and hindered delicate manipulation. To obviate the hardening of the leather with age the Americans adopted: (1) Gloves of a waterproof material coated inside with gelatine-glycerine- formalin composition and protected outside by another waterproof coating, and (2) gloves of a fabric coated with a softened layer of cellulose nitrate. An effort was made to provide clothing which would withstand mustard gas. We used cloth treated with boiled linseed oil, and the Americans cotton sheeting impregnated with boiled linseed oil, castor oil, and paraffin wax. These proved efficient, but difficulties of transport and of readi ness when wanted were great obstacles to their use. To destroy mustard gas in clothing three methods were tried : (1) Treatment with steam or hot water; (2) treatment with chlorine gas; (3) exposure to fresh air. As heavily contaminated or directly splashed clothing can not be effectively cleaned without damage to the cloth, it is considered that it should be buried. Treatment with steam is the surest method of degassing contami nated clothing, and this can be effectively carried out by means of Colonel Lelean's sack disinfector or in a plant of any delousing sta tion. The Americans found hot (not quite boiling) soapy water effica cious. The French used water at 90° C. containing mild alkalis to neutral ize the acid formed by hydrolysis of mustard gas. A solution of washing soda is safe, but it must be in correct pro portions; too much or too little retards destruction of the mustard gas. Keeping men whose clothing has been contaminated in a chamber containing 1 per cent chlorine for five minutes have been found effec tive. This treatment can be carried out with cylinders of chlorine gas in dugouts. For slight contamination exposure of clothing in open air for 48 hours suffices, but if the contamination is heavy or the weather cold, a much longer time is necessary. Dugouts may frequently be contaminated by infected mud brought in- on boots. Washing with a stiff brush and water and sprinkling with chloride of lime have been recommended. If dugouts are contaminated, it is well to evacuate and destroy them. If this can not be done, the contaminated soil and beams should be removed, the walls and floor treated with chlorine, and the No. 1. 59 RAYNOR MEDICAL CORPS UNITS. dugout shut up for 24 hours. After this period it should be well ventilated by placing a lighted brazier in it and shifting the position from time to time. The atmosphere may be slightly lachrymatory for some time, the chlorine masking the smell of mustard. Chloride of lime may also be used for this purpose and for treat ing shell holes. In the latter case the lime should be covered with fresh earth, the latter being employed to prevent chlorine masking the smell of mustard and to render the hole less conspicuous. Two pounds of chloride of lime per square foot of surface gives excellent results, but this amount is prohibitive. One-half to 1 pound gives fair results. In the time at our disposal it has only been possible to outline the chief points in measures of protection. Everything depends upon efficient preparation and training and in the impressing upon the troops that given these they may have every confidence that they will escape unscathed. THE FUNCTIONS AND ORGANIZATION OF MEDICAL CORPS UNITS SERV ING WITH THE MARINE CORPS IN THE FIELD, i By S. N. Raynor, Major, United States Marine Corpa. THE ORGANIZATION OF THE BRIGADE. [Introductory Note. —The writer has undertaken to prepare for the United States Naval Medical Bulletin a series of articles dealing with the functions and suggested organization of Medical Corps units serving with the Marine Corps in the field. Up to the present time there has been no special organization for that service. If the necessity for such special organization can be demon strated, the quo animo of this series shall have been attained.] Before taking up the question of the organization of Medical Corps units for service with the Marine Corps in the field it seems advisable to devote some time to a consideration of the organization of the military or fighting units. In general, the function of the Medical Corps during active operations is to provide sufficient per sonnel for first aid and part of the litter evacuation. It is obvious, therefore, that the organization of the Medical Corps personnel attached to any fighting unit must be governed primarily by the organization and functions of that unit. 1In the editorial section of the January issue of the United States Natal Medical Bulletin reference was made to the establishment of a correspondence course for naval medical officers to be conducted by Maj. S. N. Raynor, United States Marine Corps. It is believed that this course offers many advantages to medical officers, particularly those serving with the Marine Corps in the field. The Surgeon General is desirous of having all niedical officers who are available for duty with the marines enroll ifor tills course. Applications should be forwarded promptly to MaJ. Raynor at the Marine Corps Schools, Marine Barracks, Quantico, Va. The maps used in this course will be supplied by the Bnrean of Medicine and Surgery. 103390—22 5 60 Vol. XVII. RAYNOR —MEDICAL CORPS UNITS. At the present time the largest organization in the Marine Corps is the brigade. In this article, therefore, we will take up the organi zation of the brigade and of its component parts. As a result of the experience gained in the World War, and after a careful and exhaustive study of innumerable reports and of the conditions which presented themselves in various phases of the war, the Army Tables of Organization have been completely revised. The underlying principle in the revision of the tables was to provide organizations that would meet all the requirements for field service under conditions of modern warfare. As the reasons for using the Army Tables of Organization may not be manifest to all, a brief explanation may not be inappropriate. While the Marine Corps normally functions in conjunction with the Navy, Marine Corps forces may be, and, in recent years, fre quently have been, detached for service with the Army. Such being the condition which must be met, the Marine Corps organization and that of any Medical Corps units serving with the marines, should be such as to fit in with, and readily function with and as a part of the Army machine. While the Marine Corps organization differs in many respects from that of the Army, due to the nature and diversity of the duties which it is called upon to perform, this dissimilarity is one of practical adoption to conditions of service rather than the result of any divergence in the fundamental principles underlying their respective organizations. By analyzing the Army organization, in so far as it concerns this problem, we should get a picture of a machine whose efficacy has been proven, and thus enabled to more readily determine our own requirements. In the Army an Infantry division is composed of two brigades of Infantry and various auxiliary troops and services. A brigade, as a part of a division, is a purely tactical unit; i. e., it has no ad ministrative functions. When a brigade is detached from the di vision for independent duties it becomes necessary to provide an administrative staff along the lines prescribed for that of a di vision. (StafF organization will be the subject of a subsequent ar ticle.) The new infantry brigade is organized as follows : Brigade head quarters (10 officers) ; headquarters company (1 officer, 1 warrant officer. 88 enlisted men) ; 2 regiments of Infantry (each consisting of 103 officers, 1 warrant officer, and 2,950 enlisted men). Attached to each regiment are 11 medical officers, 87 enlisted men (Medical Corps), and 2 chaplains, making an aggregate for the brigade of 243 officers, 3 warrant officers, and 6.162 enlisted men. (See accompanying diagram). No.l. RAYNOR MEDICAL CORPS UNITS. h0 z 0 < •< u as o o as fe 1 0 £ si w ' 2 E c w « o U _ 9 ^ o So 62 Vol. XVII. RAYNOR—MEDICAL CORPS UNITS. It will be noted that no provision has been made for brigade sur geon and the necessary personnel to assist him. As will be seen later, this is because the regimental surgeons function under the di rection of the division surgeon when the division is intact. When a brigade is acting independently it is necessary to assign a medical officer to it for duty as brigade surgeon, and a quota of officer and enlisted personnel from the medical regiment of the division from which the brigade has been detached. This personnel, when so assigned, forms, for the Medical Corps, a brigade headquarters de tachment which functions as a part of the brigade staff. HISTORICAL. JONATHAN COWDKBY, SURGEON IN THE UNITED STATES NAVY, 1767-1852. PART 1. By Capt. F. L. PlbadwblI/, Medical Corps, United States Navy, and Lieut. Commander W. M. Kerr, Medical Corps, United States Navy. Jonathan Cowdery, the subject of this biographical sketch, was appointed a surgeon's mate in the Navy on January 1, 1800, and he lived to be the oldest officer in the service. A review of his life is not without interest to the medical officer of to-day for early in his naval career he took part in the war with Tripoli, was taken prisoner on the occasion of the loss of the U. S. frigate Philadelphia, and held cap tive by the Tripolitans for over a year and a half, during which time he kept a journal which throws much light on an historical event now almost forgotten. He was a descendant in the sixth generation from AVilliam Cow dery, who came to New England in 1630 from Weymouth, England, settling first at Lynn, Mass., and later at Heading in the same State, where he died in the year 1687. Jonathan Cowdery was born on April 22, 1767, at Sandisfield, Berkshire County. Mass. His father, Jabez Cowdery, was a physician who practiced his profession for many years in Tunbridge, Vt. His mother was Ruth Wickham, bora at Glastonbury, Conn. Where Jonathan received his medical education is not definitely known, but he probably served a quasi-apprenticeship with his father, and he appears to have attended lectures for two winters at Dartmouth in Hanover, N. H.. so it is not unlikely that this school was his alma mater. At any rate we find that by the time he had reached the age of 22 he felt himself qualified to support a wife, for in 1789, at New Marlboro, Mass.. he married Mary Bryant, daughter of Col. Richard Bryant, of Revolutionary fame. At this period of his life. Doctor Cowdery seems to have been somewhat of a rolling stone, for during the next six years he and his wife lived in three different localities where he practiced his pro fession. However, he was happy, as in each of these places a child came to bless his home. A son, Benjamin Franklin, was born in 1790, at New Marlboro, Mass.; another, Isaac Newton, was born in 1792, at Salisbury, Conn. In later years this child became a 63 64 JONATHAN COWDEBY, SURGEON IN U. S. NAVY. Vol. XVII. musician, playing the violin very skillfully. He taught music and penmanship. A daughter, Mary, was born in 1795, at Livingston, N. Y. She died the same year, and during the following year, 1796, Mrs. Cowdery died. After his wife's death Doctor Cowdery returned with his two sons to his father's home in Tunbridge. Leaving his children with his mother, he settled in the little town of Hudson, N. Y., where he was practicing medicine at the time he received an appointment as surgeon's mate in the Navy of the United States, as the naval force of the country was called in its early days. His commission was dated January 1, 1800, and was signed by John Adams, the second President of the United States. His first cruise was on the frigate Philadelphia commanded by the elder Commodore Decatur, in operations in the West Indies against the French. The first mention of him in official correspondence occurs in the following letter signed by Robert Smith, then Secretary of the Navy : Navy Department. 2S Oct. 1802. Doctor Jon. Cowdeby, Hampton, Virg". I have received your letter of the 19th instant and sincerely regret, as well on your own as on the public account, the occurrence that has deprived us of your services on board the John Adams the present cruise. On receipt hereof, you will consider yourself on furlough until again called into service and you will be pleased to report yourself to this department when you shall have recovered your health and are again tit for duty. It1 Smith. On July 18th, 1803, we find Doctor Cowdery once more sailing as one of the junior medical officers in the frigate Philadelphia, at this time commanded by Capt. William Bainbridge, United States Navy, for service in the Mediterranean against the Barbary States. The senior medical officer of the vessel was Surg. John Ridgely, United States Navy. The Barbary States, Morocco, Algeria, Tunis, and Tripoli, lie along the northern coast of Africa, between the Mediterranean and the Sahara, stretching from the Straits of Gibraltar to Egypt, a dis tance of 2,000 miles. The Mohammedan population of this strip of coast, consisting of Moors, Arabs, Berbers, and Turks, had long been engaged in piracy, especially since the Conquest of Granada in 1492, which was followed by the exodus from Spain of thousands of Moors who passed over to Africa carrying with them a hatred of the Spanish and a thirst for vengeance which early found vent in piratical raids on the commerce of Christian nations trading in the Mediterranean. These pirates continued to infest the Mediterran ean until their extermination in the nineteenth century. The captives taken in these raids were reduced to slavery and many of the pirates grew immensely and rapidly rich upon the No. 1. JONATHAN COWDERY, SURGEON IN U. S. NAVY. 65 plunder seized and the ransom of their captives. The redemption of slaves was procured with money raised by missions, contribu tions, and collections, and individuals and families sometimes im poverished themselves to ransom friends and relatives. William Eaton, United States consul at Tunis, writing of the corsairs in 1799, says : " Their mode of attack is uniformly boarding. For this their vessels are peculiarly constructed. Their long, lateen yards drop on board the enemy and afford a safe and easy conveyance for the men who man them for this purpose; but being always crowded with men, they throw them in from all points of the rig ging and from all quarters of the decks, having their sabers grasped between their teeth and their loaded pistols in their belts, that they may have the free use of their hands in scaling the gunnels or net ting of their enemy. In this mode of attack they are very active and very desperate. * * * Proper defenses against them are high nettings, with chains sufficiently strong to prevent their being cut away, buckshot plentifully administered from muskets or blunder busses, and lances. But it is always best to keep them at a distance, that advantage may be taken of their ignorance at maneuvering." " The attitude of Europe toward the Barbary States was cowardly and dishonorable from first to last. The action of the stronger powers was prompted largely by policy. In order to injure their enemies and to crush the commercial competition of their weak neighbors they were willing to bribe and subsidize the pirates, sub mitting to the indignity and dishonor of being tributary nations and encouraging a system of ruthless piracy and slavery."1 Shortly after the Revolution a new flag appeared in the Mediter ranean which the pirates soon learned to recognize as that of a young, weak power in distant America, likely to fall an easy prey to their vessels. Before long there were many Americans held in captivity in Barbary, who addressed letters and petitions to the Pres ident, to Congress, to the ministers of various denominations, and to Col. David Humphreys, United States minister to Portugal, who, in a letter to the American people, suggested a lottery as the means of raising the necessary funds for the ransom of their fellow country men. Various diplomats, commissioners, and agents were appointed to the difficult task of negotiating with the Barbary powers, but their efforts met with indifferent success. The rulers of the Barbary coast maintained that they were the sovereigns of the Mediterranean, and that no nation could navigate that sea without a treaty of peace with them. 1Out Navy and the Barbary Corsairs, by Gardner W. Allen. Houghton, Mifflin A Co.. Boston, 1905. 66 JONATHAN COWDEBY, SURGEON IN U. S. NAVY. Vol. XVII. In 1792, the Senate favored paying $100,000 annually for peace with Algiers, Tripoli, and Tunis, and $40,000 ransom for the captives; but many of the leaders of that time favored the early and energetic employment of force against these piratical States and through their influence three ships were built and launched in 1797, the United States, Constitution, and Constellation, forming the nucleus of the American Navy. A treaty of peace and amity with Algiers was ratified by the Senate, March 2, 1796, and it cost up to January, 1797, nearly a million dollars, exclusive of an annuity in naval stores valued at about $25,000. This treaty was not so liberal as one concluded with Mo rocco, but it was the only one which stipulated the payment of tributes. A treaty was also concluded with Tripoli and Tunis at great expense. Looking backward to those times it is easy to see how the em ployment of force would have saved time and money and won re spect for our infant nation, but, as Gardner W. Allen says, " to judge the question fairly it is necessary to look at it from the point of view of that time. Most of those who favored following the prec edent of Europe by paying tribute to barbarians, and who opposed a navy, did what they thought was best for the country and many of them were among the foremost public men of the day." The money received only enabled the rulers of the Barbary States to prepare for further depredations upon commerce and each waited for a pretext and opportunity to break peace with the United States. The pasha of Tripoli apparently did not make as good a bargain in the conclusion of his treaty with the United States as did some of his fellow pirates. Accordingly he became dissatisfied. Diffi culties arose between him and the American consul, Mr. Cathcart, and finally on May 10, 1801, the pasha declared war against the United States. Without delay he sent out his corsairs in search of American prizes but with little success, as his hostile act had been anticipated by the American Government and a timely warning had put American merchantmen on their guard. About June 1, 1801, a squadron under the command of Commodore Richard Dale, set sail from Hampton Eoads for the purpose of ob serving the situation in the Mediterranean and protecting American commerce against the threatened attacks of Tripoli. This squadron consisted of the frigates President,, 44 guns, flagship, Capt. James Barron; Philadelphia, 36 guns, Capt. Samuel Barron; and Essex, 32 guns, Capt. William Bainbridge, and the schooner Enterprise. 12 guns, Lieut. Andrew Sterrett. The squadron arrived at Gibraltar July 1. Here Commodore Dale found two Tripolitan cruisers which had left Tripoli with the intention of sailing into the Atlantic to prey upon American merchantmen off the straits, and by forestalling No. 1. JONATHAN C'OWDERY, SURGEON IN U. S. NAVY. 67 their passage through the Straits of Gibraltar he doubtless pre vented severe losses to American commerce. The Philadelphia was ordered to cruise in the straits and watch the Tripolitans, and the Essex was ordered to collect the American merchantmen in different ports and give them convoy through the straits. The commodore with the President and Enterprise cruised along the Barbary Coast where his appearance produced a salutary effect. During this cruise the Enterprise fell in with a Tripolitan vessel of 14 guns and 80 men. The two vessels were about evenly matched. They at once engaged at close range and fought for three hours. Allen gives the following account of the encounter and its results : " By his superior skill in maneuvering, Sterrett was able to avoid the enemy's attempts to board, and by choosing his position, to rake him repeatedly. Twice the Tripolitan struck his colors, and when he thought he had his adversary at a disadvantage, reopened his fire, hoisting his flag again. The third time, there being no longer hope of making up for his poor seamanship and gunnery by treachery or stratagem, he threw his flag into the sea, and by suppli cating gestures begged for quarter. Porter was then sent aboard the corsair to take possession. All her guns and small arms, with everything elese of value, were thrown overboard, and she was sent back to Tripoli an empty hidk. Sterrett's report to Commandore Dale, dated at sea August G, 1801, is as follows: 'I have the honor to inform you. that on the 1st August I fell in with a Tripolitan ship of War, called the Tripoli, mounting fourteen guns, commanded by Reis Mahomet Sous. An action immediately commenced within pistol-shot, which continued three hours, incessant firing. She then struck her colors. The carnage on board was dreadful, she having twenty men killed and thirty wounded; among the latter was the captain and first lieutenant. Her mizzen-mast went over the side. Agreeable to your orders, I dismantled her of everything but an old sail and spar. With heartfelt pleasure I add, that the officers and men throughout the vessel behaved in the most spirited and de termined manner, obeying every command with promptitude and alertness. We had not a man wounded, and sustained no material damage in our hull or rigging.7 Sterrett received the thanks of Con gress and a sword, and his officers and men a month's extra pay. The Tripoli crept slowly home, and on her arrival the pasha was filled with rage and chagrin. The unfortunate Mahomet Sous was mounted on a jackass, paraded through the streets, and bastinadoed. The effect of this severity was that men were greatly discouraged from serving in the corsairs then fitting out. For some time after this, very few Tripolitan cruisers ventured from port." 68 JONATHAN" COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. The remainder of the year 1801, was devoted to a blockade of Tripoli, which was effectual in that it caused a great scarcity of food in the capital. In 1802 the American Government determined to prosecute the War against Tripoli with more vigor. As the terms of enlistment of Commodore Dale's men had nearly expired, it be came necessary to send out a new squadron to relieve the vessels in the Mediterranean. The command was given to Capt. Richard V. Morris, who hoisted his pennant on the frigate Chesapeake, 36 guns. This squadron having reached the Mediterranean, the Philadelphia, together with some of the other vessels, returned to the United States. Commodore Morris operated in the Mediterranean until the fall of 1803 when he was relieved of his command by Capt. John Rodgers by order of the Navy Department because it was believed that he was not producing the results desired. When it was decided to recall Morris, a new squadron was fitted out, the command of which was given to Commodore Edward Preble. Commodore Preble's instructions from the Secretary of the Navy, Robert Smith, were dated July 13, 1803. The vessels of the squadron sailed as they became ready for sea in the following order : Nautilus, 12 guns, Lieut. Richard Somers, June 30; Philadelphia, 36 guns, Capt. William Bainbridge, July 18; Vixen, 12 guns, Lieut. John Smith, August 3; Constitution, 4A guns, Commodore Preble's flag ship, Lieut. Thomas Robinson, jr., acting captain, August 14; Siren, 16 guns, Lieut. Charles Stewart, August 27; Argus, 16 guns, Lieut. Stephen Decatur, September 8. The Enterprise, 12 guns, Lieut. Isaac Hull, already in the Mediterranean, was to remain there as one of the new squadron, but on the arrival of the Argus, which was a larger vessel than the Enterprise, Hull, being senior in rank to Decatur, was to exchange commands with him. The Philadelphia arrived at Gibraltar August 24, 1803, in the vicinity of which place she cruised in search of enemy vessels, until on the arrival of Commodore Preble, she was sent together with the Vixen to establish the blockade off Tripoli before which port the vessels appeared on October 7. Bainbridge was informed by the captain of a brig, coming out of Tripoli, that two Tripolitan vessels of war were out upon a cruise. Thinking they were probably to the westward, he sent the Vixen to cruise off Cape Bon where these vessels would most likely be met if returning from that direc tion, and where it was safer for the schooner than off Tripoli, as the season for heavy storms was approaching. The Philadelphia from then on, maintained the blockade alone. On the last day of October an event occurred which, according to Allen, is narrated by Captain Bainbridge in his report to the Secre tary of the Navy, dated November 1, 1803, as follows: "Misfortune No. I. JONATHAN COWDEBY, SURGEON IN U. S. NAVY. 69 necessitates me to make a communication the most distressing of my life; and it is with deep regcet that I inform you of the loss of the United States frigate Philadelphia, under my command, by being wrecked on rocks between four and five miles to the eastward of the town of Tripoli. The circumstances relating to this unfortunate event are : At 9 A. M., being about five leagues to the eastward of Tripoli, saw a ship inshore of us standing before the wind to the westward. We immediately gave chase; she hoisted Tripolitan colors and continued her course very near the shore. About 11 o'clock had approached the shore to seven fathoms water, com menced firing at her, which we continued by running before the wind until half past 11, being then in seven fathoms of water; .and finding our fire ineffectual to prevent her getting into Tripoli, gave up the pursuit and was bearing off the land when we ran on the rocks in twelve feet of water forward and seventeen feet abaft. Immediately lowered down a boat from the stern, sounded and found the greatest depth of water astern. Laid all sails aback, loosed topgallant sails and set a heavy press of sail-canvas on the ship, blowing fresh, to back her off. Cast three anchors away from the bows, started the water in the hold, hove overboard the guns excepting some abaft to defend the ship against the gunboats which were then firing on us ; found all this ineffectual. Then made the last resort of lightening her forward by cutting away the foremast, which carried the main- topgallant mast with it. But labor and enterprise were in vain, for our fate was direfully fixed. * * * Striking on the rocks was an accident not possible for me to guard against by any intimation of charts, as no such shoals were laid down in any on board, and every careful precaution, by three leads kept heaving, was made use of on approaching the shore to effect the capture of a Tripolitan cruiser. And after the ship struck the rocks all possible measures were taken to get her off and the firm determination made not to give her up as long as a possible hope rema:ned. although annoyed by gunboats which took their position in such a manner that we could not bring our guns to bear on them, not even after cutting away part of the stern to effect it. When my officers and self had not a hope left of its being possible to get her off the rocks, and having withstood the fire of the gunboats for four hours, a reinforcement coming out from Tripoli, without the smallest chance of injuring them by resistance, to save the lives of brave men left no alternative but the distressing one of hauling our colors down and submitting to the enemy whom chance had befriended. In such a dilemma the flag of the United States was struck. * * * The gunboats in attacking fired prin cipally at our masts; had they directed their shot at the hull, no doubt but they would have killed many. The ship was taken pos 70 JONATHAN COWDERY, SURGEON IN U. B. NAVY. Vol. XVII. session of a little after sunset and in the course of the evening myself and all the officers, with part af the crew, were brought on shore." Captain Bainbridge was greatly depressed in spirits over the loss of his vessel. His officers sympathized deeply with him, and in a letter signed by all of them, November 1, 1803. expressed their feel ings in the following words : " We, late officers of the United States frigate Philadelphia, under your command, wishing to express our full approbation of your conduct concerning the unfortunate event of yesterday, do conceive that the charts and soundings justified as near an approach to the shore as we made, and that after the ship struck, every exertion was made and every expedient tried to get her off and to defend her. which either courage or abilities could have dictated." On November 2. a heavy wind caused the Philadelphia to float. The Tripolitans succeeded in pulling her off the reef the next day and brought here into the harbor, amid the rejoicing of the people and to the great mortification of the Americans. The officers and crew of the lost vessel had a long bondage before them. Doctor Cowdery kept a journal during his captivity which gives much information about the fortunes of the prisoners, and which will form the subject matter of the historical essay in the Bulletin next month. The officers Avere well treated at first, and were allowed some recreation on the roof of the house where they were confined, but after three or four days this privilege was denied them and soon they were removed to the prison where the men were con fined. Doctor Cowdery attracted the attention of the pasha, who employed him as his physician, and he was allowed more freedom than any other officer. The men fared much worse than the officers. The different classes of mechanics were put to work at their various trades, and the others were employed at all sorts of hard labor, chiefly on the fortifi cations. They were beaten and maltreated by many of their task masters, and sometimes basinadoed. When Commodore Preble heard of the Philadelphia's situation he determined to destroy her and selected Lieutenant Stephen Decatur for the task. On the night of February 16. 1804. with the Siren and the ketch Intrepid, Decatur entered the harbor of Tripoli and set fire to the captured vessel which, as Admiral Nelson said, when he heard of it, " was the most bold and daring act of the age." Without a doubt the burning of the Philadelphia added much to the reputation of the Navy both at home and abroad. In July, 1804. Commodore Preble assembled his entire squadron before Tripoli and on August 3. he began a series ot bombardments which lasted a month and which caused great destruction of the gun No. 1. JONATHAN COWDERY, SURGEON IN U. S. NAVY. 71 boats in the harbor, and much damage to the city. He was relieved by Commodore Barron, who continued the blockade. Two letters written by Doctor Cowdery after the bombardment throw some light on the condition of the American captives in Tripoli at this time. One letter dated November 7, 1804, and ad dressed to his father. Dr. Jabez Cowdery, at Tunbridge, Vt., is as follows : My Dkar Father, No doubt you have often heard of the loss of the Frigate Philadelphia, and the capture of its whole crew (by the Barbarians). Among whom is your unfortunate son. We were taken on the 31st of October, 1803, and entirely robbed of our property even the greatest part of the clothes on our backs were taken from us. Our seamen were immediately put to hard labor, without mercy, and have suffered much for the necessities of life. Five have paid their last debt to Nature, and five have turned Turk. Myself and fellow officers were permitted to occupy the house where our Consul Mr. Cathcart resided, while in Tripoli. On our first arrival, we signed a Parole of Honour, but have not been allowed to enjoy it. The Bashaw (or the head of the regency) compels me to exercise my profession in his Palace, and among his slaves; to relieve the distress of the latter is a pleasure to me. About the first of Feb ruary we were removed to the Castle and placed In close confinement under a powerful guard of Turks, who examined every paper and letter with the utmost scrutiny, to prevent our having any communication with our squadron off the town, which they much feared. What few letters we received from our friends are opened before we get them ; no doubt many have been suppressed. Mr. Nissen, the Danish Consul, has done us many favours, and is entitled to our utmost gratitude. We live in hopes of being liberated in due time, and In a manner that will do honour to our country whose service we were in, and whose wrongs we were avenging, when by a sad misfortune we fell into the hands of a Monstrous foe, who divested us of liberty and property, and plunged us Into a Prison, from thence we were removed to a more gloomy one, the dreary cells of a Castle, the gloomy walls of which bespeak the miseries of Christian slaves who erected them under the lash of Tyrants, the glimmering light of which Is admitted through an Iron grating in the top ; the doors are secured by large locks and bars of iron, and guarded by infamous Turkish soldiers, who are ready to plunge their daggers into our hearts, at the nod of a tyrant, who pre serves us only for the ransom which he expects from our country. We hope and expect that the Free Sons of Columbia will soon relieve us, their oppressed countrymen, and restore us to our native shore, that we may join them in the protection of its rights, and the enjoyments of its blessings. May the day soon arrive, when we may have the pleasure of joining our Country men hand in hand to erect dungeons for vice and tfmples for virtue. May we teach the haughty tyrant, and the barbarian that our rights, the common rights of man, are sacred, and not to be infringed, that we will establish and maintain them in spite of the enemies of Mankind. Ever since our captivity the Bashaw has been possessed in favour of me : I have had two fits of sick ness, one of the Dysentery and the other Ophthalmia, both very severe during which the Bashaw paid me every attention that could be expected from a Turkish foe. On the 30th of July lie took me from the prison of my brother officers, and gave me a pleasant and well furnished apartment in his palace; I now have liberty to walk about the town when I please, and to take a short ride into the country on a mule. Occasionally a Turk who speaks the English language, is appointed to walk and ride with me, to prevent my running away, 72 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. or meeting with insult, and to act as interpreter ; he is very polite and pays me every attention, I can speak Arabic (the language of the place) tolerably well ; I have received some of the books which were taken from me when we ran on the rock, them I make use of as my best companions, I spend the best of my time in perusing them and in attending the sick slaves, particularly my countrymen. I am not allowed to hold any conversation with our officers (and our letters to each other are examined with the utmost scrutiny) who are still in close confinement. Our worthy Captain Bainbridge has established a credit with Dr. Davis, our Consul at Tunis, and with the French and Danish Consuls In this place so that we draw a little money when we are in want, by this our seamen are often supplied with bread, or perhaps they would perish with hunger. The harbor is closely blockaded by the American Squadron under Commodore Barron, who lately relieved Commodore Preble, in consequence of which there is great scarcity of provision In this place, and I fear it will be worse among us before we get from hence. Our Squadron made five vigorous attacks upon this place last summer, in which much blood was shed. Terms of Peace have been offered, without effect. The Bashaw demands $1,000,000 of dollars. Our Government has offered through Commodore Preble one hundred and twenty thousand dollars, a very wide difference ; an additional amount is expected from our country in the spring, I suppose you know more of this than I do. We expect warm work next summer. I assure you It is not very pleasant to be a prisoner in a besieged city, but God is our protector. The present Bashaw has been on the throne about eleven years. On the death of his father, the former Bashaw, he usurped the throne, by killing one of his elder brothers, and driving the other out of the dominion Into Egypt. He is very cruel to his subjects, when he finds them guilty of crimes; for murder, treason &c he beheads them; for theft, housebreaking &c he takes off the left hand and right foot, at the Joint and dips the stump Into boiling tar ; for less crimes he gives them from five hundred to a thousand bastinadoes as the Turks call It; this is done by tricing up the feet with a rope and beating upon the soles of the feet with a large stick; they often perish under the operation. Yet this cruel prince is remarkably fond of his children, and kind to the poor. He Is about thirty-five years of age. He has two wives, one white and one black ; by the former he has five and by the latter four children, a plurality of wives Is allowed in this country. The Bashaw is a white man of middling age, rather portly, and tolerably handsome. He has a bombproof room, which he occupies during the rattling of shells and shot and the sounding of Colum bian Thunder. The laws of our country allow us full pay and rations during our captivity ; this is of some consolation to us In this savage land. How long we are to remain here, God only knows; I am in hopes of once more seeing my Parents, I wrote you a letter directly after our captivity. I have an oppor tunity of sending this letter to the Island of Malta by a particular friend, from thence it will be sent to America, by our Consul who resides near that place, it therefore will escape the scrutiny of my new masters; I am in good health and spirits, thank God, and hope for better times soon. My respects to all friends, I am with the greatest respect, Your affectionate son, Jon" Cowdebt. Dr. Jabez Cowdebt. The other letter, dated 24 November, 1804, was addressed to a friend, a Doctor Mitchell, and it was published in the National In telligencer at Washington, D. C, August 5, 1805. Dear Sib: I hope you will excuse me for the liberty I take in suggesting to you a few remarks which have occurred since my captivity. The Bashaw No. 1. JONATHAN COWDERY, SURGEON IN U. S. NAVY. 73 has taken uie from the prison where my fellow officers were confined ami ordered me to attend his sick slaves who are principally Neapolitans, negroes and our unfortunate crew. Some of the latter I this morning saw chained to a cart loaded with stones which they were dragging through the town to repair the fortifications. They complain much of hunger, cold, hard labor and the lash of the whip. I confess I never saw anything that wounded my feelings equal to the sight of those poor fellows. I have liberty to walk in the town but am attended by a Turk who is loaded with weapons of war. 1 am not allowed to visit any of the fortifications nor any of the foreign con suls. Capt. Bainbridge's endeavours to relieve the wants of his crew are often countermanded by our new masters. Five of our countrymen have turned Turk, and five have paid their last debt to nature. Diarrhea and Dysentery have often appeared among our crew, but on a free use of carbonate of soda (Natron) which is found in abundance in this country and often white wash ing the walls of the prison with lime where they sleep, it soon disappears. Our crew are not very healthy. During the several attacks upon this town by our squadron under command of Commodore Preble, many Turks were killed utid wounded and several men much burnt by the explosion of their own powder. I had an opportunity of seeing their method of curing burns in particular, many of which extended over the whole body. The Bashaw has all his wounded brought to an apart ment in the castle where he visits them and makes them a present of ten dollars each. He then orders his surgeons and Mamelukes to dress their wounds; he often assists with his own hands. The Mamelukes are his body guards; the Marabouts are employed to expell evil spirits, and make Inter cession with Mahomet their prophet, for their recovery. Those that were burnt, were first annotated with honey, carefully preserving the skin as much as possible and keeping the parts exposed to the air. They then sprinkled the ulcerated parts, if any, with a fine powder of white lead (Ceruse:) this they repeated at short Intervals until a scab is formed, that is carefully pre served until a cure Is accomplished, which is remarkably soon. I hope and expect that in due time my country will honorably and to the astonishment of Barbarians and Tyrants liberate us from the chains of slavery and restore us to our native land, that happy land the thoughts of which is a healing balm to our souls in their miserable bondage." Commodore Barron maintained the blockade through the winter of 1804-5, but his health at last became so impaired as to make it impossible for him to manage the affairs of the squadron. Accord ingly, on May 22, 1805, he turned the command over to Captain Rodgers, the commanding officer of the Constitution. On June 4, 1805, Captain Rodgers, together with Col. Tobias Lear, the American consular general at Algiers, who had been invested by the President with full power and authority to negotiate a treaty of peace with the pasha of Tripoli, effected an amicable settlement of the differences between that country and the United States. Colonel Lear in his report to the State Department, writing of the termina tion of hostilities says: " I went into the harbor in the Constitution's barge, with the flag of the United States displayed, and was received at the landing place by the American officers, who had been in cap tivity, with a sensibility more easily to be conceived than described. 74 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. An immense concourse of people crowded the shore and filled the streets, all signifying their pleasure on the conclusion of the peace. * * * On the 4th of June, at 11 a. m., the flagstafl was raised on the American house and the flag of the United States dis played, which was immediately saluted with 21 guns from the castle and ports and was returned by the Constitution." The American prisoners, after a captivity of over 19 months, were released and sent aboard the ships. On June 21 the American vessels left Tripoli, leaving behind as charge d'affaires, Surg. John Ridgely, one of the late captives and formerly the senior medical officer of the Philadelphia. Doctor Cowdery, as we see by the following letter, reached home in the fall of 1805. * . Tunbridqe, Vermont, Nov. 1, 1805. I arrived here yesterday where I intend staying until spring if not sooner honoured with your command. I have the honour to be, Sir, with the greatest respect, Your Obt. Serv't, Jon" Cowdery. Robert Smith, Esq. After Doctor Cowdery's return to the United States his fortunes are best followed by a perusal of letters which he wrote from time to time to the Navy Department or to relatives or friends. With him in captivity in Tripoli was a private of marines named William Ray, who also kept a journal. In July, 1807, Doctor Cow- dry, who evidently was on leave at his father's house in Tunbridge, Vt., received the following letter from Ray : Dear Sir: My volume is nearly complete and will be put to press in a very short time, but I should nevertheless be very thankful to receive the remainder of your journal, for I have already taken the liberty of extracting from that part of it which was published in the Hudson Balance; and have made some remarks on the extracts, which perhaps, from a view of the whole, I might be induced to alter, I should also be happy to receive from you any interesting remarks you may be pleased to make ; particularly information relative to the origin of the war. I have received both from General Eaton and the Secretary of the Navy, all the information in their power ; but they arc not explicit, as respects the true rise of hostilities between the United States and Tripoli. I wish, likewise, for a list of the United States vessels of war which were lying at Gibraltar when we first arrived there. What arrivals while we lay there, and what ships of war of the U. S. were lost at that place, for I have but an imperfect recollection. I enclose you two subscriptions which I would thank you to circulate and return to Mr. John Barber, Printer in Albany, within a couple of months, by which time it is expected the work will be nearly printed. As the time is short, I must beg you to forward the papers which you have been kind enough to promise me, with all possible expedition, to the Gentlemen above mentioned. I am, sir, very respectfully, Your obedient Servant Wm. Rat. Dr. John Cowdert, Tunbridge, Vermont. No. 1. JONATHAN COWDEEY, SUBQEON IN U. S. NAVY. 75 Evidently Dr. Jonathan only " circulated " one of the " subscrip tions " as there is one folded in the letter. The following ia a copy : " To Headers, Who search for knowledge, mental food of man, " Roam the wide field, and gather all you can ; " Sweet's the repast where reason guides the way, " But ah how bitter if from her we stray"; " Here taste the product of that barb'rous clime, " Where truth is error—virtue is a crime. " No venal motive has the writer shown, " The Author's benefit is all your own ; " Subscribe, persue the volume, and you'll find " Both pain and pleasure thrill the pensive mind, " Mark the strange thesis, count the loss and gain "And feast on pleasure at the expense of pain. " Proposals. " For Publishing by Subscription, A volume entitled " Horrors of Slavery " or " The American Tars in Tripoli ; " Containing "An account of the loss and capture of the United States Frigate Philadelphia,— Treatment and suffering of the Prisoners, Description of the place, manners, customs &c of the Tripolitans, Public transactions of the United States with that Regency, including Gen. Eaton's expedition ; interspersed with interesting remarks, Anecdotes, and Poetry on various subjects, —Written during upwards of nineteen months Imprisonment and vassalage among the Turks. By William Ray " " Specimen of the Work. " Extract from a Piece written by the Author In Tripoli, 1804. " Published in the Port Folio. " Ye lurid domes ! whose tott'ring columns stand " Marks of the despot's desolating hand ; " Whose weed-grown roofs and mould'ring arches show " The curse of Tyranny, a nations woe ; " In ev'ry ruin—ev'ry pile, I find "A warning lesson to a thoughtful mind ; " Your dreary cells expressive silence break, " Echo to groans, and eloquently speaks ; " ' The Christian's blood cements the stones he rears, " ' This clay was moistened with a Christian's tears. " ' Pale as these walls a pris'ner oft has lain " ' Felt the keen scourge, and worn the ruthless chain, " ' While scoffing foes increasing torture pour, " ' Till the poor victim feels, alas ! no more ! ' " Here thy brave tars America are found " Lock'd in foul prisons, and in fetters bound." Conditions. "Hub volume will be handsomely printed on good papers, with a fair type. It will contain about 300 duodecimo pages, and be afforded to subscribers, neatly 103390—22 6 76 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. bound and lettered, at One Dollar, payable on delivery of books. The work will be put to press as soon as a sufficient number of subscribers appear to defray the expense of publication. Albany, Feb., 1807. This book was to be published in Troy, New York, in 1808, but all efforts to find a copy have been in vain. Among letters found in " Officers Letters," Navy Department Library, are some which show Doctor Cowdery's resentment at his delayed promotion. In a letter written July 22, 1807, at Tunbridge, Vt (near Chelsea, Vt.), he acknowledges receipt of orders to New York, and makes request for the promotion, which the Secretary had assured him that he should have, upon the occasion of their last meeting.2 In another letter, written at New York on August 7, 1807, he reports his arrival from Vermont, and states that he has reported for duty to Commodore Eodgers, who has assigned him to duty as surgeon's mate under Doctor Marshall.' States that he expected a "higher station," as he has been for a long time the oldest in the list of surgeons' mates. Mentions that he has attended the medical lectures at Hanover * the last two winters, and has been recommended by Doctor Mitchell 6 and others to the Secretary for promotion. Doctor Mitchell was a teacher of rare attainments and wide knowl edge in both science and medicine. His name appears in several of Doctor Cowdery's letters. In this letter Doctor Cowdery declares his fondness for the Navy and for the gentlemen belonging to it and is anxious to be of service to the country in " the present critical situation," ° but protests against being continued as a surgeon's mate, when younger men are pro moted over him. He requests the rank which was promised him when he and Lieutenant Stuart waited upon the Secretary- in Balti more. 1This letter as well as those which follow are addressed to the Secretary of the Navy, R. Smith. • S. R. Marshall, surgeon's mate, 14 May, 1799; Surgeon. 16 January, 1800; died 20 May, 1828. 'Dartmouth College (at Hanover, N. H.) established a medical department In 1797. • Probably Dr. Samuel L. Mitchell of the Columbia College and the College of rhyslclane and Surgeons, N. Y., who may have given lectures at Hanover. • The Chesapeake-Leopard affair had occurred only two weeks previous. On June 22. 1807, the frigate Chesapeake, Capt. Charles Gordon, bearing the broad pennant of Com modore James Barron, got under way from Hampton Roads bound to the Mediterranean. A squadron of British ships of war bad been at anchor in Lynnhaven Bay for several months watching some French frigates that lay at Annapolis. As the Chesapeake stood down toward Cape Henry, one of the British vessels, the Leopard got up anchor and preceded the American frigate to sea by several miles. When both vessels were well off the land the BriUsh frigate approached the Chesapeake and hailed her, Informing Com modore Barron that she had dispatches for him. In a few minutes a boat from the Leopard came alongside the Chesapeake beating an order to search the vessel for deserters from the British ships. This Commodore Barron refused to permit, Btatlng that he knew of no such deserters on board. The BriUsh officer returned to the Leopard, and almost No. 1. 77 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Navy Yard. New York, August 17, 1801. D'- Sib: On my return from captivity in Tripoli I did myself the honour of calling upon you and in addition to letters of recommendation sent to you by Dr. Mitchell, and commanders in the Navy, whom I had the honour of serving under as surgeon's mate, I delivered to you two letters of recommendation, one from Captain Bainbridge and one from Dr. Ridgely.1 late Surgeon of the Phila delphia. You read them with great satisfaction and applauded my conduct in the Navy. I then told you that I had served a number of years as surgeon's mate and now hoped you would grant me a higher station. Y'ou replied that I should be promoted when I should again be called into service. You have again called me into service, and I am on duty as surgeon's mate, which, under the circumstances, is very humiliating to me indeed, and I now beg you will send me a surgeon's commission, or, if you deem me inadequate to this, I beg you will send me a discharge from the service. Yours with esteem. Jo" Cowdery. Hon. K. Smith, Secretary of the Navy. Fortunately, the "discharge from the service " was never sent, and Doctor Cowdery was promoted to the rank of surgeon in the Navy on the 27th of November, 1807. He was ordered from New York to Norfolk. Va.. where he made his home until his death in 1852. On May 15. 1807, he bought some land of Israel Chase, in Tunbridge, Orange County, Vt., and it seems that he had left his son Isaac Newton in charge of his brother. Elihu. The following extracts are from letters written to his brother Elihu : Norfolk, Va., Jan. 26, 1808. Dear Brother. I had the pleasure of receiving two letters from you since be ing on this Station, one was dated Dec. 3. and the other Jan. 3, in which I am pleased to find that you and our Family enjoy Health. In your letter of Jan. 3d you mention that you fear that I would receive your letters with reluctance were it not for the Business you have in Charge for me. —This, my brother, is a need- legs fear. You may rest assured that I esteem you as I ought to do as my Brother, both by Nature and by Art. our former trifling disputes ought to be without warning the vessel fired an entire broadside at the Chesapeake, wounding Com modore Barron and his aid, who stood In the gangway. The gunfire was continued from 15 to 18 minutes, when Commodore Barron ordered the colors to be hauled down. The Chesapeake Immediately sent a boat to the Leopard to say that the ship waB at the disposal of the English captain, who then directed his officers to muster the American crew. Four men, claimed to be deserters from British vessels, were carried away, and the Chesapeake returned to Hampton Roads. The attack on the Chesapeake aroused public sentiment in the United States against Ureat Britain and almost led to an Immediate declaration of war. —Cooper, J. Fenimore: The History of the Navy of the United States of America, 1853, Vol. II, p. 13. 'Dr. John Ridgely. Appointed 2 July, 1803. He was surgeon on the Philadelphia, Jonathan Cowdery and Nicholas Harwood being the surgeons' mates. Dr. Ridgely was appointed charge d'affaires of the United States to the Regency of Tripoli in June, 1805. upon the recommendation of Commodore Rodgers. He resigned in 1808 and settled In Annapolis, Md. The practice of appointing medical officers to diplomatic posts In the Mediterranean was not unusual in these days. In addition to Dr. Rldgely's appointment to Tripoli, Commodore John Rodgers appointed Dr. James Dodge, surgeon of the Constitu tion, to act as charge1 d'affaires at Tunis, and Commodore Richard V. Morris, in 1802, appointed Dr. George Davis to be consul at Tunis. 78 JONATHAN COWDEKY, SURGEON IN U. S. NAVY. Vol. XVII. forgotten, they were of too trifling a nature to even remember. I wish ofteu to receive your Letters as from a Friend and a Brother. As for my horse I wish him to be used by a careful hand until he can be sold. Sell the saddle and bridle, Sell my sow as soon as she will fetch the highest price. As for my Friends who enquire for me and wish me to return to exer cise my Profession among them, tell them of the Esteem I have for them, and as I intend marrying in their vicinity if * * * I intend to return and settle among them as soon as our Navy is layed up, which I hope and expect will be soon. If Newton learns fast and well and wishes to persist, I wish him to continue in it, in a manner you may deem the most advantageous to him, and my circum stances. If he does not learn well, and is willing to go to a Trade, I wish you to consult Austin and put him to a Good Trade, if any, and under a Good and Severe Master. I am in Health and am employed the fore part of every day visiting and prescribing for the sick and Lame in the Hospital Vessel and in the Navy Yard, etc. My Mates and attendants put up the Medicine and do the other Duty of the Medical Department, the afternoon and evenings I spend in Reading, Writing and among my new friends and acquaintances in Norfolk and in Portsmouth. They are of both sexes and are very Hospitable to the officers of the Navy and Army, who are here In abundance. We are invited to all of their public amusements, etc., etc. The British officers of the Frigate which brought Mr. Rose as a minister to our Government, come on shore occasionally, they visit but little except at the British Consular House (Col. Hamilton). We all treat them much cooler than they have been used in the American Ports. Lieut. John Davis, one of our officers who Commanded Gun Boat No. 1, put an end to his existence the other day, by discharging a pistol through his Brains while lying in his Bed in the Cabin of his Gun Boat. He had been disgraced for bad conduct, he was much given to Dissipation, he found that he was despised and neglected by all his Brother Officers, and was much in debt, which is supposed caused an insanity and was the reason of his committing the horrid deed of Suicide. I was called to him before he was dead, but could not help him. * * * The winter is very Pleasant, but the summer is to be dreaded by us northern people. (Signed) Jon° Cowdeey. The winter was indeed very pleasant for him as will be seen by the following letter: Norfolk, Va. Feb. 13, 1808. Deah Brothek : I this evening am to marry a Woman whom I think is one of the best in Creation. She is of Good character, has a handsome prop erty, is of Good Family, is amiable in her Disposition and manner, and above all she is a woman I ardently admire, her name is Eliza Reddick, widow of the late Capt. Thomas Mill Reddick, who for many years commanded and sailed in different ships out of this Port, and was lost on his return from the West Indies the winter before last. I shall immediately quit my quarters on board the hospital vessel and live with my wife in Norfolk, but shall continue in the same duty in the Navy in this Station as before. I intend coming to Tunbridge as soon as my services in the Navy will admit, perhaps I shall bring my companion with me to visit our friends, if not to settle among you. [Here he gives directions about selling his property in Tunbridge.] My re spects to our friends, particularly our Parents, and my dear Son, tell him to No. 1. JONATHAN COWDERY, SURGEON IN U. S. NAVY. 79 be a good son, to be obedient to his Grandpa and Grandma and learn well his book and his father will not forget him. N. B. an extract from the Norfolk Ledger. " Married on the evening of the 13th Dr. Jonathan Cowdery, Surgeon in the U. S. Navy (one of our late sufferers in Tripolitan Captivity) to the much esteemed Mrs. Eliza Reddick, of this place, widow of the late Capt. Thomas M. Reddick. Feb. 15. 1808." 8 (Signed) Jon" Cowdery. As we see by the following letters, he was not permitted to enjoy the comforts of his Norfolk home long. New Yobk, Nov. 26, 1808. My Dear Brother : We are about getting under way for another Cruise off Boston, Portsmouth, etc. I beg you or Austin, or both of you will write me Immediately at Boston on board the U. S. Brig Argus to the care of the Navy Agent at that place. We expect War with England and France, our Country is In a woful condition, I wish you to send my Great Coat and my Blue Straitbodyed Coat to me at Boston to be left with the Navy Agent of that place until called for, I wish you to put them up in my leather thing that I used to carry my Great Coat in. Seal them up and send them by a safe hand. Inform me what you have done with Newton. I wish you to send the things soon for we shall have a cold cruise. > (Signed) Jon* Cowdery. New York Jan. £ 1809. Dear Brother, I have the pleasure of again addressing you ; we lately re turned from a very tedious cruise on the coast of New England, we had almost constant gales of wind with much Snow and Rain. Many of our Crew* were much frozen. I had thirty on my list at one time, who were frost bitten in a greater or less degree. I have saved all their limbs and the most of them are again on Duty ; We are now taking in Provisions, Water, &c for an other cruise to the northward to enforce the Embargo Laws, and to prevent Insurrection in the forests of New England. The Embargo is an oppressive law, but as it is the choice of the majority of our Country, it is the duty of ua all to Support It, I have suffered much in the cause of my country, and I am willing yet to serve It at the hazard of my Property, my Health, my Comfort and if Necessary my life. But in Vermont I was called a Federal Tory by those who are now violating the Embargo by smuggling into Canada, and these very men voted for the Member in Congress from Vermont who voted in Congress for the passing of the Embargo Laws ; but I am happy to se* a change in your People. I see that you in Vermont as well as in all the New England States have a large majority of Federal Republicans for the next Congress. I hope that the liberty and Character of our Country will yet be saved. I saw Brother Austin's name in the proceedings of the Grand Lodge of Vermont, in the newspapers at Boston. I wrote him that I wished not to meddle much with politics while I was in the service of my Country, but I now feel in a tone for it. I lately applied for a furlough and got an answer this morning that I could not have one, but must go another cruise among my Brother Yankees, etc. I wrote you when I was hoe before to send my Great ■Five children were born of this union. George Washington, born Dec. 13, 1808; Cami-lla Wickham, born Jan. 22, 1811 ; Theodorin. born Dec. 15, 1812, died Oct 13, 1813 : Ann ElUa. born June 30, 1814, died 1894; and Alexander Augustus, born May 11, 1817. died 1S99. who lived for many years with his sister. Ann Eliza, in Philadelphia, Pa. 80 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII Coat and small coat to the care of the Navy Agent at Boston, which I presume you have done before this. If you have not, you need not send it. We did not stop at Boston on our return owing to bad weather, but we expect to be- there within a few days to Blockade their harbor, when I expect to find the articles requested, and a Letter from you. —I want to hear from you all. and the state of my affairs in Tunbrldge. I also wish to know the state of our Infant Medical Society which we were establishing when I left you. Give my re spects to such of the members as you are acquainted with, and tell them that I wish them to send me a Sketch of their establishment and the name of their officers, etc. I wish to give them a place in the Medical Repository." I am with much esteem Yor loving Brother, Jon* Cowdebt. His letters written during the year 1809 indicate that the state of his health was not the best. One dated Norfolk. June 7, 1809, acknowledges orders to the Xau- tilus and expresses regret for a delay until his health is sufficiently recovered to comply with it and join the ship before she is ready for sea, " during which time, if you may deem it proper and will be pleased to command me, I will attend to the procuring the necessary medicines, instruments, etc., which may be procured at this place on very reasonable terms." Another, dated Norfolk. July 14. 1809, and addressed to Hon. Paul Hamilton, Secretary of the Navy, acknowledges orders to the Ferret, but he reports himself ill, though better of the lameness which he mentioned to Mr. Goldsborough 10 when last in Washington. He has a complaint in the breast which is no better and is much emaci ated and debilitated. His infirmity originated from sufferings on board the Argua'the previous winter off the coast of New England, when he contracted a violent cold, since which he has not enjoyed a well day. " I have yet reason to hope it will not prove to be a con firmed decay. I am now in a course of medicine and diet under Drs. Barraud and Hansford, (both very eminent in their profession) which I hope in a few weeks will relieve nie sufficiently to join Lieut. Gadsden on the Ferret. At present am not able to perform the duty required of a physician or surgeon on a vessel of war." " The first medical journal published tn America was the Medical Repository, a quar terly, under the editorship of Samuel L. Mltchill, Edward Miller, and KHliu Smith. It was founded in 1797 and continued until 1824. 10Charles W. Goldsborough was for many years chief clerk of the Navy Department and the author of the uncompleted work, the United States Naval Chronicle. One volume only was published In 1824. Goldsborough's connection with the Navy Department con tinued over a period of 44 years. He was chief clerk under Secretaries Stoddert. Smith, and Hamilton and secretary of the Navy Board of Commissioners until the separate bureaus were established, when he was appointed Chief of the Bureau of Provisions and Clothing, being the first chief of that bureau. (His portrait hangs in the Paymaster Uen- eral's office.) No. L JONATHAN COWDEBY, SUBGEON IN U. S. NAVY. 81 Dr. Cowdrey reported to Lieutenant Gadsden on August 3 as " sick and afflicted with cough, spitting of blood, and pain in my breast. I have not been out of my chambers from the day I saw you. It is with much regret that I am not able to join the Ferret under your command." On August 12 Lieutenant Gadsden reports to the Sec retary that Doctor Horseley 11 has reported. The doctor writes from Norfolk, under date of October 4, 1809, that he has spent 10 years in the Navy — 19 months of which he was in captivity in Tripoli. He has lost considerable property as a result, and also the vision of the right eye,12 and has suffered much impairment of health. He states that he has a wife and three chil dren to support, and asks if he can have duty at the navy yard at Gosport when Doctor Heerman leaves, the latter being not averse to a change of station. In a letter written on board the frigate United States on February 20, 1811, he reports joining this ship, in accordance with orders, and reporting to Commodore Decatur. He expresses the hope that the cruise will benefit his health, but requests permission to visit Wash ington on the return of the ship to Norfolk in order to settle his accounts at the Navy Department and obtain a furlough, during which he desires to make arrangements to provide for his family (a wife and four small children). In several letters written in 1808-9 and 1810, Doctor Cowdery speaks of having established a drug store in Norfolk, Va., and also mentions owning the Chase, Newhall, and Stanley places in Tun- bridge, Vt. The settlement of his affairs in Tunbridge seems to have been the cause of much perplexity, and some misunderstanding be tween him and his brother, and his brother-in-law, Samuel Austin. After much correspondence on the subject, Doctor Jonathan writes to his brother Elihu, on July 8, 1914. " I have written Mr. Paine, the attorney, to settle with you and Austin on amicable terms and not to put you to any cost or inconvenience if he possibly can avoid it. I had rather lose a thousand dollars than wrong either of you one cent. I therefore desire you and Austin will come to a settle ment with him of everything concerning me. I deprecate family disputes. I therefore hope you will settle everything amicably. I am on duty in the Navy on this Station. We have about 700 men in the service, and I have had the good fortune not to lose but one man since I had the medical charge of them, which is a year last spring. We hope for Peace soon, but are under apprehension that "In later years Horseley became surgeon ou the Lawrence with Commodore O. H. Perry, and was present In the Battle of Lake Erie on Sept. 10, 1813. "Conjnnctlvitla was very prevalent in Tripoli. 82 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVIL the war will last many years. England being left to contend with us alone, I fear will take ground that our Government cannot with the dignity of an independent Nation, submit to. My particular Love to our aged Parents. I beg you will not let them suffer, should they be in want I am ready and willing to contribute to their com fort and support." In a letter written on August, 1815, Dr. Cow- dery appoints " My honored Father Jabez Cowdery of Tunbridge, Vermong, my true and lawful attorney." Nothing appears in the files of the Navy Department's corre spondence concerning Doctor Cowdery until 11 years later, at which time we find him ordered to sea and apparently feeling the weight of his years and the disadvantages of ill health. In a letter written at Norfolk, on April 16, 1823, in reply to the Secretary's order of the 10th to join the Hornet, he states that ill health will prevent, that he is 56 years old on the 22d day of this month and in the Navy 23 years, and has made no complaints about orders until now. He asks to continue on the station and have his orders to sea revoked. He inclosed a letter from Surg. George J. Kernays which states, "that Doctor Cowdery for 12 months has feared that he was losing use of one leg and thigh. He requires care to prevent a termination in a general paralytic affection of the lower extremity." Indorsement by the Secretary of the Navy. " The order may be revoked, another must be obtained." From Norfolk, under date of January 9, 1824, he writes that he has been with Commodore Porter in former days and in trying scenes, but by reason of ill health he is not able now to render service to him and under his command " in the contemplated cruise against the enemies, not only of our country but of the human family." He wishes to have a position on the station (i. e. Norfolk) and states that he was " in all wars since the Revolution to the end of the last British war—out in the Argus and in the United States during the greater part of the embargo. In the Navy 24 years on the 1st of this month and 58 years old next April and been in sea service (I.believe) more than any surgeon in the Navy." He suggests that he may be useful at the recruiting service attending the sick and disabled officers and seamen not accommodated at the hospital and explains the he " is now attending some of this description and assisting the younger surgeons in making out their requisitions, etc., and in examining old or damaged articles of the Medical Department be longing to vessels after a cruise, and in attending sick seamen on Crany Island who may be quarantined, as I did the last two seasons." No. 1. JONATHAN COWDERY, SURGEON IN U. S. NAVY. 83 This letter bears the following indorsement by the Secretary of the Navy : " Countermand orders and leave him as he was before. 16 Jan. 24, Samuel L. Southard." 1S A letter from the U. S. R. S. Alert, dated April 19, 1827, indicates that Doctor Cowdery was still at Norfolk. When 63 years of age, Doctor Cowdery was ordered to sea as medical officer of the U. S. S. Warren and as he was to be the senior medical officer in the Mediterranean Fleet he was exceedingly anxious to secure the denomination as surgeon of the fleet and accordingly wrote the following letter to Andrew Jackson, the President of the United States: Navy Yard, New York, SO June 1829. Sib: I hereby take the liberty of addressing your Excellency on a subject which to me is of vast importance, and for which I have reason to believe you will have the goodness to excuse, and duly appreciate. I have belonged to the Navy of the United States as a Medical Officer nearly thirty years, have been on duty at sea and on shore stations the whole of this time, excepting about two years after being released from Tripoli cap tivity and I flatter myself to believe that I have performed my duty to the satisfaction of all whom I have the honor to serve. I lately received orders from the Honb" Secretary of the Navy to proceed to New York and report to Commodore Chauncey for a passage to the Mediterranean and then report to Commodore Crane for duty on the U. S. Ship of War Warren. I resolved to obey the orders as far as was in my power, and did myself the honor of calling on and taking leave of your Excellency, and also the Hon"* Secretary of the Navy. I then wanted to confer on the subject of my rank, but found your excellency so much engaged that I concluded It would be best to write you on the sub ject, and not delay the obedience of my order. The Act of Congress for the organization of the Medical Department of the Navy of the U. S. of 24th of May 1828, 2nd Section, authorizes the President of the U. S. to appoint to every fleet or squadron of the Navy a surgeon then in the naval service of the U. S. to be denominated Surgeon of the Fleet. Therefore if I am to be the oldest surgeon on the Mediterranean Station I do most respectfully ask your Excellency to grant me my rank. It would be humiliating to serve under a younger surgeon. From your Excellency's military renown and kindness of heart, you can duly appreciate the feelings of an officer on a subject of this nature. I hope I may not be allowed to leave my country, my friends, my wife and children, with a heavy heart. As for my naval, or professional character, I refer your excellency to Commodore Barron under whose command I last had the honor of serving on the Norfolk Station. "This letter Indicates that Doctor Cowdery hud been ordered to Commodore Porter's squadron, which had been operating in the West Indies against pirates, then infesting these waters. Commodore David Porter had resigned his position as Commissioner of the Navy to assume the command of this expedition. He took his squadron to sea on the Hth of February, 1823, and after successfully suppressing piracy about Cuba and Porto Eico, arrived at Thompsons Island (Key West) late in the year. Here yellow fever broke out in several ships and soon forced the sailing of the squadron to the northward. Porter's action during thla campaign in landing an armed force at Fajardo, on the island of Porto Rico, in an attempt to force an apology for harsh treatment of some of the officers and men, brought about his trial by court-martial and his suspension from duty for six months. 84 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII I am to take passage to the Mediterranean in the U. S. Ship Ontario; she is to sail from this port ; it is likely that she will be detained several weeks for want of seamen, whom are slowly procured, therefore I hope to be honored with a reply to this communication before leaving this country. I am respectfully, Sir, Your Excellency's Obedient and very humble servant, Jon" Cowdebt, Surgeon. His Excellency, Andbew Jackson, President. (Indorsed by the President:) "Referred to the Secretary of the Navy for answer. A. J." The following letter, which was written to his son, Benjamin Franklin Cowdery, then ir Geneva, N. Y., gives some insight into Dr. Cowdery's character. New Yobk, Aug. 17, 1829. My Deab Son. It is a considerable time since I had the pleasure of hearing from you. As this may be the last time, I feel it a duty now to address you. I am about to leave my Dear Country, family and friends, on another cruise of perhaps three years in the Mediterranean. I was in hopes that my former services and age, would induce the Government to allow me a shore station the balance of my days. On my receiving orders for this service, while I was on duty as Surgeon of the Naval Station at Norfolk, in Virginia, and where my wife and four children now reside, I went to the city of Washington to see the President of the United States and the Secretary of the Navy on the subject of my being ordered to sea in my old days, they both urged the neces sity of my complying with the order and said that my services were particu larly required in the fleet as being an old and experienced surgeon. I concluded that it was my duty to obey the call and again go on foreign service for my country. I am to go out a passenger in the U. S. Ship of War Ontario; she is fitting out on this station. We expect to sail within two or three days for the Mediterranean to join our Squadron at Port Mahon, where I expect to be put on duty as fleet surgeon. The Delaware 74, Commander Crane, is to return to the U. S. Commander Riddle is to take command of the Squadron. A Mr. Lee, Consul General of Algiers, two or three Lieutenants, two young Gents who lately graduated at Yale College, and several Midship men are going as passengers in the ship. I have left my son G. W. Cowdery in charge of my family in Norfolk. He will be twenty one years of age next December ; he is a moral, steady, studious and promising youth. I place great confidence in him, and hope he will become a Christian and an ornament to his fellow mortals. My son, before closing this epistle I will say a few words on this important subject of Religion. I for several years have been under serious impression on this subject. I am convinced of the truths of Christian ity, as it is set forth in the Holy Scriptures. I hope that God has forgiven the many sins of my younger days, I feel a confidence in him and a thankfulness for his many and continued blessings bestowed on me and mine. I am a member of his Holy Church. I read his Word and pray for his Blessings and Salvation. What is this world without religion. .Toys at best are but transi tory, all checkered with afflictions, even if we live a hundred years, life is but a phantom in comparison to eternity, therefore is it not best to strive to serve God, with the hope of his benediction in this world, and the world to come. My love and best respects to your Dear Family, and that all of you may be con stant in serving God and our fellow mortals is the prayer of your affectionate father, Jon* Cowdebt. No. 1. JONATHAN COWDEBY, SURGEON IN U. S. NAVY. 85 Fourteen years pass. We assume that Doctor Cowdery finished his cruise in the Mediterranean and returned to duty at Norfolk, but detailed information relating to this period is lacking. He is now well along in years, but evidently not willing to be superseded by a younger man, as the following letter to the Secretary of the Navy indicates. It is not in his usual handwriting and the signature is that of a hand tremulous with age : Naval Rendezvous, Norfolk, March SI, 1843. Sn» : Dr. G. W. Codwise, who has just arrived here from the North, I am in formed either has, or Intends applying for the situation, which I have the honor of filling, as the recruiting medical officer at this place, I have, I believe, faith fully gone through every species of service, incident upon my profession, and after 40 years servitude, find myself at the head of the list of Surgeons. I am now, Sir, 76 years old, and too infirm for the more active and rougher duties of my profession. I believe the duties of the Rendezvous, are, and can be still, performed by me, as well as any one else, and as I do not desire to be sup planted, unless the good of the service requires it, I most respectfully. Sir. re quest that I may not be detached from my present position. I have the honor to be, Very respectfully your obt. Servt. etc. , Jo° Cowdeby. Hon. A. P. Upshur, Secretary of the Navy. [Indorsed as follows:] Dr. J. Cowdery having punctually performed all the duties of medical officer at the Rendezvous to my entire satisfaction I cheerfully request for him a full consideration of his application. Jno. P. Young, Coma. Naval Rendezvous, Norfolk. [Indorsed by the Secretary:] This removal is not because of any deficiency or neglect on his part but in compliance with a rule which Is applied to all officers of the service that they shall hold such places only three years. Ansd 7 April 1843. Def1. and waiting orders. Apr. 7, 1843. Apparently his successor did not like the detail at Norfolk and Doctor Cowdery, learning that he was desirous of leaving, writes re questing the duty. Norfolk, Va., October 23, 1844. Sir: As Doct' Codwise is desirous of leaving the Rendezvous of this station and as my Infirmity of age renders me unfit for very active service, and as I desire to render some benefit to the service. I hereby respectfully ask to be ordered to attend the Naval recruiting service ax surgeon of the Rendezvous on this station. Respectfully Sir Your Obt. servt. .Io° Cowdeby, Surgeon. U. S. Navy. Hon"" John Y. Mason, Secretary of the Navy. 86 JONATHAN COWDERY, SURGEON IN U, S. NAVY. Vol. XVII [Indorsement on letter:] Surgeon Cowdery is the oldest surgeon in the Navy, to whom this duty would be particularly acceptable, on account of his age and incapacity for active service. Should the Department see fit to grant this ap plication, it would be an act of kindness to him, very gratifying to himself and friends. Very respectfully, etc. ^ c BoLTON Ref to Bureau of Medicine and Surgery J. Y. M. It is recommended that this application be granted, that the transfer occur the 1st of November and that Dr. Codwise be relieved and granted 3 months' leave. Respectfully, Thos. Harris. Done, 2 Nov. 1844. A letter dated November 6, 1844, acknowledges the receipt of orders of the 1st instant to attend the naval rendezvous at Norfolk, and in dicates that Doctor Cowdery has reported to Commander Bolton and Commander Armstrong. A letter of July 14, 1845, gives some details of a report of survey on a midshipman, " affected with bilious pleurisy, which has ter minated in chronic hepatitis and pleuritis. He is also threatened with Phthisis Pulmonalis. We respectfully recommend change of residence, as we consider such change essential to his recovery. Jon. Cowdery, Surgeon, V. S. N. Danl. Egbert, Surgeon, U. S. N." The following correspondence indicates that his service at Norfolk was once more interrupted : U. S. Naval Rendezvous, Norfolk, June 6, 1850. Sir: On the 21st of May last Commodore Sloat ordered me to take the place of Surgeon Thomas Williamson at this Rendezvous, the duty of which I continued to perforin from the date of this order. I now respectfully desire the Department to be pleased to confirm the order. Very respectfully your obt. servt. . . „ Jo° Cowdery. Surgeon Thomas Harris, Chief of the Bureau of Medicine and Surgery. Referred to Department recommending confirmation of orders. Thos. Harris. [Indorsement hy Secretary:] Is this (?) able to perform this duty? W. B. P. [Indorsement by the Chief of the Bureau of Medicine and Surgery:! Dr. Cowdery is believed to be fully competent to the duty for which he has been above detailed. Very respectfully, Thos. Harris. Order him. W. B. P. Order confirmed, 11 June 1850. U. S. Naval Rendezvous, Norfolk, Va. June 13, 1850. Acknowledges Secretary's confirmation of orders to duty at Rendezvous To : Hon. Wu, Ballard Preston. Secretary of the Navy. No. 1. JONATHAN COWDERY, SURGEON IN U. S. NAVY. 87 Doctor Cowdery's death occurred on November 20, 1852. The Norfolk Beacon of that date in referring to him said : " Few men have borne a more unblemished character or been held in such high and universal esteem for all the qualities of head and heart that constitute the efficient officer and worthy citizen." He was buried in Cedar Grove Cemetery in Norfolk, in a lot with his wife Eliza, and his sons, Alexander, Augustus, and George Wash ington. His remains are in a small vault resting on the ground, the sides of which are granite and the top marble. One visiting his grave to-day may read the following inscription covering the marble slab of the vault : " In Memory of Jonathan Cowdery, Surgeon of the Navy of the United States He was born April 22, 1767, And died November 20, 1852. Affectionate in his nature, faithful in the performance of his duty, and pure in spirit, He has left, as a patriotic christian, a character without stain, and an example worthy of emulation. He was upwards of fifty-two years in the service of his Country, and at the time of his death held the oldest commission in the Navy." (The writers of this article wish to acknowledge their indebtedness to Dr. Southgate Leigh, of Norfolk, Va., for much material relating to the personal history of Doctor Cowdery and for assistance in securing the loan of the da- guerrotype from which the portrait appearing in this article was reproduced. It so happened that when one of us had decided that Doctor Cowdery had probably spent his last days in Norfolk, Doctor Leigh was addressed with a request that he indicate some one who might give information of the place of burial of Doctor Cowdery and supply biographical data relating to him. The selection of Doctor Leigh was entirely accidental but very fortunate since he proved to be a great grandson of Dr. Jonathan Cowdery.) (to be continued) I EDITORIAL EDITORIAL STAFF. Capt. M. F. Gates, Medical Corps, United States Navy. Lieut. Commander W. M. Kkbb, Medical Corps, United States Navy. Lieut. J. H. Chaubkbs, Medical Corpa, United States Navy. Lieut. Edwin Pitebhon, Medical Corps, United States Navy. AN INVESTIGATION OF THE ETIOLOGY OF EPIDEMIC ENCEPHALITIS. The causative agent of epidemic encephalitis (lethargic enceph alitis) has apparently been demonstrated by Strauss, Hirschfeld, and Loewe, working in the pathological laboratory of Mount Sinai Hos pital, New York City. Their work has been confirmed wholly or in part by others in France (1), England (2), and the United States (3). The investigation was exhaustive, conclusive, and all the steps were well controlled. The results were published in a series of arti cles entitled " Studies in epidemic encephalitis," appearing in various periodicals. The first of this series (4) describes results obtained by subdural or intraperitoneal inoculation of seven monkeys, with ma terial obtained from human cases or from artificially infected mon keys. A saline emulsion of brain tissue from a fatal human case pro duced lesions in a monkey similar to those of human cases. Wash ings from the nasopharynx of a human case were passed through a Berkefeld filter and injected subdurally and intraperitoneally into a monkey and produced a paresis of both hind legs and an increase in the spinal fluid cells. A similar filtrate, from the mucous mem brane of the nasopharynx of a fatal cardiac case, produced no appar ent lesions in the monkey up to the date of the presentation of the report. The next report (5) describes experiments with a group of rabbits and the further results on the first seven monkeys as well as several additional ones. Rabbits were injected intracranially with a Berke feld filtrate of nasopharyngeal material from a patient suffering from encephalitis, and others with material from control cases. At the same time, others were injected with material from rabbits dying from the induced infection. By this series of experiments the authors demonstrated that a filterable virus from the naso pharynx would produce lesions in rabbits and monkeys similar to those in the human brain, and that this virus could be recovered 89 90 Vol. XVII EDITORIAL. from the nasopharynx of animals which had been previously in oculated intracranially. Approximately 50 per cent of rabbits seemed to have a natural immunity. One infected monkey that recovered was found to have developed an immunity. Up to this time attempts at culture, using the ordinary aerobic and anaerobic methods, were unsuccessful. Another paper (6) describes the successful cultivation by the method employed by Noguchi (7) of an organism resembling in appearance of colonies, of growth, and of morphology the organism described by Flexner and Noguchi in poliomyelitis (8). Details of the method of culturing and of appearance of the organism are given more fully in a separate report (9). The media used consisted of sterile kidney fragments covered with 3 or 4 cubic centimeters of sterile ascitic fluid in test tubes of 20 by 1.5 centimeters, and which was incubated for 48 hours. Contaminated tubes were discarded when contamination was detected by gross examination or by dark- field illumination of smears. Better results were obtained when an old ascitic fluid was used. This should be bile-free and of high specific gravity; the presence of fibrin helps the growth of the or ganism. The best material was that obtained from decompensating cardiac cases. The tubes were first inoculated and then ascitic fluid was added to make a column 10 centimeters high. Petrolatum of low melting point was added to make a layer of 1 centimeter in thickness. Alboline may be used, but with this a Novy jar is necessary. As control tubes they employed combinations of ascitic fluid with petrolatum; inoculum, ascitio fluid, and petrolatum; ascitic fluid, kidney tissue, and petrolatum. As inoculum they used brain fragments, spinal fluid, blood, and nasopharyngeal wash ings. The tubes were inoculated at 37° C. ' In no instance did the organism grow on solid media from in fectious material, and only grew on solid media on subculture. A successful growth appeared by the fifth to the seventh day as a clouding of the media about the kidney tissue. The optimal solid media was of gelatinous consistency, made so by the addition of one part of 2 per cent nutrient agar to four or five parts of ascitic fluid with kidney tissue. The organism appeared in solid media as minute colonies, more numerous near the kidney tissue. All con trols were negative in both solid and fluid media. The organisms were fixed in methyl alcohol and stained with Giemsa's or Loeffler's alkaline-methylene blue for one or two hours. They appeared as small globular or spherical bodies stained purple or blue and ar ranged singly, in pairs, chains or clumps. The organism lived in culture media for at least six weeks and in the older cultures showed larger degenerated forms. The organism was nonmotile. Gram staining varied with age and with the culture media ; young cultures No. 1. 91 EDITORIAL. on solid media were mostly gram positive. Morphologically, it is like the organism of poliomyelitis of Flexner and Noguchi, but it differs from the latter in its action in animals, particularly in the suscepti bility of rabbits to this organism. The virus was carried through 12 generations on culture media, and the seventh and eighth were still fatal for animals. The organism was obtained from the fol lowing locations : 1. Berkefeld nitrate of extract of nasal mucosa, 7 of 10 cases. 2. From the washings of the nasopharynx, 15 of 23 cases (66 per cent of the human cases). 3. Spinal fluid in 12 of 24 cases (8 negatives from other diseases)'. 4. Babbit nasal mucosa in 3 cases.1 5. Babbit brain, 36 of 56 positive, (64 per cent).1 6. Monkey brain, 5 of 6 cases.1 7. Human brain, positive in a few rapidly fatal cases observed. 8. Human blood, positive in 2 cases tried. Babbits were readily inoculated while monkeys were relatively refractive —the reverse of poliomyelitis. The spinal fluid of poliomyelitis patients is innocuous to rabbits or monkeys, while encephalitis is produced in animals by injection of spinal fluid from positive cases. Successful inoculations of monkeys and rabbits having demon strated the presence of the virus of epidemic encephalitis in the nasopharynx and in the spinal fluid of patients with the disease, it was suggested (10) that this be employed as a means of making a differential diagnosis. They used nasal washings or material ob tained on a swab from the nasopharynx, which was emulsified in saline, passed through a Berkefeld filter and inoculated intra- cranially. Spinal fluid was used for inoculation, in quantities of 0.5 c. c. or less. An inoculation with Berkefeld filtrates of naso pharyngeal material produced characteristic lesions of epidemic encephalitis in rabbits in 78 per cent of cases tested. A small coccoid body was recovered from cultures of filtered nasopharyngeal wash ings in 11 of the 17 cases (64 per cent). The spinal fluid from 12 of the 16 patients, or 75 per cent, when inoculated into rabbits intra- cranially produced characteristic lesions. Cultures of spinal fluid were positive in 10 of the 20 cases (50 per cent). The positive results with spinal fluid sharply differentiate encephalitis lethargica from poliomyelitis. Numerous controls were entirely negative. In France, Levaditi (1) and Harvier (11) found a virus fatal to rabbits in four to six days in many cases of epidemic encephalitis. A Berkefeld filtrate of the virus from human cases was nonpatho genic to monkeys, but became pathogenic after passing through 'These animals were Inoculated cases. 103390—22 7 92 Vol. XVII EDITORIAL. several rabbits. It could also be preserved in glycerine. A crossed immunity between poliomyelitis and epidemic encephalitis could not be induced. The serum of a convalescent from one disease had no effect on patients suffering with the other. Their cultural experi ments were negative, but they did not employ the technique of Noguchi. In England, Mcintosh and Turnbull (2) injected subdurally into monkeys an emulsion of the central nervous system from a patient who died of lethargic encephalitis, as well as a Berkefeld filtrate of this emulsion; both animals showed characteristic lesions of the disease. No attempts were made to culture. In the United States, Thalhimer (3) has confirmed the findings of the Mount Sinai Hospital Laboratory, using material from four cases of the disease—two of the fulminating type, one with marked myoclonus, one with marked lethargy. A Mandler filtrate of the central nervous system of all four cases was used as a source of ma terial as well as the spinal fluid of one fulminating and one con valescent lethargic case, with fading symptoms. He used about two hundred rabbits, giving intracranial injections through the temporal plate, and found that they withstood the injection of 1 c c. very well. Infected animals showed varying symptomatology. A few died of intracranial hemorrhage. Most of them died in from 2 to 4 weeks and some as late as 10 weeks. Material in each in stance was inoculated into groups of from three to eight rabbits. Some groups showed 100 per cent mortality, while others as low as 50 per cent. Two strains of the virus have been passed through a Mandler filter and reinoculated into six groups of rabbits. The lesions in the nervous system produced by the disease are scattered, and extensive study is necessary or they will be missed in many cases. Several series of controls were negative. In the cultural work, Thalhimer (3) used Noguchi's media and method. Spinal fluid was inoculated directly, while an emulsion of central nervous system was passed through a Mandler filter and the filtrate inoculated. Growth appeared in 5 to 10 days, and was similar to that described by Loewc and Strauss. Cultures were ob tained from the brains of the four cases studied, and from the two spinal fluids. Some cultures were carried to their sixth successful subculture. Cultures were recovered from about 84 per cent of the brains of the animals successfully inoculated. A positive culture from a rabbit's brain from the sixth series or generation was ob tained. All subcultures were made from a Mandler filtrate of posi tive cultures. Original material and cultures inoculated on ordi nary media and Rosenow's ascitic fluid glucose agar were all nega tive except for occasional contamination. Control cultures from tlie No. 1. 93 EDITORIAL,. spinal fluid obtained from patients with other diseases were all negative. In summing up his work the author stated that infectious agents were apparently constantly associated with epidemic encephalitis. The infectious agent passed a Mandler filter and produced a disease in rabbits very similar to that in man. The original dose of virus was passed through six animals, and if it were not a reproducing virus it would be so well diluted that it could hardly be held re sponsible for the lesions produced. On Noguchi's media he culti vated an organism like that of Loewe and Strauss. The organism was recovered from 80 per cent of inoculated cases and from animals inoculated from cultures. (Loewe and Strauss produced the disease in animals with the eleventh generation of the organism.) Loewe and Strauss diluted a filtered virus through six diluting tubes, putting 0.2 cubic centimeter into 15 cubic centimeters of ascitic fluid in each instance, and demonstrated that the virus was so diluted as to be innocuous in the sixth tube, thus proving that the virus must proliferate in animals in order to continue producing the disease. Amoss (12) confirmed the absence of crossed immunity by con trolled experimental inoculation of monkeys, showing that serum from epidemic encephalitis cases would not protect against polio myelitis virus. Other workers have reported several other organisms recovered from the blood stream or the brain of cases of epidemic encephalitis, but all from limited groups of cases. The organisms varied as to type, source, and pathogenicity for animals. The latter investiga tions were not sufficiently thorough and complete to be conclusive and may very well be disregarded, whereas the work at Mount Sinai Hospital was very thorough and conclusive. Koch's postulates were fulfilled and at the present writing it would seem that we have a definite causative organism for epidemic encephalitis. BIBLIOGRAPHY. (1) LevaditI, C, Compte Rendus des Seances de la Soc. de Biologle, 83:354, 1920. (2) Mcintosh, J., and Turnbull, H. M., Experimental transmission of Enceph alitis Lethargica to a monkey. Brit. Jour. Exper. Path. 1 : 89, April, 1920. (3) Thalhirner. Willinm, Cultural and experimental studies on Epidemic Encephalitis, preliminary communication. Arch, of Neurol, and Psychlat, 5:114, February, 1921. <4) Strauss, Israel, Hirschfeld, Samuel and Loewe, Leo, Studies in Enceph alitis Lethargica. New York Med. Jour. 109 : 772, 1919. (6) Loewe, Leo, Hirschfeld, Samuel, and Strauss, Israel, Studies In Epi demic Encephalitis. Jour, of Infect. Dis., 25:378, 1919. <6) Loewe. Leo, and Strauss. Israel. Etiology of Epidemic Encephalitis. Jour. Am. Med. Assn., 73 : 1056, October 4, 1919. 94 Vol. XVII EDITORIAL. (7) Noguchi, Hideyo, Cultural methods. Jour, of Exper. Med., 14:99, 1911: 15 : 90, 1912 ; 16 : 199, 211, 1912. (8) Flexner, Simon, and Noguchi, Hideyo, Poliomyelitis cultures. Jour. Am. Med. Assn., CO : 362, February 1, 1913. Jour, of Exper. Med., 18 : 461, 1913. (8) Loewe, Leo, and Strauss, Israel, Studies In Encephalitis Lethargic*. Jour. Infect. Dis., 27 : 250, September, 1920. (10) Loewe, Leo, and Strauss, Israel, Diagnosis of Epidemic Encephalitis. Jour. Am. Med. Assn., 74: 1373, May 15, 1920. (11) Harvier, P., Bull, et mem. Soc. med. d. hOp. de Paris, 44: 179, February 6, 1920, and 44 : 583, May 7, 1920. (12) Amoss, H. L., Immunological distinctions of Encephalitis and Poliomye litis. Jour, of Exper. Med., 33 : 187, February, 1921. ( j. h. c.) A DISBEBTATION ON SOUP. In an experience of about 16 years of hospital service (civil and naval, ashore and afloat), the writer has often been impressed with the fact that, except as concerns patients on " special diet," all food is consumed during a period of about 10} hours in each day. This is partly due to custom and partly to practical considerations relating to employees, but it does not seem to be the best possible arrangement as regards those who are being fed. Especially is it unsatisfactory where it is desired to build up men whose physical condition is impaired from any cause, and this includes a large pro portion of all hospital patients—postoperative cases, and convales cents from acute infections of whom only a fraction are usually carried on the " special " list, for " 8 o'clock nourishment." For about two months an experiment has been tried at a certain naval hospital, which is felt to have given such successful results as to merit report and which it may be desired to try elsewhere. Each day a large kettle of soup is prepared in the main kitchen. After supper it is transferred to the ward kitchen, in charge of the ward supervisor, and during the early evening is reheated on the gas range. Later in the evening the soup is served in Navy bowls, with bread (no butter) to all applicants—patients, Hospital Corps men, and those employees who are subsisted at the hospital. The only restriction on its issue is that the supervisor on watch shall see that a sufficient quantity is reserved for the night force coming on duty at 9 p. m., and it is allowed to be taken to the bedside or the ward table or to be eaten in the ward kitchen. The cooks are given wide latitude but are instructed to vary the kind of soup as much as may be done conveniently. The main points to be observed are that it shall be nutritious, ample in quantity, appetizing, and economical. A " stock pot " is kept constantly in use and receives all suitable bones, meat trimmings, and other proper ingredients. If soup has No. 1. 95 EDITORIAL. been served at dinner any residue that may be left is utilized. All available " odds and ends " and " left-overs " find their way into the soup kettle, and a very large proportion of these would otherwise go to the garbage can as the quantity is not sufficient to serve to a mess and it is not practicable to serve any article to a few persons only. This utilizes any small surplus of materials remaining in the ice box or in the serving dishes such as cold beans, peas, potatoes, tomatoes, macaroni, bits of asparagus, carrots, turnips, cabbage, and oatmeal. Occasionally a plain bean or pea soup is served, or a regularly made " cream of celery " or potato soup but, in general, it is an " olla podrida " and best liked when it has " lots of vege tables." I believe that the serving of soup in this way not only utilizes materials which would otherwise be wasted but that the absorption of calories and other food values contained in the evening issue reduces the amount consumed at other meals by more than enough to offset the cost of the bread served with it; therefore I think it may be said that the cost is nothing, the satisfaction immense. One evening, an ex-patient, "who was visiting a friend in the hospital, was asked, " Did you come up to have a bowl of soup with us?" and his reply was " No-o, I came to see X, but I surely will mm that soup." I feel that this serving of soup and bread may also have some effect in the direction of reducing the desire to "go ashore" in the evening, which makes for the men's good in other ways besides re ducing their expenditures in restaurants. It is possible that in larger hospitals difficulties would be encountered, but it is also pos sible that they might be surmounted. If there is a "night cook" regularly on duty, as was the case at one hospital under my com mand, the necessary service and care of utensils is easily arranged. Why should this idea not be given a try out, not only in other hos pitals but at receiving ships and barracks and even on board cruising ships? A steaming cauldron of soup, one man in the galley, a row of serving pots, each supplied with a ladle and kept filled, a pile of cut "chunks'7 of bread, and a bowl and spoon for each man who wishes to come and "help himself" at any time from 8 o'clock to taps," would not be impossible nor even difficult, and the soothing sensation of repletion following a " night cap " of bread and hot soup would add luxury to the swaying hammock and prove a real asset of welfare, comfort, and contentment, to be looked forward to by tiie men as an agreeable break in the long evenings on board ship. I'erhaps even the officer of the deck would find not disagreeable the Performance of his duty in " inspecting " this issue of food. (m. f. o.) 96 Vol. XVII EDITORIAL. ON ACUTE APPENDICITIS. In the Annual Report of the Surgeon General of the Navy for the fiscal year 1921, we find that 1,038 patients were admitted to the sick list during the period covered by this report with a diagnosis of acute appendicitis. Of this number, 861 came to operation, and of these 16 died. The causes of death were ascribed in 1 case to carcinoma, in 1 to ether poisoning, in 1 to pneumonia, and in 13 to peritonitis — truly a satisfactory showing for the naval operating surgeon; yet might not the 13 deaths from peritonitis have been reduced in number or avoided altogether by perhaps an earlier diagnosis or an operation in the early stage of the disease? The mortality from acute appendicitis is practically nil in cases which are operated upon early in the disease; the mortality is high in cases operated upon late. After the infection has invaded the peritoneum and resulted in peritonitis, either localized or general, the disease becomes a serious affair. If the diagnosis can be made within the first 12 hours after the onset of the symptoms, a prompt operation, with removal of the appendix and closure of the incision without drainage, will usually result in a prompt recovery. If, however, operation has been delayed until peritonitis has set in, the peritoneum must be drained, and the patient has not only to combat the effect of the operation but must also overcome the peritonitis. Often he is unable to do this and dies, when he might have been saved by earlier diagnosis or earlier operation. Three wrong principles of so-called medical treatment of acute appendicitis are partly responsible either for the errors in diagnosis or the hastening of necrosis of the tissues of the inflamed appendix. The first is the administration of morphine to relieve the initial pain before any diagnosis has been made. Before giving any nar cotic to a patient with belly pains every effort should be made to establish the diagnosis, for as soon as a patient is under the influence of morphine the symptoms are masked. Spasm and rigidity, two very important signs in appendicitis, disappear; the patient feels better and when seen later in the day it is often impossible to make a diagnosis. The second error in the treatment of abdominal pain of unknown origin is the administration of cathartics, usually castor oil, calomel, or salts. Any one of these excites a violent peristalsis and if ap pendicitis is present, not only tends to spread the infection over the adjacent peritoneum, but often induces a perforation. The third error is the indiscriminate use of the ice bag. Capt. A. M. Fauntleroy. Medical Corps, United States Navy, writing in the Medical Record of August 3. 1912, calls attention to a series of cases of acute appendicitis coming to operation on the U. S. S. Solace. In No. 1. 97 EDITORIAL,. 60 per cent of these cases the appendix was gangrenous, about to per forate or pus was present. The health records of this series showed that an ice bag had been applied in 50 per cent of the cases. Fauntle- roy observed that when the ice bag was used there was a noticeable lack of effort on the part of nature to wall off from the rest of the ab dominal cavity the appendix, which was frequently very much con gested, gangrenous, or perforated. Every medical officer knows the symptoms of acute appendicitis, yet when we stop to think of the seriousness of the disease, a review of the symptoms may not be out of order. In a typical case of appendicitis the symptoms are somewhat as follows : The onset of the disease is generally ushered in with severe abdominal pain which extends over the whole abdomen. However, the first pain may be referred to the epigastrium, or it may be In the appendix region. The pain is usually followed by nausea and vomiting. In a few hours the pain localizes in the right iliac fossa and the patient is exquisitely tender at McBurney's point. The tem perature is usually elevated, but it may be normal. The pulse is usually accelerated and there is pronounced rigidity or spasm over the right rectus muscle. Constipation is usually present, but occasionally there is diarrhea. Symptoms referable to the bladder may be present when the appendix is long and hangs over the brim of the pelvis. The pain and tenderness are usually re ferred to the left iliac fossa or they may be referred high up on the right side when the appendix is retro-cecal. Examination of the blood at this time will usually show a marked leucocytosis and an increased percentage of the polynuclear cells. A low leucocyte count may indicate a lack of reaction on the part of the patient with a consequent poor prognosis. The severest types of appendictis may present the mildest symp toms. The writer has operated on cases presenting few symptoms in which the appendix was found full of pus and ready to rupture. In considering a diagnosis of acute appendicitis one should not neglect to examine the patient's general physical condition. Often the pain of a pneumonia on the right side is referred to the region of the appendix. The symptoms and signs of acute appendictis are usually clear and onmistakable. As soon as the diagnosis is established, the appendix should be removed at once. The treatment of acute appendicitis is surgical, not medical. During the first 12 or 18 hours following the onset of the disease, the abdomen can usually be closed without drain age and the patient will make a prompt recovery. When the peri toneum, however, becomes involved, drainage must be employed, and if the patient recovers, convalescence is prolonged and often stormy, (w. M. k.) 98 Vol. XVII EDITORIAL. ON THE USE OF IODINE AS A SKIN DISINFECTANT. The use of tincture of iodine as a disinfectant for the skin, par ticularly for the field of operation, and for the treatment of in juries, came prominently before the medical profession about 1905 and has been used extensively since that time. It was found that a 3 or 3| per cent alcoholic solution gave the best results. The use of a solution of this strength accomplished sterilization in a few minutes. Furthermore, it was found that if a healing wound was subjected to slight irritation by iodine a much smaller scar would be left than if it was allowed to heal normally. An excellent resume of the development of the use of iodine up to the latter part of 1910 by J. F. Wollheim appeared in the Ameri can Journal of Surgery for November, 1910. Little or nothing has been written on this subject since 1912 or 1914, so to get some expression of the present uses of iodine, particularly in industrial work, inquiries were sent by Dr. F. L. Rector, who writes on "Iodine as a wound disinfectant," in the Nation's Health for Jan uary 15, 1922, to about 75 physicians asking what preliminary cleansing was done to wounds and what strength iodine was used. Replies were received from 65 physicians, all of whom were doing industrial work or surgery closely allied to industry. Of this num ber, 2 use 10 per cent solution, 18 use U. S. P. 7 per cent tincture, 21 use 3| per cent, 10 use 3 per cent, and 3 use 2 per cent solutions. The other 11 physicians reported use of solutions of 4 per cent to 5 per cent strength. It is thus seen that a majority use a solution of 5 per cent strength or less. A few of the men said they did not use iodine. One preferred camphophenol, others used dichloramine-T, chlorazene, Dakin's solu tion, 7 per cent sodium oleate, picric acid, 5 per cent liquor cresolis compositus, 10 per cent calendula for large lacerated wounds, alcohol, bichloride of mercury 1 : 2,000 in 95 per cent alcohol, to which 2 per cent hydrochloric acid has been added. Several of the physicians emphasized the importance of having the surface perfectly dry before iodine is applied. A damp surface interferes with the penetration of the antiseptic. Earlier writers laid stress upon this point. The most satisfactory method of pre paring the wound area for iodine is to use alcohol and ether as final cleansing agents. For the preliminary treatment of wounds gasoline alone or in con junction with benzine or ether was used by 23 physicians. With 4 men soap and water was the agent of choice with the addition of gasoline or benzine if grease was present. Tincture of green soap was preferred by 6 men. From the replies received by Doctor Rector it would seem that the use of iodine as a skin and wound disinfectant still holds first place in No. 1. 99 EDITORIAL. surgical technic in the industrial field, in spite of the great popu larity attained by the chlorin compounds in the treatment of war wounds. Such objections as were raised were against the danger of burns and the discomfort iodine caused rather than against its efficiency as a sterilizing agent. The Conference Board of Physi cians in Industry has since its organization recommended the use of a 3 to 3£ per cent solution of iodine, and in the light of present experience feels that this recommendation is justified, (w. m. k.) ON THE REMOVAL OF FOREIGN BODIES FROM THE EYE. In discussing the removal of foreign bodies from the eye, H. D. Bruns, writing in the New Orleans Medical and Surgical Journal for February, 1922, points out the value of a good hand magnet, not with the idea of extracting magnetizable foreign bodies from within the eyeball, but for the purpose of pulling out those stuck in the con junctiva. There is probably no small operation more embarrassing than the removal of a nonmagnetic splinter which has penetrated the cornea. If the point of such a splinter enters, or almost enters the anterior chamber, the accepted practice is to pass a keratome through the margin of the cornea while the eyeball is steadied with a fixation forceps. The point of the keratome is held against the penetrating end of the splinter to prevent its being driven in further as the operator grasps it with fine forceps. If the splinter has penetrated the iris and lens as well as the cornea an incision must be made embracing the point of entrance of the splinter. With a Graefe knife the cornea is transfixed a few millimeters from the wound, the knife is passed across the anterior chamber, and brought out at a point about the same distance on the other side of the point of pene tration. By cutting outward the incision is completed. The end of the splinter lies free in the incision and can be grasped and the object removed. If prolapse of the iris occurs iridectomy is indi cated. Metallic splinters may often be removed by a good hand magnet, especially if they have only penetrated the superficial layers of the cornea. Foreign bodies on the cornea which are not magnetizable must be removed by some instrument under cocaine anesthesia. The writer prefers a probe with a 4ittle cotton tightly twisted about its end. Standing behind the patient, who sits facing the source of light, the operator holds the lids with the thumbs and forefinger of one hand. Having located the foreign body, with a quick motion of the fingers he makes the cotton-wrapped tip of the probe describe a short curve from above downward, which strikes the body at the height of its convexity at the point where the curve is tangent to the cornea. This 100 Vol. XVII. EDITORIAL. should be done lightly at first and then with more force until he is convinced that the body can not be removed in this way. If one is successful, the foreign body should be found sticking to the cotton on the probe or in the lower conjuctival cul-de-sac where it has been knocked. If the body is not removed by this manipulation, one must resort to the use of a dull-edged spud, flat on one side, rounded on the other and with no point, using it as he used the cotton-tipped probe. Failing in this, the end of the spud should be placed above and against the foreign body, and with a quick downward and out ward flip an attempt is made to turn it out of its bed. If this fails, the point of an old Graefe knife or a flattened discission needle in serted behind the body may dislodge it. Foreign bodies either on or in the conjunctiva are easily removed after eversion of the lid. In all manipulations about the eye the greatest surgical cleanliness is necessary. Instruments and dressings should be sterile. The method of cleaning an eye in use in a New Orleans clinic consists of repeated instillations of fresh 10 per cent solution of argyrol as repeatedly washed out with sterile normal salt solution or freshly made borax—boracic-camphor water. Fresh argyrol, in freshly made solution of a strength not greater than 15 per cent, used not longer than two weeks at a time, does not irritate the eye. The diffusibility of argyrol is pronounced; it penetrates everywhere; it dislodges old secretions from the lachrymal sac and thoroughly cleans the conjunctival sac. After a foreign body has been removed and the eye thoroughly cleaned it should be occluded by a sterile dressing, which should be renewed every day after cleansing the eye until all abrasions are healed. If the abrasion is small and the patient cleanly and intel ligent, argyrol solution may be instilled every hour until redness and the rough sensation on winking have disappeared. Bathing the closed eye frequently with hot water favors this and gives comfort. The Berger binocular loup and its accessory condensing lens, together with the 5 per cent solution of fluorescine, are very useful in locating foreign bodies. The binocular magnifier greatly increases the information we derive from the examination of any small lesion, and the fluorescine solution, after it has been instilled for three or four minutes and then washed out, reveals the tiniest body by sur rounding it with a bright green ring; or if the foreign body has been swept away by the tears, the abrasion caused by it is shown by a small spot of an intense green color. If the search is not successful in the daylight, it must be continued in a dark room with the aid of artificial light. Indeed the search for a foreign body must never be abandoned until one has made use of oblique artificial light in a dark room. (w. m. k.) No. J, 101 EDITORIAL. ON KALA AZAB. With the exception of the discovery of the specific action of tartar emetic in the treatment of kala azar, Wenyon finds, in reviewing the recent literature on this disease in Tropical Diseases Bulletin for February, 1922, that very little has been added during the last 10 years to our knowledge of this infection. In addition to the well- known endemic centers in North China, India (particularly Assam), the Caspian region, Mediterranean littoral, and the Anglo-Egyptian Sudan, new foci have also been discovered in Mesopotamia, Sumatra, and Siam and in the districts around Lake Chad (Africa). The role of animals in spreading kala azar has not been determined ; in several regions, notably the Mediterranean littoral and the Cas pian region, canine kala azar occurs as does the human disease, whereas in other regions only one of the two has been demonstrated. Even if it is admitted that the two types are caused by the same organism, Wenyon does not believe that the dog plays any essential role in the spread of the human disease. The diagnosis of kala azar depends upon the discovery of the para site, and spleen puncture still remains the most reliable and rapid means of attaining this object. The organism is frequently discovered by direct examination of the peripheral blood, where it generally appears in the mononuclear leuco cytes, although it may occur in other cells. Painstaking search is often required before the parasite is found by this procedure. Blood culture on NNN medium has yielded very good results in the hands of some observers. There is a certain disadvantage in using this method, however, because the number of parasites inoculated in the medium is so small that often two or three weeks must elapse before flagellates are detectable. It should always be done, however, espe cially in cases in which spleen puncture is contraindicated. The prevalent idea that the Mediterranean type of the disease attacks only children and the Indian type only adults must be dis carded in view of more recent and careful observations. Mackie, Muir, and Knowles in India, Cochran and Wylie in China, and vari ous observers in the Mediterranean littoral have shown that the respective " types " may attack all ages, thus removing the mark of distinction between the two forms. The greatest advance has been made in the treatment of the dis ease. Since Caspar Vianna in 1913 first treated American cutaneous leishmaniasis with such remarkably good results, the specific action of tartar emetic has been confirmed both in Italy (Doctors Christina and Caronia) and in India (Bogers, Muir, Knowles, etc.), in the general infections occurring in these countries. 102 Vol. XVII EDITORIAL Attention has been drawn several times to the toxic effects of this drug. It was realized that great care had to be exercised in admin istering the drug, and that it was necessary to commence with small doses and gradually to increase them. Deaths have been reported in a few instances. Long-continued treatment is essential to bring about cure and to prevent relapses. Muir states that injections should be given every second day till fever has been absent for a month and then once a week for two to four months. Unless these weekly injections are continued relapses may occur. Knowles, in Shillong, has presented some very interesting facts regarding the effect of treatment. The immediate result is the rapid disappearance of the parasites from the peripheral blood, later followed by disappearance from the spleen and finally by cessation of the fever. The body weight increases, while the spleen decreases in size and a normal blood pressure is restored. Knowles recommends that the potassium salt (the "heavy powder" and not the "light powder") be used. He employs a 1 per cent solution in normal saline, autoclaved at 110° C. for 10 minutes and kept in a rubber-capped flask. If there is the least trace of deposit or opalescence in the solution it is discarded as not being safe to«use. The initial intravenous dose is 3 to 4 cubic centimeters for an adult. Injections are given on alternate days, the dose being gradually increased until 10 to 12 cubic centimeters are given toward the end of treatment. The intervals between the doses should be increased as there is some evidence of accumulative action. The standard course at Shillong is a course of 200 cubic centimeters distributed over a period of two and a half to three months. The injections should not be given within two hours of a meal. The sudden appearance of edema should be a danger signal. Other antimony compounds have been introduced for the treatment of kala azar, notably stibacetin and colloid antimony sulphide. Rogers treated 10 cases with the latter preparation and regards it as a dis tinct improvement over the soluble antimony tartrates in the treat ment of kala azar. The problem of transmission is still unsolved. Attempts have been made to inculpate many insects, especially the flea and bedbug. As yet, however, no satisfactory evidence has been forthcoming to sub stantiate claims made. In a telegram published in the Indian Journal of Medical Re search, January, 1922, Mrs. Adie states that she has found a swarm ing infection of Leishman-Donovan bodies in the salivary glands and ducts of Cimex rotundatus caught in the bed of a suspected kala azar case, and that this discovery positively proves that the bedbug is capable of transmitting the disease through biting. In No. 1. 103 EDITORIAL. a letter to the editor of the Lancet, published February 25, 1922, C. M. Wenyon discusses this announcement of Mrs. Adie's and in a well-arranged argument shows that in spite of her discovery con vincing evidence is still needed to prove that the bedbug is the vector of kala azar. Some of Wenyon's points are: Numerous previous experiments on the bedbug, apparently successful, have been shown not to be conclusive when the results have been critically analyzed. In Mrs. Adie's case it is evident that the bug came from a bed, not of a case of kala azar but only a suspected case, and there is no proof that the bug had even fed on this particular individual. Proof is also needed that the parasites found are Leishman-Donovan bodies. It is possible that the bedbug may occasionally harbor a flagellate of its own, although this has never been shown before. Prophylaxis as carried on in India to-day is based on the ap parent fact that kala azar is a house and family disease. Segrega tion of all families having the disease is attempted, especially in Assam. That the newly introduced treatment by tartar emetic will undoubtedly play an important role in facilitating the eradication of this disease is pointed at by McCombie Young, (e. p.) IN MEMORIAM. XXSDLSTOH SEMMES QUEST. 1869-1922. Surg. Middleton Semmes Guest, United States Navy (retired), died at the United States Naval Hospital, Annapolis, Mel., on Janu ary 7, 1922, following a protracted illness. Surviving him are his widow, the daughter of Athanase Branchand, K. C, of Montreal, and one daughter, Ann Branchand Guest. Doctor Guest was born on May 23, 1869, at the navy yard, Ports mouth, N. H. He was the son of Commodore John Guest, United States Navy, who died in 1878 while commandant of that yard, and of Anna Josephine Pleasonton, daughter of Gen. Augustus Pleason- ton, of Philadelphia, and niece of Gen. Alfred Pleasonton, United States Army. He chose medicine as his profession, graduated from the Uni versity of Pennsylvania and, drawn by his associations, and the love for the service which remained such a prominent characteristic throughout his life, he entered the Navy as assistant surgeon in 1891. His professional career was marked by evidence of his conscien tious devotion to the details of duty, and a nice sense of discrimina tion in estimating the value of the rapidly succeeding advances in the theory and practice of medicine. Unfortunately, Doctor Guest was not given to writing for publication and consequently relatively few realized the shrewd, sane judgment he habitually displayed in matters of medical practice and administration. He exhibited similar reticence in his personal intercourse, and only intimates knew what an acutely observing mind functioned actively beneath his usually reserved exterior. His fund of remi niscence was a source of unending enjoyment to his friends, light ened as it was by a wit that was keen and penetrating, and yet always kindly. As is common with men of a retiring disposition, he found his recreation in the active pursuits of fishing, gunning, and the sailing of small craft. Of these amusements he never tired, and on occa sions when the actual sports were impossible he passed much of his leisure in studying the natural history of game birds and fish. He 105 106 Vol. XVII. MIDDLETON SEMMES GUEST. took great pride in his strength and endurance, so that the misfortune of prolonged invalidism was hard for him to understand and doubly hard to bear. Doctor Guest possessed an ardent love for the service, its customs, traditions, and even the minor features of a ship's routine. This de votion to the Navy was so absorbing that his retirement in 1910 came to him as a' great shock, the separation from the service entailed quite overshadowing in his mind the personal significance of his dis ability ; and when the United States entered the recent war, against the advice of those near him, he earnestly requested active duty. It was given him, but he could not carry on for long. The disease for which he was retired became active, and it proved necessary again to place him in an inactive status. In reference to this, he wrote in a private letter, " This is a villainous blow and upsets my hopes and plans completely. I hoped to have kept on until the close of the war and at least to have released some younger man for sea duty * * *, but it seems that my desire was greater than my strength to perform * * *." Comment would add nothing to these characteristic phrases. Liv ing comfortably, his disease quiescent, and urged by all his advisers to remain inactive, he could not tolerate the idea of taking no part in the struggle going on. Although, when the end was approaching, he realized clearly that his war duty had activated the disease, he had no regrets. By no other course could he have remained at peace with himself. REPORTS. A EEPOET OF THE HOSPITALIZATION7 OF THE VETEEAN AT OEEAT LAKES. By H. O. Datis, Lieutenant Commander, Medical Corps, United States Nary. The hospitalization of the veteran of the late war has become an important function of our naval hospitals and we are constantly seek ing the best method to efficiently administer to his needs and expedite the treatment that will make possible his complete vocational re habilitation. The usual hospital routine in professional, administrative, and clerical procedures becomes widely varied when an institution is handling and treating a class of patients largely unacquainted with naval customs. The veterans admitted to the naval hospital at Great Lakes, 111., differ greatly in mentality, temperament, and in their general attitude toward any form of treatment due probably to their experience in other hospitals or to seemingly unsatisfactory compen sation adjustments. The admission of ex-service men began in a small way early in 1921, when 50 beds were allotted to patients of the Bureau of War Risk Insurance. Those admitted were distributed among the Navy patients with no specific supervision other than general hospital care, and as there were no very definite regulations for handling them there soon arose petty disputes over working details in general. As the Navy patients decreased more beds were assigned to the War Risk patients, and it was deemed advisable to establish a special office apart from the main hospital offices in which business in connection with these patients could be carried out. A medical officer was placed in charge of this office. His specific duties are to admit all patients, ex plain the plan of treatment and something of the hospital, administra tion. He is concerned with all matters relative to ex-service patients during their stay in the hospital. After the passage of the Sweet bill, September 9, 1921, the Vet erans' Bureau was established, replacing the Bureaus of War Risk and Vocational Rehabilitation. By Executive order that portion of the naval: hospital at Great Lakes known as Camp Ross, was turned over to the Veterans' Bureau for the care of 300 neuro- 103390—22 8 107 108 HOSPITALIZATION OF THE VETERAN AT GREAT LAKES. Vol. XVII. psychiatric cases under naval administration. The bed capacity of the main hospital was enlarged to 300 general medical and surgical cases, making a total of 600 beds available for the care of ex-service men. All patients for observation, treatment, and final diagnosis are received through the eighth district office in Chicago representing Illinois, Wisconsin, and Michigan. A board of three medical officers make a recommendation for the disposition of each case which, ac companied by a clearly stated word picture in the medical history, makes possible a proper compensation adjustment when the case is reviewed by the rating board. A network of subdistrict officers in these States keeps the central office in Chicago supplied with cases needing hospitalization, and after a medical examination, authority for the admission of each patient to enter one of the various hos pitals throughout the district is issued. From 10 to 30 patients are admitted daily at Great Lakes. Each man is assigned to the depart ment especially fitted to care for his particular ailment. On arrival these patients report to the special office representing the Veterans' Bureau which is connected with the receiving ward. A special in patient report card, the Navy Form F card, and an identification card is made out, after which the medical officer takes a brief history of the case, recording the dates of enlistment and discharge from the service, together with the chief points of the present complaint. After a preliminary examination, the patient signs a receipt for a copy of the hospital rules which also contains excerpts from Gen eral Order 27-A issued by the Veterans' Bureau. A short explana tion of the plan of treatment is given to him and any questions answered, so that the patient is sent to his ward with a clear under standing of what is expected of him by the hospital authorities re garding his cooperation in the treatment. All patients pass through a general routine of laboratory, dental, and X-ray examinations. A complete urinalysis is made, also a blood count and blood Was- sermann test. There are repeated examinations of the sputum in all suspicious cases, examinations of the stools of all patients coming from southern Illinois, where hookworm infection is prevalent. A spinal Wassermann test is made on cerebrospinal suspects in ad dition to other observations on the spinal fluid. The X-ray department radiographs and fluoroscopes all suspi cious chests and makes fluoroscopic examinations of all gastro intestinal cases which are referred for an opinion. The dental officers note all cases of infectious and carious teeth for treatment. About 75 per cent of the medical cases are admitted as being possibly tuberculous. Special wards are set apart for these patients and a regular routine is followed. Preceding the first physical ex Xo.1. HOSPITALIZATION OF THE VETERAN AT GREAT LAKES. 109 amination. the following three-day temperature, pulse and respira tion chart is filled in and the routine X-ray examination is made. TEMPERATURE PULSE RESPIRATION CHART. First dav (in bed.) 7 a. m. 9 a. m. 11 a. m. 1 p. m. 3 p. in. 5 p. m. 7 p. m. 9 p. m. Second day. 7 a. m. 9 a. m., before exercise. 9.30 a. m., after exercise. 10 a. m., after rest in bed. 1 p. m. 3.30 p. m., after J hour exercise. 4 p.m., after i hour rest in bed. 7 p. m. 9 p. m. Third day. 7 a. m. 9 a. m. 11 a. m., after 2 hours exercise. 11.30 a. m., after J hour rest in bed. 2 p. m., before exercise. 4 p. m., after 2 hours exercise. 4.30 p. m., after J hour rest in bed. 7 p. m. 9 p. m. The sputum of each suspicious case is examined daily until five to seven negative reports or three positive findings are obtained. In negative cases a second series is started after an interval of one week. Physical examinations of the chest are made weekly. A large number of the negative cases are found to be suffering from nose and throat infections which, when removed, result in a cessation of the symptoms simulating tuberculosis. About 10 per cent of the cases are really tuberculous and are promptly transferred by the district office to a suitable sanitarium. The negative cases are discharged to take up light work, vocational training, or dispensary treatment. The 300 beds set apart for neuropsychiatry cases are generally filled. The average period of hospitalization for this class of pa tients is about 90 days. The larger per cent are neurasthenic and require protracted study by the various departments of the hospital in order to rule out organic disease. The following outline which has been found very useful is employed in recording the history of each case of this type : Name. Organization. Claim No. Date admitted. Nativity. Vge. Education. Occupation. Religion. Social status. Address. Date of induction. Date of discharge. Status on admission. Family history : Grandparents. Parents. Brothers and sisters. Collaterals. Personal history : Prenatal. Birth. Infancy and early childhood. Education and school life. Character and home environment. Industrial history. 110 HOSPITALIZATION OF THE VETERAN AT GREAT LAKES. Vol. XVII. Disease of adult life and injuries: Habits. Sexual life. Venereal history. Crimes and misdemeanors. Marital history. Reflexes : Deep. Superficial. Mental examination : General attitude. Psychomotor state. Emotional status. Delusions. Hallucinations. Dreams. Insight and judgment. Orientation. Disorders of attention. Intelligence tests. Special senses: Sensation. Psychobiological make-up. Disposition. Temperament. Instinctive demands. Adaptability. Military or naval history. Present illness: Before discharge from service. After discharge from service. Physical examination : Cranial nerves. Sensori-motor-general motility. Special tests and examinations : Spinal fluid. Nutrition of muscles. Tone of muscles. Active movements. Coordination of movements. Motor irritation. Approximately TO per cent of the neuropsychiatric cases repre sent the various types of psychoneurosis and 20 per cent are suf fering from mental and nervous diseases. Epileptics are trans ferred to their home or to special institutions, and the insane are sent to the Cook County Psychopathic Hospital for further com mitment to a State institution. The majority of the neuropsychiatric patients possess little educa tion and fail to appreciate the problems incurred in settling their claims. The present economic depression has resulted in the hos pitalization of many border-line incompetents. A reconstruction center has been established in Camp Ross with an educational director in charge, to give prevocational training and to gauge the individual's qualifications for a new vocation after considering his educational qualifications, intelligence, past experi ence and present handicap. Courses are offered in elementary academic and commercial branches, also in mechanical drawing, drafting, automechanics, machine-shop practice, electrical, wood and cabinet work, printing, shoe and watch repairing, truck garden ing, poultry raising, bee husbandry, and in the arts and crafts. The local Red Cross chapter is rendering very valuable assistance in obtaining social histories and furnishing financial assistance to dependent families while compensation claims are being adjusted. They are fully equipped to file claims, assist in obtaining the essen tial affidavits and to investigate delays. No. 1. ACTIVITIES OF MEDICAL, DIVISION, SAN DIEGO, CALIF. Ill The general morale of the ex-service patients has been excellent, and serious infractions of discipline have been few. Every effort is made to assist each patient in straightening out his difficulties and to prevent trivial complaints and misunderstandings from as suming any degree of seriousness. The hospital office of the Vet erans' Bureau is constantly ironing out these wrinkles and keeping an ear to the ground for any echos of discontent. It is significant that only two disciplinary boards have been convened in the past seven months in handling nearly 1.500 nonnaval cases from all walks of life. Upon the recommendations of medical officers daily liberty and periods of leave are granted. Moving pictures and vaudeville are furnished by the Morale Division and various organizations give parties and dances under the direction of the Red Cross hostess. The Bed Cross distributes clothes, shoes, and toilet articles when requests signed by medical officers are presented. The Knights of Columbus distribute cigarettes and toilet articles weekly, and fre quent concerts are given by the naval station band. A well-stocked library and several recreation rooms add to the diversion of ward life. BEPOBT OF THE ACTIVITIES OF THE MEDICAL DIVISION OF THE UNITED STATES NAVAL HOSPITAL, SAN DIEGO, CALIF,i Br W. D. Owbsb, Lieutenant Commander, Medical Corps, United States Navy. The activities of the medical division during the year have been directed to the detailed study of each case admitted and of series of eases of the same disease. This study has been conducted in order that the value of the latest methods of diagnosis and treatment might be determined with the view of establishing a routine for the general management of medical cases. The diseases which have been espe cially studied include thyrotoxicosis, neurosyphilis, acute and chronic nephritis, diabetes mellitus, amebic dysentery, cholangitis, the pneu monias, malarial fever, Vincent's angina, and acute and chronic rheumatism. In each instance observations have been directed along special fields of interest, such as basal metabolism estimations, functional kidney tests, blood chemistry and Allen's treatment for diabetes, intubation and visualization with the duodenal tube, and the location and elimination of foci of infection. Spinal punctures, performed in some 95 of our cases have thrown light upon the frequency of neurosyphilis and the diagnostic value of this procedure. Several cases of atypical, ataxic gastric crisis, neurasthenia and epilepsy in which the blood Wassermann was negative have been determined to be syphilitic by means of the examination of the spinal fluid. Blood 'From the Annual Sanitary Report of the U. S. Naval Hospital, San Diego, Calif. 112 ACTIVITIES OF MEDICAL DIVISION, SAN DIEGO, CALIF. Vol. XVII Wassermann reactions have been determined in all medical cases admitted. Nine cases of thyrotoxicosis have been studied. In this series of cases we determined that, with the exception of basal metabolism estimations, the various other diagnostic tests, including the Goetz and Bram tests, are of little or no value and in some cases do actual harm. Basal metabolism findings, however, are of real value, par ticularly in the differentiation of cases of thyrotoxicosis from "effort syndrome cases." As the result of our studies we have abandoned the other diagnostic tests and confine our efforts to basal metabolism observations. We have learned to accept readings over +10 or +15 as evidence of a hyperthyroid condition. Of the various medical treatments for exophthalmic goiter we have had most success with hydrobromide of quinine. In our hands X-ray exposures have been of doubtful value. Our plan has been to withhold surgery until all medical efforts have failed. In one case, however, on which a partial thyrodectomy was performed, the results have been satisfactory, but only for a limited time. In nephritis we have made certain observations with the functional kidney tests, and have studied the " Fisher treatment." We have not been able to obtain the excellent results claimed by Fisher and have abandoned its use in our nephritic cases. Of particular interest has been our work with the Einhorn tube. Intubation and visualization of the duodenum "has an important field of interest. More than 100 intubations have been done, and our ob servations show that it is an excellent adjunct in the treatment of acute cholangitis, and that its use shortens the course of the disease. It also has considerable value in the treatment of cases of atony of the gall-bladder, and is useful in differentiating between duodenal and gastric ulcers. Visualization with the X-ray of the tube passed into the jejunum, affords an excellent method of determining peri cystic adhesions and assists in the differentiation of cholelithiasis, chronic appendicitis, gastric and duodenal ulcer. With amebic dysentery gratifying results have been obtained by the administration of ipecac by means of the Einhorn tube. The following method of administering ipecac by the duodenal tube has been adopted in our most recent cases : The patient is put to bed under the usual restrictions. An Einhorn duodenal tube is passed on a fasting stomach early in the morning. When the tube is well into the duodenum, 1 ounce of syrup of ipecac, containing 40 grains of the drug to the ounce, is passed through the tube by gravity. This is washed out by a pint of warm water and the tube withdrawn. This treatment is given every morning for 10 days and the course is <sonsidered complete. The patients usually take the tube very readily after the first or second time and retain the drug well until the Xo. I. ACTIVITIES OF MEDICAL, DIVISION, SAN DIEGO, CALIF. 113 system becomes saturated. Then a slight nausea may be complained of, but will subside if the dose is reduced. This has been tried on two patients here with excellent results. One case had symptoms for two and one-half years in spite of the usual treatments. The first examination showed the stool loaded with amebse. After the fourth treatment with the tube the stools were reported negative. After the seventh treatment the stools were normal in number and consistency. The case has been watched, and after five months has shown no signs of recurrence. Eight dysentery cases have been treated during the past eight months and of this number six have been Veterans' Bureau patients who contracted the disease in France. A number of cases of malarial fever have been observed in order to estimate the therapeutic value, if any, of a combined treat ment consisting of neosalvarsan administered in conjunction with Oschner's quinine treatment, but the results have not been encouraging. Salvarsan seems to have no place in the treatment of malarial fever. Likewise in the case of Vincent's angina, our studies have been di rected to a determinataion of the best method of employing salvarsan in this disease and its therapeutic and prophylactic value. Un doubtedly salvarsan suspended in glycerin and applied locally is the treatment of choice in this disease. In the pneumonias we have established the value of the early ad ministration of digitalis, the advantages of proctoclysis to furnish an increased water intake and as a very satisfactory means of adminis tering sodium bicarbonate in order to diminish the possibilities of acidosis. In pneumonia we administer from 2,000 to 2,500 cubic centi meters of liquid by mouth and by proctoclysis, and are convinced that this liberal quantity of fluid slows the heart action and makes the patient more restful. It is no uncommon occurrence to see our cases quietly sleeping during proctoclysis. We have been impressed with the value of daily blood-pressure estimations, and have estab lished the custom of performing venesection when the systolic blood pressure is above 150 or 160, and especially in those cases in which the pulse pressure is increased and there are evidences of impending circulatory failure. The vast majority of pneumonias which occur at this hospital are of the broncho-pneumonic form. A study of the clinical manifestations of these cases discloses certain clinical features not usually observed in this form of pneumonia. A high temperature terminating by a sudden fall to normal, is not uncom mon, and has occurred in fully one-half of our cases. A leucocyte count from 16,000 to 20,000 occurs more often than the low count, and in typing our cases pneumococcus type II has been encountered. There have been 12 cases of pneumonia treated with no deaths. In the treatment of diabetes mellitus, the Allen technic has been found most satisfactory. A patient now under treatment when ad 114 ACTIVITIES OF MEDICAL DIVISION, SAN DIEGO, CALIF. Vol. XVII. mitted gave 5 per cent sugar estimations, and under Allen's treat ment has been sugar free for two months. An endeavor has been made to develop cooperation and interest in our work amongst the other departments of the hospital in order to encourage the group study of medical cases. In no other condition has the group study been so instructive and so highly developed as in the study of foci of infection. Every department in the hospital has rendered excellent service in assisting us to detect and eliminate foci of infection occurring in our patients. In practically every medical case we have had the teeth, nose, sinuses, and tonsils ex amined to determine the presence of foci of infection ; and less fre quently studies of the prostate, the bladder, the intestines, the ap pendix, and the gall-bladder have been made. Some of the results following removal of definite sources of infection have been re markable, and there is no doubt that this factor, when intelligently and honestly studied, has an important place in the management of medical cases, and especially so in thyrotoxicosis, nephritis, cardiac, and rheumatic conditions. As a result of the study of acute and chronic rheumatic cases the following conclusions have been reached : (a) Acute rheumatic fever—in the majority of cases —is due to infection of the tonsils. A few cases have shown numerous apical abscesses. (b) Apical abscesses occur in the majority of cases of chronic arthritis, myositis, muscular rheumatism. Heart involvement, usu ally uncomplicated mitral lesions, developed in 60 per cent of our cases. The importance of a complete history in a medical case is so well recognized that the medical officers of this hospital have adopted a plan of procedure which has been found highly satisfactory. In conjunction with certain permanent additions to the clinical chart hereafter to be indicated, the routine employed is as follows: The medical officer taking the history records the complaint, the family history, previous history, the present illness, and the physical find ings. In lung cases the picture is more clearly defined by using symbols to record the physical findings on a skeleton diagram. Standardized symbols taken from Norris and Lander's Diseases of the Chest are employed for this purpose. Finally, the medical officer, as a result of the medical history, physical examination, and the laboratory findings, determines certain "impressions" —and from a study of these " impressions " the diagnosis is accomplished. In order to utilize the advantages to be derived from recording at definite intervals the blood pressure, basal metabolism, the weight, intake of fluids, and the urinary output, additional permanent nota tions have been made on the clinical chart, and curves indicating these factors are recorded. These records have been found particu Sfcl. ACTIVITIES OF MEDICAL DIVISION, SAN DIEGO, CALIF. 115 larly useful in such conditions as thyrotoxicosis, nephritis, cardiac infections, and the pneumonias. When indicated, as in thyrotoxi cosis, weekly basal metabolism readings are recorded, and on the same day the blood pressure and weight are added. Such a set of observations, when completed, is of great value in the study of exophthalmic goiter. We have been particularly interested in the value of frequent blood-pressure readings. The blood pressure of every patient who is admitted to the medical section is determined and in acute cases additional readings are made every week as long as there are any indications. Probably the greatest value of frequent blood-pressure readings occurs in the treatment of pneumonia. Daily estimations are recorded and, as already mentioned, when under certain condi tions the systolic pressure is above 160, venesection is indicated. Two other routine entries are made in every case paper; these are notes of tropical service and service in France. Knowledge of tropical service in the Navy is important, while with the Veterans' Bureau patients, on account of the frequency of amebic infections, the information that a particular patient served on the Argonne front is of considerable value, as amebic infection occurred frequently in that sector. NOTES AND COMMENTS. Form K Dental has been revised to the form of a simple statistical report, thus obviating the necessity for sending to the bureau each month the names of patients receiving dental attention. In order that permanent records of dental treatments may be pro vided for, it is directed that the dental appointment books, furnished by the supply depots, be used for recording in ink the names, rates, and operations or treatments received by patients under the date of each appointment. These appointment books or records are to be retained as part of the permanent records of the ship or station, and are to be forwarded to the bureau when the ship or station is placed out of commission. In order to facilitate a search for the treatments rendered an individual, it is directed that an index of the dental patients' names be kept on the last pages of the dental appointment book, entered under the first letter of the surname and followed by the numbers of the pages on which the appointments, operations, and treat ments for that patient have been recorded. The form as revised should not take much time to prepare at the end of each month if a systematic record is kept of each operation, number of dental charts made, etc. It is believed that the following method will prove of value in obtaining correct records with a mini mum expenditure of energy and time : Cut the new Form K in the center from top to bottom ; this pro vides two papers, each containing the operations, etc., which it is desired to record. Paste a sheet of letter-size paper sufficiently over the right edge of each piece, leaving the " operations," " number of persons," etc., uncovered. Then with a rule continue the lines under each operation to the right edge of the sheet, which has been pasted on. Immediately upon the completion of the work upon a patient after each appointment, make a mark after the correspond ing operation— thus a totaling of the marks after a given operation will give the number performed during the month. The British Medical Journal of January 28, 1922, informs its readers that a gallery has been set apart at the Wellcome Historical Medical Museum to illustrate the history of chemistry, from the most primitive use of still and furnace to the exact and elaborate 117 118 NOTES AND COMMENTS. Vol. XVII methods of the present day. It has been arranged in such a mail ner as not merely to interest or even instruct the casual visitor but to inspire the student, and to furnish, so far as this can be done by pictures, manuscripts, and models, a graphic outline of the progress of chemistry through the ages, not forgetting the cloud of magic and superstition out of which it emerged. On the pillars and frieze the student is reminded of the epochs into which the history of chemistry may be divided, the names of its pioneers, and the symbolism which has been employed by ancients and moderns. At one end of the gallery there is placarded the definition of chemistry which appears in Johnson's dictionary, and at the other the defi nition which appears in Murray's. The objects in the collection in clude examples of ancient glass apparatus employed by the alchem ists; these include matrasses, cucurbits, alembics, and the like. A model of the alchemist's hearth, with its pewter and stoneware, has been installed, as well as the " aludel " of the sixteenth century, used for subliming sulphur or mercury, and, in curiously shaped bottles, specimens of the elements and their symbols as they were known at this period. A most interesting section illustrates the history of perfumes and aromatic substances. The curator has gathered together many specimens of the little containers in which, from Roman times onward, mixtures of substances of powerful odor have been carried in the hope of warding off plague and other infections. In another cabinet there is a collection of the chemical substances known in ancient times, together with speci mens of alkaloids, with the names of those who isolated them, and the date of their introduction so far as these can be ascertained. Other articles, in original or replica, have an interest on account of a particular individual; these include appliances used by Dalton and Faraday in their demonstrations, the pneumatic trough used by Priestley for collecting gases, a porcelain retort which belonged to Joseph Black, the discoverer of carbonic acid, old books on chemistry which had been in the possession of the Boyle family, and docu ments in the handwriting of Caventou, one of the discoverers of quinine, and Labaraque, whose name is associated with the manu facture of sodium carbonate. On the walls of the gallery are care fully chosen pictures, in oil and water-color, representing personal ities and episodes of interest to chemists. Such primary figures are depicted as the Greek Hermes, the Arabian Rhazes, and the German Paracelsus, who insisted that the function of chemistry was not to make gold artificially, but to prepare medicines and substances useful to .the arts. The various alchemical processes used in the search for the " philosopher's stone " are depicted on long scrolls by a fifteenth century draftsman, and there are many paintings of the Dutch and Italian schools, whose artists appreciated -No.1. 119 NOTES AND COMMENTS. the pictorial value of the alchemist in his laboratory, lighted by lurid flames and heaped up with strange accessories, though their rendering may not always have been quite faithful. One interest ing portrait is that of Mayow, the father of pneumatic chemistry, who was originally a physician ; the visitor is reminded in the same way of Lavoisier, and of Scheele, to whom we owe glycerin and. prussic acid; of Dalton, Humphry Davy, and Liebig, and many others. The gallery is dominated by the statue of Joseph Priestley, the discoverer of oxygen and nitric and nitrous oxide. Public drinking fountains of the "bubble" variety in which the spurt of water is less than 2 inches have been banned in Cleveland by Health Commissioner H. C. Rockwood. Fountains with in sufficient pressure to force the water 2 inches or more are a serious health menace and assist in spreading communicable disease. The Royal Air Medical Service Rules to improve respiratory and circulatory efficiency are formulated by Wing Commander Martin Flack, Royal Air Force Medical Service, in the Milroy lectures re cently delivered before the Royal College of Physicians of Lon don, on " Respiratory efficiency in relation to health and disease." This system of 10 exercises he has elaborated for the purpose of producing circulatory and respiratory fitness, the work being based on physiological principles and observations made in the training of fliers. In the performance of these exercises Commander Flack lays stress on the great importance of the contraction of the dia phragm at the initiation of inspiration, protruding the " pit " of the abdomen together with a movement of the lower ribs, full inspira tion being obtained by a wave-like movement spreading from the lower ribs to the upper part of the chest, and on no account should the upper part of the chest be expanded first. Expiration is ac complished by the contraction of the muscles of the abdomen and of the lower part of the chest. The exercises are here given : 1. In bed. (a) Lying flat, inhale to the fullest extent, at the same time raising the hands above the head in a natural "stretching" motion. (6) Exhale to the utmost extent, using the abdominal muscles forcibly to press out as much air as possible from the lungs, at the same time carrying the arms to the sides. Repeat five times. 2. Using the weight of the bed clothes turned down to the hips as a means of keeping the legs down, raise the body from the hips and bend forward as much as possible, at the same time breathing out forcibly to the fullest extent, then slowly return to the lying posture, inhaling deeply meanwhile. Repeat five times. 3. (a) Using the bed clothes as before, from the lying position raise the trunk, with the hands by the sides, through an angle of 45°, then twist round 120 Vol. XVII. NOTES AND COMMENTS. the trunk upon the hips, keeping the legs flat and endeavor to make the forehead touch the bed, meanwhile exhaling forcibly as far as possible. (&) By a reverse movement assume the lying position, inhaling deeply meanwhile. Repeat five times to right and left sides. 4. (a) From the lying position, flat on the bed, with the hands clasped behind the head, raise the legs from the hips, carrying them as far over the head as possible meanwhile, (ft) Lower legs slowly to the fullest extent, meanwhile exhaling deeply and forcibly. Repeat five times. (5) Out of bed. (c) By a "stretching" movement raise the arms slowly and strongly forward and upward, then lower them sideways until they are in line with the shoulders, which are well thrown back, meanwhile inhaling to the fullest extent. Brace up the muscles of the abdomen and all the accessory muscles of inspiration. (6) Keeping the body as upright as possible, carry the arms forward until they overlap and hold sides of trunk ; expire meanwhile to the utmost extent, working specially the lower chest and abdominal muscles. When in the position of full expiration brace up all muscles of lower chest and abdominal wall. Repeat five times. 6. (a) With the feet about 18 inches apart (or other comfortable distance, which may be gradually decreased as proficiency is attained) carry the arms forward, upward and backward, inhaling meanwhile to the fullest extent. (6) Bend trunk forward and full downward, carrying the arms between the legs to touch the ground with the fingers as far as possible behind the feet, meanwhile exhaling to the fullest extent. Repeat five times. 7. With the feet about 18 inches apart (this distance may be decreased as proficiency is attained) and arms raised sideways and in line with the shoulders, bend the trunk to the left (right) until the left (right) hand touches the ground, keeping legs straight, meanwhile breathing naturally or holding the breath. Repeat five times to each side. 8. (a) With the feet as above, carry the arms forward, upward, and bnckward, inhaling meanwhile to the fullest extent. (6) Turn and at the same time bend the trunk to the left (right), and touch the ground on the outside of the left (right) fast, expiring meanwhile to the fullest extent, (c) Stretch trunk up ward to upright position, inhaling meanwhile to full extent. Repeat five times to each side. 9. Inhale as fully as possible, then exhale sharply to the fullest extent, and, with the chest and abdominal muscles, alternately forcibly contracting and relaxing. Repeat two or three times. 10. Stationary running; shadow boxing; shadow skipping; rhythmic balancing exercises ; jumping or any other form of exercise preferred by the subject until out of breath. These exercises take about 10 minutes to perform and should be followed by a tepid or cold bath and a brisk rub down. They are par ticularly useful for those engaged in sedentary occupations and will enable them to engage in open-air exertions without undue fatigue. They are to be especially recommended as requiring no special appa ratus.— (The Nation's Health, February, 1922.) We learn from the British Medical Journal of January 28, 1922, that Dr. James Waterston, in a short monograph on " The Louse as No. 1. 121 NOTES AND COMMENTS. a Menace to Man," issued by the Natural History Department of the British Museum, gives a straightforward account of the life histories of the three forms of lice which prey on man and describes methods for their destruction. He insists that the essential factor in the spread of lice is a person who is already infested by the parasites, and, as a rule, transference to a clean person is effected by contact of a more of less direct kind. Contact has long been recognized as the determining condition of disseminataion in the case of the crab louse, but it is no less true of head and body lice, in regard to whose spread many misconceptions are prevalent among the lay popula tion. The importance of close association between clean and infested persons in spreading these pests was abundantly demonstrated in the late war, when men were crowded for long periods in dugouts and billets or herded together in prison camps. The normal activity of both head and body lice is found to be greater than was commonly supposed, and this is responsible for their spread; but in certain circumstances —temperature being the decisive condition —lice will leave their host without the stimulus afforded by contact with the fresh victim. Broadly speaking, says Doctor Waterston, body lice tend to leave a host whose temperature rises above or falls below the normal; they are stirred to activity by violent exercise on the part of their host, and in cases of fever will be found moving on the upper blankets. Similarly after the host's death lice appear, sometimes in enormous numbers, while the body is cooling and migrate to surrounding bodies. Typhus fever, relapsing fever, and trench fever are, of course, well known to be spread by lice, while Bacillus pestis has also been found in lice feeding on plague patients. There is no evidence, however, that lice are of importance in spread ing this disease, although, in Doctor Waterston's opinion, there is reason to believe that they might on occasion do so. In regard to the destruction of lice, he recommends, for lice on the body, smearing the skin thickly with undiluted paraffin emulsion, followed by a hot bath and clean clothing. In cleansing the head he recommends paraffin oil (preferably) or its emulsion, rubbed in thoroughly, the head being afterwards swathed in a tightly wrapped towel for an hour. Mr. A. Bacot found wood-tar oils effective. Mr. Burt Ham ilton recently, however, pointed out in our columns that the one essential to safety in any mixture that is to be prescribed for home use is noninflammability, owing to the ingrained carelessness of the class for which such treatment is usually required. He considered paraffin effective for institutional use, but refused to prescribe so dangerous a method for home use. The question of a suitable mix ture for this purpose, which should be cheap, noninflammable, and harmless to the skin and hair, is one which merits further study. 122 Vol. XVII. NOTES AND COMMENTS. Referring to tests for color blindness in seamen, an editorial writer in the British Medical Journal of January 28, 1922, states that until comparatively recently candidates for certificates as mates and masters in the mercantile marine, and men working on the railways, were examined for color blindness by means of pigments of different colors. In the sea service Holmgren's wools were employed, in the railway service the men were asked to distinguish between the colors of dots on a white card. The dot test was employed until quite re cently upon the Great Western Railway, and may even now be in use. The Northwestern and other railways have for some years given up pigment tests and used an efficient lantern. The Board of Trade not only prescribed Holmgren's wool test for the examination of officers in the marine, but they also laid down the rule that candidates were not to be asked to name colors, but were to match skeins of wool with three standard, so-called confusion colors. Doctor Edridge-Green and others pointed out that these methods of testing were open to grave objection, in that many who were able to match the colors were in reality dangerously defective in color perception, while others who failed were not color blind at all, or at any rate not dangerously so. Doctor Edridge-Green also drew attention to the fact that by none of these tests were men eliminated for whom the red end of the spectrum was shortened. Such men—and there is no doubt that they exist— are unable to perceive a red light of low intensity which is plain to a normal individual. In other words, in a fog at sea they may fail to appreciate a red light which is obvious to the normal sighted. It is only necessary to allude to the fight, long and fierce, waged by Edridge-Green and his supporters with the Board of Trade. Step by step, in face of bitter opposition from officials, from physicists, and from some physiologists and ophthalmologists who might have been expected to know better, ground was gained, although the Board of Trade were supported by the Royal Society, till eventually a committee was formed to examine the whole question. As a result of its report, a lantern was used in the examination side by side with the now obso lete wools. The battle was all but won. The final victory coincided with the appointment of Doctor Edridge-Green as adviser to the Board of Trade on color vision and eyesight. Doctor Edridge-Green has just issued his report, which lies before us. It is agreed that any one who can distinguish between red, green, and white lights at a distance of a mile has sufficiently good color perception for naviga tion. Edridge-Green states that 25 per cent of men have diminished color perception, and that 5 per cent will fail to differentiate red, green, and white lights, in a properly constructed lantern, or the actual lights themselves, at a distance of 1 mile. We gather that, in the opinion of Edridge-Green, men who fail with the lantern are No. 1. 123 NOTES AND COMMENTS. to be held dangerous at sea, and those who pass the lantern test are safe, and this no matter what degree of abnormality in color per ception they may show with other tests. He says definitely that the possession of a sense of yellow is a sure indication of safe color vision. There are many who will not agree with that portion of the report which deals with the Edridge-Green theory of color blindness. In the main it may be true, but there are some anomalous cases which the theory fails to explain. As regards the tests we are on surer ground. The men have to name colors shown in a ship's sidelights or from shore lights. It is not part of their duties to match wools. Common sense demands that if the men have to distinguish lantern colors they shall be examined with a lantern. This will in future be done. The Board of Trade will come into line with the Royal Navy and the more enlightened railway companies, and will test its can didates for the work they have to do, and as far as possible under conditions similar to those which obtain at sea. In the Journal of the Royal Naval Medical Service for January, 1922, Surg. Commander G. R. McCowen writes on " Immediate surgery with the siege guns in France." In the first portion of the paper the writer describes the difficulties under which the surgeon at the front works, and he gives a brief outline of the composition, distribution, and work of the artillery with which he served, and comments on the conditions under which officers and men lived. As the batteries were stationary, the medical organization was very much more simple when compared to a mobile army unit, such as the infantry or field artillery. Fortunately, only 6 miles behind the most advanced batteries, was the Belgian hospital at La Panne which was magnificently equipped and organized. This hospital could be reached in 20 minutes by motor ambulance and it acted as an ad vanced dressing station, casualty clearing station, and base hospital all combined in one, caring for the wounded of the batteries until such time as they were fit to be evacuated farther back. All preparations to meet casualties were based on the principle that, in advanced units, surgical intervention should be reduced to the minimum and should be restricted to dealing solely with complica tions likely to prove fatal and to protecting wounds from contami nation. Therefore, as a routine, only such operations as were abso lutely necessary were performed. Operations for hemorrhage which threatened life and those for removal of hopelessly smashed limbs were the only ones done. Exactness of surgical technic gave way to speed in order that the cases might be gotten away to the hospital as soon as possible. 103390—22 9 124 Vol. XVII. NOTES AND COMMENTS. The medical personnel of the siege guns consisted of 3 medical officers and 17 Hospital Corps men. Their distribution was as fol lows : Two medical officers were stationed with the foremost section, i. e., the senior medical officer, who lived with the group commander and his staff in a dugout central for the foremost batteries, and an other medical officer who lived in one of the battery positions. Each was responsible for an equal number of batteries as far as sickness and hygiene were concerned. The third medical officer was respon sible for the casualties, sickness, and hygiene in the rear section. Each battery had one Hospital Corps man with it, with the ex ception of the antiaircraft batteries, which, because of their isolation, had two. The Hospital Corps men were taught to be proficient in the following four things: (1) The first-aid treatment of wounds; (2) the control of hemorrhage and treatment of fractures; (3) the treat ment of shock; (4) the transportation of wounded. Each battery had its own supply of medical stores, and the Hos pital Corps man on duty with the battery was responsible for re plenishing it. Surplus supplies were kept in the foremost batteries with the senior medical officer, and at the rear with the medical officer responsible for that section. " The following were the stores kept in water-tight boxes in each gun position, allowing 25 men to each, of which probably not more than 15 would be in action in the gunpit at the time, the rest being in dugouts close by. Thus two gunpits being close to one another constituting the battery, enabled double this amount of stores to be available, and always one lot was close by should the other be destroyed by gunfire. Absorbent wool pounds— 3 Gauze, aseptic tins — 8 Oils for burns ounces. _ 10 First field dressings 10 Bandages (various) 40 Antigas ampules boxes — 10 1(Kline tincture ounces — 6 Safety pins ~ 20 Splints, leg (2 Thomas's and 2 back with foot piece) 4 Tourniquets 6 Extra supply of blankets. Cyanide gauze yards — 12 Bint (white) pound — 1 Picric acid dressings 5 Shell dressings 20 Bandages (triangular) 6 Hydra rg. perchlor. (solution pellets 8.75 gr.) 20 Scissors pair__ 1 Splints, anrr (2, Thomas's and 2 Bowlby's) 4 Stretchers 3 Tow for splints pounds 5 No.l. 125 NOTES AND COMMENTS. Besides the above there were also the following utensils: One bowl, one basin, soap, and buckets of water. These stores were found to be ample and to contain everything required, even should the maximum number of casualties take place at one time, as they did on a few occasions, when an 11 -inch shell in each case came in through the embrasure of one of the batteries and either killed or wounded every one inside. Kach medical officer, in addition to the above, had his own haver sack, which he carried about with him, the contents varying accord ing to his taste. From experience the following stores were found useful and adequate and a comfortable amount to carry : Absorbent cotton-wool pound J Antlgas ampules boxes — 2 Bandages, 3-inch 10 Bandages, triangular 2 •'arbolic acid, pure ounce 1 Cyanide gauze yards— 0 First field dressings 3 Iodine ampules 10 I'ocket case of instruments. Picric acid dressings 1 Scissors -y Pair— 1 ■Spirits, methylated (for occasionally flushing out hypodermic syr inge) ounces 4 Safety pins 2." shell dressings :t Hypodermic syringes (1 Wlldey's and 1 Down metal glass) 2 Injection, hypodermic morphia in Wildey's bottle, J gr. in each 5 min ims ounce 1 Sterilized sutures with needles :— Horsehair tubes 5 Silk do 5 Catgut do 5 Tourniquets 3 Pituitary extract, i cubic centimeter capsules 10 A book of tallies for wounded. " In addition to the gun position and medical officers' stores, each ambulance carrying four stretchers had a cabinet specially made for it containing sufficient stores, instruments, anaesthetics, etc., to perform a major operation, should one be required, but this was found unnecessary and from a practical point impossible in any advanced position near the line. Besides the impracticability of Informing any elaborate surgery, it was found impossible to get amlmlances up to advanced positions during the shelling, and only 'luring a lull were they able to approach near the positions, and then only to collect the wounded with the minimum amount of delay and convey them to the hospital six miles in the rear."' 126 Vol. XVII. NOTES AND COMMENTS. Communication was by means of telephones, ground wires being laid to exchanges, so that all batteries were able to communicate with each other. Each medical officer was supplied with a motor cycle which greatly facilitated his rounds. Two Sunbeam am bulances and one light Ford ambulance served the unit. The Ford car was used to evacuate cases from certain advanced batteries where the heavier Sunbeam would run the risk of stalling in the sand. The immediate treatment of casualties encountered is considered by the writer under the following headings: (A) General treatment, (B) Local treatment with reference to special wounds. The majority of the casualties were caused by fragments of " high explosive shells" which in the case of large shells were apt to tear off a limb or crush it to pulp. The mere explosive force of the gases of a large shell exercise great power of destruction and a few men were severely injured by the expansion of the gases alone. The wounds caused by high-explosive shell fragments are infinitely vari ous, so that it is not possible to describe a characteristic shell wound of a type. All shell fragments tear away parts of the clothing and carry them into the depths of the wound. The large fragments tear large masses of skin and muscle away from the limbs and trunk, so that the whole of 'the calf or the front of the thigh, or the gluteal or deltoid regions may be destroyed, and the tissues from which they have been avulsed are themselves so crushed and lacerated that all the vessels are pulped and extensive areas die. In the neighboring tissues there is widespread contusion and extravasation of blood, and, as a result of these injuries, the exposed muscle often loses all its natural char acteristic appearance and looks like a mass of mud, and as it is quite dead, it may be cut away without causing pain or bleeding. The condition of the wounded man himself is greatly influenced by the time that elapses before assistance arrives, by the amount of blood lost, by exposure to cold and wet, by want of food and drink, and by exhaustion from lack of sleep. Most of the wounded were found with some degree of shock. Three factors in the general treatment of wounds which have to be combated in their early stages, and which react on one another in a marked degree are shock, hemorrhage, and sepsis. Shock was generally due to the combined action of several causes, among which the most common were hemorrhage; exposure to cold, wet, and hunger, and fatigue; pain and anxiety; the presence of mul tiple injuries, particularly those complicated by compound fracture of the femur. Next to the actual injury, unavoidable early handling; and transport of the patient were found to be potent factors in pro ducing shock. It was soon learned that the good work of an ad vanced unit rests on attention to the various causes of shock rather than on the performance of surgical operations. No. 1. 127 XOTES AXD COMMENTS. The methods employed by the medical officers with the siege guns, were the protection of the injured man against cold by the liberal use of blankets, both under him and over him. the avoidance of exposure by unnecessary removal of clothing, the administration of morphia in large doses, the quenching of thirst by hot drinks, and finally by gentle handling. The following method of folding blankets in order that the maxi mum advantage may be obtained from them was used by practically all army units in France and is worthy of remembrance. "Two blankets are laid on the stretcher, each with a double fold correspond ing with the width of the stretcher. The breadth of the blanket is used, as it is sufficient to reach from the foot to the pillow of the stretcher. Xo part of the blanket is placed under the pUlow, as here its objective would be wasted. If they ore not found long enough to reach well down to the foot of the stretcher they need not be made to exactly coincide, but the upper one may be placed slightly higher on the stretcher than the lower one. When not in use, the free portions of the two blankets may be rolled up and laid on the stretcher. When required, the free portions are opened out, the patient is lifted onto the two double folds, and the free portion of each blanket wrapped around him. The ends of the blanket at the foot of the stretcher are tucked in underneath the feet. He has thus four thicknesses of blanket beneath him and two on top. In rainy weather a mackintosh sheet is added to protect him from fur ther wet. If a third blanket is available, it may be folded along its length and placed over him, the lower end being tucked well in be neath the feet and the two corners brought round and secured above the legs by a safety pin. This third blanket is, of course, applied to the patient before the free portions of the two blankets are wrapped round him. He has now four thicknesses of blankets above him as well as below. By this procedure the maximum benefit is obtained by using blankets in this manner, and also when thus ad justed they do not work out of position as often happens when other methods are employed." With the siege batteries on the Flanders coast, where casualties were generally caused by high explosive shells of large caliber lacerating the tissues and pulping the vessels, severe hemorrhage was not common; still one had alwa\rs to be prepared "for it. " The majority of external hemorrhages can be controlled by firm pressure with a pad over the bleeding point, at least until a field ambulance fT hospital is reached, where it can be thoroughly dealt with. Such i pad can be made from a first field dressing, or. if necessary, two held dressings, one on top of the other. The unnecessary use of tourniquets should be avoided, as limbs may be lost by the indis criminate use of them. The application of a tourniquet to any case 128 Vol. XVII. NOTES AND COMMENTS. of hemorrhage must always be regarded as a purely temporary means. Every patient on whom a tourniquet has been placed should have the fact clearly indicated on the tally, and be evacuated as promptly as possible. With regard to tourniquets, the use of the round rubber one is strongly advocated in place of the web tape with buckle, as it is more easily applied and more effective. If circum stances permit, severe hemorrhage should always be tried to be con trolled by seeking for the bleeding vessel and ligaturing it, and, if necessary, enlarging the wound to do so. If this is impossible, due to circumstances, or delay entailed, or lack of surgical facilities, and if packing fails in such a case and a tourniquet is out of the ques tion—such as in a wound of the neck—the wound may, if possible, be closed by sutures embracing the skin, fascia, and muscle, and so converting the case into one of diffuse traumatic aneurysm, in the hope that the pressure will prevent further loss of blood. "Any wound of a limb in which bleeding has had to be specially controlled should be splinted, as sudden movement or jarring will often restart bleeding that has only been temporarily checked. "A type of wound which, though possibly it may not appear to be severe, is likely to give rise to serious results, is one in which there is a slow, continuous oozing that is at no time sufficiently rapid to be regarded as severe hemorrhage, but which in a long run may cause more loss to a patient than a brisker hemorrhage that has received prompt treatment. Such a case may not be in danger of death from bleeding, but he will start his fight against sepsis severely handi capped, for hemorrhage, shock, and sepsis go hand in hand." The sepsis most to be feared was gas gangrene, but fortunately it was not common with the siege batteries, due to their location in the sand dunes of Flanders, and to the fact that evacuation was very quickly accomplished and the man reached the operating table at La Panne within an hour of being hit. At this hospital every wounded man was given a prophylactic dose of 1,500 units of anti- tetanic serum as soon as he was admitted. With the siege guns, iodine was used for cleaning the surrounding skin and outside of wounds, but with the infantry a 3 per cent solu tion of picric acid in alcohol was used and, it was claimed, with bet ter results. In the majority of the cases the only dressing was the application o'f a very large " shell-wound dressing." All fractures were immediately immobilized in splints before re moval of the patient. The earlier a limb is immobilized the better ; shock is diminished and the patient stands a better chance for his life. For fractures of the humerus, the small Thomas's arm splint. Jones's extension humerus splint, and the Depage modified humerus splint were the most popular. No. 1. 129 NOTES AND COMMENTS. Fractures of the femur were the most important of all. Early in the war the mortality from this injury was 90 per cent, but with the use of Thomas's splint it was reduced to about 15 per cent. These splints were supplied to advanced posts and were applied without removing either trousers or boots. If no Thomas's or Listen's splint was available the following im provised means of temporary fixation in a case of fractured femur was found useful: "A puttee or bandage was passed under the perineum and round the handle of the stretcher opposite the injured side at the head of the patient, pulled tight and tied. Another band age was then passed by means of a clove-hitch around the ankle of the injured leg, extension applied, and the bandage tied to the handle at the foot of the stretcher on the same side as the injured thigh. A couple of splints were then fixed to the broken thigh by bandages or tapes. Finally, the toe of the boot of the injured side was connected by a bandage or puttee to each handle at the foot of the stretcher. This kept the foot stationary and prevented rocking from side to side. An additional bandage was generally put around the hips and stretcher to keep the pelvis firm against the latter." The British Medical Journal of January 21, 1922, comments edi torially on the sources of vitamines. Though the chemical nature of vitamines is still unknown, recent researches have thrown light on the conditions under which they are formed. It has generally been assumed that plants can synthesize vitamines, but doubt has been cast upon this by various workers. Bottomley stated in 1916 that certain plants obtained these accessory food substances from the growth of certain organisms in the soil. Recently Williams and other workers have gone further and have claimed that vitamines, and especially the water-soluble vitamine B, are necessary for the growth of yeast and other microorganisms. These statements made it very difficult to conceive where and how the vitamine supply of the world was produced. Fortunately recent work has cleared up this question. Nelson, Fulmer, and Cessna (Journal of Biological Chemistry, 77, xiv, 1921), grew yeast for a year on a medium com posed of inorganic salts and, cane sugar ; they made subcultures every other day, and calculated that the final solution only contained a minute portion of the original constitutents of the medium or yeast. The yeast thus grown on a synthetic diet was found to contain a normal amount of vitamine B. Harden and Zilwa (Biochem, Journ.. 438, xv, 1921), also showed that yeast grown on a pure synthetic diet contained almost as much vitamine B as yeast grown under normal conditions. 130 Vol. XVII NOTES AND COMMENTS. These experiments seem fully to establish the contention that yeast can grow freely without any supply of vitamines, and that it can synthesize vitamine B from a diet of inorganic salts and sugar. Yeast does not synthesize the fat-soluble vitamine A, but the origin of this vitamine appears to have been demonstrated by recent experi ments of Coward and Drummond. (Biochem. Journ., 530, xv, 1921.) These observers showed that dried seeds contained little vitamine A, and that this amount was not increased by germination, but that as soon as the seeds formed green leaves a considerable amount of vitamine A appeared. Experiments made with Tradescantia shoots grown on Sach's solution also showed that green plants could synthesize vitamine A from inorganic salts. The production of vitamine A was shown to be dependent upon the presence of chlo rophyll in plants, for etiolated seedlings contained no vitamine A, nor did white leaves from the interior of cabbages. In green sea weeds, containing chlorophyll, vitamine A was present, but red sea- Aveeds contained none. Mushrooms were found to be almost com pletely deficient in vitamine A. It appears, therefore, that the pres ence of chlorophyll is essential for the synthesis of vitamine A, and that chlorophyll-containing plants can synthesize vitamine A when fed on a pure synthetic diet. The chemical nature of vitamine A is still unknown. Coward and Drummond found that it could be extracted by fat solvents from green leaves and that it appeared in that fraction of the fat which is resistant to saponification. Vitamine A was at one time believed to be one of the yellow plant pigments. These plant carotinoids are the source of the lipochromes which produce the yellow color of animal fat, and, as a general rule, those animal fats which contain most lipochrome also contain most vitamine A. Various workers have shown, however, that this association is not constant and that the association between lipochromes and vitamine A is probably ac cidental. These researches give a fairly clear picture of the vitamine ex change in living organisms. Vitamine B is synthesized by all forms of plant life, whilst vitamine A is only synthesized by plants con taining chlorophyll. Fishes and whales obtain the rich supply of vitamine A present in their oil either directly or indirectly from the chlorophyll-containing algae or from the chlorophyll-containing organisms which passively float in water. Land animals derive their vitamine A supply from the green vegetables. The source of the vitamine A in milk has been shown very clearly by Drummond, Coward, and Watson. (Biochem. Journ., 540, xv, 1921.) They measured the vitamine content of the milk of a herd of cows from April to July, 1921. The animals were stall fed until the end of April, and in April their milk contained little No. L 131 XOTES AXD COMMENTS. vitamine A : after the cows had been a week at grass their milk Yielded a high content of vitamine A, which persisted during May and June. The drought last year spoiled the pasture, however, so that in July the cows had to be fed on cake, and the vitamine A content of the milk at once dropped. A quantitative study of the vitamine A content of butter showed that during the process of butter making a certain amount of vitamine A disappeared, but that butter could be stored in tins for many months without any marked diminution in vitamine content. The conclusion was drawn that the vitamine A content of butter was much more dependent upon the reason at which the butter was made than upon the length of time for which it has been stored. This conclusion is obviously of great practical importance. The cow can only secrete in its milk the vitamines which it receives in its food, and the milk or butter of a cow fed on a vitamine-poor diet will contain very little vitamine. Our knowledge of the importance of vitamines has emphasized the necessity for obtaining fresh milk in which the vitamines have not been destroyed, but now it appears that it is equally important to obtain milk from a cow receiving a vitamine-rich diet. Drummond and his fellow workers have examined also the vitamine A content cf the body fats of animals, and in this case also they found that the fat of a stall-fed animal often contained very little vitamine A; whilst on the other hand, the fat in tinned beef obtained from grass-fed animals was often rich in vitamines after many months' storage. These conclusions as regards the vitamine content of tinned foods apply only to fats which have been stored under good conditions, and are probably true only for the case of vitamine A, which is more stable than either vitamine B or C. It is. of course, a matter of extreme difficulty to preserve vita mine C; the only substances in which this vitamine is preserved for any length of time are the fruit juices, and even from them the vitamine slowly disappears. Harden and Robison (Biochem. Journ., 521, xv, 1921) found that when dried orange juice was stored in a desiccator for 15 months it lost 50 per cent of its vitamine C con tent, and dried orange juice kept under ordinary conditions lost s5 per cent of its activity. The supply of vitamine A and vitamine C therefore appear to present two separate problems. In the normal adult there is really no problem, for an adequate quantity of green vegetables in the diet provides a full supply of all three vitamines. In the case of bottle-fed babies, however, the supply of vitamine A appears to depend chiefly upon the diet on which the cows supplying the milk are fed, while the supply of vitamine C is determined chiefly by the treatment which the milk undergoes during its pas sage from the dairy to the infant. The conclusions of Coward and Drummond certainly suggest that during the winter it is desirable 132 Vol. XVII NOTES AND COMMENTS. to add cod-liver oil, or some other rich source of vitamine A. to the food of infants on a milk diet. The British Medical Journal of January 14, 1922, makes the fol lowing comment on Moliere : " Jean Baptiste Poquelin, who when he became author and dram atist assumed the nom de theatre ' Moliere.' was horn in Paris on January 5, 1622— at least, his baptismal certificate bears that date. His father, who was upholsterer to Louis XIII, came of a prosperous bourgeois family of Beauvais, and there was once a tradition that some remote forbear was Scottish. Of medical practice in his day Moliere was a bitter critic. He first satirized physicians in his farcical comedy Le Medecin malgre lui, and returned to the attack in L'Amour Medecin. His last comedy was Le Malade Imaginaire, in which he himself played the part of the sick man when it was produced for the first time on February 10, 1073. During its preparation and rehearsal he had been suffering from cough and haemoptysis, and before the third representation, on February 17, he was so ill that he was advised not to act. He did act, however, but during the performance a violent paroxysm of coughing came on and he was carried away dj-ing from the theater to his house. Fielding's version of Le Medecine malgre lui, bearing the title of ' The Mock Doctor,' was first produced in 1732. In a later play, M. de Pourceaugnac, Moliere gibed at the physicians, and there can be little doubt that lie suffered much at their hands during his long illness. The physicians and apothecaries of the day could not for give Moliere his bludgeon blows; but in exposing humbug and formalism he was a true friend of medicine, and medicine will join with the other arts in celebrating the tercentenary of the great French dramatist." The United States naval hospital at Olongapo, P. 1., was placed out of commission on February 15, 1922. There are comparatively few people- in or out of the medical pro fession, who know how enchanting a writer was the late Dr. William Osier, that great Canadian diagnostician and teacher whose brilliant and many-sided career came to an end just a few hours before the close of the year 1919. Why is not Doctor Osier more widely read to-day? Why are not those writings of his, covering a great range of subjects beside those pertaining to medicine and medical history, better known to the general public ? There are several reasons. The chief of these is that his fame as a physician and scientist completely overshadows his fame in any other direction, and as a result the general reading public shies No. 1. 133 NOTES AND COMMENTS. away from his books. It is well nigh incomprehensible to the public that a great scientist can write anything that is not of the dry-as-dust category. The public has a deep and abiding abhorrence of anything too deep, and does not like to take chances on the product of a man with the reputation of a profound thinker. He is never given the credit of versatility and moods. The taint of superhigh-browism is on him and he remains a sealed book to all and sundry outside the inner circle. Doctor Osier made the mistake (?) of becoming too renowned in his line of work. He was quoted too much and dis cussed too much in print— perhaps, during his life, more than any other physician the world has known. The fact that he was a physician, and a great one, was burned into the public mind on divers occasions, especially after the odd circumstance at Baltimore which brought into being the verb " to Oslerize." It killed his chances, for this generation, of becoming a best seller even in, that neglected de partment of literature in which he excels. It associated him, for the time being at least, in the mind of the average man as one of those intellectual giants whose processes are unintelligible to the common run of men. He has failed of popularity as a writer for the same reason that an intellectual drama fails while a girl-and- music show next door succeeds. He requires too much involuntary concentration. Men. alas, are slow in finding the treasures that lie close about them. Perhaps by the time the Osier centenary is celebrated things will have changed. The human mind and intellectual appreciation will have progressed to the point where fame in one direction will not hamper fame in another. Or perhaps Doctor Osier's fame as a physician will by that time have become so dimmed, outside his profession, that the public will think of him first and last as a writer. That sort of thing has happened frequently. If it happens in the case of Doctor Osier it will be an approbation of his work that is justly deserved. Doctor Osier's writings are many and varied. His bibliography, covering a period of 49 years, comprises no less than 730 titles, including his collected essays and addresses, according to Dr. Harvey Cushing, his biographer. " His charm as a writer," says Doctor Cushing, " had much to do with his great success as a teacher. * * * His Textbook of Medicine (200,000 copies) was translated into French, German, Spanish, Chinese, and other languages. * * * It remains the most used and most useful book in medicine to-day." Doctor Osier was extremely fond of literature and of literary allu sion. He was an omniverous reader, and, having a retentive memory, his mind was stored with quotations and incidents. It was a quo tation that brought about the famous 60-year deadline story that made him the talk of two continents. In his farewell address at Bal 134 Vol. XVII. NOTES AND COMMENTS. timore, where he had been connected for 16 years with Johns Hop kins University, he quoted from The Fixed Period, one of Anthony Trollope's rarer novels, in which the theory is advanced that the greatest work of man is done before he reaches 40 and that it would benefit society in general if chloroform were administered to all on their reaching 60. This is how he happened to be misquoted as to chloroforming all men over 60. In quoting Trollope he jested, trusting to his hearers, as well he could, confidently enough to un derstand that he knew as well as they did that the utility of man has no such limitation. He was himself 55 years old at the time and his remaining 15 years were years of great activitj* and his greatest influence. — (New York Medical Journal, February 1, 1922.) Possibly the days of the "master" and "disciples" in medicine are passing or have passed, and with wider dissemination of special ist teaching the world over the delights of a continental Wunderjahr will be less frequently sought; but no one who has sojourned in the ancient becastled tow7n by the Neckar will forget Erb and Nissl, or admit that stay at homes can ever sense the fascination of contact with master minds of foreign schools, under foreign skies, in days when receptivity is at its maximum and when the chosen career is at its opening. For this reason, if for no other, the death last month of the veteran neurologist of Heidelberg, Wilhelm Erb, can not be al lowed to pass unnoticed, though a new generation of neurologists has arisen to whom he must be little more than a name. It is true that in Erb's birth palsy and in the Erb variety of myopathy we have a means of perpetuating his memory, but these serve but feebly to indicate the prominent part he played over many laborious years in the development of scientific neurology and in that movement which has led to its commanding position in medical studies to-day. The student now entering on his curriculum finds in nearly every hospital a neurological department, or at least one teacher of medi cine who devotes himself largely to neurology; and he can have little or no idea of the epoch when the voice of the pioneer was as of one crying in the wilderness. It was in 1865, as assistant to Friedreich, that Erb began his career in neurology, and succeeding years saw him establishing, by exact clinical observation and equally important classification, the foundation of scientific neurology in Germany ; myotonia, myasthenia, muscular dystrophy, intermittent claudica tion, the syphilitic etiology of tabes dorsalis and of certain para plegias, were all differentiated and elaborated and erected on sure foundations, and this before modern methods of investigation came into vogue. Erb was, after Duchenne of Boulogne, one of the first to employ electricity for purposes of diagnosis and treatment; his No. 1. 185 NOTES AND COMMENTS. " Elektrotherapie " appeared in 1875, and his diagrams of the motor points have since then reappeared in textbooks time without number, until, indeed, one may suppose they are one of the few things which will never be better done. From a note in the Miinchener medi- zinische Wochenschrift we learn that no fewer than 237 publications stand to the credit of Professor Erb, that he had in the course of his life's work no less than 61 assistants, and that it was said of them, * Untersuchen konnen die Erbschen Schiiler alle." From such data we may better understand what Erb's school meant to neurology, what stimulus to research, what inspiration and enthusiasm; we may compare it, indeed, in respect of scientific and clinical attainment, to that of Charcot at the Salpetriere. — (The Lancet. January 7, 1922.) It was formerly taught that yellow fever was endemic in West Africa, but the recent commission of the Rockefeller Foundation which traveled through West Africa from Senegal to the Congo had <rreat difficulty in finding there any account of recent epidemics, such as have occurred in the Southern United States and in South America. The commission —of which General Gorgas was presi dent till he died, when his place was taken by General Noble who had worked with him at Panama— had the advantage of the cooper ation of Dr. Juan Guiteras, of Havana, whose life's work has been with yellow fever. At the present time yellow fever is found chiefly in South American ports where temperature is higher than in West Africa, where there are more mosquitoes, and where there are many white people. Negroes and their children have a marked immunity to yellow fever, and it is only where, amongst the blacks, there are many susceptible white people that a considerable epidemic can arise: and only in a place which is a great center of trade and visited by many strangers can repeated epidemics occur. Like sev eral other communicable diseases, yellow fever rather quickly infects those susceptible and is brought soon to an end by the raised resist ance of the community, unless fresh nonimmunes are continually coming into the area. The cleaning up of the American endemic areas with the destruction of mosquitoes, and the disappearance of the sailing ships which carried infected stegomyia from port to port are the chief agencies which have led to the disease dying out in West Africa. Prof. W. H. Hofmann, of Havana, is of opinion that the best proof that yellow fever is not longer endemic in West Africa is that no outbreaks occurred there during the war, though so many susceptible white men were sent to the region. He men tions that Doctor Guiteras, with his large experience, does not sup port Noguchi in claiming Leptospira icteroides to be the cause of the fever. Noguchi has, however, recently claimed that the injection 136 Vol. XVII. NOTES AND COMMENTS. of killed cultures has definitely protected thousands of susceptible persons in Central and South America, while the immune horse serum, if used before the fourth day, has a curative action. — (The Lancet, January 7, 1922.) Before the war the bacteriologist always obtained his stains from Germany. That country was supreme in the field of aniline dyes. While other countries were wasting their coal tar Germany was con verting this valuable and unsightly material into all sorts of drugs and into dyes of all the shades of the rainbow. One German, more over, realizing the laboratory uses of the dyes, took it upon himself to purify and standardize those dyes which the bacteriologist and biologist particularly needed. It was a very small business com pared to the textile dye industry, but the whole world was his mar ket and his business flourished. When the war broke out and the stock of these standardized and reliable German stains already in the country gradually became exhausted, the bacteriologist had a hard time finding what he needed for this important work. The American dye business was born to meet the emergency; but the dyes made in America were particularly textile dyes and ordinarily were not suited to the work of the bacteriologist. Finally, one or two men in the business tried adapting their dyes to biological purposes, and very shortly after wards several other companies started to do the same thing so many in fact that none of them made a satisfactory profit and their prod ucts differed so much that no two samples of the same stain could be counted on to give the same result. The first attempt to standardize these stains was made by the Society of American Bacteriologists. With the assistance of cer tain dealers in biological stains they have been working on the mat ter for about a year and find that American manufacturers have already met the bacteriologist's needs in an admirable way. A little standardization is all that is now needed. The work that has to be done in this way by the bacteriological society appeared so important that the National Research Council of Washington, D. C, offered to take it over so as to put it on a broader basis and place facilities at the disposal of the worker which were not available to the bac teriological society alone. Under this new arrangement the work has been organized on a broad basis, with the cooperation of the Department of Agriculture and several of the large national scien tific socities besides the Society of Bacteriologists. The hope of the committee in charge of this work is not only to standardize the stains and to secure American products as good as Germany can produce, but to secure the production of biological stains in this country decidedly better than those available before the war. NURSE CORPJ-. WHAT IS PROFESSIONAL ETHICS t One of the questions frequently asked the applicant for appoint ment in the Naval Nursing; Service is " What is meant by professional ethics?" From the answers received, which convey such varied meanings, it would seem that the word " ethics " is losing some of its fullness. A protesting patient recently exclaimed " What is this ■professional ethics ' which hampers my choice of physician and nurse and which further hampers me if I desire to change my physician or nurse?" The general definition of ethics is probably summed up in the statement that we mean those rules which govern actions relating to the duty and discipline demanded by the profession or vocation with which we are identified. Since the inception of a nurse body there have been certain principles which are the ethics of our calling. In teaching the meaning of professional ethics, we become aware of confusion in the minds of those who have preceded us produced by a more or less successful training in social ethics. The term should not be confined to social or professional customs which have been established by the consensus of opinion. The history of our pro fession, or vocation, points significantly to the influence exerted by religious bodies. This is especially true of the nurse standards in Germany and England from which countries we received the incentive to establish our training schools. The history of the evolution of the hospital shows the recognition of the necessity of religious teaching to develop moral standards. Here we find the ethical principle of authority with the responsive obedience among those who took unto themselves the care of the sick. Religion formed the background and gave to us the rule that though a cure could not be effected, the patient could be given care and com fort in dying. Without the religious background and the voluntary service of the religious sisters trained from childhood by the church in self-denial, we of the present day have our background in teaching in the homes and the training of schools and colleges. It may be safely affirmed that the resulting development of our training attains a success in proportion to the strength and soundness <>fthe foundation. " Ethics." therefore, if so well understood, as to an intrinsic part of the nurse, is not learned from a definition, but 137 138 Vol. XVII. NURSE CORPS. from an absorption of the idea that discipline is necessary to develop thoughts and actions in relation to others. The result is respect for teachers, thoughtfulness toward associates, and, in the struggle for mastery in any line of endeavor, mental development, and formation of character. When this home background is lacking the understanding of ethics is so slowly absorbed that the professional knowledge is obtained before the spiritual nature has developed, and the practical prepara tion is accomplished while the qualities of heart and mind are absent or unawakened. Some vocations demand a greater accountability than others. In the profession of nursing the existence and development of the ethical principle is a fundamental necessity. The conception of the ethics of nursing, therefore, is the development to the point of un conscious possession of the characteristics which every nurse should possess, to spend and be spent for others: Truthfulness, not the studied correctness, but involuntary truthfulness; obedience in the meaning of " dutif ulness ; " respect for those in authority, one of the first lessons taught by Christ ; gentleness in speech and manner ; con trol of tongue, abstaining from destructive criticism. " Thoughts Unexpressed may sometimes fall back dead, but God himself can't kill them when they're said." When these characteristics have been acquired there will follow self-respect, dignity, observation, judg ment, and tact. Where these characteristics have been implanted in the home life the correct conception of professional ethics is innate. The defect in the foundation can only be fortified by efforts well directed on the part of those in authority ; and conscious rebuilding without resentment or animosity, on the part of those who have chosen the profession of nursing for their field of work. The incul cation and the willing conception of right principles will innoculate our profession with the knowledge that ethics and ethical standards rest in a rooted feeling that to realize our greatest ideal we must toil and work for the development of our lives in relation to others. Nothing perfect is given to us ; each day we must take up the struggle and live the highest that is given us to live; working, not despairing: not rebellious, but having a mind open to every new and worthy experience. The following citations were inadvertently omitted from the list of those receiving honors or distinctions published in the January issue of the Bulletin : " Certificate of citation for exceptionally meritorious and conspicu ous service at Navy Base Hospital No. 1, bestowed upon Miss Frances Van Ingen, chief nurse, United States Navy. I Vol. XVII. 139 NURSE CORPS. "The Elizabeth medal of Belgium presented by the Queen of the Belgians on the U. S. S. George Washington to Miss Sophia V. Kiel, chief nurse, United States Navy, in appreciation of her work and also of the work of the American nurses during the war.'' Recently the Bureau of Medicine and Surgery has been presented with an historic flag which was used when the hospital of base No. 1 was commissioned in Brest. The flag hung in the office of the chief nurse of the unit, Miss Frances Van Ingen, of New York, who was also the chief nurse of the hospital, and has been presented to the bureau. When Brest was in gala array on the occasion of the armistice this flag was used in the decorations. When one opens the door of the office of the superintendent of the Navy Nurse Corps this flag is the first object which meets the eye. Just beside this flag, which shows marks of service, hangs the beautiful banner of the Navy Nurse Corps, which was presented by the Sixth Division, and which has been used in various official parades where the Nurse Corps was represented. After viewing the flag and the banner, the eye travels around the wall, resting on the various groups of members of the Navy Nurse Corps on duty at many of the hospitals in the United States. He is a rare visitor who fails to notice and make favorable comment on these photographs showing the nurses in their uniform of the Navy Xurse Corps. 103390—22 10 BOOK NOTICES. Publishers submitting books for review are requested to address them as follows: The Editor, L\ S. Naval Medical Bulk-tin, Bureau of Medicine and Surgery. Navy Department, Washington, D. C. (For review.) Books received for review will l>e returned in the absence of directions to the contrary. REVIEWER. Lieut. Commander W. M. Kerr, Medical Corps, United States Navy. "A little music, a choice picture or tiro, and a shelf of good books ritnrk a real home, for they distinguish those ir-ho appreciate the finer things in life from those who don't." Medical Service in Modern War, by Lieut. Coli. P. S. Bond and C. F. Martin, ilftlieal Corps, L". a. Army. George Banta Publishing Company, Menasha, Wis., 1920. This is an admirably written pamphlet of 76 pages delineating the functions and tactical employment of Army Medical Department formations and units in a modern campaign. The surgeon with the combatant forces in modern warfare must be more than a surgical operator. He must be well versed in admin istration. He must be forceful and able to organize and direct. Above all, he must be a tactician with the ability to foresee coming events. With this in view, the authors have described, in a general way. the functions of the medical department of an army in the field ; the medical equipment of divisions, corps, and army ; the evacuation and treatment of sick and wounded, and medical service in open warfare. When the United States entered the World War, the Army adopted an organization which was a compromise between American ideas and those of our Allies. This organization proved to be satisfactory, although it was by no means perfect. This treatise is based upon it, but since the war a number of changes have been agreed upon which 141 Ii2 Vol. xvir. BOOK NOTICES. appear to tend toward greater simplicity. These, the authors make clear to their readers. In an appendix will he found some excellent diagrams which illus trate the more important tactical functions with which all officers should be familiar. The Surgeon General of the Army, in a short preface to this work, says: "All officers will find in its perusal a well-arranged and co ordinated exposition of standard doctrine, which is the resultant of the extensive experience of the Medical Department of the United States Army in the World War." Naval medical officers who are taking the Correspondence Course for Medical Officers now being conducted by the Marine Corps Schools, Quantico. Va., will find this pamphlet a valuable addition to their working library, (w. sr. k.) South America from a Surgeon's Point of View, by Franklin H. Martin, M. D.. F. A. C. S. Fleming H. Revell Co.. New York, 1922. This is a delightful collection of notes gathered during two visits to South America during 1920 and 1921 in behalf of the American Col lege of Surgeons, the first visit being made in company with Dr. William J. Mayo, then president of the college, and the second in company with Dr. Thomas J. Watkins of Chicago. The itinerary of the first journey included Jamaica. Panama, Peru, Chile, Argen tina, and Uruguay: the second journey covered the same ground with the addition of Brazil. This book really is a report to the American College of Surgeons; in it are included some observations of Dr. Francis P. Corrigan who, at the time of the second journey, was making a survey of the medical conditions of Bolivia and Ecuador, together with some extracts from papers written by Dr. Martin's traveling companions. The visits to South America were made with the object of securing the affiliation of the surgeons of South America with the American College of Surgeons. Dr. Martin tells in a readable manner of the party's reception and of the hospitality afforded them by the Gov ernments of the various countries and by the members of the medical profession in each city visited. The conditions encountered made a profound impression on the visitors who regard the surgeons of South America in their hospitals and operating rooms as equals of any representative group of oper ators in the world. The book contains descriptions of the medical schools and the hospitals visited, especially in the cities of Lima, Santiago, Buenos Aires, Montevideo, Sao Paulo, and Rio de Janeiro, as well as much interesting information concerning the social and professional con ditions in South America. So. 1. 14? BOOK NOTICES. It is copiously illustrated with portraits of eminent surgeons and photographs of interesting buildings and scenery. The medical man of North America who contemplates a visit to the regions south of Panama will find this little volume of great assist ance, (w. If. K.) Abdominal Pain, by Prof. Norbert Ortner, chief of the second medical clinic at the University of Vienna. Translated into English from the second anil latest edition by William A. Brams, M. D., formerly Lieutenant Commander, Medical Corps, United States Navy. Rebman Co., New York. 1922. Medical men whose good fortune it was to study in Vienna in the days before the war have many pleasant recollections of Professor Ortner. and many of them will welcome an American edition of his book on Abdominal Pain, a work which is the product of many years of personal experience and observation. In a short preface which Professor Ortner wrote for the American edition, he remarks that he hopes the book will be well received, and that it will be of help in reestablishing friendly relations between members of the medical profession of English-speaking countries and of his own. One can assure him that the American medical profes sion at least is willing to meet him more than half way in this recon ciliation, although we fear that it will be some years before the clinics of Vienna attain the popularity they formerly enjoyed. The work is a concise and competent discussion of abdominal pain in all its phases. In abdominal disease one is not often called upon to make a diagnosis on the consideration of the pain alone. There soon develop other symptoms which are of assistance, but the pain often points out the direction one must follow in the objective exami nation in order to arrive at the proper diagnosis. As the author re marks : " It is one of the early symptoms and serves as a guide through the maze of possibilities, and, therefore, it seems justifiable * * * to consider the pain as the starting point in the differential diagnosis." This is not a book to pick up in an idle moment, but one to be read carefully, if one is to extract all the meat it contains. The author considers abdominal pain in the various localities in which it occurs. Hence we find first a discussion of diffuse abdominal pain ; then a section on localized abdominal pain. This is followed by con siderations of epigastralgia or stomach cramps, pain in the right hypochondrium, pain in the right ileocecal region, acute pain in the left iliac region, pains in the lumbar region, flanks and lateral parts of the abdomen, pain in the left hypochondrium. bilateral hypo- chondrial pain, pain in the region of the navel and pain in the hypogastric region. In an appendix various other phases of ab dominal pain are treated fully. 144 Vol. XVII. BOOK NOTICES. Each of these topics is elaborated extensively until every variety of abdominal pain together with associated symptoms have been pre sented to the reader in a systematic manner. Nothing has been left out, and the careful reader gains not only a comprehensive knowledge of the meaning of abdominal pain, but considerable knowledge of the diagnosis of abdominal disease in general. The book is written in the heavy style characteristic of the German school of scientists, but in spite of this handicap it should prove to be a useful volume to one concerned with abdominal disease, (w. m. k.) Diseases of the Skin and Eruptive Fevers, by Jay Frank Schambrrg, A. il., M. D., professor of dermatology and syphilis, Oraduute School of Medicine, University of Pennsylvania. Fourth Edition. W. B. Saunders Co., Phila delphia, 1921. An admirable book which has been revised and amplified in order to bring it abreast of the recent advances in dermatology. Whoever attempts to treat skin diseases should be skilled in the diagnosis not only of the ordinary dermatoses, but of the rashes of the various eruptive fevers. These two classes of affections frequently resemble each other to such a degree as to present great difficulty in differenti ation as is exemplified by the striking manner in which syphilis may simulate smallpox. The differentiation of various skin lesions requires skill which is usually acquired only through years of experience with many patients. Unfortunately most of us do not have an opportunity to develop the diagnostic acumen so often noted in the skin specialist to whom we have referred our puzzling cases and we grope about in the mazes of what seems to us an intricate subject. Should one wish to acquire a good working knowledge of dermatology, or merely to obtain light on an obscure case, Schamberg has written just the book to aid him. Each skin disease is presented in a brief and practical manner, special attention being devoted to symptom atology, diagnosis and treatment. The exanthemata are dealt with in a separate portion of the book and, because of the importance attached to their diagnosis, they are given greater space than is usually accorded them in textbooks. The text is supplemented with excellent photographic illustra tions, which add greatly to the value of the book from the view point of the general practitioner, (w. m. k.) Pneumonia, by Frederick T. Lord, 51. D. Harvard Health Talks, No. 9, Har vard University Press, Cambridge, Mass.. 1922. The Harvard University Press has issued from time to time val uable little books which form a series known as the Harvard Health Talks. This series aims to provide in easily accessible form modern No. I. 145 BOOK NOTICES. and authoritative information on medical subjects of general im portance. So far these talks have been on the care of children, pre servatives and other chemicals in food, the care of the skin, the care of the sick room, the care of the teeth, adenoids and tonsils, an ade quate diet, and the avoidance of injection. The last of the series to appear is a little book on pneumonia, the text of which was originally delivered as a popular Sunday afternoon lecture at the Harvard Medical School. The book sets forth in nontechnical terms our present knowledge of pneumonia, and con tains valuable suggestions for the prevention and treatment of this disease, (w. m. kl.) The Americanization of Edward Bok. The Autobiography of a Dutch Boy Fifty Tears After. Charles. Scribner's Sons, New York, 1921. " Sir, the biographical part of literature is what I like most," said Dr. Samuel Johnson; and many of us agree with him, especially when the biography is so full of human interest as is the American ization of Edward Bok. Here a strong, honest, upright man has written a book out of his own rich personal experience, relating in simple and convincing lan guage what he has accomplished, giving, as it were, an account of his stewardship and of the intellect with which he was endowed. He has written the story of a little Dutch boy " unceremoniously set down in America " in 1870, unable to make himself understood or even to know what people were saying, but who "by some curious decree of fate " was destined, as editor of the Ladies Home Journal, to write for 30 years to the largest body of readers ever addressed by an American editor. He lived a busy life in his adopted country. At an early age a hobby —that of collecting autograph letters —resulted in his ac quaintance with many of the notable men of the early eighties. Although he possessed enterprise and energy, the continuous good fortune which followed him resulted from the friendships he had made and the men with whom his life had come in close contact at its most formative period. At the age of 21 he became associated with the Scribner publishing house, where he received a training in magazine management which fitted him for his life work. Of course he met obstacles — every suc cessful man does —but obstacles to him " soon became merely difficul ties to be overcome, and he trusted to his instinct to show him the best way to overcome them. He soon learned that the hardest kind of work was back of every success; that nothing in the world of business just happened, but that everything was brought about, and only in one way— by willingness of spirit and a determination to carry through. He soon exploded for himself the misleading and 146 Vol. XVII. BOOK NOTICES. comfortable theory of luck; the only lucky people, he found, were those who worked hard. To them luck came in the shape of what they earned. There were exceptions here and there, as there are to every rule, but the majority of these he soon found were more in the seeming than in the reality. Generally speaking a man got in this world about what he worked for." In 1889 Edward Bok became the editor of the Ladies* Home Jour nal and he was eminently successful, for he possessed the faculty of rightly gauging the psychology of his public. He gave his readers the subjects they asked for, but always " on a slightly higher plane: and each year he raised the standard a notch," and each year the circulation of the magazine increased. No one can doubt the great influence which the Ladies' Home Journal has had on American life, for many of us have noted the changes for the better which have been brought about by its en deavor. One of the first we remember was the alteration in the character of the American small house. The houses of the early nineties were for the most part wretchedly planned, so Bok devoted his attention to better American architecture, gardening, and in terior decoration, with special application to the small house. For 25 years he pursued the plans adopted and in time his dream of better homes came true. " Bok had begun with the exterior of the small American house and made an impression upon it ; he had brought the love of flowers into the hearts of thousands of small householders who had never thought they could have an artistic garden within a small area; he had changed the lines of furniture and he had put better art on the walls of these homes. " It was a peculiar satisfaction to Bok that Theodore Roosevelt once summed up this piece of work in these words : ' Bok is the only man I ever heard of who changed for the better the architecture of an entire nation, and did it so quickly and yet so effectively that we didn't know it was begun before it was finished. That was a mighty big job for one man to have done.' " Bok next turned his attention to certain civic questions —the im provement in the decorations of the Pullman parlor car; the elimi nation of billboard advertising and of untidy spots in prominent por tions of various municipalities; the improvement of rural schools; and the education of women in civic matters, with equal success. The Ladies' Home Journal, under Bok's direction, was the first of America's magazines to refuse to accept advertisements of patent medicines. The magazine attacked the patent -medicine evil from all sides. It aroused the public by showing the actual contents of some of their pet medicines, or the absolute worthlessness of them, and was instrumental in securing legislation which abated this traffic. No. 1. 147 BOOK NOTICES. Then Bok took up the question of venereal disease and he had a lonely fight for a while. But it was a question that had to be faced, and he faced it with a will. There was much opposition from his readers at first, which only proved to Bok that he was right. With a series of well-selected articles he presented his case so ably that soon women began to realize that the Ladies' Home Journal was working for their best interests and for those of their children. In the end he accomplished what he had set out to do. " He had taken the question of natural life and stripped it of its false mystery in the minds of hundreds of thousands of young people; had started their inquiring minds ; had shown parents the way ; had made a for bidden topic a debatable subject, discussed in open gatherings, by the press, an increasing number of books, and in schools and colleges." He next attacked and abolished the public drinking cup; insti tuted the movement for a "safe and sane" Fourth of July, and for " better babies." These are only some of Edward Bok's achievements. His story is fascinating to the very end. It is full of lessons and encouragement for all who are striving to make the world a better place in which to live. Perhaps he was influenced by a sentiment that was voiced by his Dutch grandmother on sending her sons out into the world : "Make you the world a bit more beautiful and better because you have been in it." At any rate Bok believed : " No man has a right to leave the world no better than he found it. He must add something to it; either lie must make its people better and happier or he must make the face of the world fairer to look at, and the one really means the other." (w. m. k.) QUERIES. Medical officers are invited to submit queries and to present their problems to the Bulletin, which, being in a position to draw on varied and extensive sources of information such as are not available elsewhere, ioill use every means of securing authoritative opinion. All queries will be answered by mail; and the replies, if of sufficient general interest, will also be published in this column. To the Ewtob : I was much interested in reading the discussion of the toxic effects of picric acid as commonly employed in the treatment of burns which appeared In the January number of the Bulletin in reply to Ambrine's request. Personally, I am confident that, in spite of all theoretical considerations to the contrary, picric acid is not good to use in burns. I am inclosing a series of com munications from different sources regarding the. treatment of burns, and from them you will see the point of view of men who are probably treating more emergency burns than anyone in the country. I have no doubt that you could get a great deal more data by writing to a large number of industrial plants, out believe this will show quite definitely that picric acid is considered as some what obsolete. Akbustio. The treatment of burns is an important subject and one worthy of consideration by the naval medical officer, as the Annual Report of the Surgeon General of the Navy for the fiscal year 1921 shows 736 original admissions to the sick list during the year for this class of injury. The use of a 1 per cent solution of picric acid is quite routinely em ployed in the treatment of burns throughout the Navy, but the use of this preparation is open to certain objections and, as Ambustio's letter indicates, is not universally popular. It may be that picric acid, by suspending skin respiration and exudation in the areas on which it is applied, or by doing something to a skin area already elaborating a toxic substance as a, result of the burn, or by further irritating a nervous area already irritated to the point of inducing shock, may produce definite injury, but such actions seem never to have been demonstrated, and before we can learn much that is definite concerning such speculative effects, it will be necessary to learn more about the toxicology of burns, which as yet is very obscure. Abstracts of the correspondence referred to in Ambustio's letter are given in order that medical officers may be familiar with treat 149 150 Vol. XVII. QI/EKIES. ment advocated by the surgeons of several large industrial establish ments. It will be noted that these men do not speak against picric acid, but they do not recommend its use. Armour & Co., Chicago, III.: V. S. Cheney, M. D.—" We do not use the picric-acid treatment on any of our burn cases. " We have had considerable experience with the paraffin treatment, and it has given very good satisfaction in extensive burns of the legs and arms due to scalding water. We have also tried the open- air treatment, and in my opinion the result has not been as satis factory with that method as it has with the paraffin treatment. In a great many cases with the open-air treatment we have had exuber ant granulations, with very pronounced scars, resulting in contrac tures; this, however, was in very extensive burns. I believe that the open-air treatment is suitable for superficial burns and those not covering a very large area. I believe that the paraffin method is preferable in burns of the third degree and involving most of an extremity." Tennessee Coal, Iron &■Railroad Co., Birmingham, Ala.: L. No- land, M. D.—" We have conducted rather extensive experiments for a number of years, using a number of different treatments; but for the past four years we have used the so-called ' open treatment ' only, and are satisfied that we are getting very much better results than we ever did with any other type of treatment. "As soon as cases of burn are received in the hospital they are placed on a sterile bed under a bed tent, with electric bulbs inside in sufficient quantity to insure warmth. " When the burned surface begins to dry and crust over, com presses freely moistened with normal saline solution are applied each morning for two or three hours, followed by the easy removal of crusts and necrotic tissue with forceps. If there is a tendency to spreading infection, moist hot dressings of one-half of 1 per cent carbolic acid are used for periods of from 12 to 24 hours, but other wise the open treatment with exposure to light is constant. " We are convinced that this treatment is giving us far better re sults than we have ever secured any other way, with a minimum of pain and scar." Bethlehem Steel Co., Bethlehem, Pa,: Loyal A. Shoudy, M. D.— " Before talking about the direct treatment of burns I should like to call your attention to the care of the patient generally. I find that the burn of itself is not the part which causes the trouble, but the " tox emia " produced. I am not sure that it is a toxemia, but that is the nearest I have been able to come to it. Because of this, in all cases of extensive burns, the general care of the patient must be considered. " For the so-called minor burns, by this I mean those which do not confine to the hospital or bed. but those which come from the shops No. 1. 151 QUKRIKS. and can Ik> cared for as ambulatory cases, we cleanse with benzine, dry. and then apply dressing of ointment of the following : Parts. Bismuth subnitrate 6 " The paraffin in this is sufficient to hold the ointment above the melting point of the body heat, and I believe this is the main point in all the paraffin dressings. In some cases we find it easier to heat the ointment and apply it directly to the burn ; but in most cases we spread it on lint or gauze. "This you will find gives a flexible dressing and enables a man to return to work in the case of hand or finger burns. It is our expe rience that the burns from the hot-metal departments — splashes, and mostly of the feet—are the ones hardest to ' get well.' partly due to the fact that they are mostly third-degree burns, and also that they are in the dependent position. These we cleanse, dry, remove all 'cooked' skin, then apply a wet dressing of chinosol and cover with a dressing of the ointment. Latter used to keep the wet dressing from sticking and to keep it moist. If extensive we use the paraffin gauze for a protection. If extensive and ' deep ' we use the wet dressing of chinosol and keep moist and elevated. "Support and protection are helps in all cases of burns. If wet dressings are used, use paraffin gauze, which prevents sticking. The so-called bad cases must, from the start, be treated generally as well as locally and don't forget that if the man is or has been a user of alcohol that it should be supplied now. " These men we cleanse if not in a condition of shock. If in shock, a hypo of morphine sulphate is given and the patient is kept warm until recovery. If able to cleanse do so; blisters we open under sterile conditions, but do not cut away the skin. Cleanse, dry. and apply the ointment described. Keep clean daily with warm saline, chinosol. and a little green soap. Then keep well covered with the ointment. In the ' deep ' cases use the wet dressing of chinosol or saline. " In general measures we have found that the use of the Murphy saline drip is good measure for the help of elimination. We give water freely and try in every way to keep the spirit of the man ' up.' " We believe in fresh air and keep the body warm. •' We have almost reached the state where we believe that the so- called ' general measures ' are of as much value as the particular treatment used. "Dakin's solution is good, but sometimes the men complain of the continued stinging. Pa raffin Petrolatum 14 SO 152 Vol. XVII. QUERIES. "In burns of the skin around the eyes we use zinc oxide, with paraffin, as we have learned that it gives better results; why I do not know. " As to picric acid we have not used it for the past six years. " Chinosol I learned from Doctor Murphy's clinic as a general antiseptic." Carnegie Steel Co., Clairton, Pa.: A. W. Colcord, M. D.—In 1910 Doctor Colcord said at a meeting of the Pennsylvania Railway Sur geons' Association : " For the past 10 years I have been using an ointment known as Burn Ointment, old formula, and composed of: Carbolic acid, thymol, menthol, camphor, of each 5 gains; ichthyol, balsam of Peru, of each 10 grains; zinc oxide; starch, of each 1\ drams; petrolatum to make 1 ounce. Mix well. " It occurred to me that carbolic acid had some good properties in the treatment of burns. It is germicidal, a deodorizer, and a local anesthetic, but it is irritating and poisonous. For some years I ex perimented to find a combination which would retain the three good qualities and remove the two bad ones. I believe this mixture has accomplished the result. These four crystalline substances —carbolic acid, thymol, menthol, and camphor—rubbed together produce a new product, which has neither the physical, chemical, or thera peutic properties of either drug taken alone. It is a clear sirupy liquid. You may put your tongue into it and experience only a slight burning. Painted on the unbroken skin, it produces no red ness, pain or gangrene, only a cooling effect followed by a slight local anesthetic. The balsam of Peru and ichthyol, advocated by Doctor Estes, are valuable aids in stimulating granulation and epi dermis formation. The oxide of zinc and starch incorporated in a petrolatum base make of it a protective dressing of about the right consistency. After treating over 2,000 burns with this ointment, I am convinced that it has the following advantages: "1. It is an efficient germicide and not only renders the surround ing skin sterile, but also keeps the discharges and burned surface free from germs and, therefore, free from pus. The only pus cases we get are: " (a) Those who take off their own dressings and so infect the burn. " (b) Those who come after several hours or days with burns al ready infected. " (c) Burns near the mouth, nose, or hair, or near the buttocks in babies. " (d) Possibly some bad sloughing burns of the third degree, but these are treated as soon as a slough begins to form with continu ous wet dressing of Ochsner's fluid, which prevents bad odor or pus. No. 1. 153 QUERIES. "2. It is a powerful local anesthetic and soon stops pain, espe cially in burns of the first or second degree. A badly burned baby, screaming with pain, will often go to sleep from the relief afforded before the bandages are all on. " 3. It is a deodorizer. Our burns have no bad odor except badly sloughing third degree ones, and the odor is best controlled by the wet dressing. " 4. It is nonpoisonous. I have never seen a case where I thought absorption of the drugs produced any unpleasant symptoms. " 5. It is with some exceptions, to be mentioned later, nonirritant. "6. It is easily and quickly applied and convenient to carry in the grip. "7. With this, dressings do not stick as they do with picric acid and many other applications. Men with slight burns can, with this dressing, work in comfort. "8. It is especially adapted to mill and office practice, where we do not have the perfect cleanliness of the hospital and where the open-air (Sneve) dry method or the continuous bath is impracti cable. It is the only method I have found that will keep a burn clean in the dirty homes of some of the foreigners working in the steel mills. "9. The recovery is much more rapid by this method, because (1) the edema and inflammation of the skin soon subside, (2) there is no pus, (3) granulation and epidermis formation are stimulated. " 10. There is less scarring, because less destruction of tissue. " Some years ago I treated 30 cases with picric acid, and there was a general demand from these patients that we return to the ointment. " Let us suppose we are called to treat a severe burn of the second degree. . We find the patient suffering agonizing pain, with oncoming shock and a chill. We at once administer a hypodermic of one-fourth to one-half grain of morphia, one-fortieth to one-twentieth grain of strychnia, and one one-hundredth to one-fiftieth grain of atropin to stop his pain and apprehension and combat the shock. We then see that the room is warm—80° to 85° —clear it of unnecessary furniture and bystanders and order hot-water bottles or hot bricks gotten ready. The bed should also be prepared. If we have a nurse or assistant at hand we can order her to prepare the necessary things for a hypodermoclysis or a Murphy drip. "We must bear in mind that in every bad burn three things are more important than the local treatment. "1. Stop pain. / "2. Combat shock. "3. Provide for dilution and elimination of the toxins, which at once are thrown into the blood. 154 Vol. XVII. QUERIES. " Having gotten thus far with our work, we can proceed to do the local dressing. The clothing should be carefully cut away —never pulled off or dragged over the burned area. We must remember that a burn is, at first, sterile and we must try to keep it so. Unless we believe that it has become infected through dirty handling, dirty clothing dragged over it, or a dirty blanket laid on it, it is best not to wash the burn. Estes washes the surrounding skin with 5 per cent carbolic solution, protecting the burn with pledgets of wet gauze. With our burn ointment we have not found this necessary. " Pieces of gauze of convenient size are now spread thickly with the ointment and applied somewhat beyond the burned areas. Over this cotton and over all a bandage is placed. The patient is now put to bed. and if shock continues the normal salt solution is repeated every eight hours, giving plenty of water to drink. Nourishment for the first three days should be liquid on account of the intense conges tion of the alimentary tract; then we may gradually feed according to conditions. " There should be the usual care of the bowels, skin, kidneys, etc.. not forgetting, in our zeal over the local treatment, that we have on our hands a sick man with blood loaded with toxins, with meninges, lungs, stomach, kidneys, and other organs congested. u We re-dress our burns daily, gently wiping away the discharges of serum and broken-down cells, which is poisonous and irritating, with dry gauze or cotton. Blisters are opened and pieces of loose skin removed with sterile scissors or forceps, but all skin is left in place as long as possible to protect the underlying, new-forming skin. " Every dressing should be made with aseptic care, clean hands, clean gauze, and clean instruments. ''As the old epidermis is shed we have a red, raw, irritable sur face, and we must reduce our ointment to one-half or even one- fourth strength.1 In an occasional case even this is too irritating, and we change to oxide of zinc ointment, or. better, to strips of gutta percha tissue wet in normal salt solution. When the islands of epi dermis have coalesced, we can change to aristol or any dusting pow der. " Of course, the greater number of burns are not so extensive, have no shock, and come to the office for daily dressing. " In burns of the third degree the initial stage of shock, pain, and toxemia is treated as in extensive burns of the second degree, and the ointment applied. As soon as the slough begins to form, if there is much odor, it is well to change to a continuous wet dress ing; we prefer Ochsner's fluid (or Dakin's solution) with gauze. 'In a personnl communication Doctor Colcord states: "We now use on practically- all burns an ointment : Burn Ointment —old formula, one-sixth ; 5 per cent boric acid In white vaseline, flve sliths." No. 1. 155 QUERIES. cotton, and bandage. The patient or nurse is given a bottle of the fluid, which is poured on every three hours without removing the bandage. The burn is re-dressed daily, and sloughing masses are re moved when ready. We often see new epidermis forming along the edges before the slough has all come away from the deeper parts. The sloughing area is rapidly filled with red granulations, and if kept clean, the epidermis from the edges starts to cover it. During this period we usually apply the ointment daily, one-half strength, using silver nitrate if granulations are too high at the edges. Where ulcers, following deep burns, are sluggish with a poor blood supply at the base, balsam of Peru or bovinine is used daily. " When the area is large in a third-degree burn, skin should be grafted as soon as the slough is well away and the hole is filled with granulations. To wait until the granulating mass is old and high, we not only invite failure of the grafts to take, but we have a mass of scar tissue formed which will eventually contract, with resulting deformity. " Murphy says : ' In late grafting where a heavy mass of connec tive tissue forms beneath granulations, I advise that this be dissected out, down to the normal fascia, muscle, bone, or other tissue beneath, before placing the graft.' " We use mainly Reverdin or Thiersch grafts, covering with gutta percha tissue strips and wet gauze dressing of normal salt or borax solution. "' Young, of Glasgow, following the method of Wolf, Krause, and Matas, has obtained some excellent results by grafting the whole skin with the subcutaneous fat removed. He claims much more perma nent results than with the other methods, greater elasticity and better appearances. " Much of the ugly scarring and deformity resulting from third- degree burns is due to the neglect of skin grafting. It is often done too late or poorly done, and in many cases not done at all. "Reverdin grafting can be performed without an anesthetic and at the home of the patient. No apparatus is needed but some gutta percha tissue, a pair of sharp scissors, mouse-toothed forceps, and some sterile salt solution. The wound surface and surrounding skin must be clean, the granulations firm and healthy, and there must be no bleeding. If near a joint, apply a splint to insure perfect rest, keep the parts constantly wet with normal salt solution. Leave the strips of gutta-percha tissue in place three days, then change to clean strips. Put on grafts, one-half inch apart, in rows, both ways, so that the strips may be crossed like basket work. "First-degree burns are dressed once or twice with the ointment and discharged cured. Those of the face are coveved with sterile 103390—22 11 156 Vol. XVII. QUERIES. vaseline or zinc-oxide ointment, or the Burn Ointment, and are left without bandages. They rapidly dry and heal without further atten tion. " Burns of the eye are dressed with Lippincott's Ointment : Bichlo ride of mercury. 1 grain; ammonium chloride, 1 grain; sterile vase line. 5 ounces. "This can bp put in the eye where the burn is on the eyeball or under the surface of the lid. and gauge and bandage applied. These burns also do well with a wet dressing of boric acid solution. When the cornea is burned, atropin is used.'' In a recent communication Doctor Colcord said : " In my address before the Pennsylvania Railway Surgeons' Association. I reported the treatment of 1,000 burns with no clinical infection. I can now add 9.000 more to the list. Nurses, assistants, and patients have al ways been enthusiastic about the results of this ointment. As you will note, I am now using it much weaker than at first. "Am just finishing the treatment of a very deep third-degree elec tric (6,600 volt) burn, destroying skin, facia, and a portion of mus cles of ball of thumb. Slough was 2 by 3 inches and three-fourths inch deep. Ointment used first four days. Then a constant wet dressing of 10 per cent Dakin. mopping slough daily with pure Dakin solution. Skin of hand was protected with the Burn Ointment. Swelling of hand was slight and soon subsided. There was the usual amount of discharge from a rapidly dissolving slough but no signs at any time of clinical infection about the burned area. As soon as slough was complete I returned to the Burn Ointment and the cavity rapidly filled with healthy granulations covering in from the edges with epithelium. I had told the patient that skin grafting would be needed, but the new skin came so rapidly that I did not use it. Throughout his treatment he has been free from pain and has worked in comfort. There has been no perceptible odor. I cite this case as typical of our treatment and its results. " I treated 200 cases with paraffin and got good results, but not nearly so good as with the ointment. The paraffin does not prevent infection, does not deodorize, does not provide for the carrying away of the discharges, does not tend to sterilize the surrounding skin, but on the other hand keeps the wound discharges in close contact, per mitting them to become infected by the pus germs ever present in oil glands, sweat glands, and hair follicles, and so carrying infection to the burn. In about 25 per cent of cases I got pustules or furuncles around the burn. Yet paraffin has great advantages and has been an advance over the antiquated methods in vogue before the war or those used to-day by many otherwise good surgeons.*' From a communication recently received by the editor, the follow ing is quoted : No. 1. 157 QUERIES. " 1. For burns, either erythematous or vesicular, in which the epi dermis is not broken, I use picric acid. "2. (a) For second or third degree burns in which the epidermis is removed. I use the open-air treatment, with some means for main taining desiccation of the surface. "(b) If, however, infection supervenes and the crusts are inter fering with drainage, I saturate the individual with citric acid in ternally, and keep the parts wet with citrated solutions until the in fection is overcome. I then revert to the dry treatment (2 a) or the pus dressing (3). "3. The tissues in the neighborhood of a burn always show, as you know, signs of damage from the heat, a condition similar to that produced by therapeutic thermo-coagulation, so that a prolonged period following the injury is occupied in repair of damage before definite healing processes start. " When the healing process is well under way, as shown by healthy granulations and advance epithelium, I use my old pus dressing— a sheet of rubber dam covering the whole granulated area. The theory of this dressing is: (1) It protects the granulations and tender epidermis from mechanical injury, (2) conserves all the exudate, which, in clean wounds, consists of nutritive and reparative mate rial, and (3) by the conservation of this exudate, the young, ' naked ' cells and capillaries are bathed in fluid which is not only nutritive but ideally adapted in chemical constitution, being far superior to any salt solution that we can concoct. " I speak at length of the theory of the ' pus dressing,' since the rationale of paraffin dressings is,I believe, identical. Consequently, I regard the healing period as the indication for paraffin, if it is to be used at all." The Bulletin woidd welcome the ideas of individual medical officers on the subject of the treatment of burns in order that it may present to its readers treatments which have been found to be effi cient. THE DIVISION OF PREVENTIVE MEDICINE. Lieutenant Commander K. F. Jones, Medical Corps, United States Navy, in charge. Notes on Preventive Medicine for Medical Officers, United States Navy. INSTRUCTIONS TO MEDICAL OFFICERS. THE VENEHEAL DISEASE PR0B1EH. By Pail Richmond, Jr., Ueutenant. Medical Corps, United States Navy. The problem of combating the venereal diseases lias not been Bolved either for the Navy or for civilian communities. Comprehen sive and well-defined plans are being carried out to reduce the harm ful effects of other communicable diseases but considerable difference of opinion exists as to the best method of procedure in directing activities aimed at minimizing the incidence of the venereal diseases. During the World War the liberal contributions of patriotic citizens and popular enthusiasm made it practical to carry out more extensive measures than had previously been possible. Resulting therefrom there was a widespread suppression of the old type of " restricted district" which has changed the outward aspect of commercialized prostitution. Another factor influencing the problem has been the advent of prohibition. It is, therefore, difficult to compare present conditions with pre-war standards. From 1910 until the beginning of the war there had been a gradual reduction in the annual admission rates for venereal disease in the naval service. By some, this diminution has been attributed to the more general use of medical prophylactic treatment, whereas other medical officers claim that improved conditions in seaport cities as well as more extensive instruction and warning of the men were the determining factors. This was true especially in those cities where restricted districts and other resorts of commercialized pros titution were closed. During the two years of the war the rates suddenly fell to not much more than half the pre-war rates. Undoubtedly this was due to many influences : the causes tabulated below are listed in what is believed to be the order of their importance : 1. Enlisted men of a higher type than in time of peace. 2. Improved social status of enlisted men. 159 160 Vol. XVII. THE VENEREA!, DISEASE PROBLEM. 3. Suppression of all forms of prostitution in the vicinity of naval establishments and in seaport cities in the United States. 4. Prohibition of alcoholic beverages for men in uniform. 5. Military activities occupying a greater portion of the men's time than normally. 6. Improved facilities for recreation and amusement. 7. More intensive instruction as to the nature and dangers of the venereal diseases. 8. Patriotism, with a desire to avoid sickness during war. Since the war the rates have again reached almost to the 1916 level and are about where they would have been if the pre-war rate of decline had continued uninterruptedly. Inasmuch as the low war rates were not destined to be lasting in spite of a continuance of as many activities aimed at reduction as was possible, the questions have been repeatedly asked: "What should be done in the future and what permanent policy should the Bureau of Medicine and Surgery adopt in regard to these diseases?" and "Should the propaganda against venereal disease be abandoned or should new lines of activi ties be sought?" Before undertaking to answer such questions an analysis of the possibilities of present methods will be attempted. Inasmuch as the type of the men enlisting in the naval service in time!- of peace is more dependent on conditions of industrial employ ment and wages in civil communities than on service inducements, it remains only for officers on recruiting duty to select the best men who present themselves for enlistment. Since this policy has always been carried out, it may be presumed that the best types of men available have been and will in the future be obtained, so that ef forts from within the service can not be expected to make any par ticular improvement in this factor. Suppression of prostitution can not be undertaken by the naval service. However, such organizations as the Interdepartmental So cial Hygiene Board, the American Social Hygiene Association, and many local agencies are active in this field and have gone, far toward eliminating open prostitution in the United States. Women's po litical clubs are especially interested in this matter and are able to exert so much influence on mayors of cities, city and State boards of health, and police officials that few cities will again tolerate open prostitution. As a result of these activities, prostitution in the United States is rapidly assuming a clandestine form and, as active suppression continues, women of this character will be more and more difficult for men in the naval service to find. This has already been reported to be an important factor in reducing exposures in San Diego, Calif., where strenuous measures were employed to sup press prostitution. On the other hand, medical officers of ships re No. 1. 161 THE VEXEREAL, DISEASE PROBLEM. port that the exposure rate increases markedly when liberty is given in European or South American ports where prostitution is unre stricted. The active suppression of prostitution by municipal po lice authorities promises more in the way of reducing the incidence of venereal disease in the naval service than any other available measures. The venereal rate for military forces in the United States- should gradually improve as the practice of prostitution becomes more precarious. While many men will continue to Hud prostitutes in every large city, solicitation by the women will cease to be a con siderable factor. However, many men, especially those recently en listed and those whose sexual habits are irregular, will often be dis appointed in their search. Medical officers may occasionally render assistance to the local authorities by reporting foci of infection. The commanding officer by bringing pressure to bear on those in po litical power can aid in improving conditions. But, in the main, the Navy can not take an active part in solving this phase of the problem. -Nation-wide prohibition by reducing the amount of drinking is thought to have reduced the number of exposures to venereal disease. Many men are restrained while sober, but when intoxicated tend to seek out and associate with prostitutes. Medical officers on ships visiting foreign ports almost invariably mention drunkenness as a factor in increasing the number of venereal infections. Men under the influence of alcohol are notably careless concerning exposure and prophylactic treatment. The facilities for amusement, recreation, and athletics are recog nized as of great importance in reducing exposure to venereal disease. Inasmuch as the Morale Division of the Bureau of Navigation has funds with which to aid ships and stations, there is no reason why every ship and station should not have adequate amusements, etc., for >ts complement, when the officers take an active interest. Medical officers, in general, encourage athletics and other recreations among the men, as such activities have a beneficial effect on the body and thus diminishes all forms of physical disability. Although indirect this K one of the best methods of reducing the incidence of the venereal diseases especially since the war, when the men have more spare time and less engrossing duties. Its preventive value is believed to be in direct proportion to the character of the men, however, for some types of individuals will not be restrained to any appreciable extent. In the matter of instructing the men as to the nature of venereal disease and warning them as to the dangers of such diseases, the medical officer has definite obligations and should have a broad view °f the problem in order that he may not be discouraged if his efforts are often apparently futile. It is important that those phases most likely to have a lasting beneficial effect, however small, be emphasized, out fallacies which lead to opinions which can not be defended and 162 Vol. XVII. THE VENEREAL DISEASE PROBLEM. are contrary to the policies of the Navy Department must be avoided. The first consideration of educational measures aimed at the preven tion of venereal disease is the prevention of promiscuous sexual rela tions. The number of cases of venereal disease will bear a definite ratio to the number of exposures, i. e., after all other factors have reached the best possible efficiency. From a study of the Forms A from all ships and stations for a period of a year and a half, it appears that many medical officers give this phase of the problem little or no consideration, but concentrate their efforts on instructing the men how to use prophylaxis. Those having tried to reduce the number of exposures by instructing and warning the men of the dangers of venereal disease are divided as to whether any reduction has resulted. A few report that " much good was accomplished," others state that " it is believed that the pamphlets, posters, and lec turers do good." A great many more medical officers state that " the men continue to expose themselves in spite of intensive instruction as to the nature and danger of the venereal diseases, both by lectures and the distribution of the literature provided." Although the actual restraining power of such propaganda can not be measured, some men are known to be influenced thereby. Whether such instruction will be of any avail is believed to be entirely due to the individual man's moral viewpoint. The group of men who believe that promiscuous sexual relations is morally wrong in the same way that theft, lying, and other forms of dishonesty are con sidered wrong can, it is believed, be dissuaded, in great part, from what they consider lapses of morality. The number of exposures for this class can thus be greatly reduced. However, similar propa ganda is of no avail for that group who regard promiscuous sexual intercourse as a matter for individual choice, in the same way that the use of alcohol is usually considered, and who do not attach any moral stigma to those practicing such irregular sexual relations. The exposure rate may, nevertheless, be reduced in this class by caution ing the men to avoid intercourse with prostitut«s, who are practically all diseased. Opinions on this subject are usually fixed before men enter the service; consequently the influences of later environment and teach ings to change the viewpoint are of no avail, except in the occasional instance. The lack of success experienced by medical officers who have given the propaganda a thorough trial is attributed mainly to the relatively small number of men in the first group, as well as to the fact that such instruction may have been given at a time when oppor tunities for sexual relations were especially numerous and attractive. For instance, this seemed to be true on the U. S. S. Utah in Mediter ranean waters where the monthly exposure rate exceeded the number of the complement. Certain variations in exposure rates must be due No. 1. 163 THE VENEREAL DISEASE PROBLEM. to other factors also. For example, in case of the U. S. S. KUtery and the U. 8. S. Gulf port, which regularly visit practically the same West Indian ports, each medical officer states on Forms A that he instructs and warns the men of the dangers of venereal disease. For the last quarter of 1921 the U. S. S. Gulf port, with an average com plement of 92, reported 2,746 exposures, whereas the U. S. S. Kittery, with an average complement of 121, reported only 191 exposures for the same period. Such variations in the exposure rates, where other factors appear to be the same, can possibly be attributed to the example set by cer tain men among the crew who, by their conversation and conduct, more than neutralize any beneficial effect produced by educational measures. Such environmental influences induce many men to seek sexual gratification much more frequently than the}- would otherwise be inclined to do. This may also be a factor on large ships and shore stations among any particular group of associated men. The writer had occasion to observe such an example among a group of Hospital Corps men. following the arrival of a pharmacist's mate whose sexual habits were unusually irregular. Although transfer of this man to other duty did not immediately reduce the rate of exposure to aver age, a much more salubrious character of conversation immediately prevailed among the corps men. Unfortunately, recruits get most of their information or misinformation from conversation with other enlisted men " between decks." For this reason is it to be wondered that an occasional talk by the medical officer, however forceful, can not displace the effect of the continual reiteration of fallacious statements? Fear of disease is rapidly dissipated when an ''old timer" tells of his "career" and appears none the worse. As these conditions can not easily be changed, those carrying out ed ucational measures will have to be contented with scant evidence of improved rates for venereal disease. Recently a case of syphilophobia was reported to the Navy Department. From this it can be seen that our appeal to the fear of disease may do harm in some instances. Instruction as to the value and use of the new form of medical pro phylactic treatment must continue to form a part of the educational program. The percentage of infections following any form of pro phylactic treatment in a large group of cases is a good index of the relative value of such measures. Tabulation from Forms A of over 36.000 treatments given within one hour after exposure indicate that i.' per cent of infections may be considered the average rate of disease following early treatments by the methods applied during 1921. It is expected that the use of the prophylactic packet will reduce the ratio for all exposures to this minimum. Present methods are deemed both justifiable and adequate. New departures are not to be looked for. nor should existing measures be 164 Vol. XVII. THE VENEREAL DISEASE PROBLEM. despaired of. The venereal diseases result from human conduct which follows age-long customs. As social conditions generally improve the venereal diseases must diminish. In southeastern Europe a social collapse has produced the inevitable increase of these infections. In asmuch as the sexual impulse depends on a primitive instinct it can not be expected that promiscuous sexual relations will diminish faster than other forms of antisocial conduct. ABSTRACTS FHOM THE ANNUAL SANITARY REPORT, FLEET SURGEON, UNITED STATES ATLANTIC FLEET, FOR THE YEAR 1921. A review of the health statistics of the fleet for the year 1021 shows rliat, as far as sickness and injuries are concerned, the return to peace-time conditions lias been practically fulfilled. By this it is meant that the admission rates per 1,000 for diseases and injuries now approximate those rates that were in ex istence prior to the entry of the service into the World War. The returns avail able for examination indicate that there is improvement in nearly all classes of diseases and injury. In fact, it can be stated with more optimism than for many years that the health of the fleet during the year 1921 has been excellent. The admission rate for the entire Navy for the previous year was 07(3 per 1,000. For the 5-year period immediately preceding the war the mean rate was 464 per 1,000. Therefore, the annual rate of 398 per 1,000 for the year 1021 may be considered as reflecting very satisfactory health conditions in the fleet. Communicable diseases.—About 22 per cent of the total admissions to the sick list belong to those ailments classified as communicable. The kind and number of each of the communicable diseases that occurred in the tieet during the latter half year are as follows : Diseases and number of Admissions. Tonsillitis 665 Influenza '9 Cellulitis 71 Abscess (all) 39 Pneumonia (all) 25 German measles 22 Fever, unknown cause 21 Furunculosis 18 Malaria 17 Chickenpox 16 Measles 13 Tuberculosis (all) 11 Mumps 8 Rheumatism (all) 6 Scarlet fever 4 Erysipelas 2 Diphtheria I Dysentery 1 Total 1.019 There were 605 admissions for tonsillitis, which amounts to about two-thirds of the total number of admissions for these communicable diseases. Next in importance to tonsillitis is that group made up of those diseases caused by the pus-forming organisms ; that is, cellulitis, abscess, and furunculosis. Tonsil litis and the latter group have a total of 803 admissions, or about 80 per cent of the entire number of admissions for the diseases of tins class. It is singu lar that miliaria, measles, mumps, chickenpox, and other similar diseases have such low admission rates. Unfortunately, the two diseases most menac ing to life, pneumonia and tuberculosis, are represented by a considerable number of admissions. No. 1. 165 THE VEXEREAL DISEASE PROBLEM. The above table shows that tonsillitis anil diseases of the pus-forming or- pmisnis are the principal contributors to this class of communicable diseases and that if it were possible to control these contusions a relatively large amount of sickness would be avoided. An explanation as to the reason for the predominance of these two diseases can not readily be offered. It is prob able that a predominance of tonsillitis and diseases of the pus-forming organ isms is due to some defect in ship sanitation. Unfortunately, no definite state ment to this effect can be made. But whenever the admission rate for one or both of these diseases is unusually high, experience indicates that the condi tion of the sculleries, drinking fountains, and other similar sanitary factors should be carefully examined with the view of finding the probable cause of the increased incidence. Smallpox and typhoid fever. —During the latter half of the year there was no admission for smallpox or typhoid fever. Two isolated cases of modified smallpox occurred in the first half of the year. These two cases were handled with a minimum of inconvenience to the fleet. It is believed that the Atlantic Fleet is now fully protected against typhoid fever and smallpox. If either of thes»> diseases appear, it is quite certain to be in a mild or modified form. Therefore, it is improbable that the health of any persons in the fleet will be jeopardized by their contracting smallpox or typhoid fever, or that the move ment of the fleet, or any ship of the fleet, will be restricted on account of the appearance of either of these diseases. Fatalities. —A total of 29 deaths occurred among the personnel of the fleet . during the year. Of these, 8 were due to natural causes and 21 to external violence. Of those due to disease. 3 were caused by pneumonia, 3 by inflam matory brain affections, and 1 each was due to acute peritonitis and dilatation of the stomach. The following is a summary of the 21 fatal accidents: Drowning " Fell overboard tone unwitnessed) 3 Swimming (one unwitnessed) 3 Capsizing of canoe (unwitnessed) 1 Suicide (unwitnessed) * Fell overboard on watch (unwitnessed) 1 Airplane accidents 3 Crash 2 Caught by revolving propeller 1 Street accidents Trolley car 1 Fell down street stairs 1 Coaling, drawn into winch * Engine room, bursting steam pipe 1 Asphyxiation, working in confined space (unwitnessed) 1 Drug poisoning, drug addict 1 Homicide, unwitnessed Fall on board, unwitnessed Jumped in front of train, suicide 1 21 It is seen from the above that drowning as a cause of death leads all other causes. It is natural to expect that the hazard of drowning is greatest In a seagoing occupation. Consequently, there are many recognized precautious that are constantly being enforced. But in spite of all these, drowning accidents 166 Vol. XVII. THE VENEREAL DISEASE PROBLEM. occur. Accidents resulting from swimming and men falling overboard account for the greatest number of drownings and these are difficult to guard against. Of course, no man should be permitted to enter a swimming pool when no other person is present, and the breaking of this rule seems to have accounted for one death. Each year a number of deaths occur among swimming parties. The unnoticed disappearance of a member of such a party is a frequent occur rence. To prevent this a plan has been suggested by which the members of a swimming party pair off before going into the water, each one of a pair to be responsible for the safety of the other. Under such a plan the occurrence of an unnoticed disappearance of a man would seem quite improbable. The fleet regulations require that care be taken for the safety of the lives of the personnel, in particular, when new activities are being carried on, and. also when conducting activities known to be hazardous. Furthermore, there is an order that when an accident resulting in a fatality occurs a copy of the board of inquest or investigation, as the case may be, shall be furnished the commander in chief. These reports are carefully considered to ascertain if blame or responsibility for injury to personnel can be attached to any person or persons, and also to determine if it is possible to institute any safe guarding or precautionary measures against the recurrence of the same or a similar accident. Venereal diseases. —According to incomplete statistics collected within the fleet during the past year it appears thnt the venereal situation for 1921 will . be relatively good. Calculations for the last half of 1921 give an annual rate of 102 per 1,000. The rate for the entire Navy for the previous year was 126 per 1.000. and for the year before that 111 per 1,000. The last half of the present year does not include the period during which the fleet is at Guantanamo, when a comparatively small number of infections occurs. It does not seem improbable that when a complete calculation is made the venereal admission rate of the Atlantic Fleet for 1921 will be found to compare favorably with the low rates of the war-time years. The last annual report of the Surgeon General of the Navy notes that " in general * * * the rates for the venereal diseases were lower for shore stations than for the entire Navy." It appears that the reverse is true for the Atlantic Fleet for 1921.1 The rate of 102 per 1,000 is small for a force afloat. It would be worth while in the interest of further prevention to deter mine, if possible, the reason for this reduced venereal rate. This year medical prophylaxis and educational propaganda were carried out with about the same amount of zeal as during previous years. The presence of a less changing personnel might be assigned as a cause for fewer communicable diseases, but this condition would appear to be practically without effect to reduce the number of venereal diseases. It is probable that the favorable results of 1921 followed some definite cause or causes. In attempting to annlyze the venereal situation it should be taken into consideration that the enlisted personnel nowadays, in consequence of various propaganda that have been forced upon it, is better informed concerning venereal matters than formerly. Also, vice conditions on shore have changed. In the past the sailor was often exploited by commercialized vice, which Is seldom the case any more. When the present-day sailor encounters vice on shore it is probable that he has sought it instead of the vice having sought him. In other words, the sophistication concerning venereal matters which 1 Provisional statistics In the Bureau of Medicine and Surgery do not bear out this statement. The admission rate for venereal diseases for 1921 for shore stations was 73 per 1,000 per annum. No. 1. 167 THE VENEREAL DISEASE PROBLEM. ihf enlisted mau now possesses has resulted more in his avoiding the conse quences of his moral transgressions than it lias in bolstering up his better inclinations. The administering of prophylactic treatments on board ship has many ob jectionable features. Among them, and not the least of them, is the attending publicity, which tends to dull the moral sensibility of th>> applicant for treat ment. The fact that the taking of medical prophylaxis is considered a require ment after an Illicit exposure has resulted in a great many untrue statements being made to the attendant in charge, and, consequently, considerable erroneous data are now entered in the prophylactic records. Many men are providing themselves with their own methods of prevention. If the method fails, or If the individual believes it to have failed, he takes a treatment on board ship, thereby having his name recorded and giving any number that happens to come into his mind as the number of hours after exposure. It is probable that this practice, more than anything else, causes the high percentages of failures and, without doubt, the erroneous percentages that are now being obtained on Form A. A summary of the Forms A from the fleet for six months, representing an average complement of 23,414, is as follows : Hour. 1 2 3 4 5 6 6 to 12 . . Over 12. Number of treatments. 3, 952 4, 403 2,851 2,151 1,411 1,253 2,073 837 Diseases. 66 110 106 87 r,i 64 126 68 18, 931 088 Per cent. L6 2.4 3. 7 4.0 4.3 5.1 6.0 8.1 3.6 It is seen in the above table that the percentages of failures for each hour after exposure are unusually high. The inference is that medical prophylaxis In the fleet has been particularly unsuccessful. It seems inconsistent to have among the same personnel a high rate of infection following prophylaxis and at the same time the low rate of admission of 102 per 1,000 per annum previously noted. This phenomenon may be explained by the suggestion already advanced ; that Is, that the enlisted man, through greater knowledge of the subject, is seeking In his own way to avoid venereal disease. Some men are avoiding disease by comparative or absolute continence, while others resort to various mechanical or medicinal means of prevention. The result is that, the ship's prophylaxis is used to cover up errors or neglect, thereby causing a considerable distortion of the compiled results. On the other hand, there is a better appre ciation on the part of the crews at large of the dangers of illicit intercourse. This is associated with a more intelligent effort to avoid or prevent infection, which is apparently the cause of the low rate per 1,000. 168 HEALTH CONDITIONS OF THE NAVY. Vol. XVII. HEALTH CONDITIONS 07 THE NAVY. The iinnual admission rate for all causes, entire Navy, for the five-week period ending June 10 was 488 per 1,000 per annum, as compared with a rate of 506 per 1,000 per annum for the previous four-week period ending: May G. The progressive average rate for the entire Navy on June 10 was 624 per 1,000 per annum, which is considerably lower than it has been at any time during the year or. in fact, at a similar time for the past four years. There has been a gradual decline in the annual admission rate for diseases only since about the 1st of March; the admission rate for the five-week period ending June 10 was 422 per 1,000 per annum. The morbidity rate for accidents and injuries for the week ending June 10 was higher than it has been at any time during the past two years, the rate being 1)2 per 1,000 per annum. The average rate for accidents and injuries for the five-week period ending June 10 was 66 per 1,000 per annum. The morbidity rate for communicable diseases continues to be very low. The following table shows the rates for certain com municable diseases for May, 1922, as compared with the average rate for this month for the previous four years: Annual admution rate* per 1,000 for attain rommunieabU diseases, current month of May, 1922, in comparison with the mtan annual admission rates, month of Map, for the.four-year period 1918-1921, inclusive. March, March, 191S-1B21. | 1922. Cerebrospinal fever 0.32 0 Diphtheria , s- 29 , ^20 German measles ■W 2. 44 Influenza 4 1 I 12. P0 Malaria 5.98 | 12.89 Measles &■79 2.83 Mumps 15.76 1.27 Pneumonia -.8.? Scarlet fever 2.40 .20 Smallpox ■ Jjj ° Tuberculosis 345 X* Typhoid fever , •0:5 0 It will be noted that the morbidity rates for German measles, malaria, and tuberculosis are higher than usual. German measles has been reported from several battleships of the fleet; this, no doubt, accounts for the high rate for this disease. Malaria has not only been prevalent among marines stationed on foreign shore service, but also at Quantico, where there were 31 cases admitted during the past month. No. 1. 169 HEALTH CONDITIONS OF THE NAVY. The morbidity rate for the venereal diseases has continued to de cline during the past five-week period, the progressive average now bein<r 108 per l.()00 per annum as compared with 112 per 1.000 per annum for the four- week period ending May 6. The mortality rate for the entire Navy is not only much lower than for a previous five-year norm, but is also lower than for the year 1921 ; the progressive average rate for 1922 now being 1.83 per 1.000 per annum, as compared with 3.20 per 1,000 per annum for 1921 and the five-year norm rate of 5.40 per 1,000 per annum. Health conditions at training stations have been excellent, few cases of communicable diseases having been reported. DIPHTHERIA IMMUNIZATION IN ADULTS. By J. r. Leake, Surgeon, L". S. Public Ilenlth Service, in charge of biologic products, Hygienic Laboratory. Questions are frequently asked as to the advisability of immuniz ing adults against diphtheria by the use of toxin-antitoxin mixture, a procedure which gives promise of definite reduction in diphtheria mortality among children. The case in regard to adults is very different from the use of the preventive in the younger age groups. For one thing, diphtheria is not the serious problem which it is in children. Among males in the registration area of the United States for 1919, the last year for which the mortality statistics are available, 60 per cent of the deaths from diphtheria and croup were before the age of 5. 88 per cent before the age of 10, 94 per cent before the age of 15, while only 5 per cent occurred in the age group 15 to 44. In the ages 2 to 9. which are those chiefly concerned for diphtheria prophylaxis, 13 per cent of all deaths were due to diphtheria, a proportion of 1 death out of every 8, while at the ages of 15 to 29, 1 in every 300, and at the ages of 15 to 44, only 1 in every 600 was caused by diphtheria. The diphtheria death rate per 100,000 below the age of 15 was 45, only 2 at 15 to 29 years, and 1 per 100,000 at 30 to 44 years. The year 1919, for which the figures are given above, was not a year of exceptionally low diphtheria incidence in the registration area, and it is not to be expected that in the future the deaths in the Savy, for example, will frequently exceed the high point of 14 per 100,000 reached for the year 1920. For the six years before the World War the death rate was continuously below 2. There is no considerable evidence as to the permanency of diphtheria immunization in adults, but it is reasonable to suppose that persons who have reached adult years without being able to 170 Vol. XVII. HEALTH CONDITIONS OF THE NAVY. maintain the degree of immunity which is usual at that time may not only be difficult to immunize, requiring more injections than do children, but also be uncertain in their hold on the immunity thus produced, losing it more rapidly than normal individuals. The presence of a larger proportion of pseudoreactions to the Schick test in adults than in children corresponds to the observed fact that the injections of broth cause less discomfort in children than in older persons. For all these reasons — the slighter need, the more uncertain value, and the greater trouble to the persons receiving the treatment—the testing and immunizing of adults against diphtheria is on a different footing from the same procedure in the case of children, and is to be advised as a routine for adults, at present, only in the case of individuals who are likely to suffer a considerable and prolonged ex posure to diphtheria. FRESH-WATER FISH AS CONSUMERS OF MOSQUITOES. The following was abstracted from an article entitled, " Notes on the use of fresh-water fish as consumers of mosquito larvae in containers used in the home," by N. E. Connor, published in the American Journal of Public Health, March, 1922: With the exception of metal tanks, for which no satisfactory fish has yet been discovered, fish can be employed as larva? destroyers in all classes of reasonably large water-storing receptacles. The four factors needed to insure their effectiveness are— 1. That the fish be in a sound condition when placed in the con tainer. 2. That the water in the container receive sufficient air to support fish life. 3. That the container be protected from the sun. 4. That there be placed at the bottom of the container, against the side, a cave-like arrangement beneath or behind which the fish can rest or can hide when frightened. A condensed milk can, a curved piece of earthenware, or an elevated stone device made by resting a flat stone on two other stones will suffice. As a general rule, all fresh-water fish that can adapt themselves to the confines of containers will consume mosquito larvae. Species of top minnow, carp, pike, mullet, and perch, and also shrimp and small turtles, have been used with excellent results. Unfortunately, some species of fish which consume great quantities of mosquito larvae are unable to adjust themselves to the narrow limits of the average container. Larva-eating fish may be roughly divided into " top feeders " and " bottom feeders.'' Top-feeding fish are most Xo. 1. 171 HEALTH CONDITIONS OF THE NAVY. effective where there is plenty of sunlight. They seem unable to locate larvae in dark containers. The bottom-feeding fish have, how ever, given the best results. One fish is enough for a cistern, barrel, or well. PROMOTION OF BETTER HEALTH IN THE NAVY. Dr. F. G. Barr. medical director, National Cash Register Co., Dayton, Ohio, in an article appearing in the National Safety News, June, 1922, states that— "The selling of health must begin in the medical department, for so long as the doctors, nurses, dentists, and clerks do not act as sales men and saleswomen meager results must be expected. " The medical force at the National Cash Register factory at Day ton consists of three doctors, two dentists, three nurses, two treat ment-room men (physiotherapy), one masseuse, and three clerks. To insure success in the work among the employees, we believe that every member of the staff should have the following qualifications : "1. A vision of the value of preventive medicine. "2. Adaptability. Patients ranging from the foundryman or trucker to the president of the company must receive medical care which will lead them to have confidence in the medical department. The president and other executives must not feel that it is merely a department for the laborers, nor must the trucker or foundryman feel that the department is only interested in the executives and "white-collar men." " 3. Interest in the employees' troubles, no matter how trivial they may seem from the medical viewpoint. A curt, ill-considered answer to one of these trifling questions is often enough to make the em ployee a confirmed " knocker " so far as the medical department is concerned. " 4. The ability to sell health as a factor in production. " 'k Honesty. There is no place in industry for the physician or nurse who merely asks the patient a few questions, looks at his tongue, fills in a report, and sends him back to work. A doctor should be discharged upon the second offense of this kind, for thor oughness is one of the first essentials of success in industrial hygiene. "6. The medical department employee must have his heart in the work." Inasmuch as the Navy, in many ways, is very similar to a large industrial organization, it seems that the qualifications which have been laid down by Doctor Barr for the staff of an industrial concern, might be applicable to the personnel of the Medical Department of the Navy. In this connection it will be of interest to know that the 103390—22 12 172 Vol. XVII. HEALTH CONDITIONS OF THE NAVY. average time lost by the employee of the National Cash Eegister Co. was 11.5 hours per year, whereas the average time lost by all indus trial workers in the United States on account of sickness is variously estimated from six to nine days per year per employee. In other words, a saving of more than 75 per cent has been accomplished as a result of Doctor Barr's most excellent work with the National Cash Register Co., which, no doubt, is largely due to the efficiency of his organization. ABSTRACTS FROM THE ANNUAL SANITARY REPORT. DESTROYER SQUADRONS, U. S. ATLANTIC FLEET. FOR THE YEAR 1921. The most Interesting fenture of epidemiological interest hns been the venereal situation and the influence thereon of our two buses. For example, in February, 1921, representing the middle of the stay of the destroyer squadron at Charles ton, it was reported in '• Notes on Preventive Medicine " that the mean rate for venereal disease from destroyers, Atlantic Fleet, was 225 per 1,000 per annum, whereas in August. 1921. representing the middle of the stay at New port, R. I., the mean rate was 103 per 1.000 per annum. That this is not merely fortuitous is confirmed by the increased rates reported in November and De cember, when vessels were again at Charleston, S. C. In the United States Public Health Reports for December 16. 192L it is noted that the physicians of the State of South Carolina reported 11,826 cases of vene real diseases, including 5,719 gonorrhea and 5.508 syphilis, between July 1. 1919. and June 30. 1920. The Rhode Island physicians reported 1,224 total cases, of which 485 were gonorrhea and 732 syphilis. If the reported syphilis were used ns au index, it would npj>ear that South Carolina, with two and one-half times the population of Rhode Island, was reporting about three times as much syphilis per capita. In the " Report of the Percentage In the Second Million of Drafted Men Found Infected with Venereal Disease" (war statistics). South Carolina stood fourth, with 13.1 per cent, and Rhode Island was thirty-fifth, with 2.8 per cent. The average for the whole United States was 5.7 per cent. We expect, then, to record a higher morbidity rate for venereal diseases when the destroyer squadrons are in Charleston than is recorded at Newport. This is borne out by the actual returns. The situation in Charleston and its adverse effect on the personnel is com mented upon in several of the Annual Sanitary Reports for 1921 submitted by the medical officers attached to this force. Charleston, on the other hand, recognizing the desirability of having this force make this port a permanent base, has begun a clean-up eompalgn. The first step was taken during the summer before the destroyers returned. The white vice district was closed. The local follow-up efforts have not been as energetic nor as effective as the first steps. Prostitution is still rampant. Real improvement of vice conditions probably will be slow in becoming manifest. This is an inherent defect in our present political conscience. The clean-up idea is merely dormant now and may at some future date eventually carry Its point. Economic pressure has been the factor most useful In getting results. All local effort has been entirely on the initiative of the residents themselves. No. 1. 173 HEALTH CONDITIONS OF THE NAVY. but the Navy lias cooperated fully in every measure tending to improve condi tions. The former practice of maintaining a first-aid and prophylactic station on the Government landings at Charleston and at Newport has been continued. ABSTRACTS FROM THE ANNUAL SANITARY RETORT, U. S. S. "PENN SYLVANIA," FOR THE YEAR 1921. During March, 1921. while anchored in Guantanamo Bay, Cuba, an epidemic of acute bronchitis occurred aboard this vessel. There were approximately 100 cases. In order to cope with the epidemic about 50 per cent of the cases were transferred to the hospital ship Relief for treatment. The cause of the epidemic was undoubtedly due to infection with Pfeiffer bacillus. The infec tion was either airborne or carried through the agency of mess gear. The symptomatology common to all of the cases was a nonproductive cough, mild fever, tightness and constricted sensation of chest, headache, and moderate prostration. There were seven battleships at Guantanamo during the period of tliis epidemic, but five of them had no cases. A similar epidemic occurred at this time on the U. S. S. North Dakota. Acute follicular tonsillitis has been prevalent during the year. This disease lias not appeared in epidemic form, but has been endemic, there being always one or two cases of tonsillitis reported on the morning report of sick. The cnuse of this disease is believed to be due in large part to nonsterllization of the mess gear. The condition of the decks—worn-out linoleum with residual water beneath —has probably been a contributing factor at times when repair was delayed. The etiology of these cases has been carefully studied, and certain ones have been found to closely follow exposure to wet and cold weather. Defects in the ventilating system may also contribute to the etiology of this disease. Throat infections by Vincent's organism were common while this vessel was "n the Atlantic coast, but since a change of station occurred in September, 1921, to the Pacific coast, Vincent's angina has rarely occurred. The influenza cases occurring during the latter part of 1921 have been char acterized by marked selective action for the nervous system. The symptoms were mild fever, with cough or pulmonary symptoms; mild rhinitis; severe neuralgias, usually of head, face, or neck ; and prostration disproportlonal to the mildness of the other symptoms. Recovery from attacks has been compara tively rapid. The absence of certain diseases which were present in 1920 is noted with satis faction. There has been no case of cerebrospinal fever, typhoid fever, or lobar pneumonia. Three cases of encephalitis lethargtca occurred during January, 1921. Two of these cases terminated fatally on board the U. S. S. Relief. Several cases of subtertian malarial fever occurred among members of the marine expeditionary force, which was aboard this ship while at Panama in Anzust. 1921. These cases attracted interest, as it was definitely found that the infection did not occur in the Tropics. The cases occurred too soon after arrival at the Isthmus of Panama to permit of the belief that the infection had hec-n acquired there. As these men had been stationed at Quantico, Va.. prior to embarkation, and as they had never lived in the Tropics previously, it is as sumed that they were infected while serving at Quantico. 174 Vol. XVII. health conditions of the navy. Preventive measures against epidemic diseases have been carried out aboard ship in routine manner. The sanitary drinking cups are burned out with a gasoline torch daily. Linoleum decks have been washed down with cresol solution each morning. Air-bedding orders have been made to include officers' bedding. Divisional officers and crew have been instructed by medical officers regarding venereal diseases and the prophylaxis and hygiene relating thereto. Instructions regarding typhoid prophylaxis and vaccination against smallpox nave 'jeen carried out scrupulously and energetically. The principles of venereal prophylaxis have been rigidly enforced. Disciplinary measures for failure to take venereal prophylaxis have been very rarely used. Ventilation. —There has been no change made in the structural details of the ship's ventilating system since certain recommendations were made in the sanitary report from this vessel for the year 1920. The deficiencies of the supply system reported, upon at that time are in no way improved and are found to be worse on the third deck and in the storerooms below. Late in 1921 the main air ducts leading forward and aft from the forward air-intake vents were examined and the following conditions found : The walls of the ducts were entirely covered with impacted black soot to a thickness of 2 to 3 inches. In other words, the lumen of the main air ducts was reduced from 2 to 3 inches at the place of their largest circumference and their air- carrying capacity was proportionately reduced and choked by the accumulation of dirt and soot on their walls. The insanitary aspect of this condition is most obvious. So much soot is blown through the terminal louvers that it becomes necessary in many com partments to filter the air through gauze veils tied over the louvers. While this plan acts to keep out dust and dirt, it also reacts to diminish the air supply. The presence of dirt at each end of a ventilating system indicates that the entire system Is air choked and in consequence is incapable of functioning to full capacity. It Is natural that the smaller ducts should be most affected by this condition, and consequently it is in the storerooms that the air supply is most deficient. The dangers from insufficiently ventilated storerooms have recently been made the subject of a special bulletin sent out by the Bureau of Medicine and Surgery. Vcmrrnl dixenxcx. —Preventive measures against venereal infections have been carried out through the agency of warning posters, venereal prophylaxis, and instruction to the divisional officers and crew by the medical officers. On such occasions emphasis has been placed on instructions that eontinency is the sure preventive against venereal diseases. Venereal prophylaxis has been given as a matter of routine to those men who admit having risked infection. The system employed has been efficacious and has undoubtedly served to prevent many cases of disease. During the period of February 1 to 4, while at Callao, Peru, venereal prophylactic treat ment was given to 737 men. Diseases resulting from these exposures were confined to 11 cases of gonococcus infection of urethra and two' cases of chancroid. During the period from February 10. 1921, to February 22. 1921, while at Balboa, Canal Zone, 472 prophylactic treatments were given, with no venereal diseases resulting from these exposures. Conditions on the Pacific coast are found to be less favorable for the effective ness of venereal prophylaxis, and the admission rate has been high during the time that the ship has been based at San Pedro. Calif. No. 1. 175 HEALTH CONDITIONS OF THE NAVY. ABSTRACTS FROM THK ANNUAL SANITARY REPOR T, UNITED STATES SUBMARINE BASE. NAVAL OPERATING BASE, HAMPTON ROADS, V.\.. FUR THE YEAR 1921. Living conditions on a submarine are apparently far from healthful. In ventilating a submarine during surface runs there are many fluctuations in the atmospheric conditions within the boat, the rapid changes of air causing drafts of cold air to enter a warmed space: on the other hand, during sub merged runs or runs in heavy weather, when hatches are closed, there is com plete stagnation of air in an overcrowded space. The older type submarine is poorly heated and when lying in cool water the temperature within the boat is always cold and damp. The air is saturated with water, and as a result the bedding and spare clothing become soggy, cold, and damp. Facilities for bathing are much curtailed. Men are living closely crowded together and have no opportunity for exercise other than what their duties in this small space provide. It would seem that living under conditions of this kind would be conducive to the development of respiratory and rheumatic affections of various kinds, but experience in this division of submarines shows that men serving on submarines are not more subject to such diseases than men doing duty at Hie Hampton Roads Base. Most of the men are young, only a few of the chief l*tty officers being in the neighborhood of middle' age. This Is undoubtedly another example of how young men, kept in good physical condition, may be made to stand adverse conditions and is no argument whatever for minimizing 'lie disadvantages nnd discomforts of such living conditions. ABSTRACTS FROM THE ANNUAL SANITARY REPORT. U. S. S. " MONOCACY," FOR THE YEAR 1921. The incidence of venereal disease for the year was very high, there being admitted to the sick list 13 cases of gonococcus infection of the urethra, 13 '•ases of chancroid, and 3 cases of syphilis. Thirteen of these 29 cases occurred during the month of June. It is believed that the entire crew appreciates the seriousness of the venereal diseases, for they have been given frequent indi vidual instruction as to consequences of such diseases. A prophylactic station lias always been accessible, and the men have been Instructed in the proper method of taking prophylaxis. After having been in the upper part of the Yangtze River for the entire winter, the Monocacy returned to Shanghai in June, where liberty was given freely to the men. The 13 cases of venereal disease for that month does not prove that the men had failed to receive the proper instructions :!iid warnings against the dangers of venereal disease, but rather that they ■iail disregarded them. Shanghai is overrun with houses of prostitution; the number of Chinese, Japanese, Russian, and European prostitutes is very high and no attempt is made to cleanse the city of this terrible vice. The " houses " usually frequented by sailors are along the water fronts. In localities where filth and disease are prominent and where the men have free and easy access lo an unlimited quantity of intoxicating liquors. The latter, I believe, is in a large measure responsible for the high incidence of venereal disease on the Asiatic Station. Many men have told me that when they went ashore they "ere determined to abstain from illicit intercourse, but that after having con sumed " liquor " they did not realize what they were doing. Under the influ ence of intoxicating liquors they would thus become easy victims of this large army of prostitutes. 176 Vol. XVII. HEALTH CONDITIONS OF THE NAVY. In the smaller ports up the Yangtze River there are fewer prostitutes and no all-night liberty is granted, and, as a result, there Is a lower incidence of venereal disease. All these facts will explain why the venereal report for June was so very high. I believe that the number of cases of venereal disease would be greatly diminished if the Navy Department would return to its former cus tom of allowing the men to furnish themselves with prophylactic tubes such as the Royal Navy issues to their sailors. Certainly such a custom could not do any harm, for as long as houses of prostitution are tolerated and whisky is easily obtained men will respond to their sexual desires. The Yangtze River ports lack recreation centers and clubs; there is no mental diversion for the men when they go ashore, and there is nothing with which they can advan tageously occupy themselves. I am not attempting to uphold the men or offer any apologies for their misconduct; I am merely stating facts —facts of which all medical officers on this station are fully cognizant. INSTRUCTIONS TO MEDICAL OFFICERS. Circular letter. Serial No. 186-1922. WJCA : ESK 129733 ( 53 ) . Washington, D. C, 16 May, 1922. To : All naval hospitals. Subject: Occupational therapy for Veterans' Bureau patients In United States naval hospitals; quarterly reports concerning. Reference: (a) Bureau's circular letter, Serial No. 185-1922 of 6 May, 1922, No. 129733(43). 1. On May 1, 1922, the Bureau of Medicine aud Surgery, Navy Department, assumed entire charge of all personnel, equipment, and material used in con nection with occupational therapy and physiotherapy for Veterans' Bureau patients in United States naval hospitals. 2. In the future no reports or other information will be furnished by the occupational therapy personnel. These employees are employed by the Navy Department and have no further connection with the Veterans' Bureau. All reports, etc., must be forwarded by, and information furnished by, the com manding officers of the various hospitals. 3. On June 30, 1922, and at the end of each quarter thereafter, command ing officers will forward to the Bureau of Medicine and Surgery reports con cerning occupational therapy for Veterans' Bureau patients in the form and order indicated below and containing the following information : (a) Name, rate under civil service, date of appointment, and salary of each employee connected with occupational therapy for Veterans' Bureau patients. (6) List of courses taught Veterans' Bureau patients giving names of instructors or teachers in each course. (c) Hours spent by instructors in connection with occupational therapy. (i) Hours actually occupied in teaching and manner in which time is spent when not actually teaching. (e) Number of Veterans' Bureau patients availing themselves of courses In occupational therapy, giving number of patients and hours devoted to each subject. (0 Detailed report of duties performed by educational director. is) Report of duties performed by clerks and stenographers. Note. —In making reports, time spent by Veterans' Bureau patients in study outside classroom shall not be counted in with time actually under Instruction. A separate report of time devoted to study can. If practicable, be made. E. R. Stitt. Circular letter. Serial No. 187-1922. H\VS:MFD 130402 (53). Washington, D. C., May 17, 1922. To: All medical officers. Subject : Consultation service in roentgenologic interpretation. Reference : Manual for the Medical Department, section 3221. 1. The general adoption of celluloid films in roentgenology has made prac ticable an extension of the service rendered by the U. S. Naval Medical School for many years in the examination of pathological specimens. 177 178 Vol. XVII. INSTRUCTIONS TO MEDICAL, OFFICERS. 2. Any medical officer desiring to consult with a roentgenologist regarding tlie appearances in an X-ray iilni can obtain an opinion by forwarding the film or Alms in question addressed to the Commanding Officer, U. S. Naval Medical School, Washington, D. C, accompanied by a brief abstract of the clinical history of the case, and the following data written on each film : (ft) Name and rate of patient; (b) name of hospital, and (c) "right" or " left." 3. In cases of injury to a joint, and always in any affection of the knee, a corresponding plate of the unaffected side should be inclosed. X rays of fractures should be taken in two directions, as nearly perpendicular to each other as possible. In chest cases, take stereograms if available apparatus permits making them. 4. In order to comply with postal regulations, celluloid films are to be mailed in a metal container, sealed, and labeled " Inflammable." 5. Medical officers de'siring photomicrographs of tissues, blood, or bacterial preparations or photographs of gross specimens for use as illustrations are reminded that the school is prepared to undertake such work on request. E. R. Stitt. Circular letter. Serial No. 18S-1922. W.ICA : ESK 129733 ( 52 ) . Washing-ton. D. O., IU May, 1922. To: All naval hospitals. Subject : He Transportation for Veterans' Bureau patients upon discharge from I". S. naval hospitals. References: (a) Telegram from District Manager. I". S. Veterans' Bureau. At lanta. Ga.. to Commanding Officer. T". S. Naval Hospital. Pensacola, April IT. 1022. <b) Letter from Commanding Officer. IT. S. Naval Hospital, Pen- sacola. to District Manager, IT. S. Veterans' Bureau. Atlanta. Ga.. April 29, 1922. (c) letter from Director, V. S. Veterans' Bureau, MCG : ecr : 10 Hospital Section to the Surgeon (ieneral of the Navy. May 13. 1922. 1. For your Information and guidance the ((intents of the above reference's are hereby quoted : (o) " Rertrans Edwards (' eleven fifteen five three naught issue transporta tion to Cincinnati Ohio." (h) "The above-named man was this date discharged from further treatment at this hospital and has been furnished twenty-one meal and lodging requests in lieu of transportation to Cincinnati. Ohio, which was authorized by your telegram reference above." The following statement was signed by the man concerned: "I hereby waive transportation to Cincinnati. Ohio, and accept in lieu thereof meal and hnlging requests mentioned above." (r) "There are inclosed herewith copies of a telegram from the district man ager of the fifth district. Atlanta, Ga., to the Commanding Officer. Naval Hospi tal. Pensacola, Fla.. and a letter from the commanding officer. It will be noted that the commanding officer, presumably upon the request of the claimant, is sued in lieu of the transportation to Cincinnati, authorized by the district man ager's telegram. 21 meal and 5 lodging requests. The commanding officer, as noted above, presumably di'l this upon the request of the claimant. No. 1. 179 IXSTPiI'CTIOXS TO MKIHCAI, OFFICERS. "It will he noted that the claimant waived his transportation to Cincinnati and accepted in lieu thereof the meals and lodging request noted. This, of course, is contrary to the practices of the Veterans' Bureau, as it is felt that the transportation to the claimant's home is a privilege baaed on humanitarian con sideration and is not a vested right which the claimant may demand in cash or other valuable consideration. "It is therefore requested that you instruct the commanding officers of the different naval hospitals caring for Veterans' Bureau claimants that transpor tation requests are to be issued only for legitimate and actual intended travel and can not he exchanged either for cash or for other valuable consideration." E. R. Stitt. Circular letter. Serial No. 189-1922. WJCA : ESK 132687-0(54). Washington. D. C, 22 May. 1922. To: All naval hospitals. Subject : Occupational therapy for Veterans' Bureau patients In United States naval hospitals. —Red Cross personnel. Reference: (a) Bureau of Medicine and Surgery circular letter Serial No. 184-1922-WRJ-THC 132687-0(51) of May 2, 1922. 1. In order to simplify administrative control and reduce overhead expenses in connection with occupational therapy in naval hospitals, the Bureau of Medicine and Surgery has adopted the following policy in this connection : 2. Commanding officers will arrange the instruction of Veterans' Bureau patients in such a manner that all work in connection with the former term of occupational therapy (i. e., beadwork. basketwork, and any other branch which may have been included under the old terminology of occupational therapy) will be designated (assigned) to Red Cross personnel, and all other work such as that formerly Included under the term of prevocational train ing (i. e.. stenography, typewriting, English, reading, writing, bookkeeping, commercial subjects, agriculture, etc.) will be designated to civilians employed for that purpose. 3. In this way all naval and Veterans' Bureau patients will receive their instruction in branches included under the occupational therapy (old term) (par. 2) from the Red Cross personnel, and Veterans' Bureau patients only shall receive training and instruction in branches formerly included under prevocational (old term) (pnr. 2) from the civilian personnel supplied by this bureau for this particular work. It Is not the intention of the bureau to furnish prevocational training to naval personnel. 4. Red Cross personnel will request all necessary material and equipment necessary in connection with occupational therapy (old term) for Veterans' Bureau patients from the commanding officers of the naval hospitals, who will furnish the material and equipment in accordance with reference (a) ; that necessary for naval personnel will he obtained in the same manner as is now practiced by the Red Cross. 5. All articles made by Veterans' Bureau patients will be held pending legislation regarding their disposal, and information concerning this will be supplied in a subsequent circular letter. E. R. Stitt. 180 Vol. XVII. INSTRUCTIONS TO MEDICAL OFFICERS. Circular letter. WJCA : ESK 129733 ( 52 ) . Serial No. 190-1922. Washington. D. C, 22 May, 1922. To: All naval hospitals. Subject: The handling of records for patients of the United States Veterans' Bureau in United States naval hospitals. Reference: Letter from the Director United States Veterans' Bureau to the Surgeon General of the Navy, ML/EG: 6 of May 13, 1922. 1. For your information there is quoted herewith the contents of the above reference : " In order to facilitate the handling of records for patients of the United States Veterans' Bureau, it is desirable to extend to other Government insti tutions certain procedure now followed in United States veterans' and United States marine hospitals. You are therefore respectfully requested to Issue orders to all United States Navy hospitals treating patients of the United States Veterans' Bureau as follows : " THE ASSIGNMENT OF REGISTER NUMBERS. "a. Every patient of the United States Veterans* Bureau should receive a register number upon admission to the hospital. This number should be retained by the patient until his discharge, and it should appear on all records of the patient during the period of hospitalization, particularly admission ami disposition cards, Form 1971-F. " 6. The register numbers for United States Veterans' Bureau patients should be assigned consecutively from one distinct series for each hospital. " c. Only one number should be assigned to each patient during one con tinuous hospitalization. "d. A new register number should be assigned upon readmission of the patient to the hospital. " e. The series of register numbers for United States Veterans' Bureau pa tients should start with 1 and be carried on indefinitely until further advised. " In order to start this system of register numbers all patients of the United States Veterans' Bureau remaining in the hospital on June 1, 1922, will be numbered from 1 up. The first new patient admitted on June 1, 1922, will be assigned the next highest number. For instance, if on June 1 there are SS patients in the hospital, numbers 1 to 88 will be assigned to these patients. Number 89 will he assigned to the first new patient. "A list of patients in the hospital on June 1, 1922. giving name, register number, date of admission, and diagnosis, should be sent in to the Director United States Veterans' Bureau, Washington, D. C, attention Medical Sta tistics Section. "TRANSMISSION OF REPORT CARDS. FORM 1U71-F. "Two copies of report cards, Form 1971-F, will be executed upon admission and discharge of each patient in addition to copy retained at the hospital. One of the copies will be forwarded to the manager of the district where the hospital is located and one direct to the United States Veterans' Bureau. Wash ington, D. C. Cards to the Director United States Veterans' Bureau, will be forwarded as follows: No. 1. 181 INSTRUCTIONS TO MEDICAL OFFICERS. "a. A man i la envelope of special size (6 by 8* indies), a supply of which may be obtained by requisition, should always be used. " b. All envelopes bearing the name of the forwarding station should be numbered consecutively, beginning with 1 and marked thus, Cards 1971-F, package No. — . " c. All envelopes are to be addressed to The Director, Attention Medical Statistics Section, United States Veterans' Bureau, Washington, D. C " Cards should never be allowed to accumulate any length of time, but should be forwarded as soon as possible after admission or discharge of patients. "It is requested that two copies of above orders to hospitals be supplied to the Director United States Veterans' Bureau, attention Medical Statistics Section." K. K. Stitt. Circular letter. Serial No. 191-1922. HBS:DKG 132609-0(54). Washington, D. C, 25 May, To: All medical officers. Subject : Surveys on Medical Department property. 1. The attention of all medical officers is called to the necessity for greater care in the preservation of Medical Department property. 2. Surveys are daily reaching the bureau which show many costly items re- wived within the past year or two with recommendation from the board of survey that they be destroyed as of no value, deterioration due to " use," etc. In many instances the date of receipt is given as " unknown," original cost "Qnknown," or the word "missing" is used with the statement "no responsi bility." Again, pocket cases, surgical instruments, or other cases are recom mended for return to supply depot, and upon arrival at the depot it is found that they have been looted of their contents and only the bare cases returned. 3. The new supply table of the Medical Department, 1922, provides Instru ments and spare parts for cabinets, cases, and pouches; therefore, when a few of their contents are deteriorated or broken only the actual instruments so affected should be surveyed and requisitions submitted to supply the missing parts. Medical officers and Hospital Corpsmen should carefully study the new supply table of the Medical Department. 4. Upon receipt of nonexpendable medical supplies property cards must at once be prepared showing date of receipt, cost of each item, and number and fiscal year of requisition. The bureau will then be able to determine when such property is surveyed If reasonable service has been obtained therefrom. Sursical instruments should, with reasonable care, last for a number of years, and platinum needles, which are so frequently surveyed in quantities and are expensive, should last indefinitely. 5. It is impracticable to enumerate in detail the many expensive items sur veyed which appear to have rendered but little service, but if the same care is given hy medical officers and Hospital Corpsmen to Government property that is used with respect to their personul property the bureau will be relieved of considerable embarrassment from needless expenditures, which is essential in these days of economy. 182 Vol. XVII. INSTRUCTIONS TO MEDICAL OFFICERS. C. The Secretary of the Navy, in a recent letter to all bureaus, directed that disciplinary action he taken against persons guilty of neglectful responsibility in the care of Government property. Property .surveys will therefore receive special attention in future. E. It. Stitt. Circular letter. Serial No. 192-1922. HBS : DRG 132079(54) . Washington, D. C, 24 May, ldii. To: Medical officers on shore stations in the United States. I. This bureau's reply to an inquiry made by Commanding Officer. Naval Medical Supply Depot, Brooklyn, New York, is published for information of officers concerned : "To: Commanding Officer. Naval Medical Supply Depot. Brooklyn, New York. " Subject: Complement of shore stations relative to quantities of medical de partment supplies to be furnished. "References: («) Letter, Commanding Officer. NMSD., Brooklyn. M-2-2— EKR: KG of 12 April. 1922. {b) U. S. Navy Regulations, 1920, Article 1185 (l)-(7)-<9). (c) U. S. Navy Regulations. Article 1575-1580." 1. Replying to question contained in reference (a), "Are expenditures author ized under Medical Department of the Navy appropriations for double Hie num ber of civilian attaches to the number of Navy personnel attached to a sta tion." It lias been decided that on shore stations in the United States where the treatment of families of officers anil enlisted men and first-aid treatment fin- civil employees, as provided in reference I'/), is required, medical and surgical supplies shall lie requ sitioned for on the basis of active Navy and Marine Corps complement allowance. 2. Medical supplies over the complement allowance will be furnished such stations in such quantities as may be necessary for the treatment of families of officers and enlisted men, and first-aid treatment of civil employees, as provided in reference (b), but the additional supplies required for this purpose must be made the subject of a special letter to the Bureau to accompany the requisition in each instance. 3. The unlimited expenditure of Medical Department supplies for treatment of civilians, not authorized by reference («), is not approved, and the medical officers of shore stations concerned will be so informed. K. R. Stitt. Circular letter. Serial No. 193-1922. \V.ICA:ESK 132li!S7-Oi 01 > . Washington, D. C. .7 June, 19£i. To : All naval hospitals. Subject : Care of Veterans' Bureau patients in U. S. naval hospitals. Reference: Letter from Director. I'. S. Veterans' Bureau, to Surgeon General. U. S. Navy, dated May 29. 1922. 1. Arrangements have been made whereby, during the liscal year 1923. the Bureau of Medicine and Surgery. Navy Department, will designate and main tain the following number of beds in the respective naval hospitals mentioned below for the use of U. S. Veterans' Bureau patients: Xo. 1. 183 INSTRUCTIONS TO MEDICAL OFFICERS. Chelsea. .Mass 500 Great Lakes, 111 650 League Island, Pa 125 Newport, H. I 50 New York, N. Y 400 Norfolk, Va 100 Pensaeola, Fla 25 Portsmouth, N. H 50 Washington, D. C 250 2, 150 2. Should the necessity arise the Veterans' Bureau lias been authorized to utilize from time to time a certain limited number of beds at the following naval hospitnls : U. S. Naval Hospital, Mare Island, Calif. D. S. Naval Hospital, San Diego, Calif. U. S. Naval Hospital, Honolulu. Hawaii. U. S. Naval Hospital, Manila (Canacao, P. I.). It is not thought that the utilization of hospital facilities in these hospitals will be of a sufficiently continuous or extensive nature to warrant any increase of personnel to care for Veterans' Bureau patients. 3. Commanding officers of naval hospitals other than those referred to in para graphs 1 and 2 are directed to admit Veterans' Bureau patients in emergencies and to notify the Bureau of Medicine and Surgery of all such admissions. E. R. Stitt. Circular letter. Serial No. 194-1822. HBS-DRG 125884(61). Washington, D. C, ~ June, 19tZ. To: All medical officers. Subject : Alcohol, X-ray supplies, laboratory supplies, and surgical instruments, requisitions for. References: (a) Bureau medicine and surgery circular letter, No. 172-1922; dated 28 March, 1922. (6) Supply table of the Medical Department, U. S. Navy, 1922. I. ALCOHOL. 1. Alcohol for use by the Medical Department of the Navy will iu future be obtained on Form B or Form 4 requisitions from nearest naval medical supply depot : quantities required will correspond with complement allowance pre scribed on page 9, supply table of the Medical Department, 1922. This product is furnished in 500 cc. bottles exclusively is a cologne spirits, and suitable for internal administration. Naval hospitals are authorized to procure additional alcohol needed for nonmedical use from supply officers on stub requisitions, chargeable to allotments granted by this bureau for the purpose. II. X-BAY SUPPLIES. 2. Estimates for laboratory and X-ray supplies submitted to the bureau, in accordance with instructions contained in reference <n) indicate that these instructions were in many instances misinterpreted, and numerous Items were included in the estimates for laboratory supplies which are listed in the supply 184 INSTRUCTIONS TO MEDICAL OFFICERS. Vol. XVII. table of the Medical Department, 1922. The following additional instructions relative to proper procedure for obtaining such supplies are therefore issued: (o) X-ray dental films and duplitized films will be furnished by Naval Medi cal Supply Depot, Brooklyn. X. Y., on letter request direct to that depot. These requests will not exceed estimates submitted to the bureau In compliance with reference (o). Upon receipt of such request by the commanding officer Naval Medical Supply Depot, Brooklyn, the contractor will be directed to forward films direct to the activity requiring them. The expenditure will lie covered by emergency issue slip in the same manner as are biologicals at present. Upon receipt of the films by the activity concerned the responsible officer will imme diately accomplish the emergency issue slip and return to the supply dei>ot. This is important, as authority for payment for the films is contingent upon the receipt of these receipted slips. The films supplied will be freshly prepared and will bear a date of expiration of period of usefulness. It is contemplated that requests will be promptly filled, which will obviate the necessity for carrying o large stock Of films on hand and insure fresh supplies when needed. Sufficient films for three months' supply only should be required at one lime. (6) X-ray chemicals (nonsupply table) will be obtained on Form 4 requisition from Naval Medical Supply Depot, Brooklyn, direct, within the estimates sub mitted to the bureau. These products will be supplied in the following standard size packages : Barium sulphate for X-ray diagnosis, 1-pound carton or can. Sodium sulphite in 5-pound bottles. Chrome alum in 1-pound- bottles. Sodium hyposulphite in 25-pound kegs. X-ray powders in size sufficient to make one gallon of developing fluid. Potassium ferrlcyanide in 1-pound bottles. Other chemicals required are Form B items. (c) Requisitions for dental film mounts, X-ray photographic papers, film- filing jackets, lantern slides and accessories, film hangers, developing trays, gloves, X-ray aprons, X-ray and kidney compressor bags, will be made on requisition Form 4, and forwarded direct to Naval Medical Supply Depot, Brooklyn, if within the estimates submitted to the bureau. (rf) Requisitions for X-ray Coolidge tubes will be made on requisition Form 4, submitted direct to the Naval Medical Supply Depot, Brooklyn, if within the estimates submitted to the bureau. In preparing requisition for Coolidge X-ray tube, radiator type, 10 milllampere capacity, specify the make of machine with which tube is to be used. (e) Requisitions for cassettes and intensifying screens will be made on requisition Form 4 direct to Naval Medical Supply Depot, Brooklyn, if within the estimates submitted to the bureau. Requisition for cassettes must specify dimensions of cassette required, especially the thickness, and the make of machine with which It is to be used. In preparing requisition for intensify ing screens, specify the size of cassette with which they are to be used and whether the standard, thin, or both standard and thin, are required. These two items will not be carried by supply depot, but will be purchased upon re ceipt of requisition giving specifications. (f) Requisitions for any other X-ray material required in emergency will be submitted to the bureau for approval together with explanatory letter. in. LABORATORY SUPPLIES. 3. Requisitions for laboratory supplies will be submitted in accordance with instructions in the supply table of the Medical Department, 1922, and will specify items listed in Parts I and III thereof wherever possible. Special No. 1. 185 INSTRUCTIONS TO MEDICAL OFFICERS. attention is called to contents of cabinet, labosatory, Navy standard, which together with Form B chemicals, includes practically all apparatus and re agents required for usual laboratory examinations in accordance with modern methods. It will not be necessary to requisition for reagents of any other size containers than those specified in the supply table, nor to require a multiplicity of sizes of items such as test tubes, flasks, bottles, pipettes, etc. (a) Requisitions for laboratory supplies listed in Part III of the supply table will be prepared on requisition Form 4 and forwarded direct to naval medical supply depots. (b) Requisitions for items not listed in Part III of the supply table will be made on separate requisition Form 4 and forwarded direct to the Naval Medical Supply Depot, Brooklyn, N. Y., if within the estimates submitted to the bureau. (c) Requisitions for laboratory supplies other than specified above will be made on requisition Form 4 and submitted to the bureau for approval, together with explanatory letter. IV. 6UBGICAL INSTRUMENTS. 4. All " requisitions for surgical instruments other than those listed in Part III of the supply table will be made on requisition Form 4 and submitted to the bureau for approval together with explanatory letter. E. R. Stitt. M-§. #13267!) (43). 41822CO-SD. U. S. Naval Medical Supply Depot, Sands and 1'eabl Street, Brooklyn, A". V., April 18, 1922. To: All medical and dental officers. Subject: Typographical errors in supply table, Form B and Form B-Dental. 1. The above-mentioned forms contain errors which should be corrected on each copy, as follows : supply table. I "age .1, 4th line, change " Snick " to " Schick." Page 10, column B, strike out "Less than T.*i men" and insert "75 to 150 men." I'age 21, strike out "Case, diagnostic, electric (recruiting)." Page 27, items " Corks, bottle, Nos. 3, 4, 5 6, 7 (16) . . . dozen 10 10 20 30 40 "i<i 60 70 100 " out of alphabetical order. Indicate by arrow that this item should follow item "Cork presser." (This change necessary to conform with Form B. I'age 36. item " Illuminator, bracket, electric." strike out " 110 volts " and insert reference number "(40)." Page 36. Item " Illuminator, bracket, electric, lamp for," strike out " 110 volts " and insert reference number "(40)." i'age 40, Item " Syringe, conductive anaesthesia, etc.," change " 88 " to " 87." Page 42, Item "Atomizer, hand, etc.," change allowance " 3 " in eoulmn " Stand ard equipment." to " 0." Page 44, items "Argentum eolloldale," change reference number "(24)" to "(42)." 186 Vol. XVII. INSTRUCTIONS TO MEDICAL OFFICERS. Pages 46 ami 47, insert reference number "(42)" after the following Items: "Apron, operating," "Gown, operating." "Towel, hand," "Toweling, crash," " Book blnnk, small quarto," " Envelope, official size," " Eraser, rubber," " Ink stand," " Pad. memorandum," " Paper clip," " Paper fastener," " Pencil, lead," " Penholder." " Pen, steel," " Rubber band," and " Rule." Page 60 item "Gauge steel (Handerson )'* change to read "(Henderson)." Page 88, item " Water heater, electric," strike out the Hue " Water heater . . . number 1." INDEX. Page 90. " Bistoury, straight," strike out "84." Pago 91, " Bone surette," strike out "69." Page 91, " Bucket, agate." change " 29 " to " 30." Page 92. "Card confusion colors" change "87" to "88." Page 92. "Case diagnostic electric (recruiting)" strike out "2,1." Page 93. " Combination syringe," strike out " 77." Page 93, " Corkscrew " insert page " 27." Page 93. " Cotton, absorbent," stroke out " 65," " 66," " 86." and " 87." Page 93, insert after " Cotton, absorbent," " Cotton, absorbent, compressed . . . pages 65, 66, 86, 87." Page 93. " Curette, bone," strike out " 69." Page 94, " Diagnostic case, electric (recruiting)," strike out "21." Page 9."). " Diagnostic tags " change to " Diagnosis tags." Page 97, " Hagedorn needles " change " 24 " to " 23." Page 99. after " Laryngeal mirror, handle," insert page numbers " 58 " and "72." Page 99. strike out "Matches, waterproof . . . 65." Page 99. strike out " Methyl violet . . . 81." Page 100, " Morphine sulphate hypo, tablet," insert page number " 65." Page 100, " Needle, suture, Hagedorn," change page " 24 " to " 23." Page 103. " Reamer, root," insert page number " 39." Page 103, " Repair tools, bridge," change " 49 " to " 51." Page 105, "Suture, needle, Hagedorn," change " 24 " to " 23." Page 107, " Urethroscope," insert page " 63." FOBM B. Page 13, strike out " Case, diagnostic electric (recruiting) (19) . . . number." FOBM B—DENTAL. Page 3, Item " Illuminator, bracket, electric," strike out " 110 volts " and insert reference number "(40)." Page 3, item " Illuminator, bracket, electric, lamp for," strike out "110 volts" and insert reference number "(40)." Page 11. the following items are not in alphabetical order according to the supply table : "Caryophylli, oleum," "Collodium flexile," and " Hydrargyrum." Pages 13 and 14, insert reference number "(42)" after items: "Apron, operat ing," "Gown, operating." "Towel, hand," "Toweling, crash, (38)," "Book, blank, small quarto," "Envelope, official size," "Eraser, rubber," "Inkstand." " Pad, memorandum," " Paper clip," " Paper fastener," " Pencil, lead," " Pen holder," " Pen, steel," " Rubber band," and " Ruler." Xo. 1. 187 INSTRUCTIONS TO MEDICAL OFFICERS. VITAL STATISTICS. In the future the " Monthly Health Index," which will be published on the fifteenth of each month, will contain statistical data for individual ships and shore stations. The statistics appearing in this bulletin are summaries com piled from those published in the "Monthly Health Index." Annual rates, shown in the succeeding statistical table, are obtained as follows : The total number of admissions to the sick list or the number of deaths re ported during the period indicated is multiplied by JA4 or -V/ or 12, depending upon whether the period Includes four or five weeks or a calendar month. The product Is then multiplied by 1,000 and divided by the average complement. E. R. Stitt. Table No. 1.—Monthly report of morbidity in United States Navy and Marine Corps for the nwnth of Man, 1022. Atlantic stations Pacific stations Entire Navy. Forces afloat. Atlantic Fleet. Pacific Fleet. Shore stations. in United States .i in United States. Marine Corps. ADcauses: •122,870 ■82,122 •32,652 •29,760 •40,748 •22,958 •6,104 21,612 Annuxl rate per 1,000 4 929 481.37 2,529 369.54 988 363.10 984 398.78 2,400 706.78 1,318 688.91 215 422.67 1,238 687.39 Di&t&»only: 4,237 415.74 2,179 318.40 867 318.63 870 350.80 2,078 611.95 1,075 596.S8 Annual rate per 1,000 Injuriesand poisons: Number of admissions... 672 65.63 350 51. 14 131 4a 14 124 50.00 322 94.(3 103 90.50 Annual rate per 1,000.... Communicable disease ex clusiveor venereal disease: Number of admissions. . . 1,061 108.62 575 169.33 386 143.12 57 29.79 19 297 164.91 Annual rate per 1,000 37. 35 Venerealdisease: 170 ! 38 88.86 74.70 Number of admissions... 1,088 106.25 677 98.92 365 134.14 212 85.48 411 263 146.03 Annual rate per 1,000 121.04 1Doesnot include 9th naval district. 1includes Navy and Marine Corps personnel. Note.— Asiatic and unaligned ships not reported. 103390—22 13 188 Vol. XVII. INSTRUCTIONS TO MEDICAL OFFICERS. Table No. 2.—Number of admissions reported by Form F cards for certain dis eases for the five-week period, April 29 to June 3, 1922, inclusive. Forces afloat, Navy and Marines (com plement), 82,122. Forces ashore. Navy and Marines (com plement), 40,748. Total (comple- plement), 125,870. Number of admis sions. Annual Number of admis sions. Annual rate per 1,000. Number [ Annual of admis- rate per slons. 1,000. 2, 179 rate per 1,000. 3IX. 40 51. 14 2,078 322 611.95 94.83 4 257 41V 74 350 672 65.63 2,529 369.54 2,400 706.78 4,929 481.37 class nr. a 6.28 1.02 3.65 34 11 10.01 3.24 5.01 .59 77 18 42 7.52 1.76 4.10 7 25 0 1 17 2 0 23 13 8 41 30 18 4 2 .20 10 19 .15 1.46 2.78 6.77 3.83 2.36 12.07 8.83 4. 71 1. 18 1 33 32 .10 3.22 3. 13 Gastritis, acute catarrhal 1 19 39 11 .15 2.78 5.70 1.81 9 60 69 27 .88 5.86 6.74 2.64 3 .44 7 .68 Clan VII. Clou VIII. 178 26.01 199 58.60 377 36.82 11 1.61 15 4.42 26 2.54 1 0 21 7S 23 11 2 8 2 0 .15 2 2 4 .59 .59 3 2 25 129 29 13 12 17 2 1 :2 3.07 10.96 3.36 1.61 54 6 2 1.18 15.90 2.44 12.60 2.83 1.27 1.17 1.66 .20 .10 1.77 .59 Pneumonia, broncho .29 1.17 10 9 0 1 2.94 .29 2.65 .29 Clatt IX. CUut X. 143 20.90 90 26.50 233 22.75 0 1 .29 1 . 10 Dengue 5 0 13 .73 12 2 119 3.53 .59 35.04 17 2 132 1.66 .20 12.89 Filariasis 1.90 CUut XI. Clan XII. 18 2.i'.:: 133 39.17 151 14.75 9 1.32 34 10.01 43 4.20 141 478 20.60 69.85 a 47 98 223 90 28.86 65.67 26.50 239 701 148 23.34 68.46 14.45 58 Clau XVIII. 677 98.92 411 121.04 1,088 100-25 111 1 9 18 19.00 .IS 1.32 2.63 95 6 7 18 119 27.98 1.77 2.06 5.30 225 7 16 36 Tonsilitis, acute follicular 249 36.38 35.04 368 Clasi XX. 407 36.38 245 72. 15 652 63.67 29 4.24 26 7.66 55 ... Xo. L 189 INSTRUCTIONS TO MEDICAL OFFICERS. Table No. 3. —Summary of annual admission rates for venereal disease reported from ships for April and from rxirious shore stations for the five-week period, April 29 to June 3, 1922, inclusive. All ship* Battleship and cruiser force: Atlantic Fleet Pacific Fleet Asiatic Fleet Destrover force: Atlantic Fleet Pacific Fleet Asiatic Fleet Miscellaneous: Atlantic Fleet Pacific Fleet Asiatic Fleet ■ Unaligned, including ships on special duty Annual rate per I,O00t April. Average rate since Jan. I, 1922. Mini mum rate. Mean rate. Maxi mum rate. Mini mum rate. Mean rate. Maxi mum rate. 0 102.70 902.25 0 126.01 831.02 10.38 98.68 326.84 16.62 103.49 321.25 22.26 77. 21 106.09 68.61 98.82 142.01 112.50 212.07 393. 19 0 118.54 902.25 0 147.12 697.39 0 79.84 631.57 0 96.33 476.19 0 78.68 103.66 o . 280.3S 831.02 0 105.12 666.6* 0 123.ST 403. 15 0 85.26 448.59 0 73.96 258.06 0 321.95 698.41 0 340.34 814.81 0 194.28 700.00 0 163.27 491.80 Annual rate per 1,000.Apr. 29- June 8. 1922. Average rate since Jan. 1, 1922. Mini mum rate. All naval districts In the United States First naval district Third naval district Fourth naval district Filth naval district Sixth naval district Seventh naval district Eighth naval district Ninth naval district Eleventh naval district Twelfth naval district Thirteenth naval district. . . . 0 13.92 0 0 0 35.93 0 0 24.12 41.60 61.57 0 Mean rate. 76.26 11.80 72.00 91.43 107.52 73.71 0 85.80 24.12 53.15 122.87 0 Maxi mum rate. 287.71 14.47 119.81 89. 16 216.06 287.74 0 87.81 24. 12 51.61 167.60 Mini mum rate. 0 12 45 4.33 0 17.96 50.99 29.81 0 66.14 13.69 60.61 17.14 Mean rate. 89.07 21.30 65.04 188.04 145.25 54.01 29.81 129.91 66.14 31. 78 111.11 37.84 Maxi mum rate. 253.24 32.30 127.48 225.24 253.24 171.42 29.81 87.81 66. 14 48.37 139.21 88.88 RATIO OF GONOCOCCUS AND SYPHILIS INFECTION TO TOTAL CASES OF VENEREAL DISEASE. All ships Battle-Slip and cruiser force: Atlantic Fleet Pacific Fleet Asiatic Fleet Destrover force: Atlantic Fleet Pacific Fleet Asiatic Fleet Miscellaneous: Atlantic Fleet Pacific Fleet Asiatic Fleet Unassjgned, including ships on special duty. Per cent, April. Percentsince Jan. 1, 1922. Gono- coccus. Syphilis. Gono- coccus. Syphilis, 66.05 10.8S 65.80 11.42 64.70 16.47 68. 49 82.52 61. 11 12.87 9.70 16.66 91.13 1.26 52. 17 81.35 100.00 14.78 60.95 77.00 45.65 8.83 7. 31 14. 13 6.77 0 44.73 10.52 6.38 0 59.94 13. 16 78.72 72.72 61.76 17.64 81.25 51.29 59.24 7.38 18.53 13.02 190 Vol. XVII. INSTRUCTIONS TO MEDICAL OFFICERS. Table No. 3.—Summary of annual admission rates for venereal disease reported from ships for April and from various shore stations for the five-iceek period, April 29 to June 3, 1922, inclusive —Continued. RATIO OF GONOCOCCrS AND SYPHILIS INFECTION TO TOTAL CASES OF VENEREAL DISEASE—Continued. Per cent Apr. 29- Per cent since June 3, 1922. Jan. 1, 1922. 72.59 15.00 67.87 16.96 S n 66.56 2ft 83 72.22 16.66 65.16 24.71 90.47 9.53 80.68 4.82 65.71 16.19 62.45 15.77 So.71 14.28 78.00 3 0 100.00 0 42.85 57. 15 65.3,8 30.76 100.00 0 68.12 15.62 100.00 0 80.76 65.62 It S3.33 13 33 0 0 84.61 15.37 . Table No. 4.—Number of admissions reported by Form F cards and annual rates 1.000, entire Navy, for the five-week period, April 29 to June S, 19t£, inclusive. Navy (complement), 101,258. Num ber of admis sions. Annual rate per 1,000 Marine Corps (complement), 21,612. Num- Annual ber of | rate admis- per sions. I 1,000 Total (complement), 122,870. Num ber of admis sions. oral and Diseases of blood Diseases of circulatory system Diseases of digestive system. Diseases of ductless glands ar Diseases of ear Diseases of eve and adncxa Diseases of genlto-urinary system (nonvenereal) Communicable diseases transmissible by oral nasal discharges •- ••■ Communicable diseases transmissible by intestinal discharges Communicable diseases transmissible by insects and other arthropods Tuberculosis (ail forms) Venereal diseases Other diseases of infective type Diseases of lymphatic system Diseases of mind Diseases of motor system Diseases of nervous system Diseases of respiratory system Diseases of skin, hair, and nails Hernia Miscellaneous diseases Parasites (fungi and cert Tumors Diseases of women Total I 33 477 1 93 71 163 228 40 39 926 ■_';t 62 15 76 29 793 89 50 62 105 9 1 560 19 0.12 3.91 56.52 .12 11.02 8.41 19.32 27.02 4, 176 4. 74 4.62 109.73 27.73 7.35 1.78 9.01 3.44 93.97 10.55 5.93 7.35 12.44 1.07 .12 66.36 2.25 494.S6 n 6 147 16 16 40 124 7 263 99 17 4 38 14 139 41 11 24 40 1 0 141 22 1,238 3.33 81.62 .56 8.88 ass 22.21 14.44 .56 68.85 3.89 146.03 54.97 9.44 2.22 21.10 7.77 77.18 22.76 6.11 13.33 22. 21 .56 78.29 12.22 ••.ST.Ki Ka.L 191 INSTRUCTIONS TO MEDICAL OFFICERS. Table N'o. 5—Deaths reported, entire Navy, for the flve-tceek period, April 29 to June S, 1922, inclusive. Meningitis,cerebrospinal Pneumonia, lobar Tuberculosis,chronic, pulmonary Tuberculosis, other forms Dermatitisexfoliative, general (Twlocystitis. Enterocolitis Poliomvtiitis, chronic, anterior fvpluBs Utber diseases Drowriinr Otheracudents and injuries " ' BOS Total J admission rates per 1,000, all causes. . . 1admission rates per 1,000, disease only Navy (comple ment), 101,258. Marine Corps (comple ment), 21,612. Total (comple ment), 122,870. 1 0 1 1 0 1 1 0 1 1 0 1 0 1 1 1 0 1 0 1 1 1 0 1 2 1 3 5 2 7 3 0 3 S 1 6 2 1 3 23 2.73 1.54 7 :«) 2.1)3 1.76 3.88 2.77 o VOL. XVII NO. 2 UNITED STATES NAVAL MEDICAL BULLETIN INFORMATION OF THE MEDICAL DEPARTMENT OF THE SERVICE THE BUREAU OF MEDICINE AND SURGERY ■ NAVY DEPARTMENT DIVISION OF INSTRUCTION AND PUBLICATIONS COMMANDER H. W. SMITH, MEDICAL CORPS, U. S. NAVY IN CHARGE EDITED BY LIEUTENANT COMMANDER W. M. KERR, MEDICAL CORPS, U. S. NAVY PUBLISHED FOR THE ISSUED BY AUGUST, 1922 (MONTHLY) Compiled and published under authority of Naval Appropriation Act for 1922, approved 12 July, 1921 WASHINGTON: GOVERNMENT PRINTING OFFICE 1922 Navy Department. Washington, March 20, 1907. This United States Naval Medical, Bulletin is published by direction of the department for the timely information of the Medi cal and Hospital Corps of the Navy. Truman H. Newberry, Acting Secretary. Owing to the exhaustion of certain numbers of the Bulletin and the frequent demands from libraries, etc., for copies to complete their tiles, the return of any of the following issues will be greatly appreciated : Volume VII, No. 2, April, 1913. Volume VIII, No. 1, January. 1914. Volume VIII, No. 3, July, 1914. Volume VIII, No. 4, October, 1914. Volume X, No. 1, January, 1916. Volume XI, No. 1, January, 1917. Volume XI, No. 3, July, 1917. Volume XI, No. 4, October, 1917. Volume XII, No. 1. January, 1918. Volume XII, No. 3, July, 1918. Subscription Price or the Bulletin. Subscriptions should be sent to Superintendent of Documents, Government Printing Office, Washington, D. C. Yearly subscription, beginning January 1, $1.50; for foreign subscription add $1 for postage. Single numbers, domestic, 15 cents ; foreign, 21 cents, which includes foreign postage. Exchange of publications will be extended to medical and scientific organiza tions, societies, laboratories, and journals. Communications on this subject should be addressed to the Surgeon General, United States Navy, Washington, D. C. n TABLE OF CONTENTS. Page. PREFACE v NOTICE TO SERVICE CONTRIBUTORS vi SPECIAL ARTICLES: Fish poisoning in the Virgin Islands. By Lieut. F. D. Walker, Medical Corps, U. S. X 193 Chemical analysis of the dlood. By Lieut Commander C. W. O. Bunker, Medical Corps, U. S. N_ 202 The Weil-Felix keaction. By Lieut. J. H. Chambers, Medical Corps, U. S. N 211 Aviation medicine in the United States Navy. By Lieut. J. F. Neuberger, Medical Corps, U. S. N 214 Functions and organization of Medical Corps Units serving with the Marine Corps in the field. By MaJ. S. N. Raynor, United States Marine Corps 220 Gas warfare: Effects of poisonous gases —Early and late. By Maj. W. R. Gahvey, Royal Army Medical Corps 230 HISTORICAL: Jonathan Cowdery, surgeon in the United States Navy, 1767- 1852, Part II. By Capt. F. L. Pleadwell and Lieut. Commander W. M. Kerr, Medical Corps, U. S. N 243 EDITORIAL : Sir Patrick Manson — Demand for trained leadership In sanitation — Use of Schick test, antitoxin, and toxin-antitoxin in prevention of diphtheria —Quinine and malaria —Oral hygiene as applied to hos pital practice — Ischiorectal abscess —Treatment of high blood pres sure—Neuropsychiatry disabilities—Airplane ambulances 269 CLINICAL. NOTES: Notes on the orthopedic service, U. S. Naval Hospital, Chelsea, Mass. By Lieut. J. W. White, Medical Corps. U. S. N 287 Notes from the of.nito-i'kinary service, U. S. Naval Hospital, Chelsea. Mass. By Lieut. P. O. Northington, Medical Corps. U. S. N 293 MeBCCBOCHROME-220 AS A GERMICIDE IN 8PTHALMIA NEONATORUM. By Lieut. C. C. Croft*, Medical Corps, U. S. N 295 AN" VSl'Sl'AL CASE OF FOREIGN BODY IN PHARYNX. By Lieut. S. B. Forbes, Medical Corps, U. S. N 296 NOTES AND COMMENTS: What is an epidemic? —Gonorrhea — Immediate surgery with the Royal Marine Artillery Howitzer Brigade in France, 1916-1918 — Contraction of tularaemia by laboratory workers —Carbon monox ide poisoning —Thomas Dover— Destruction of vitamins 299 NURSE CORPS 313 BOOK NOTICES 319 QUERIES 327 NOTES ON PREVENTIVE MEDICINE. PREVENTIVE MEDICINE STATISTICS, LETTERS, ORDERS, AND COMMENT 331 m PREFACE. The United States Naval Medical Bulletin was first issued in April, 1907, as a means of supplying medical officers of the United States Navy with information regarding the advances which are continually being made in the medical sciences, and as a medium for the publication of accounts of special researches, observations, or experiences of individual medical officers. It is the aim of the Bureau of Medicine and Surgery to furnish in each issue special articles relating to naval medicine, descrip tions of suggested devices, clinical notes on interesting cases, ab stracts of current medical literature of special professional interest to the naval medical officer, reports from various sources, historical essays, notes and comments on topics of medical interest, and reviews or notices of the latest published medical books. The bureau extends an invitation to all medical officers to prepare and forward, with a view to publication, contributions on subjects of interest to naval medical officers. In ord«r that each service contributor may receive due credit for his efforts in preparing matter for the Bulletin of distinct origi nality and special merit, the Surgeon General of the Navy will recommend that a letter of commendation be forwarded to him upon the acceptance of his manuscript for publication, and that a copy of this letter be attached to his official record. The bureau does not necessarily undertake to indorse all views or opinions which may be expressed in the pages of this publication. E. It. Stitt, Surgeon General United States Navy. NOTICE TO SERVICE CONTRIBUTORS. When contributions are typewritten, double spacing nnd wide margins are desirable. Fasteners which can not be removed without tearing the paper are an abomination. A large proportion of the articles submitted have an official form such as letterheads, numbered paragraphs, and needless spacing between paragraphs, all of which require correction before going to press. The Bn.r.ETiN endeavors to follow a uniform style in headings and captions, and the editor can be spared much time and trouble and unnecessary errors can be obviated if authors will follow in the above particulars the practice of recent issues. This is not only important in special articles, but still more so in reviews. The greatest accuracy and fullness should be employed in all citations, as it has sometimes been necessary to decline articles otherwise desirable because it was impossible for the editor to understand or verify references, quotations, etc. The frequency of gross errors in orthography in many contributions is conclusive evidence that authors often fail to read over their manuscripts after they have been typewritten. Contributions must be received two months prior to the d;ite of the issue for which they are Intended. The editor is not responsible for the safe return of manuscripts and pictures. All materials supplied for illustrations, if not original, should be accompanied by a reference to the source and a statement as to whether or not reproduction has been authorized. The Bulletin intends to print only original articles, translations, in whole or in part, revietrs, ami reports and notices of Government or departmental activities, official announcements, etc. All original contributions are accepted on the assumption that then have not appeared previously and are not to bei reprinted elsewhere without an understanding to that effect. VI 103 U. S. NAVAL MEDICAL BULLETIN Vol. XVII. AUGUST, 1922. No. 2. SPECIAL ARTICLES. FISH POISONING IN THE VIEGIN ISLANDS. By F. D. Walker, Lieutenant, Medical Corps, United States Navy. The records of the sanitation office, St.- Thomas, Virgin Islands of the United States, show that each year there have been cases of fish poisoning. During the months of August and September. 1918, 34 cases occurred, due to the fish known as " carang " which had been caught in deep sea fish pots. The greater portion of carang caught are seine fish, caught near the surface of the sea and considered good food, in contrast to the "yellow jack" variety of carang which is generally considered poisonous and never used for food. On October 14, 1919, 11 cases were reported due also to the carang. There were no deaths, and the predominating symptoms were gastrointestinal. In 1920 there were only two cases of fish poisoning, one each in the months of July and August, both from eating carang latus (locally called horse-eyed "jack'' or "yellow jack"). This fish is seldom eaten in the summer months, because the natives have learned to fear it. However, poverty or indifference often leads to its being used and poisoning generally follows. In this year, fish poisoning was made a reportable disease. Although only two cases were reported, inquiry brings out the fact that many mild cases occurred that did not re quire medical attention. The first case for 1921 was reported in February, and was due to an "amber jack" carang. From March until June, there were no more cases. June and July show one case each due to amber jack. August had no cases. September showed 14— 6 carang, 7 king-fish {scomberomorus cavalla), 1 barracuda. In October there were 10 cases, 8 from carang and '2 from barracuda. In November there was one case from carang. In one of the cases of barracuda poisoning, the fish weighed about 3 pounds, and was handled in the following way: The patient caught it in the early morning; it was out of the water for about four hours, when he cleaned it, split it up by long knife cuts and packed it in salt over night. The next day he cooked it and 193 194 Vol. XVII. WALKER— FISH POISONING. ate at least a pound. No other person ate any. The other case of bar racuda poisoning resulted after a similar treatment of the meat. Both these patients caught the fish and handled it themselves: both were aware that there was some danger of poisoning, and the salting pro cess was to avoid the effects. Both men had been poisoned some years ago from eating this fish without salting. They declared that the fish weighed about 3 pounds. A small barracuda is not considered dangerous and large ones are never eaten. In the history given the sanitary inspector, the patient said that about three hours after eating the fish he had " reeling in the head, and an hour later diarrhea set in, which kept him from sleeping at night " ; he states that " the bones throughout his body became very weary and as well he had an itching of the skin very bothersome." The itching and weakness lasted two weeks and his convalescence was slow in view of his mild illness. In 1918, 1919, and 1920 all cases reported were carang poisoning, more especially the fish called " horse-eyed jack." " cavalla," or " yel low jack" {carang latus), and these were all taken in deep-sea pots. However, in 1921, out of the 28 cases reported, 18 were carang. 7 king fish, and 3 barracuda. The cases of carang poisoning occurred in eight different groups; one group of 6 cases all in one family; one of 5 in one family; one of 2, and the others singly. Groups of five, two, and one occurred on the same date— October 9. 1921. The group of six occurred on September 19, 1921. All of these fish were caught in deep-sea pots. On investigation it was learned that many families which had eaten carang had mild illness among the members for which they had had no medical attention and therefore were not reported. The after-effects were weakness and itching that lasted sometimes for three weeks in some degree. Our inference from this investigation was that a day or two of illness in a family group that had eaten carang, at a time when other cases were being reported, especially when the illness consisted of gastro intestinal symptoms, syncope, and weakness with subsequent itching, was enough to make a diagnosis of poisoning from fish. It is safe to presume that with 18 cases of carang poisoning reported there must have occurred for the season about 50. No cases were reported among any American people or local whites. These people eat fish less frequently, and their cooks are very careful to get the best fish. On the other hand, in the fishing villages of Honduras and in the locality known as Cha-Cha town, populated by French people whose chief article of food is fish, and where every marketable variety of fish is eaten, including carang and small barracuda, no cases of fish poisoning have been reported. In connection with carang poisoning in 1920, the following warn ing was published in the daily papers of St. Thomas by Lieut. E. 104-1 19J-2 No. 2. 195 WALKER—FISH POISONING. Peterson. Medical Corps, U. S. Army, then chief sanitation officer for St. Thomas-St. John: WARNING AGAINST POISONOUS FISH. CAKANOS CAUGHT IN FISH POTS APT TO CAUSE FI8H POISONING. September 22, 1918, an epidemic of fish poisoning occurred In St. Thomas. Investigation of the cases revealed the fact that all the victims had partaken of earang, caught in a deep-sea fish pot. In all, 34 cases of fish poisoning occurred. October 14, 1919, practically the identical occurrence was repeated. Nine carangs were caught in a deep-sea fish pot, and of the 11 people who ate this fish, all were taken sick with fish poisoning. It may be stated that the carangs caught on nliove occasions were identical in appearance with the ordinary seine carnng, a distinct species as compared with the well-known poisonous yellow-jack cnrang. The underlying factors, causing fish poisoning, are, in the majority of cases, obscure. In some fishes u well-defined toxin has been isolated, whereas in others no positive findings have been ascertained. Willi regard to the earang, the consensus of opinion on the subject seems to be that this fish at certain times is very prone to spoliation with the forma tion of poisonous substances, probably in connection with their spawning periods. Due to the above facts that fish poisoning hns been caused two years in suc cession by eating earang caught in deep-sea fish pots, around the same time of the year, it is likely that carangs, caught in this manner, between the months of August and November, inclusive, are poisonous. Hence a warning Is hereby given against eating carnngs caught in fish pots during the nbovp period. E. Peteksox. Chief Sanitation Officer. The Carangidse, or the Pompanos, are pictured and described in " Naval Hygiene," Gatewood, and mention is made of the fact that the earang latus seems to be poisonous only at certain seasons and under certain conditions. In the waters about St. Thomas it is a dangerous fish always during the hot months of summer, especially when caught in deep-sea pots, and is always dangerous when the fish is large. No deaths have ever been reported, and it never has seemed necessary to forbid the eating of the fish, since so many people depend upon it for a cheap food. The naval personnel of this station rarely ever get earang as food. The principal thing for visiting ships to remember when in the waters of the Virgin Islands is that it is a safe policy to reject all fish of the earang variety, commonly called by the natives " jack," " yellow jack." " am ber jack," and " horse-eyed cavalli." Some species may not be harm ful, but many other better food fish abound that can be accepted with little or no risk. Whether or not the poison is in the fish or is due to rapid decomposition can not be settled because of the man ner in which they are handled. 196 Vol. XVII. WALKER—FISH POISONING. In spite of the fact that in 1921 the kingfish {Scomberomorus re- galis, cavaJla) was responsible for a number of severe sicknesses, it is considered the finest food fish in these waters. When caught around these islands these fish weigh about 12 pounds: some heavier but few less than 8 pounds. All cases of poisoning reported occurred in the month of Septem ber. There were four separate poisonings, one involving three in a family and one two. The fish in each case was caught in deep water early in the morning, probably about 5.30, and cooked in the late afternoon about 4.30. The symptoms as given were loose stools, vomiting, " bad feelings," griping, prostration. The writer saw these cases and can testify to the " bad feelings " and prostrations, which were all out of proportion to the quick recovery, the patients being able to get about the next day. However, the prostration continued in part for two weeks or more and some of the patients were troubled for days with severe itching. Authorities call this fish a mackerel, akin to the Spanish mackerel (Scomberomorus macu- latus), a smaller fish abundant here, and considered a toothsome and entirely safe fish. The National Geographic Magazine. January, 1922, says: "The kingfish sometimes attains the weight of 100 pounds, is an excellent food fish, and is. next to the Spanish mackerel, the principal export fish from the Florida coast." The month of September when this fish is thought poisonous' is a very hot month, and no doubt the poisonings that occur are true food and not fish poisonings. The manner in which fish is han dled by the fishermen of St. Thomas, while the best possible for the average month, is a bit faulty for the hot season. They go out about 4 a. m., get their catch and return about 9 a. m. The fish are brought in without any cleaning or cooling. The sale occurs on th? wharf or in close proximity to it and by 11 a. m. all have been sold. As a rule, the natives carry their fish home personally and cook it at once. The high price of ice or cooling systems, and the impracticability of making the fishermen, who are very poor, pro vide " live-well " boats, makes it possible only to endeavor to lessen the length of time between the catching and cooking of the fish. In St. Thomas it is very important that nothing shall be done to increase the price of food, unless it can be shown that an advan tage in health is gained thereby. It is thought Letter to have an abundance of cheap food, and trust to the general warning issued by the health department, and more especially to the native ability to know "good fish." than to attempt more regulations and restric tions. A king-fish caught, cleaned thoroughly, and well cooked within two hours, is probably not poisonous in any season. The fisherfolk of the American Virgin Islands in general consider the barracuda (Sphyraena barracuda) caught in these waters as an No. if. 197 WALKER FISH POISONING. unsafe food. Some will eat a small fish, about 3 pounds, others will not eat any. Here again the facts seem to favor a food rather than a fish poisoning. The natives who eat barracuda are usually those who fish for their families and do not sell. They have on many occasions eaten the fish without harm. In the cases reported here, the fisherman had attempted to cure the fish by the local method which consists of thoroughly cleaning it, making long, deep cuts in its flesh, and then packing the whole in coarse salt. The fish is allowed to stay 12 hours, then cooked and eaten. Two fishermen who so prepared the fish said that once they were poisoned by "uncured" barracuda and that they had since often eaten small fish " uncured and fish of over 3 pounds " cured " by their method and had experienc ed no ill effects. The efficacy of salt to prevent poison ing from barracuda has been under discussion for many years. As early as 1829, Currier and Valenciennes quote a French naturalist, M. 1'lee, who lived in the West Indies, as saying that the inhabitants of St. Croix never ate the fish until it had been in salt for 24 hours. A French physician in 1823 reported a case of poisoning in Marti nique, the fish having been so cured. The symptoms complained of in our cases came on three hours after eating a good portion of the fish and were extreme dizziness and diarrhea, followed later by "aching" bones and extreme itch ing. Prostration was marked for three days, and in one case the writer saw the patient still incapacitated for work after three weeks. T. L. E. Clarke, medical officer in the British Virgin Islands, in 1918. reported that in his experience barracuda of a good size from certain fishing grounds were always poisonous, and that the poison was not due to any decomposition from poor handling. However, many other specimens of edible fish from these same fishing grounds proved poisonous. The different theories regarding the poisonous qualities of this fish are interesting, but none is based on experiment. The idea that the fish eat the fruit of the very poisonous manchaneel tree can not be proven. About St. Thomas there are plenty of these trees overhanging the water, but to connect them with the barracuda seems trivial. Very little fruit gets in the water: fish food for the barracuda is very plentiful, and this fish shows no particular desire for this highly irritating berry. The theory that the fish feeds on copper banks and thereby attains poisonous qualities is also firmly believed here. There are few copper-bottomed wrecks in this vicinity now. and no copper banks near the fishing grounds. The idea that during the summer months this fish eats a poisonous moss is well established in the native mind, but has never been proven. One thing, however, is constant, and that is the symp tomatology. As proof of this constancy can be quoted a French author in 1829 and a native St. Thomas sanitation inspector in 198 Vol. XVIL WALKER FISH POISONING. 1921. The older observer says: "The signs of poisoning by the becune (barracuda) are a general trembling, nausea, vomiting, sharp pains, particularly in the arms and hands." The inspector, quoting the patient, says, " Three hours after eating the fish, he took in with a reeling in the head, and an hour after diarrhea set in, which kept him from sleeping at nights. His bones throughout his entire body became somewhat weary as well, and he had an itching all over his skin." In 1675 an observer states : " The fish that are here are many of them poysonous, bringing a great pain in their joints who eat them, which continues for some short time, and at last, with two or three days' itching, the pain is rubbed off." The inspector reports : " The fish was caught and corned for about three weeks before it was cooked and eaten, and about two hours after eating they took in with the reeling in their heads, vomiting, and bowels." The fish weighed about 18 pounds. The writer saw the patients to whom the inspector referred; one was incapacitated for a month and suffered, for clays from extreme itching. In the 28 cases reported in St. Thomas in 1921 and treated at the municipal hospital, reliable data were available. The most striking: thing in the histories is the fact that regardless of whether the fish was barracuda, king-fish, or carang. the symptoms were all alike, namely, that of acute food poisoning. Vomiting and diarrhea were always present, as was prostration in some degree. Many other symptoms were noted in addition, such as violent gastric pains, muscular weakness, slow, feeble pulse, flushing of the skin with ex treme itching. The symptoms were so uniform that in family groups often only one case was described in detail, the others being so similar. Few of the patients had any after effects, and these only showed les sened capacity for daily tasks and some uncomfortable itching of the skin. One of the most common food fishes eaten in St. Thomas is the Batistes vetula Linnaeus, locally called " old wife." Gatewood says, in " Naval Hygiene," that the family Balistidse or trigger fish, of which he says Batistes vetula, is a suitable example, should not be used as food, as the flesh in some localities is said to cause very marked toxic symptoms. W. R. Dunlop, writing in the West Indian Bulle tin, 1917, upholds this view and quotes other observers, including Evermann and Marsh, who say " shore fishes of the tropical seas of rather large size are carnivorous or partly herbivorous; they are rarely used as food, many of them being reputed as poisonous." In another issue of this periodical Clarke states that this fish is readily purchased in the British Virgin Islands and is undoubtedly whole some for food. He has. however, seen two cases of poisoning from this fish that he could not attribute to ptomaine formation between SOME EDIBLE FISH FROM ST. THOMAS. 1. Sparisoma chrysopterum (Bloch and Schneider). Brown goutu. 2. Scarus cceruleus (Bloch). Blue goutu. 3. Balistes vetula (Linnaeus). Old wife. EDIBLE FISH OF ST. THOMAS. 1. Epinephalus odsensionis (Osbeck). Hind-fish. 2. Anisotremus surinamensis (Bloch). Paugy-fish. 3. Pomacanthus arcuatus (Linnaeus). Flat-fish. 4. Sparisoma abiidgaardi (Bloch;. Speck-tail gutu. ms-2 No. 2. 199 WALKER —FISH POISONING. capture and preparation. The " old wife " as sold in St. Thomas is a small fish weighing only a few pounds. Like a well-known patent medicine it is " unlike any other " and anyone who sees a picture of it can readily pick it out of any group of fishes. It is pictured well in "Naval Hygiene, Gatewood." Tradition has it in St. Thomas that this fish is sometimes poisonous, but since 1918 no case has been reported. A very large number is eaten in all seasons, and one of the most common sights in the streets is the line of housewives going home from the wharf carrying a small string of fish with the inevitable "old wife." The dried skin is supposed to have some virtue as a scrub brush, and native women use it on the floor in preference to a more modern brush. Many other fish are used as food here and have no stigma of poi soning attached to them. The red snapper is highly prized; fish of this type are locally called rock fish. The National Geographic Magazine for January, 1922, shows a plate of a similar fish called mutton fish. The groupers and grunts are palatable and safe fish, as are also the fish called locally the " Goutu," a blue fish of about 4 pounds weight with a flat nose like a dolphin. Xo difficulty is ever experienced in keeping the people from eating such well-known poisonous fish as the Puffers (Spheroides spengleri) and similar ones equally dangerous. No cases have ever been noted by the writer of poisoning from the toxic effects of handling the fish. The conclusions drawn from the cases observed point to the fact that at certain seasons some usually good market fish are harm ful, either due to inherent poison from whatever cause, or from bac terial products produced by poor handling. The absence of mortal ity in these cases lightens our responsibility and permits us to allow the most liberal use of all fish that a Virgin Islander sees fit to eat. Visitors, especially in the months of August, September, and October, will profit best by listening to the advice of local fish savants, even though they can not prove the point at issue. Dr. H. F. Taylor, assistant, United States Bureau of Fisheries, has published certain notes concerning poisonous fishes and a selected bibliography of references to literature on the subject which will be found exceedingly valuable. He states that it appears to be true that poisonous fishes are much commoner in tropical than in temperate waters, and that fishes that are harmless and a regular article of diet in the latter may be regu larly or frequently poisonous in the former; that certain species are constantly and always poisonous, and that others only occasion ally cause sickness. The members of the family Tetradontida? (puff ers, swell toads) are looked upon generally as poisonous in tropical waters, while several others are said to be occasionally poisonous. In 200 Vol. XVII. WALKER FISH POISONING. the book by Ciatewood there is a list with illustrations, mentioning the toxic characteristics of many fishes. The causes of poisoning by fishes are diverse (no account is taken here of venomous fishes that inflict with their teeth or spines poison ous wounds). It appears that some people exhibit idiosyncrasies in this respect ; in such cases there appears to be an inability to digest fish, due, it is said, to a deficiency of hydrochloric acid in the gastric juice; violent digestive disorders, such as acute indigestion, may follow a meal composed of fish. In other cases, the oil in the fish is an obstacle to digestion. Some fishes, not themselves poisonous, may transmit poisons through their food to persons eating them. This is alleged to be true in the West Indies where fishes eat the manchineel fruits. Other foods, sometimes poisonous to man, but apparently harmless to fishes, include molluscs, zoophytes, corals, medusae, holothurians, and protozoans. Fishes that live in putrid detritus may undoubtedly convey some poison to man. This case is unlikely, however, in open sea water. The deliberate use of poisons to capture fish, such as fish berries {Cocculus indicus), may cause poisoning in this class, though it is not known that persons have been actually poisoned from this illegal method of capture. The most important cause of poisoning by fish relates to cases where the meat of the fish is in itself poisonous. There are two im portant subdivisions of this general class ; first, inherently poisonous ; second, and flesh which acquires poisonous quality after death of the fish. In the former subdivisions certain fishes (Tetradons) undoubt edly belong. The poisons are called " leucomaines " or animal alka loids that are normal and physiological in the fish, and represent no derangement. The poisons seem to be concentrated in the genital organs, viscera, and surrounding tissues, especially during the breed ing seasons. They are violent piosons causing death in a short time. They are also distributed to a lesser degree in the flesh of the fish. It is possible that other chemical poisons, possibly cynates, exist in other fishes, especially the liver, of certain selachians. The other subdivision of this class of poisons relates to poisonous quality developed after death of the fish, and the opinion is general, though not unanimous, that the poisoning by the barracuda is of such a nature. It appears almost certain that poisoning by Ca- rangidae is of this kind. Fish flesh may spoil very readily, especially in tropical climates, and when slightly spoiled contains the so-called " ptomaines. " or substances of a putrescent origin. The degree of poisonous quality may vary from mild to very great virulency. A close examination of the methods of handling may reveal that the fish are not properly chilled, or are otherwise improperly handled, so that opportunity arises for this decomposition to occur. In tropi EDIBLE FISH SOLD IN THE MARKETS AT ST. THOMAS. 1. Epinephalus morio (Cuvier and Valenciennes). Grouper. 2. Teuthis hepatus (Linnaeus). Doctor-fish. 3. Haemulon album (Cuvier and Valenciennes). Margot. No. 2. 201 WALKER FISH POISONING. cal waters every effort should be made to ice the fish immediately upon capture and keep them at ice temperature at all times, and also to shorten the time between capture and consumption as much as possible. The markets should be rigidly supervised so that their fish are never exposed to warmth at any time. One method that has been used to prevent " ptomaine " poisoning consists of dropping the freshly caught fish into boiling water, thus cooking it. It will then keep under moderate precautions until eaten, better than raw fish. Poisoning by fish is called in the AVest Indies " Ciguatera " ; in the Philippine Islands the name for the puffer " botete " has become the general name for poisoning by fish. Poisoning by inherent fish poisons is called " ichthyotoxism. " During the frequent mortalities of fishes in the West Indies, many fishes are found afloat, recently dead, and apparently good. Cases are known where such fishes have been eaten. Needless to say, this practice is extremely dangerous, for there is no means of knowing how long the fish have been dead, and the looks of a dead fish af ford no necessary indication of its chemical constitution. Perhaps such dead fish may be taken intentionally or unintentionally. Every effort should be made to prevent their being taken at all. SELECTED BIBLIOGRAPHY. AX-BAHAKY, A. J. Toxic fish with venemous milts. Chemical News, Vol. CVIII, p. 188, 1914. London. Aj.HAHAHY, J. M. Sur quelques poissons toxiques n laitances veneneuses. Bulletin de la Societe Centrals d'Aquieulture et de Peche. T. XXIV, p. 131-141. Paris. Ari stasiow, Ueber die Natur des. Fischglftes. Therapeutisehe Monntshefte, 1S92. COCTIERS. HENRr. Poissons venimeux et Poissons veueneux : venins, toxalbumins du serum et des orpines, toxiues mlerohionnes d'infection et de putrefaction. Paris. Georges Carre et C. Naud, Editeurs, 3 Rue Racine, 3, 1899. DrMERiL, A. H. A. Des poissons veneneux. Ann. Soo. Linn. Depart. Maine et Loire, Vol. VIII, p. 1-17, 1866. Same author: 1867 (translation of above). Annals and Magazine of Natural History, 3 ser., Vol. XX, p. 153-167. Fischel. Friedrich, uwl Carl Enoch. Ein Beitrag du <ler Lehre von den Fischgiften. Fortschrltte der Medicin, Bd. X, p. 277-290. 1892. Gatewood. James Duncan. Naval Hygiene, Chapter V, The Navy's Food. (Poisoning from eating fish, cases reported and species responsible, p. ."">36-5G9.) Philadelphia, 19(19. P. Blak'ston's ,Son & Co. ( Gives descriptions of many species alleged to be poisonous and cites many cases of poisoning. Makes no effort to explain the nature of the poisoning.) 202 BUNKER CHEMICAL ANALYSIS OF THE BLOOD. Vol. XVII. Gudoeb, E. W. (Sphyreana barracuda) : Its morphology, habits, and history. Carnegie Institute of Washington, Publication No. 252, IV, p. 53-108 ; Washington, 1018. Use of barracuda as food and poisoning resulting therefrom, p. 83-03. Cites numerous accounts and discussions in the literature, includ ing accounts of old voyages. Fish-poisoning diseases called " Ciguatera." Considers ptomaines and poisons in the food of fish derived from man- chineel fruits and from other poisonous fishes. Extensive bibliography. Heiser, Victor G. (Poison fish) subhead. Annual report of the bureau of health of the Philippine Islands for the year ending June 30, 1907. Manila, 1907. Short statement and list of fishes prohibited from sale in the Philippine Islands. Robert, . Ueher Giftfische und Fischgifte. Stuttgart, 1905. Mauriac, E. Cases of poisoning caused by spoiled codfish and the unnecessary pro hibition of the sale of reddened codfish. Report of the United States Fish Commission for 1886, p. 1027-1053 (translation). Mowbray, L. L. Fish poisoning. (Ichthyotoxisnms.) Bulletin of the New York Zoological Society, Vol. XIX, p. 1422-1423. 1916. Peixegrin, Jacques. Les poissons veneneux. 121 p., 16 figs. Paris, 1900. Augustin Challamel. Editeur, 17 Kue Jacob, Libralrie Maratime et Colonilo. Reichard, C. Animal poisons (German title). Pharm. Zentralhaile, Vol. LIV, p. 1099- 1108, 1914. A review. SCHREIBER, . Ueber Flschvergiftung. Berliner klinische Wochenschrift, 1884. VON SOBBE, . Ein bemerkenswerter Falle von Flschvergiftung. Ebenda, 1884. Stoll, . Mitteilung ueber 7 Falle von Flschvergiftung an der medizinischen Polik- llnik Zurich. Korrespondenzblatt fur Schweizer Arzte. 1905. CHEMICAL ANALYSIS OF THE BLOOD. By C. W. O. Bunker, Lieutenant Commander. Medical Corps, United States Navy. The chemical analysis of the blood has attained a clinical simplic ity and significance that demands recognition. It provides points of value in diagnosis, prognosis, and treatment, and is especially use ful in nephritis, diabetes, acidosis, comatose conditions, gout, and in questions of kidney function and treatment, especially dietetic. Few diseases have been as j7et studied thoroughly in this respect, but our fund of knowledge is receiving constant additions. The field of tropical medicine is practically untouched, and it is quite possible that an investigation along this line might there yield facts of inter est and value. Some naval medical officers have access to such ma terial, and the time is ripe for the endeavor. Numerous articles relative to this subject have appeared in medical literature during the past few years. Most, however, have been in So. 2. BUNKER—CHEMICAL ANALYSIS OF THE BLOOD. 203 journals to which the average naval medical officer does not have access. So it is the intent of this brief summary to emphasize the clinical advantages to be obtained by examinations along this line, and to touch in a general manner upon the significance of findings. I have considered acidosis in a previous article, and will endeavor to do the same for kidney function later. No exhaustive consideration will be attempted, nor will matters of technique be considered. For those who desire such elaboration or details, I would suggest two hooks —" Practical Chemical Analysis of Blood," by V. C. Myers (C. V. Mosby Co., St. Louis, 1921), and "Practical Bacteriology, Blood Work, and Parasitology," by E. R. Stitt (P. Blakiston's Son & Co., Philadelphia). The former considers the question of sig nificance very satisfactorily, and the two works supplement one an other very nicely as regards methods. Current literature must be consulted for advances. One must not anticipate the solution of all his difficulties when the sample of blood is sent to the laboratory. Very few matters are entirely settled there. Abnormal findings relate to the patient, but not necessarily to the disease under consideration. The malarial parasite found in the blood smear establishes malaria, but does not eliminate other concurrent disease, perhaps rheumatic fever. Simi larly, a marked nitrogen retention in the blood would be strongly suggestive of uremia in a case of coma, but would not exclude cere bral concussion as the cause. It is for the clinician in charge of the patient to consider the blood chemistry report just as he does that of examination of urine, feces, cerebrospinal fluid, etc., and to deter mine its possible significance in view of the other evidence present. And it is also well to bear in mind that nephritis is a common com plication, especially in chronic conditions, and will itself affect the blood picture. The peculiar advantage of examination of the chemical con stituents of the blood lies in the fact that we thus pass behind the barrier of the kidneys. Findings in urine are always dependent upon the renal function. The kidneys normally excrete but traces of certain substances, e. g., cholesterin, fats, proteins, sugar, etc. Others, such as urea, uric acid, creatinine, chlorides, etc., are con centrated in the urine from the blood with varying facility. The kidney is said to have a certain threshold value for certain sub stances, i. e., they must be present in the blood stream in a certain concentration before they can be excreted in the urine either at all or in abnormal amounts. Thus, for sugar, there normally must be more than 160 to 180 milligrams per 100 mils of blood before gly- curesis occurs; no chlorides are excreted unless the blood plasma 108165—22 2 204 BUNKER—CHEMICAL ANALYSIS OF THE BLOOD. Vol. XVII. contains 562 milligrams chlorides per 100 mils. Kidney function, may be impaired, a situation in which there is not necessarily any parallelism between the effect upon the excretion of different sub stances. The function for chlorides, for instance, is independent of that for urea. Such an impaired function could cause our being led widely astray by urine examination alone. It is not unusual for diabetes mellitus with a blood sugar of treble the normal to show no glycuresis; there is upon record a patient who had 1,100 milli- grames sugar per 100 mils blood and only 0.5 per cent sugar in the urine. The net result, then, of our blood chemistry is a more intimate picture of metabolism. We can study substances that are not avail able in the urine. Early metabolic changes are detected, as well as the first disturbances of renal function. Abnormal concentrations of constituents may arise on the one hand from overproduction, defective assimilation, or retention, or, on the other hand, from decreased production or depletion as the result of excessive excretion or assimilation. Consequently, the findings in the urine are natu rally complementary to those in the blood, and their joint considera tion quickly settles the bearing of kidney function on the latter. Alone the urine is a very unsafe index of conditions beyond the genitourinary tract. Our chemical examination is directed toward many substances, which are conveniently grouped as nitrogenous and nonnitrogenous. Enzymes are also studied, especially diastase. The following list includes the constituents most frequently under consideration, as well as normal values for adults. These are expressed in the usual terminology of milligrams per 100 mils of whole blood unless other wise noted. Values elsewhere in this article will also follow the same system. Normally, total solids are 19-23 per cent, and total nitrogen is 2.7-3.5 per cent (0.6-1.1 per cent in plasma). Nitrogenous : Proteins — Hemoglobin 14 per cent by weight. Serum albumin 4. 5 per cent. Paraglobulin 3 per cent. Fibrinogen 0. 4 per cent. Nonproteins— Urea 20-30 milligrams per 100 mils of whole blood (10-15 for urea nitrogen). Uric acid 2-3 milligrams per 100 mils of whole blood. Creatinine 1-2 milligrams per 100 mils of whole blood. Creatine 3-5 milligrams per 100 mils of whole blood. Amino acids 6-8 milligrams per 100 mils of whole blood (constituent nitrogen only). Ammonia about 0. 1 milligram per 100 mils of whole blood. Bile pigments. No. 2. 205 BUNKER—CHEMICAL ANALYSIS OF THE BLOOD. Nonnltrogenous : Sugar 90-120 milligrams per 100 mils of whole blood. Chlorides 450-500 milligrams per 100 mils of whole blood (570-620 for plasma). Bicarbonate 53-77 vol. per cent C02 (plasma). Oxygen 18. 5 vol. per cent (oxygen capacity). Carbon dioxide about 40 nun. tension in arterial blood. Fat about 600 (Bloor's fat method). Cholesterin 170-250 milligrams per 100 mils of whole blood (Bloor's method). Lecithin (Bloor's " lecithin ")__ 3o milligrams per 100 mils of whole blood 122 for plasma). Acetone bodies 0-4 milligrams per 100 mils of whole blood. Calcium 5. 3-6. 8 milligrams per 100 mils of whole blood (7. 2-12. 1 for serum or plasma). Magnesium 2. 3-4 milligrams per 100 mils of whole blood (1. 6-3. 5 for serum). Potassium 153-240 milligrams per 100 mils of whole blood ( 18-21 for serum ) . Sodium 170-225 milligrams per 100 mils of whole blood. Phosphorus (total, as H«P04) — about 120 milligrams per 100 mils of whole blood (35-40 for plasma). Phosphorus (of inorganic phos phates) : 1-3.5 (serum). Sulphur (of sulphates) 0.5-1 milligrams per 100 mils of whole blood. This rather lengthy list, however, is of more theoretical than prac tical interest at present. C linically, we desire only that which helps us in our problems. The routine examination, then, confines itself usually to nonprotein nitrogen, urea nitrogen, uric acid, creatinine, sugar, and chlorides of whole blood, and plasma bicarbonate. There might be added cholesterin and oxygen capacity, the latter being a measure of the hemoglobin. Two technicians can complete about six such routine examinations in an ordinary working day. And I wish to reiterate that the technique is not complicated, usually being quite simple and within the capacity of an intelligent hospital corpsman. Moreover, the new test case has been equipped with these methods in view. Phosphorus and calcium are receiving considerable attention in connection with pediatrics. As time progresses others on the list may assume definite clinical importance and be generally useful, providing a simple technique for estimation is available. Whole blood, plasma, corpuscles, and serum have each been studied, as the list would indi cate. And I might mention that volume relations are being scruti nized —the effects of increased or decreased blood volume upon con centrations of constituents, as well as the relation of such concentra 206 BUNKER CHEMICAL ANALYSIS OF THE BLOOD. Vol. XVII. tions to variation in corpuscle volume relative to the plasma. In fact, the antipyretic effect of such drugs as sodium salicylate, aspirin, anti- pyrin, quinine, etc., is considered to be the result of the mobilization of sugar in the blood and the consequent general blood dilution. I have found that the meaning of " nonprotein nitrogen '' is not clear to some. It simply signifies, as the name would indicate, all nitrogen except that from the proteins. The nitrogen of the blood is in the proteins (serum albumin, hemoglobin, corpuscles, etc.) and also as a nonprotein portion. The list above shows that the non protein nitrogen would then be the nitrogen from the urea, uric acid, creatinine, creatine, amino acids, etc. It amounts to 25 to 30 milli grams per 100 mils of whole blood, while the total nitrogen is about 3,000. The nonprotein nitrogen is at present especially important clinically, and our chemical examination uses it, precipitating and discarding the protein portion. It is well to bear in mind that urea is largely exogenous in origin, and subject to considerable variation as the result of food. TTrie acid comes about equally from exogenous and endogenous sources; a high concentration in the blood is usually due to decreased elimination. Creatinine is almost entirely endoge nous. For the nonprotein nitrogen 30 to 35 milligrams per 100 mils of whole blood is considered a slight, 35 to 50 a considerable, and 50 to 100 a great increase, and uremia may be expected with values as high as the last. With advanced retention the urea nitrogen may be 75 per cent of the nonprotein nitrogen. The following table (amplified from Myers) is a concise summary of normal findings and those encountered in various clinical condi tions. In general, the blank spaces indicate normal findings, although in a few they ma}' mean no data. The diagnostic significance is evi dent. Some of the results are based upon the analysis of man}- cases, others upon but few. The values are in the terms already noted above, except those for diastatic activity (recorded in Winslow's empirical units) and acidosis (expressed in terms of plasma carbon- dioxide combining power—volumes per cent carbon dioxide—follow ing Van Slyke). "Inc.'" and "Dec." signified increased and de creased, respectively. No. 2. BUNKER CHEMICAL ANALYSIS OF THE BLOOD. 207 HESUr.TS OF CHEMICAL EXAMINATION OF IlUlOU. Condition. Non pro tein nitro gen. Urea nitro gen. t'ric Creat- acid. inine. Sugar. Choles- terin. Chlor- Dins ides. tase. Plas ma CO'. Normal Exercise, short and violent Exercise, long and fatiguing Tropics Aviation Foruiiculosls Dlalietes raellitus, mild Diabetes mellitus. severe Pancreatic disease Arteriosclerosis , passive congestion of. . s, acute s, Interstitial, early Nephritis, interstitial, terminal. , parenchymatous (ne- , dlifuse. severe ir. double atic obstruction 25-30 10-15 2-3 Inc. 1-2 90-120 Inc. 167-255 450-500 I 8-64 53-77 30 100- 350 00-350 Inc. conditions . Hyper, mesis gravidarum. Eclampsia Cholelithiasis Acute yellow atrophv of liver. . . Intestinal obstruction, acute Fever, acute Pneumonia, severe and late Anemia, pernicious Leukemia Leukemia, myelogenous Malignancy, late Dementia precox, catatonic Shock Edema I'll poisoning. 75-170 to 108 to 110 Inc. Inc. Alcoholism Ether anesthesia.. Adrenalin , antipyrin, quinine. to 370 Inc. 4-10 inc. 2-4 Inc. Inc. Inc. 150-300 300-1200 Inc. Inc. 201)-SHI inc. 400 Inc. Inc. 10-50 40-100 15-25 60-300 20-50 to 230 to 75 70-300 12-40 5-15 5-12 5-27 2-5 to 10 to 5 5-28 2-4 to 16 to 8 120-180 120-150 120-240 120-200 to 250 to 200 to 300 Inc. Inc. 150-fiOO 450-600 MO 100 ■< «>-<; in Inc. Dec. Dec. 3 9 4-10 1.5-3.5 110-16.1 Inc. 60-90 10-25 45-120 ■ Inc. to 53 to 75 to 20 Inc. 6-10 Inc. to 300 Inc. Inc. Inc. to IS to 10 Inc. to 7. 6 Inc. Dec. Inc. to 4 to 3.5 to 3.1 to 180 to 300 to 15 Inc. Inc. inc. to 33 Inc. Inc. 120-200 Inc. J no. Inc. to 500 Dec. 130-300 . to 87 . Dec. Inc. to 60 Dec. Dec. Dec. to 600 Inc. to 350 inc. Inc. Dec. Inc. 20-45 i2^40 Dec. 43-58 Dec. Doc. Dec. Dec'. Dec. The table gives definite values, but it is worth while for the person analyzing a report to endeavor to determine how much any variation from normal is due to such factors as food, increased metabolism, defective assimilation, retention by a kidney whose function is impaired, etc. Nephritis produces blood changes essentially by reason of the usual inability to properly excrete the waste products of metabolism. Acidosis, edema, or uremia are the clinical evidences of such reten tion. Interstitial nephritis is characterized by the retention of nitro gen, the first changes being noted in the uric acid. Urea and non protein nitrogen increase later. The significance of albumin in traces and occasional casts in urine has been more definitely estab lished by examination for increase of uric acid in the blood — an increase arguing for an organic lesion. On a high purine diet there will be an accumulation of uric acid, a result that does not occur in 208 BUNKER—CHEMICAL ANALYSIS OF THE BLOOD. Vol. XVII. normal persons. Inasmuch as the urea furnishes such a large por tion of the nonprotein nitrogen and varies so markedly by reason of diet, a high nitrogen value affords definite information only if the intake is known. The nonprotein nitrogen has, however, always a negative value. Associated cardiac decompensation will further increase the blood urea. Values of over 4 for creatinine do not occur without great impairment of renal function, and findings of more than 5 have practically uniformly foretold a fatal termination in less than six months, except in acute nephritis and mild bichloride- of-mercury poisoning. The creatinine is also the best guide to the status of renal function in terminal cases. Parenchymatous nephritis shows relatively little nitrogen reten tion, but does evidence a decided tendency toward chloride retention. Low urea values, due to superpermeability of the kidney, are found occasionally with chronic diffuse nephritis and in hypersensitive cardio-vascular disease. The imminence of uremia may be judged by the extent of the nitrogen retention. We have an aid in the differentiation of the uremia of nephritis accompanied by a flagging heart from the passive congestion of cardiac decompensation, especially as to which is the secondary condition, and thus therapeutic indications relative to mooted questions of treatment, such as hot packs, morphine, renal stimulants, etc. Unsuspected cases of nephritis showing only gastric symptoms subjectively have been detected by blood chemistry. Essential hypertonia, with its normal blood chemistry, is differ entiated from arteriosclerosis with its frequent nitrogen retention. It is of interest to note that experimental administration of choles- terin has caused histologic changes in the aorta. The important questions of acidosis and kidney function, as already stated, will not be considered in this paper, although the former is an integral part of blood chemistry and the latter is an important factor in determining the blood picture. Their discus sion requires considerable space, and it is probably preferable to con sider them separately, while bearing in mind their relation to the chemistry of the blood. The surgeon is especially concerned with them if he desires the best results and uneventful convalescence. The pediatrician should always bear acidosis in mind. The blood may indicate a prediabetic state, and place the practi tioner upon his guard. Nephritis may be present with diabetes mellitus, and usually is when the latter is severe, so one must be pre pared for the blood picture of the former. The blood sugar and plasma C02 are usually considered the only safe guides in the treat ment of diabetes mellitus, and no extended medical or surgical inter ference should ever be attempted without their estimation. Glyco No. 2. BVXKER CHEMICAL ANALYSIS OF THE BLOOD. 209 suria is a poor guide, especially in advanced cases, as is readily in ferred from the remarks relative to renal function in the early part of the paper. A persistently low blood sugar is extremely favorable. A high threshold for sugar in a mild case on diet usually indicates some complication, such as arterial hypertension. A rising or per sistently high threshold for sugar despite diet is serious. Blood fats are considered by some to be a better index of the patient's condition than the blood sugar, but their estimation is by no means simple. The cholesterin determination is not difficult, and this compound is said to parallel and be an index of the fats. Some diagnostic significance is attached to the sugar tolerance text. There is some variation in methods for its application, and the following may be considered as good as any. After an overnight fast, ingest 100 grams glucose dissolved in 300 mils black coffee. Collect blood samples just before feeding and at 45 and 120 minutes after same, and determine the blood sugar in each sample. If the blood sugar has not by then returned to about normal, one may test further samples taken at hourly intervals. The urine may also be collected and tested for sugar. Under such conditions a normal person will show no glycuresis, and his blood sugar will be at its maximum (about 150) after 45 minutes, and approximately normal at the end of 120 minutes. The usual abnormal variation consists in increased height, or, especially, duration of curve before reaching normal, as much as six hours being not unusual. Until the significance of the test is more fully estab lished, it will probably be better to interpret such an abnormal curve as indicating an impaired sugar tolerance and its degree. Practi cally equivalent results are obtained in such diverse conditions as diabetes mellitus, nephritis, hyperendocrine (thyroid and hypo physeal) conditions, tuberculosis, epithelioma, pregnancy, fatigue, etc. There is a condition but recently recognized in which there is a normal blood sugar, a persistent glycuresis of usually less than 1 per cent and independent of carbohydrate intake, occasionally polyuria, but with no other symptoms of diabetes mellitus. It is known as renal diabetes, is apparently harmless, probably not uncommon, and may comprise most of those " diabetics " who can disregard diet with impunity. Fumnculosis often shows an increased blood sugar, and diabetic restriction of sugar may be of much aid in its treatment. In comatose conditions, nitrogen retention will select the uremic and hyperglycemia the diabetic cases. But acute nephritis should always be borne in mind, as it may have a pronounced acidosis but no nitrogen retention. 210 BUNKER CHEMICAL ANALYSIS OF THE BLOOD. Vol. XVII. The frequent hyperglycemia of hyperthyroidism is useful in dif ferentiating the irritable heart. The solitary increase of blood uric acid (probably the result of re tention) in gout aids in the differential diagnosis from simple rheu matic fevers and other arthritides, any uric acid retention in them being usually accompanied by retention of other nitrogenous ele ments. It is especially useful in the diagnosis of gouty arthritis without tophi. Of course this increase of uric acid alone is also characteristic of early interstitial nephritis, but, with the latter, a general nitrogen retention usually supervenes and there is commonly albuminuria and cylinduria. The amount of uric acid in the blood bears no relation to the severity or the chronicity of gout. A purine- free diet tends to lower the uric acid. This can be accomplished more effectively, however, by drugs, such as tolysin (neocincophen) or cincophen (Acidum phenylcinchoninicum). These increase the excretion of uric acid, and will also reduce increased blood urea or chlorides. They act as renal stimulants, and this excretory action is rapidly secured (that for tolysin reaches its maximum in about one day) and gradually lost. They apparently are not toxic, and are analgesic, the latter effect being gradually lost. Ten grams of sodium chloride by mouth in a glass of water is said to decrease blood chlorides if the gastric secretions are normal. If the secretory disturbances are marked, an increase in blood chlorides may be expec ted. Pregnancy is accompanied by low values for blood urea, and cholesterin is said to increase beginning with the fourth month and progressing to term. An increase in blood uric acid is definitely as sociated with the toxemias of pregnancy, and should place the obstetrician upon his guard. Diet is concerned particularly with retention, especially of nitro gen and chlorides, and defective assimilation, especially of sugar. The blood examination definitely settles such questions, and it should precede and then guide dietetic treatment. The efficacy of treatment will, in general, be shown by the degree of approach to normal blood findings. As a general rule, it is preferable to determine the chlo rides of whole blood rather than of plasma. Plasma, if used, should quickly be separated from the corpuscles. It is appropriate to mention here the ferment, diastase. This is an amylolytic enzyme whose activity is considered to be normally under the inhibitory control of the internal secretion of the pancreas, and whose function is concerned with the production of the blood sugar from the glycogen of the body. It is found in the body fluids and excretions. An impaired kidney function may cause its retention in the blood, and thus be the etiological factor in the hyperglycemia of such cases. Its diagnostic significance is still debatable, but very No. 2. 211 CHAMBEKS THE WEIL-FELIX KEACTION. high values, especially in the blood and with no evidence of impaired kidney function, should be considered confirmatory of impaired pan creatic function. For a complete examination one should secure at least 10 mils of blood, and it is best taken Z\ hours after a meal, preferably be fore breakfast. The values obtained from the sample taken after the shorter interval are probably satisfactory for clinical purposes. Truer values require the longer interval. Hammett found no prac tical difference between samples secured after fasts of 14 or Si hours. The sugar was variable, while the nonprotein nitrogen, urea, and uric acid were slightly lower after the longer interval. Plasma sugar concentration is not affected by ingestion of water. A rich carbo hydrate meal causes a slight increase of sugar that may last for several hours. . A protein meal causes a temporary increase of non protein nitrogen and amino-acid nitrogen. Fifty grams of protein, eaten by a normal person, produces an increase in urea nitrogen for 8 or more hours, the blood sugar being unaffected. With severe diabetes mellitus or nephritis the increase in urea nitrogen is more marked and sugar is increased, although the latter effect may be overlooked in the presence of a marked hyperglycemia. The values for many of the blood constituents will decrease the longer the sample stands. Twenty hours at room temperature does not change the nitrogenous substances, and the sugar only slightly. The sugar then deteriorates rapidly, especially when the sample is agitated. The other ingredients show but little change for two or three day's, especially if preserved as blood filtrate and in the re frigerator. THE WEIL-FELIX REACTION. By J. H. Chambers, Lieutenant, Medical Corps, United States Navy. The Weil-Felix reaction has gradually come into general use within the past few years as a laboratory diagnostic measure in typhus fever. It is an agglutination reaction, employing the patient's serum and a member of the Proteus group of microorganisms. The particular organism employed is known as X19, and was isolated by Weil from the urine of a patient suffering from typhus fever. From experimental evidence it is not believed that the Proteus organism has any causative relation to the disease, nor is it apparently a secondary invader in the ordinary sense. It is, however, very often present in the urine of tjTphus patients, particularly in the later stages of the infection. The strain used in the test has the usual characteristics of members of the Proteus group that ferment glu cose and saccharose, but do not ferment lactose, maltose, or mannite. Another organism having cultural characteristics similar to those 212 Vol. XVII. CHAMBERS —THE WEIL-FELIX REACTION. of Xl9 is known as X2 and is frequently used along with X19 as a confirmatory test. It has recently become apparent that Xl9 gives uniform and consistent results and is now commonly used alone. Sufficient work has been done in typhus centers to demonstrate conclusively that a positive reaction occurs only in serum obtained from typhus patients and not from other diseases. Napier (1) reports results on a number of cases of typhus, including 40 with mild attacks, and all of these gave a positive reaction. The highest titer was 1 :20,000 on the eighth day, the lowest 1 :200 on the eighth day, rising to 1 :10.000 on the sixteenth day. The average titer of the 40 cases was 1 :2,600, and was present on the seventh to the thirtieth day. Eleven cases clinically doubtful at the onset gave positive Weil-Felix reactions. The highest titer in this group was 1:20,000; the lowest 1 :50 on the fifth day, rising to 1 :800 on the seventh day. Two groups of control . cases were used, one of 50 refugees with no record of treatment in the hospital, and the other of 24 patients suffering from febrile conditions incompatible with a diagnosis of typhus. Of the first control group, one gave a titer of 1 :100, four 1 :50. Of the second group, two gave a titer of 1 :100, eight 1 :50. In the latter group, if cases of typhoid were excluded, none gave a titer of 1 :100, and only five of 1 :50. He concludes that eight per t ent of normals give a titer of 1 :50, and 25 per cent of febrile con ditions, other than typhus or typhoid, give a titer of 1 :50. Hence a positive Weil-Felix reaction must show a titer greater than 1 :50. Of his 59 cases, only 12 failed to give a titer above 1 :1,600, and none below 1 :640. Of the 77 control cases, none gave a titer above 1 :400, and only one that high. In Fairley's report (2) of cases in Egypt, 63 of 65 showed a positive reaction. Of the 120 cases other than typhus, none were positive in dilution of 1:20. Felix and Weil (3) reported positive reactions in 125 of their 126 cases. Of 632 patients not having typhus, including typhoid, meningitis, and relapsing fever, 12 per cent gave agglutination as high as 1 :25, with the agglutination incomplete or delayed. Sacquepee and Delavergne (4) report the Weil-Felix reaction constantly positive in typhus fever and negative in 14 cases other than typhus. Montefusco (5) reports reaction posi tive with a titer of 1 :800 in all but one of 100 cases, and constantly negative in a large number of acute diseases other than typhus, except one case of smallpox. Compton (6) reports 47 tests on 14 cases in Syria, with all but one case positive. Numerous other writers have reported series of positive results in typhus, and negative results in other diseases. Kraus and de la Barrera (7) reported positive results in all cases of typhus fever, with two positive reactions in other diseases. One of the latter was a case of typhoid (Widal, 1 :4,000, agglutination X19 1 :10.000) who had lived in Russia till a few years previously, and the other, a case of measles, with a history No. 2. 213 CHAMBERS THE WEIL-FELIX REACTION. of previous residence in an endemic focus of typhus, whose serum gave a titer of 1 :'20O. The authors termed these " anamestic reac tions." The exact technique of the test varies with the individual. Kesults obtained by using live or killed suspensions seemed to be equally satisfactory: and inasmuch as killed suspensions are more con venient, they were used in the majority of tests reported below. Cultures of X2 and Xl9 were obtained through the courtesy of Dr. G. W. McCoy and Miss I. A. I5engtson. of the Hygienic Labora tory of the United States Public Health Service. Twenty-four hour agar cultures were washed into normal salt solution containing 0.3 per cent formalin and kept in the refrigerator for four days, by which time all organisms were killed. This suspension was stand ardized to make a 0.1 per cent suspension of each strain. One cubic centimeter of this suspension was added to an equal amount of diluted serum, each serum being tested against both organisms and each series of tests having the usual control of salt solution. Living cultures in broth were used in 20 tests and living organisms in salt solution in 25. The results differed in no way from those obtained with killed organisms. Sera for these tests were obtained from patients in the naval hospital. Washington. D. C, on whom complement fixation tests for syphilis were being done. About 14 per cent of these gave a posi tive complement fixation reaction and the remainder included a wide variety of diagnoses. The serum, which was kept in the refriger ator, was always used within 24 hours after withdrawal. Four dilu tions, ranging from 1:16 to 1:128, were used for both organisms. After thorough shaking the tubes were placed in an incubator at 37° C. and readings made at the end of three hours. A final read ing was made on the following morning, and in no instance was there any change in the reaction. Of 370 sera examined, only one showed an agglutination in any dilution. In this case agglutination was present in a dilution of 1 : 128. In another test on fresh serum of the same patient agglutination was complete up to 1 : 160, whereas it was present but incomplete at 1:320 with X2 and Xl9. This is in accord with results obtained elsewhere. Much of the work hith erto reported has been done on individuals coming from or residing in districts where typhus is endemic and epidemic, whereas the majority of the patients seen here had never been exposed to typhus, and this may well explain the greater frequency of agglutinations in the low dilutions reported elsewhere. The one patient showing agglutination was a native of Denmark, had been in the merchant marine for eight years, and in the United States Navy for a number of years, so might very well show a mild form of the happily termed "anamnestic reaction" of Kraus and de la Barrera (7). 214 Til. XVII. NEL'BERGER .AVIATION MEDICINE. This additional evidence is added to the already lengthy series of tests showing a negative reaction with diseases other than typhus. All the patients examined here had received vaccine as prophylaxis against typhoid and paratyphoid within the past five years, the majority within three years and a few cases very recently. The immunity thus acquired did not seem to influence the Weil-Felix reaction in any way. As the titer of typhus serum is not very high prior to the fifth or sixth day, and a diagnosis on clinical findings alone is then often quite definite, the test is not needed in such cases. However, in the large group of atypical or doubtful cases, it is of much practical value, particularly in the diagnosis of the early cases of an epidemic. Here, it is in the first cases that the diagnosis is most often missed till late and it is then that the most effective preventive measures may be instituted. Conclusions.— (1) The reaction is negative in diseases other than typhus; (2) it is not influenced by serum showing positive com plement fixation test; (3) it is not influenced by typhoid prophy laxis. BIBLIOGRAPHY. 1. Napier, L. E., Well-Felix reaction in a mild epidemic of typhus, occurring among a typhus- rid den people. Lancet, 2 : 863, November 15, 1919. 2. Fairley, N. H., Laboratory diagnosis of typhus; further observations on value and significance of Weil-Felix reaction. J. Hygiene, 18 : 203, August, 1919. 3. Bengtson, I. A., Weil-Felix reaction as laboratory test in diagnosis of typhus. 'Pub. Health Reports, 34:2446, October 31, 1919. 4. Saequepee, E. and Delavergne, P., Serodiagnosis of typhus, Bull, et mcim. Societe medicate des HGpitaux de Paris, 43 : 151, February 21, 1919. 5. Montcfusco, A., Agglutination test in diagnosis of typhus. La Riforma Medica, Naples, 35:782, September 13, 1919. 6. Coinpton, A., Weil-Felix serological test. Lancet, 2 : 860, November 15, 1919. T. Kraus, R., and de lu Barrera', J. M., Typhus in South America. Semana Medica, Buenos Aires, 28 : 371, March 31, 1921. AVIATION MEDICINE IN THE UNITED STATES NAVY. By J. P. Nki bkkuer, Lieutenant, Medical Corps, United States Navy. THE FLIGHT SURGEON. The British, French, and Italians, all stated early in the war that it was fortunate that the air forces of the United States were profit ing by the mistakes of the allied flying forces, and in recognizing at the beginning the fact that the medical problem of aviation is a very special problem and can not possibly be conducted except by medical officers specially trained for this sort of work (1). The British were the first to recognize the advantage of medical officers specially NO. 2. 215 NEUBERGER AVIATION MEDICINE. trained for aviation. During the first year of the war, 2 per cent of air casualties were caused by the Germans, 8 per cent were due to defective planes, and 90 per cent were due to physical defects of pilots. As soon as they had established an independent air medical service and specialized in the care of the flier, statistics changed im mediately and in the next year the 90 per cent was reduced to 20 per cent and in the following year to 12 per cent. When the United States entered the war, it was decided to follow in the footsteps of our Allies and medical officers with special qualifi cations for aviation duty were selected. At that time we knew very little about the medical problems of aviation, and in order to prop erly investigate these problems the United States Army established a research laboratory in Mineola, Long Island, N. Y. The labora tory was subdivided into seven professional departments, and each department studied the problems of aviation that concerned its own particular field. These departments were physiology, cardiovascular, ophthalmology, otology, psychology, psychiatry, and physics. This laboratory has produced wonderful results in this connection and the highest praise is due to the officers connected with it. A most im portant phase of their researches was the study of the effect of low oxygen on the circulation, respiration, mental reaction, and the eye. One of the early ingenious devices developed at the laboratory was a low-pressure tank with which it was possible to simulate air con ditions from sea level up to approximately 36,000 feet. Later a re- breathing machine was developed. With this apparatus the subject breathes the same air over and over again with the impurities elimi nated. The oxygen, of course, is constantly diminished, and the re sult is similar to that in the tank, for it was soon found that the im portant factor in altitude is the decrease in oxygen, the decrease of atmospheric pre&sure and temperature being of secondary considera tion. The primary duties of the medical officer assigned to aviation duty can be described under the headings : 1. The selection of the flier. 2. The maintenance of the fitness of the flier. The most important factor in the selection of the flier is the physi cal examination. One can not be too careful in this examination and should always carry the old rule in mind— " when in doubt, reject." This rule might work an injustice on an individual, but it will ultimately benefit the service as a whole and it certanly will save the lives of many men. The maintenance of the fitness of the flier is of equal importance to the physical examination. The aviator is subject to certain con ditions, which have a tendency to produce mental fatigue, which, if not discovered in time, will cause the aviator to deteriorate and make 216 Vol. XVII. NEUBERGER AVIATION MEDICINE. him useless for further service. This condition of mental fatigue is commonly spoken of as " staleness." It is in reality a functional degeneration of his mental and nervous system. After prolonged flying without a rest the aviator begins to do unusual things. He makes a bad landing. Perhaps he has a crash, or he hesitates to go into the air. He may completely lose his nerve. The aviation medical officer should watch the flying in order to see how pilots are withstanding the effects of flying, to take steps to combat at an early stage the onset of flying stress and to prevent undue fatigue. The term " Flight surgeon " is used in the United States Army to designate medical officers assigned to aviation activities. While this term is not used officially in the Navy, it simplifies matters to employ it in this article, as referring to medical officers of the United States Navy assigned to aviation duty. The flight surgeon in the United States Army officially receives training and instruction in actual flying in aircraft, which is not the case in the Navy. The Navy Department, however, has never voiced any objections to a medical officer taking flight, or instruction in actual flying, providing he can find an instructor at a station willing to give him flight in structions. The writer has found that all pilots realize the impor tance of the services of a medical officer on aviation stations and ap preciate the fact that he is looking after their health and safety. They are always more than willing to assist him in any way possible. The question should a medical officer of the United States Navy officially receive flight training? has been often discussed. The Army surgeons claim that in order to understand the medical prob lems of aviation, one must be a qualified flier. From the writer's personal experience, he has come to the conclusion that training in actual flying of aircraft is not essential, although it might be desir able, and that a medical officer, not a qualified pilot, can perform his duties just as well as though he had received actual training. It is, however, essential that he fly with the pilots as often as time and cir cumstances permit, in order to obtain first-hand knowledge as to the work the pilots have to perform, to experience the different air con ditions, to notice any changes in the human body in the air at high altitudes and in general, to have the same experience as a qualified pilot. It is believed that this experience can be obtained just as well by accompanying the flier as by oneself piloting the plane. The writer has taken numerous flights under all sorts of conditions and at the end of each flight he has found, on discussing different occur rences, that everyone had practically the same sensations, ideas, and opinions about all that happened while in the air. It is. of course, obvious that some men have keener powers of observation than others and notice things which others do not. The writer personally is not So. 2. 217 NEUBERGER — .AVIATION MEDICINE. in favor of making a doctor a " flier." He can not be expert in both. If the medical officer is a qualified aviator, it is necessary for him to spend a good deal of his time in the air in order to keep in practice and he develops the same peculiarities, attitude and symptoms as other pilots. He can no longer observe them in any one else, as prac tically all the symptoms of " staleness " are objective, and his useful ness as a flight surgeon is therefore at an end. He is just as likely to develop symptoms of staleness as any other flier without realizing it, for many pilots showing objective signs of this condition, yet un aware of it, protest most vigorously if the medical officer recommends a temporary " grounding," stating that they are perfectly all right and capable of flying, despite the fact that they show signs of com plete mental and nervous exhaustion. It is honestly believed that more can be accomplished and greater progress will be made in avia tion medicine if the, medical officer assigned to aviation duty is not a qualified aviator provided he takes sufficient interest in aviation, becomes engrossed in air problems, sees and experiences them himself in the air, either as an observer or passenger. "A medical officer assigned to aviation duty must have a thorough knowledge of internal medicine, including physiology and psychol ogy, and he must be able to make thorough eye and ear examina tions. It is believed that every flight surgeon should have special training in eye, ear, nose, and throat work." A medical officer as signed to aviation duty should be selected with as much care as the pilot. With deep and interested self-devotion to his work, he must be unselfish, approachable, gentlemanly, at the same time possessing firmness, and must have all other qualities expected of a medical officer, and, above all, he must not be afraid to fly. He must be " a pood mixer," and must obtain the implicit confidence of all pilots and should spend as much time as possible in informal association with them. He should make it a practice to be at the flight office as often as practicable and whenever the pilots " take the air." Half of the fliers are usually watching the others, and one can obtain a lot of valuable information from their remarks and general conversa tion. The flight surgeon should be a young man, about the same age or a little older than the fliers. He must work in close cooper ation with the instructors in order to gain as much information as possible about the student flier. He must be on the station whenever there are machines in the air, be it day or night, for when his serv ices are required they are certainly very badly needed. The flight surgeon must keep in touch with the flier's physical con dition and become acquainted with all affairs pertaining to him. He should spend as much time on the flying field as is possible, watch ing for defects in flying, such as bad take-offs, bad landings, uncer 218 Vol. XVII. NEUBERGER —AVIATION MEDICINE. tainties of action, and he should make it a point of seeing each flier every day, either on the fields, at mess, or in the quarters. At the United States naval air station on Rockaway Beach the commanding officer issued an order for all officers to have the midday meal at the bachelor officers' mess. This order at first brought forth a storm of protest, especially from the married officers who had quarters on the station or in the vicinity, as they preferred to have lunch with their families. However, they soon saw the benefit of the order and adjusted themselves to it. This order brought the officers together at least once a day and gave them an opportunity to know each other better and to discuss the different events of the day ; they obtained different viewpoints and oftentimes better under standing of a happening whether it was a successful maneuver or a fatal crash. The writer knows from personal experience that argu ments and scientific discussions during this meal hour resulted in many improvements, increased knowledge, better understanding, and the greater efficiency of all the flying personnel. It is considered an excellent procedure and recommended for all naval air stations. One of the most important duties of the flight surgeon is the repeated physical and mental examination of the aviator to deter mine his continued fitness for flying. Its accomplishment is not an easy task, as it inconveniences the pilot. The average pilot dislikes frequent physical examinations, because he is afraid that something may be found which would ultimately disqualify him physically from flying. It is quite hard for him to realize that this examina tion is carried on for his benefit and personal safety. The frequency of these examinations depends upon circumstances and the amount of flying carried on. It is believed, however, that this examination should be made at least once a month and an entry of the result should be made in the health record. In making this examination the possibility of staleness should always be borne in mind. The flight surgeon should always keep in intimate touch with the flight commander and the instructors, especially on stations used for training purposes. He should act in an advisory capacity to the flight commander, and by mutual cooperation many men may be discovered who a re for some reason not flying at their best. It is the flight surgeon's duty to see that all of the flying personnel have sufficient, proper, and suitable exercise. He should impress upon the fliers that they should regard themselves much in the light of athletes, and that they must bear in mind the rules for the train ing of athletes, such as temperance in all things, good hours and plenty of sleep, good food and comfortable quarters, and the right kind of recreation. It is believed that comfortable quarters for the aviator are just as necessary as a comfortable flying suit, as flying is accompanied by great mental and physical fatigue, and the No. 2. 219 NET'BERGER AVIATION MEDICINE. aviator should have a comfortable and pleasant place to rest after his work is done. The flight surgeon should organize the medical department of the air station so that all accidents may be handled quickly and efficiently. He should investigate every crash, to determine whether it was due to a physical or mental defect of the pilot. If the defect is of a tem porary nature, grounding should be recommended, but if the defect is permanent, the pilot should be disqualified for further flying. When in doubt the pilot should be kept under observation until his status is definitely determined. The flight surgeon must appreciate his work. There is no duty for the Navy medical officer of to-day in which there is more chance and opportunity for progressive research than that of the flight sur geon. It is a known fact that marked reduction in fatalities has occurred where efficient flight surgeons have been placed. While we can not reduce the incidence of accidents due to mechanical or struc tural defects, we certainly can reduce those due to the men themselves. A recent publication (2) of the United States Army Air Service on the subject of aviation states : " The value of the flight surgeon has been abundantly proved in the training schools of the United States and France; but the signing of the armistice prevented the full realization of the hope that flight surgeons would be placed where they are of the greatest value — at every aerodrome and balloon sta tion at the front. " It can readily be seen that a skillful flight surgeon would have been very valuable at the aerodrome where Guynemer had his head quarters. That marvelous flier had shown increasing nervousness and physical unfitness for some time. In his delightful book, Mr. Driggs says: 'A new Guynemer revealed himself to his friends and comrades. He became nervous, sick, and irritable. His comrades, unable to control their captain, telephoned to Paris, informing their old commanding officer, Brocard, that Guynemer was sick and in no condition to fly, and imploring him to come back to the aerodrome to take their captain away for a much-needed rest. He arrived about half an hour after Guynemer had left on his last flight.' " " Rickenbacker says: 'It is plainly imperative that one keeps one's self always fit and clear minded. It is a matter of life and death to every air fighter—this quick-thinking, unburdened mind.' His words in speaking of the fatal accident of Lieutenant Kurtz are very illuminating : ' I had noticed before starting that Lieutenant Kurtz appeared nervous, but did not give the matter any great considera tion. The explanation was given by a brother officer who had come with Lieutenant Kurtz to the squadron. Before starting on his last flight Lieutenant Kurtz had confided to him that he was subject; to 108165—22 3 220 Vol. XVII. RAYNOR —MEDICAL CORPS UNITS. fainting spells when exposed to high altitudes, and the only thing he was afraid of was that he might be seized with such a fit while in the air. Alas, his fear had been only too well founded. But what a pity it was he had not confided in me. his flight commander.' " After a flight of over 15,000 feet, Lieutenant Kurtz was making a turn over an adjoining field, when his Xieuport dropped into a vrille, crashed, and caught fire. Experience has shown over and over again that a flier will confide in his flight surgeon when he will be silent with his commanding officer." REFERENCES. (1) The Air Medical Service and the Flight Surgeon, by Lieut. Col. L. H. Bauer and Maj. W. McLake, U. S. Army, Mil. Surgeon, January, 1920. (2) Aviation Medicine in the A. E. F. Offlce of the Director of Air Service, U. S. Army, February, 1920. THE FUNCTIONS AND ORGANIZATION OF MEDICAL CORPS UNITS SERVING WITH THE MARINE CORPS IN THE FIELD.i By S. N. Raynob, Major, United States Marine Corps. ORGANIZATION OF THE DIVISION STAFF. In the preceding article we discussed in brief and general terms the organization of a brigade. Because the brigade, except when serving alone, is not an administrative unit, and, because the regi mental medical officers function directly under the division surgeon (when the brigade forms a part of a division) and should, there fore, have at least a working knowledge of the duties and functions of the latter in order that they may intelligently cooperate with him, it is believed that the next logical step is a description of the organi- 1 There has been established at the field officers' school, Marina Corps schools, Marine Barracks, Quantlco, Va., a correspondence course for medical officers which offers many advantages to medical officers of the Navy, particularly those serving with the Marine Corps in the field. The duties required of medical officers on board naval vessels and at shore stations in the United States are totally different from those required when serving with the Marine Corps in the field, where, during active operations, aid stnUons, dressing stntions, field and base hospitals must be established, and problems of evacuation must be solved. The staff problems connected with a military force in the field are complicated ones — much more so than those presented on board ship, and require a high degree of initiative on the part of all staff officers and in whom must be centered a great deal of responsi bility. The senior medical officer of any military organization is a technical advisor to his commanding officer, and upon him rests the responsibility for the coordination of all the medical units assigned to the command, their disposition to most effectively serve the combatant troops, and the procurement and issue of medical supplies in adequate quantities. To perform these duties most efficiently requires a more or less intimate knowledge of the organization of the combatant units ; their tactical dispositions under varying condi tions ; familiarity with the organization of the Medical Corps units best calculated to meet the demands made upon them ; and a knowledge of topography and tactics. In time of peace the only means available to the average officer for acquiring this knowledge lies in the solution of map problems. The general purpose of medico-military map problems is to invite attention to the varying conditions and factors which might .No. if. 221 BAYNOB — MEDICAL CORPS UNITS. zation and functions of the division general staff, and an outline of the administrative and technical services. A division consists of approximately 20,000 officers and men. Manifestly, it would be impossible for one man to control such a great number of individuals. For this reason we find these indi viduals organ:zed into a great number of subordinate groups, each having its own commander and varying in size from the squad of seven men under a corporal to the brigade, which is the largest sub ordinate unit in the division. It is by means of this organization that the commander, by dealing with a very few men, is enabled to exercise his authority over each individual in his command. This organization, by means of which a commander controls and directs the movements of his troops, is called the chain of command. The number of subordinates with which one man can deal effectively varies from five to nine, and it is upon this principle that military organization is largely based. Let us assume that a division has been directed by some higher authority to march from X and attack the enemy at Y. The first task of the division commander would be to draw up a plan for the movement. But before a plan can be formulated the commander must obtain as much information of the enemy as possible. The size of the enemy's force, its composition, disposition, condition, morale, probable intentions, etc., will all have a material influence on his plan. So also will it be influenced by the routes available and the nature of the terrain. In addition to the foregoing, he must study the question of supply in relation to the movement. He must deter mine and decide how much food and ammunition will be required, the kind and quantity of clothing and equipment to be carried, and innumerable other things that affect the fighting efficiency of the command. influence the management of the Medical Corps units serving with troops in the field. The correctness of the solutions rendered Is of relatively small Importance. Such solu tions merely apply to Individual concrete cases ; but the solution of a sufficient number of problems demonstrates broad general principles upon which the efficient solution of such problems or the handling of actual situations liable to be encountered in the field must depend. The practical value of map problems lies in the stimulation of thought along lines ordinarily relatively unfamiliar. Medical officers of the Navy are urged to take advantage of this opportunity. Further information regarding the course may be obtained from MaJ. S. N. Raynor, Marine Corps Schools, Quantico, Va. Officers enrolling for the course would be required to provide themselves with the fol lowing maps, which may be purchased from the book department, General Service Schools, Fort Leavenworth. Kans., or which will be supplied free by (he Bureau of Medicine and Surgery, upon request, to medical officers enrolling for this course : General map, Gettysburg-Antietam ($0.10). Gettysburg-Antletam, 3-inch map, 12 quadrangles, either mounted together on muslin '$3) or mounted singly ($0.25) each, or single unmounted sheets ($0.05 each), at their option. Geological Survey map of Gettysburg and vicinity, 1 : 62,500, 6 sheets, mounted together on muslin ($1.60). 222 Vol. XVII. RAYXOR MEDICAL CORPS UXITS. Having gathered together all the information obtainable, the com mander is then ready to draw up his plan, and after having done so to communicate it in the form of orders to his subordinates. These questions all relate to strategy and tactics, and naturally group themselves under the head of planning, directing, and coordi nating. In addition to his tactical and strategical functions, there are others of a more technical and administrative nature for which he is held responsible. Having decided that he will need so much am munition, food, clothing, equipage, etc., he must also take the nec essary measures to procure it. Such questions as the kinds and pro portions of the artillery ammunition to be carried must be decided. If the operation involves crossing a river where the bridges have been destroyed or are inadequate, he must determine and decide the kind and quantity of bridge material to be carried. Questions of signal communication, hospitalization and evacuation of men and animals, disposition of prisoners of war, traffic control, kinds and quantities of various materials for the construction of command posts, shelters, etc., must also be decided. These functions are all closely related, and are therefore placed in a group by themselves — a technical and administrative group. There are still other functions which group themselves into a purely administrative group. These functions, such as the assignment of officers and men to subordinate units, records of personnel, awards of merit, infractions of discipline, and many others of a like and routine matter, while they do not directly affect the tactical handling of the division, do affect its morale, its discipline, and its personnel, for all of which the commander is held directly responsible by his superiors in command. It is quite obvious that it would be beyond the powers of any one man to perform more than a very small proportion of the functions enumerated. He would become so involved in the mass of details as to preclude any possibility of his exercising his higher functions of command, viz., the study and consideration of questions affecting the tactical and strategical handling of his division, and upon which depends the success of his command as a combat unit. Evidently, if the division commander is to successfully carry out the tasks assigned his division, he must have competent and trust worthy assistants who are specialists in the various tasks assigned them. These assistants constitute the staff. While the duties of these staff officers pertain to the functions of command, they do not, as such, exercise command. Where orders are issued they are issued in the name of the commander, who alone is responsible for them and to whom falls the lot and right of making a decision. The staff No. 2. 223 RAYNOR —MEDICAL CORPS UNITS. z z F 1 8 G-2 00 O 5 d n tf 3 <! M h C k s T 5 c 5 0 ■Ha >- •<sn jopireuraioa jajsBuuajJBnt) itwtyo aammpjo .tusdmoo Musnpio uoo8jiig j<K>nj3ua J80UJO IBuSlg XaodniOD pra8is japuBtn joiaao aSsssojv laoujo jaUpnoH pas-o'W ■jpraoo'SuaVi - --f Bp •qsaow isoaojj pns jpiuoD bH ■03 bH 1 Li : c ■ a Si i 2 a I e o 224 Tol. XVII. EAYNOR — .MEDICAL CORPS UNITS. is charged (1) with gathering and furnishing the commander with the information upon which he bases his decisions; (2) with work ing out the details necessary to complete the decisions and enable the subordinates to carry them out; and (3) to see that the tasks assigned are carried out in accordance with the ideas of the com mander. We have seen that the functions of the division commander are divided into three groups: First, that pertaining to command and called the planning, directing, and coordinating group; second, that pertaining to the technical arms and services, and called the techni cal and administrative group; and third, those pertaining to routine functions, and called the administrative group. This division of the functions forms the basis of staff organization. Officers assigned to the first group constitute the general staff ; those assigned to the second group the technical and administrative staff ; arid those to the third group, the administrative staff. We will now consider those three groups separately and in more or less detail in order that we may see the relationship that exists be tween them and the commander, with the troops, and between them selves. THE GENERAL STAFF. The general staff is the connecting link between the general and his command. It relieves him of the mass of detail and leaves him free to devote his attention to the higher functions of command; it furnishes him with the information necessary to reach a clear and correct decision ; works out tentative plans and the details thereof ; and gives expression to his decisions in the form of orders and in structions, and insures their execution. By referring back we will see that this group naturally divides itself into four sections —one having to do with information of the enemy; another with questions of supply as affecting strategy and tactics; another with administrative questions; and still another section which having received all the information required from the first two sections, and the commander having drawn up a tentative plan, works out the details of this plan and, when a decision has been reached, communicates that decision to the subordinate commanders in the form of an order. From this division of duties has evolved the four sections into which the general staff of the division is divided : To the second sec tion or G-2 appertains intelligence of the enemy ; to the fourth section or G—1, questions of supply; to the third section or G-3, the prepara tion of plans of operation and their promulgation in the form of field orders so that they may be intelligently executed; and to the first section or G-l , personnel and routine matters. In Armies and higher No. 2. 225 RAYNOK MEDICAL CORPS UNITS. headquarters, the G-3 section is again divided into a G-3 section and a G-5 section, the former being confined to operations and the latter responsible for questions of training. The volume of work required from each of these sections is such as to require considerable personnel, varying with the size of the com mand. The work of this personnel in each section is coordinated and controlled by the chief of that section. Each chief of a section is officially designated as assistant chief of staff G-l, G-2, G-3, or G^, depending upon the section to which assigned. Jn order that all parts of the staff may function smoothly and that all questions of differences of opinion may be settled, and that all may be coordinated into an efficient team, the four sections of the staff are placed under the command of the chief of staff, who is the mouth piece of the division commander and the officer through whom he communicates his decisions and wishes, and through whom he re ceives the information and tentative plans upon which he bases his decisions. It is not the purpose of this article to go into a detailed description of the organization, functions, and operations of the four sections of the general staff. Only a very general outline of their functions sufficient for a clear conception of the staff organization as an entity will be given. As a concrete example let us go back to the division which was ordered to march from X and attack the enemy at Y. The operations or G-3 section is the group which will plan and work out the details for the movements of the division. The commander may, through his chief of staff, submit to this section a general outline of how he wishes the movement to be carried out, or, he may simply transmit to it the instructions he had received from higher authority and direct it to draw up tentative plans for his approval. The chief of this section, before he can draw up any plan, must get in touch with the chief of the intelligence section (G-2) in order that he may familiarize him self with any new information concerning the enemy, for, as already stated, the strength and disposition of the enemy will, very naturally affect the formation of the division for the movement. If the enemy is near, the formation must be such as to facilitate early and rapid deployment. This might best be accomplished by an advance in several columns over parallel roads. On the other hand, the presence of a hostile force on one flank would necessitate a flank guard. The strength and composition of the advance guard would also be influ enced by the strength and disposition of the enemy. It is evident, therefore, that there must be the closest cooperation between the G-2 and G-3 sections. The same sort of relationship must also exist between G-3 and the supply (G-4) section. This latter section works out and plans 226 Vol. XVII. RAYNOR MEDICAL CORPS UNITS. the operations of the services. If there is not the most complete coordination between these two sections, confusion and the most se rious consequences are likely to result. Ammunition and food sup plies, without which an army is helpless, may fail at a critical moment. For example, G-3, in drawing up his plans for the attack, may wish to use smoke or gas on certain sections of the enemy's posi tion, or he may desire to put over a long and heavy bombardment. He should first ascertain from G-4 if this ammunition is procurable, for otherwise he may find out, when it is too late, that his plans were faulty because the ammunition he desired was not obtainable. Likewise, G-4 must obtain from G-3 the latter's plans in order that the field and administrative orders will not conflict with one another. If the division is to be deployed for action G-4 must know the relative position of the various organizations before he can determine and designate the distributing points for rations and the distributing stations for ammunition, as well as the numerous other details that go to make up the administrative order, and which are dependent on the field order. (Note. —The administrative order will be discussed in a subsequent article.) THE TECHNICAL AND ADMINISTRATIVE STAFF. It has been previously stated that the administrative (G-4) sec tion of the general staff directs and controls the operations of the technical and administrative staff. Before we go into the details of this latter group, let us examine for a moment the reason for this group of the staff. As a matter of principle every staff should be reduced to the minimum consistent with efficiency. What are. the functions of the technical and administrative staff? Day after day the 20,000 men of our division must be fed, which means that rations must be procured and delivered. Furthermore, they must be properly and adequately clothed and equipped at all times. During combat they must have a plentiful supply of ammu nition, which must be procured and distributed. Every day a large number of men are taken sick and require medical attention. Dur ing combat many become casualties through wounds or gas. Arms and equipment are constantly being lost, destroyed, or worn out, and must be replaced. Animals, like men, become casualties, and some must receive medical attention, while others must be evacuated and replaced. Constant communication must be maintained withan the division and with headquarters, and this requires the supply and installation of signal equipment, such as telephones, switch boards, wire, radio apparatus, flags, panels, pyrotechnics, etc. When marches are undertaken the road may be in need of repair or bridges may require strengthening or have to be replaced. To distribute the supplies we must have both horse and motor transportation, and KAYNOR— MEDICAL CORPS UNITS. 227 this transportation must be so regulated as not to cause congestion on the roads or interference with the troops, otherwise the supplies may fail to reach their destination in time to be of any value. It is quite evident that no one man could perform all of these multifarious duties. Moreover, many are of a technical nature and require technical knowledge and skill which no one man could ex pect to master. This, then, is the reason for the technical and admin istrative staff: the officers who compose it being specialists in the bran, hes they direct. These officers are the technical advisers of the general and his general staff, and while they ordinarily function un der the direction and control of the G—4 section, nevertheless, at times and for some purposes they may function under the direction of some of the other sections of the general staff. Within a division the staff officers forming the technical and ad ministrative staff, and functioning, as a general rule, under the G-4 section of the general staff, are as follows : Field Artillery brigade commander. Machine gun and howitzer officer. Air service commander. Signal officer. Engineer officer. The surgeon. Ordnance officer. Quartermaster. Tank commander. Chemical officer. With the exception of the duties of the surgeon, it is not believed necessary to go into details regarding the functions of these staff officers. The functions of the division surgeon will be the subject of the next article. THE ADMINISTRATIVE STAFF. If, as has already been shown, it is beyond the powers of one indi vidual to perform all the duties pertaining to the administrative and technical staff, it is equally impossible for any one individual to dispose of the innumerable details of routine administration which fall within the province of the administrative staff. These functions divide themselves naturally into certain classes which are clearly de fined and pertain to the routine administration of the division, its correspondence, records, statistics, finances, questions of personnel, and others of a like nature. There are other functions which con cern inspections, questions of morale, discipline, military justice, and spiritual welfare. 228 Vol. XVIJ. RAYNOE —MEDICAL CORPS UNITS. These duties, which constitute the functions of the administrative staff, are divided among the following staff officers : The adjutant. The inspector. The judge advocate. The chaplain. The postal officer. The finance officer. The headquarters commandant and provost marshal. In the channel of staff control and coordination these officers oper ate under the G-l section of the general staff. RELATION BETWEEN HIGHER AND LOWER STAFFS. In the foregoing discussion the staff organization of a division has been taken as a model. The staffs of all organizations are, however, organized on the same general principles. Although in principle each staff functions under the authority and in the name of its com mander, it will be found that in matters of a purely routine nature the higher and lower staffs deal more or less directly with each other. However, it should always be remembered that a staff officer, as such, can not exercise command except in his own office and over his own assistants. Before closing it seems to be advisable to define and illustrate the words coordination, supervision, and control, which are continually being used in reference to the general staff. Webster's Dictionary defines coordination as " The act of regulat ing and combining so as to produce harmonious results." Let us apply this definition to an example and assume for this purpose that the division which was to march from X to Y reaches the vicinity of the latter place late in the afternoon, and that the com mander decides to bivouac for the night and attack the enemy's position early the next morning. There are many questions of sup ply and administration which will conflict and produce confusion at this critical time unless there is some one in authority to make harmonious adjustments of these conflicting claims of the adminis trative and technical staff in the light of their bearing on the plan of the commander and which can not be known to them. There is the quartermaster who is responsible for feeding the troops; the ordnance officer who must see that all small-arms am munition needed for the battle on the following day reaches the troops in sufficient quantity and on time; the surgeon must make plans for the evacuation of the wounded and that necessitates the establishment of collecting stations, field hospitals, ambulance routes, etc. ; and the engineer and signal officers who must get supplies to the front. Each of these officers is. quite naturally, interested only in No. 2. 229 RAYNOB— MEDICAL CORPS UNITS. his own particular task. If some one does not pass upon and regu late their conflicting claims, the evening before the battle will find the road leading to the front blocked with traffic and, instead of all the supplies reaching their respective destination that night, traffic jams will probably prevent any of them from reaching their desti nations. In addition to the foregoing, the quartermaster has selected a point where he wishes to establish a ration distributing point, but it appears that the ordnance officer has selected that same point for establishing his ammunition distributing station; or that the sur geon wishes to establish a collecting station there; or that the engi neer officer would like to use that spot as a dump for engineer ma terial. Not one of these officers is in a position to decide as to who shall have priority because not one of them is familiar with the gen eral plans for the attack, and, even though they did know, each one would naturally decide in favor of his own service. There must be some one, other than these technical staff officers, to make harmo nious adjustment of these conflicting claims, so that no one particu lar class of supplies will reach its destination but that all of them will reach their destinations on time and without confusion. The officer best qualified to coordinate the activities of these officers of the administrative and technical staff, and to produce a harmonious and smooth working machine, is one who can view all of the func tions from the viewpoint of the commander — in other words, a mem ber of the general staff, and in the ease in question, the assistant chief of staff G-4. Control is defined as "To restrain, rule, govern, manage, guide." The assistant chief of staff G-4, having coordinated the conflicting claims of the technical and admisistrative staff, and having decided on such other matters of a supply and administrative nature as required direction and adjustment, governs, manages, or guides the operations of these services by the issuance of administrative orders and instructions to the command in the name of the division com mander. The mere issuance of orders is not sufficient, as we are all well aware. There must be a follow-up to see that the instructions and orders of the commander are carried out in accordance with his plans and wishes. This overseeing, inspection, superintendence, etc., con stitutes the general staff supervision. The accompanying chart shows graphically the organization of the general staff of a division. Note. —The subject matter of this article has been compiled from War De partment publications and pamphlets used In the courses of instruction at the General Service Schools, Port Leavenworth, Kans., and the Marine Corps 8chools, Quantico, Va. From its nature much of it has been copied verba 230 Vol. XVII. GALWEY GAS WARFARE. tim. By quoting or modifying the text of those publications and pamphlets where, for the purposes of this article, such modification seemed desirable, the writer has endeavored to present a clear and understandable picture of the general staff of a division, but disclaims any credit for originality except in the method of presentation. GAS WARFARE. EFFECTS OF POISONOUS GASES—EARLY AND LATE.1 By Maj. W. R. Galwbv, O. B. E., M. C, Royal Army Medical Corps. Since the advent of chemical warfare a very large number of sub stances have been examined with a view to determining their suita bility from the points of view of production in quantity, use in shells, bombs, or projectors, and the physiological effects on human beings and other animals exposed to them. A detailed list of these substances would serve no useful purpose, and it will suffice to show how thej' may be grouped into the follow ing classes according to their physiological effects and to mention one or two of the more important substances in each group. (1) Lachrymators. (2) Sensory irritants of the eyes, nose, and upper respiratory passages. (3) Vesicants. (4) Asphyxiants or acute lung irritants. (5) Direct poisons of the nervous system. (6) Gases which act by interference with the respiratory property of the blood. Compound. Formula. Boiling point °C. Characteristics. Benzyl bromide.. . C«H(CU5Br 198 Colorless liquid with pungent smell. Group (1) Lachry mators. Xylyl bromide CH^HsCHjBr... CHjBrCOCH, 185 137 Brom. acetone Pale yellow liquid with pungent smell. (2) Sensory irritants of the eyes, nose, and upper respiratory passages. Examples: Di-phenyl. chlor. arsine (C6Hr,).,: AsCl melt ing point 43° C. ; boiling point 333° C. ; faintly odorous, yellowish oil or as a solid; ethyl-di-chlor. arsine, C2HsAsCl2< boiling point 156° C, faint ethereal smell. (3) Vesicants. Examples: Di-chlor. ethyl sulphide (mustard /CH CH CI gas) S<^ c^CH^Cl^0^11^ P0^'' a Pa*c yeH°wisft \ 2 2 odor of garlic or mustard. (4) Asphyxiants or acute lung irritants. Examples: Chlorine Cl2, boiling point 33° C, greenish-yellow gas, smell of bleaching 1 Reprinted from the Jour. Royal Army Med. Corps, London, February, 1922. No. 2. 231 GALWEY —GAS WARFARE. lime; phosgene (carbonyl-chloride) COCL, boiling point 8° C. ; col orless pas, smells of musty hay, tobacco gives a characteristic taste after phosgene has been inhaled. (o) Direct poisons of the nervous system. Example: Hydrocy anic acid HON. boiling point 26.5° C, melting point 13.8° C; color less mobile liquid with smell of bitter almonds. (6) Gases which act by interference with the respiratory proper ties of the blood. Example : Carbon-monoxide ; colorless, odorless gas, lighter than air. This classification is to some extent artificial, for in certain in stances the groups merge into each other, e. g., some lachrymators are asphyxiant in high concentrations and the asphyxiants cause lachrymation. Again, the arsine compounds besides being sternu- lators cause lesions in the lungs and possibly in the central nervous system. A8PHTXIANTS. Confined to the upper air passages these substances may reflexly inhibit breathing and may produce anesthesia of the mucous mem brane with loss of taste and smell. If they reach the larynx in quantity, they may cause immediate suffocation through spasm of the glottis. In the pulmonary air passages they may cause intense bronchial spasm, also necrosis and stripping of the mucous membrane leading to mechanical blocking of the air passages. If they reach the air cells in large quantities, they may penetrate the epithelium and the capillary walls and directly affect the blood, and so lead to those changes which bring about a blocking of the pulmonary circulation. Immediate death has occurred in laboratory animals exposed to high concentrations of phosgene. When this happens, intense ven ous and capillary congestion and subdural hemorrhages in the brain are found. The lungs show practically no edema. The blood ves sels in the lungs are much congested and inundated with a brownish granular material. The blood in the systematic circulation is nor mal to spectroscopic examinations. Death is thus accompanied by and probably due to an immediate pulmonary vascular stasis re sulting in acute asphyxia. Cats exposed to chlorine 1.700 died in less than 15 minutes, the blood being almost black, arterial pressure falling rapidly and there being no asphyxial rise, and practically no lung edema. Pulmonary changes appear to be a necessary stage in all the patho logical effects of the irritant gases. With doses of such a strength as to cause death in two hours, damage of the lung seems a neces sary factor. 232 Vol. XVII. GALWEY —iGAS WARFABK. In smaller quantities than those giving rise to effects just de scribed, the asphyxiants may injure in various degrees the bronchial mucous membrane and the epithelium of the air sacs and capillary walls, without actually penetrating into the capillary vessels, the lesions giving rise to intense pulmonary edema. Finally, a secondary bacterial infection may lead to pneumonia and infective inflammation of the respiratory passages. The condition brought about after the injury to the capillaries and air cells is one of want of oxygen, and to this most of the serious symptoms and the sequelae of asphyxiant gas poisoning are due. In fact, there is no good evidence that with moderate concentrations of gas, any system of the body other than the respiratory is pri marily damaged. So far as the evidence goes at present, the lesions found in the other organs are a consequence of the interference with the respiratory exchange of oxygen. Of the typical asphyxiants chlorine affects the upper air passages and bronchial tree primarily; while the action of phosgene is chiefly on the cells of the lung alveoli. Chlorpicrin is intermediate between the two. Experimenting with dogs, Underhill found that chlorine has a very strong irritative action, an animal gassed therewith becoming excited and in evident distress. With chlorpicrin the character of the reactions is very similar but less pronounced. With phosgene, on the other hand, the animals appeared to be in no immediate distress. To some extent this difference of reaction can be explained. When the substance is introduced in the atomized condition, if the spray is coarse it may be entirely held up in the upper respiratory passages. A fine spray, on the other hand, may reach the alveoli. If the sub stance is very soluble, as ammonia, the moisture of the surfaces of the air passages would largely entrap it. Possibly also a substance may be comparatively innocuous to the more resistant epithelium of the air passages, and only effective on the more delicate lining of the alveoli. Or again, the vapor may have an affinity for some tissues while it is relatively indifferent to others, as in the case of mustard gas, which attacks the epithelium of the air passages, but not that of alveoli. In acute deaths from asphyxiant gas poisoning, i. e.. those occur ring in about 24 hours, the most striking changes are found in the lungs. The following are the gross lesions found in human beings : On opening the thorax the lungs are voluminous, and hardly collapse at all. Distended lymphatics and small subpleural hemor rhages are visible on the surface. Rarely the hemorrhagic areas coalesce with stripping of the pleura. Xo. 2. 233 GALWEY — WARFARE. <!AS i Air from damaged lungs is visible as chains of bubbles below the visceral pleura along the interlobular fissures, and occasionally pene trating into the tissues of the mediastinum and into the subcutaneous tissues. The whole external surface of the lung shows deep purple areas of collapse or consolidation slightly depressed below the surface, alternating with irregular areas of acute emphysema of a light grayish color. Emphysematous patches are more numerous along the margins and diaphragmatic surface of the lung where bullae are sometimes found. In the pleural cavities are found serous fluid in varying quantities and some traces of blood. The lungs, on removal, weigh several times their normal weight. They feel wet, and on section drip frothy fluid and blood. The irregular patches of collapse and emphysema extend throughout the lung substance. Occasionally definite infarcts are found. The fluid collected from the lungs of animals dying with acute pulmonary edema is clear straw-colored, and occasionally contains a few red blood corpuscles. Underhill found that its chloride con tent is essentially the same as that of a simultaneous sample of blood plasma. This shows that there is complete permeability of the pul monary capillaries for salts. The edema fluid and blood plasma are in equilibrium as regards their salt content. The trachea and bronchial tubes are largely filled with thin, yel lowish, highly albuminous fluid, which sometimes escapes as a froth from the mouth and nostrils after death. The degree of inflammatory change in the mucous membrane is variable. In severe cases the lining of larynx, trachea, and bronchi is of a deep purple color, swollen and edematous. The epiglottis is affected to a less extent than the trachea and the edema of the larynx is not sufficient to endanger life. The mucous membrane of the pharynx is generally dry, glossy, and somewhat congested. Sometimes only the lower trachea and bronchi are affected, and occasionally (as in cases of pure phosgene poisoning) they are nor mal save for frothy fluid. It is stated that a false membrane was rarely found in cases which survived to reach a medical unit. If death is delayed to the second or third day the aeration of the lung tissue is better; and if the patient survives till the fourth day areas of broncho-pneumonia and pleurisy may be found. In examining lungs from animals killed at various periods after gassing one is struck by the very small amount of sound lung tissue with which the animal appears to be able to carry on. 234 Vol. XVII. GALWEY —GAS WARFARE. On examination of the circulatory system engorgement of the large veins is found. The right heart is generally but not invariably distended, and sometimes petechial hemorrhages are found in the endocardium. Sometimes there is an increase in the pericardial fluid. The blood clots rapidly and its concentration is above normal. Abdominal organs. —There may be petechial hemorrhages and slight ulceration in the stomach. Large hemorrhages in the stomach cavity have been described. There is a general engorgement of viscera; enlargement and nut meg appearance of the liver and enlargement and congestion of the kidneys are found ; but frequently in experimental animals no abnor mal appearances are observed. Central nervous system. —In early deaths as a general rule only engorgement of vessels, both meningeal and cerebral, is found; but when death follows after two or three days of cyanosis and uncon sciousness due to want of oxygen, tiny petechial hemorrhages are seen surrounding vessels throughout the whole of the white matter. Similar hemorrhages have been found in the brain in deaths which were ascribed to shell shock, but as Sir F. Mott has pointed out, such deaths may in reality have been due to poisoning by the carbon-mon oxide generated by the shell explosion. The punctiform hemorrhages occurring in the white matter are primarily due to the anatomical conditions of the vessels in the cerebrum, where they are terminal, each small artery having a sepa rate capillary system, as is also the case with the emerging veins. A tendency to stasis may be brought about in these separate vascular systems by the failure of the heart as a force pump, also by respira tory conditions which lead to right heart dilation and interference with return of blood from the skull. In those gas cases where the hemoglobin has been converted into pigment the hemorrhage may arise from occlusion of the arteries. Observations on animals have enabled observers to give a fairly clear account of the sequence of events which lead up to the post mortem appearances desmbed above. .Professor Shaw Dunne made^ extensive observations at Porton on goats gassed with phosgene, and the following account of the changes in the lungs is abstracted from his paper: By the end of half an hour after gassing on inspection of the lungs red areolae are observable in the centers of alveoli. Fluid accumulates In the interlobular planes, which are seen as fissures and under the pleura. On miscroscopic examination alveolar edema is found. Masses of light granular mnterial are seen most commonly in the openings of the infundibular cavities toward the centers of the lobules. This light edema is found all over the lungs. At this stage desquamated pulmonary epithelial cells and red-blood corpuscles can be seen in the edema in small numbers. No. 2. 235 GALWEY GAS WARFARE. The Interlobular planes of connective tissue show marked edema, the fibers forming them widely separated by granular material representing fluid. The lymphatic vessels in these planes are distended us are those In the bronchial and arterial walls. In the central lobules there Is blocking of the capillary vessels in the alveolar walls by minute thrombi. This phenomenon may be seen as early as half an hour after gassing, but is usually well advanced by two or three hours. In the earliest recognizable stage the damaged vessels appear collapsed and con tain few red-blood corpuscles but many leucocytes. The process Is confined to the rows of alveoli nearest to the infundibular openings. On the fringe of this area the capillaries are much engrossed with blood in contrast with those situ ated more peripherally. The latter are almost empty as in a section of normal lung. The engorged state of the capillaries points to stasis of blood in them during life. At quite an early stage the musculature of the bronchlolar termination and infundibuiu is affected. The fibers are swollen and tend to lose their striation. In some cases these muscles are in a condition of spasm so that groups of alveoli are distended with air which can not escape. This condition has been found to persist as late as 12 hours after gassing. As it affects the airways to both edematous and nonedematous areas it tends to prevent loss of function in the former being compensated by the latter and so Increases the lack of oxygen of the animal. At this stage the superficial layer of ciliated cells of the bronchi also show evidence of damage. During the Initial period of three to four hours the amount of fluid which remains In the air spaces is very small, though a great excess must escape from the capillaries which have undergone a less severe lesion than those which are actually thrombosed. The edema in the interlobular planes indicates this and also shows how rapidly an abnormal exudate can be got rid of from the alveoli. After this initial stage, naked-eye examination shows extension and intensifi cation of the edema with progressive diminution of the normal post-morten collapse of the lungs. The reddening In the center of lobules extends to whole lobules and deepens in tone. The surface of the lung is mottled In varying shades of red, as some lobules are more affected than others. Later large areas become entirely filled with fluid to the exclusion of air. By the end of 48 hours the condition of light profuse and universal edema is no longer seen. In the majority of the animals observed there are greater or less tracts of solid lung, contrasting with areas in which edema is slight or absent and aeration well established. Histological examination shows a further development of the changes observed in the early stage. The alveolar edema is more abundant and more generally distributed. The solid residue of the edema is denser in consistence. It may appear as a reticulum like fibrin or a homogeneous masslike colloid. Every alveolus in a lobule and also the infundibular cavities and terminal bronchioles may be full of It. Even where there is a vacant space representing air this may be situated centrally so that it is away from the capillaries and alveolar walls. If edema persists for more than 24 hours the alveolar walls may show thicken ing and many of their epithelial cells may be desquamated and He in the edema residue. There may be a few polymorphonuclear leucocytes in the exudate. There is evidence of loss of tone in the elastic fibres in the alveolar walls. The smaller bronchi and bronchioles show loss of superficial ciliated cells, bnt rarely is the whole epithelial coat destroyed. 108165—22 4 236 Vol. XVII. GALWEY GAS WARFARE. In places bronchioles are partially blocked. Those which lead to solid lobules become filled by albuminous material, mucus and epithelial debris. Capillary thrombosis undergoes very little extension after the initial period, and persists practically unchanged for 36 to 48 hours. It <s always accom panied by much engorgement of the neighboring capillaries. The fluid in the alveoli diminishes the lumina of the capillaries since it subjects their walls to greater pressure than would the normal content of air. Up to 48 hours after gassing, then, the outstanding feature is progressive diminution of aerating surface by fluid accumulating in the alveolar spaces. As the distribution of the edema is not uniform, a greater or less extent of lung may remain relatively free and may suffice to keep the arterial blood sufficiently aerated till the edema subsides. There is experimental evidence to show that though the circula tion in the capillaries is much impeded by intense edema the total blood flow is fairly well maintained, therefore a greater proportion than usual must pass through the less edematous portions where some degree of oxygenation can be effected. The accumulation of fluid seen in the interstitial planes and under the visceral pleura and the exudation in the pleural cavity shows how the fluid escaping from the alveolar capillaries is being con tinuously drained off. The amount remaining in the alveoli shows how far supply is in excess of disposal. As a rule in animals gassed with phosgene, death during the first 48 hours is associated with an extreme degree of pulmonary edema, and as a result of fluid in these spaces the greater part of the respira tory area is out of action. Death is thus due to diminution of the supply of oxygen to the blood, and this conclusion is confirmed by blood gas analysis. In animals dying in first 24 hours the edema, though universally distributed, is not so intense. Death in these cases may be due to oxygen lack combined with shock or lower resistance. In animals dying on third day it is found that the pulmonary lesions are on the decline ; the alveoli could take in air if the neces sary respiratory effort were forthcoming. In such cases it is possible that the earlier lack of oxygen has brought about failure of the heart and respiratory center. It is usual for animals to die within the first two to three days after gassing with phosgene ; deaths at a later period are frequently due to secondary infection. In animals which have survived till the third or fourth day and have then been killed for purposes of exami nation there is evidence of the decline of edema. The only visible edema is on the ventral aspects of the lungs, but the affected portions are almost entirely solid. The lesions may be scattered or occupy large areas. The main body of the lungs appears fully aerated. The aerated portions collapse less completely than normal. No. 2. GALWEY GAS WARFARE. 237 t The contrast between the solid areas and expanded areas is ex treme. It is probably due to the edema in the greater portion of the lungs being insufficient to interfere seriously with aeration, so that expansion and contraction is not checked. The movement of the lung tissue and compression of air will aid drainage of fluid through the lymphatics. On the other hand, in solid lobules no such help is ■riven and air may not even enter choked bronchioles. In the worst cases amongst goats which recovered, Dunn found solid edema in one-third to half of each lung and edema in some degree in the remaining portions. By the fourth day there is definite evidence of the absorption of edema. The lungs are less bulky and there is obvious shrinkage of the solid areas. The dorsal parts of the lungs are fully aerated. The margins of the solid and aerated areas are not sharply differen tiated ; there is an intermediate zone where reexpansion is proceeding slowly. By the fifth day scattered lobules in the solid areas are aerated. By the eighth day only small areas remain unexpanded. In animals surviving to the fifth and sixth week the lung has resumed its normal appearance. Microscopic examination shows how reparation is brought about. The more lasting the edema in a lobule the greater is the amount of histological change developed. The maximum alteration is in the area of thrombosed capillaries. The alveolar walls here become thickened, partly owing to edematous swelling of their connective tis sue elements, partly to increase in the number of their cells. The thrombi are disposed of by phagocytic action, and the capillary net work is ultimately completely reformed. The thin pulmonary epi thelium is replaced by closely set cubical cells like those in the termi nal bronchioles. The reparative changes are therefore of a subacute inflammatory character. The albuminous material shrinks and is attacked by phagocytes from the pulmonary epithelium. In the more peripheral portions of the lobule outside the thrombosed area there is slight thickening of the alveolar epithelium which later dis appears. The signs and symptoms of asphyxiant gas poisoning.—All the gases which act as lung irritants cause practically the same type of symptoms, though the time of onset and the concentration necessary to cause symptoms of the same severity differ with particular gases. The picture also varies slightly according to whether the gas affects primarily the respiratory passages of the alveoli of the lung. Exposure to an atmosphere containing one of these gases causes immediate sensory irritation accompanied by smarting and watering of the eyes. The irritation of the respiratory passages causes catch ing of the breath, coughing, and a sensation of tightness in the chest. 238 GALWEY GAS WARFABIi. Vol. XVII. The intensity and duration of those early symptoms depend upon the concentration. Even a very mild dose of phosgene may cause a feeling of lassitude and general discomfort for some hours. As a rule nausea, vomiting, and retching are prominent features in the early stages. Inhalation of phosgene causes a very characteristic change in the taste of tobacco. The onset of edema of the lungs is signaled by deep cyanosis or leaden-colored facies, the cough and frothy expectoration, the dis tress and restlessness, the quickened respiration and rapid pulse which are characteristic of a serious case of gas poisoning. These signs are usually well established by the time a patient is admitted to a field ambulance or casualty clearing station. In the case of phosgene poisoning there is, however, sometimes, considerable delay and a man apparently only slightly gassed may carry on his duty for several hours and then become seriously ill. Headache, pain behind the sternum and in the epigastrium are asso ciated with these signs and symptoms in the majority of patients. As the case develops, want of oxygen becomes more serious and domi nates the clinical picture. The serious cases may be divided into two groups : (1) Those which show definite signs of venous engorgement, i. e., congested and deeply cyanosed face, blue lips and tongue, visible distension of the superficial veins of the face and neck, increased breathing which is often deeper than normal. Cough may be present and accompanied by abundant thin frothy fluid. The pulse is full, of good tension, and beats about 100 per minute. (2) In the second group the deep cyanosis is replaced by an ashen pallor, the lips being pale and of the color of lead. The patients are collapsed, respiration is rapid and shallow, the pulse is rapid, weak and running up to 130 to 140 per minute. There is often little cough or expectoration. This latter group predominates in phosgene poisoning. Of these serious cases in both groups, some exhibit extreme restlessness and anxiety; others a semicoma and muttering delirium. Consciousness may be maintained to the end. Sometimes a case in the first group will gradually assume the characteristics of the second group. Four-fifths of the deaths occur in the first 24 hours and very few after the third day. This has also been observed in animals gassed for experimental purposes. A case apparently slight during the first 24 hours may rapidly go downhill and die on the second day ; but, generally speaking, for the less severe cases the danger is passed on the second day. -No.2. 239 GALWEY GAS WARFARE. Bacterial infection may lead to the characteristic signs and symp toms of broncho-pneumonia developing on or after the fourth day, and this complication may rapidly kill the patient. Deaths from this cause are not so common as might be expected. As a rule by the end of a week a patient is convalescent. During convalescence there is often a temporary bradycardia. Complete recovery may take a considerable time, and a certain percentage of patients develop symptoms which are very trouble some and intractable to treatment. These cases fall into three main groups : (1) Cardiac. (2) Spasmodic dyspneic. (3) Combined cardiac and dyspneic. (1) Cardiac.—These patients exhibit the characteristic signs and symptoms of the effort syndrone or irritable heart, i. e., precordial pain, dyspnea, exhaustion, and persistent tachycardia after exercise. The patient may look "done" after walking half a mile in 10 minutes and may be quite incapable of going upstairs quickly. (2) The characteristic symptom of the second group is spas modic attacks of dyspnea at night. They may occur every night or at intervals of a week. During an attack the patient sits up in bed, his breathing is rapid and shallow, but not difficult, resembling the dyspnea of uremia rather than that of asthma. Slight cyanosis may be present. The attack may last up to 30 minutes and several may occur during the same night. The pulse may be slow and full or rapid and thready. Such a patient on exercise suffers from intense headache and giddiness. The pulse rate after exercise may fall rapidly, unlike that of the cardiac group. In these patients the blood usually shows a hemoglobin percentage over 100. (3) A third group combines the symptoms of the first two. All these groups suffer from pain in the head, pain in the abdo men, usually worse after food, and pain in the chest. The above description gives a fairly typical picture of the course of a case of gas poisoning : there remain, however, a few observations made either clinically or by laboratory examination of gassed ani mals which are of importance. (1) Respiratory system. —The percussion note may remain reso nant all over the chest, notwithstanding the presence of marked pulmonary edema. The breath sounds are weakened, especially behind. Fine rales and rhonchi are heard. Considering the extreme danger to the lungs the physical signs give little indication of the seriousness of the case. (2) Circulatory system. —In the early stages the pulse may be so rapid as to be uncountable. This may be due to shock or to an early developing condition of oxygen want. Another early sign 240 Vol. XVII. GALWEY— GAS WARFARE. in some cases is acute dilatation of the right heart. This may be only temporary, disappearing during convalescence. The second cardiac sound is accentuated; this is connected with raised tension in the pulmonary artery. In experimental animals blood pressure falls early and the fall is permanent. The initial fall may be preceded by a temporary rise, and this occurs before there are distinct signs of lung edema or as asphyxial state of the blood. This fall may be due to the development of an early want of oxygen reacting on the spinal and medullary centers, or to dilatation of the pulmonary vessels leading to stasis of blood in the lungs and its withdrawal from the systemic circulation. (3) Changes in the blood. —Concentration of the blood is a marked feature of cases of gas poisoning. This is brought about primarily by the production of pulmonary edema, but is contributed to by shock which leads to stagnation of the blood in the capillaries, and by partial asphyxiation of muscular and other tissues which brings about increased local production of lymph. The curve of the concentration of the blood follows closely that of the percentage of hemoglobin as measured by a hemoglobinometer, and Hb. values up to 140 per cent have been obtained. This means that the concentration of red blood corpuscles is really 40 per cent greater than normal, and therefore the potential oxygen-carrying capacity is increased; but on the other hand analysis of the blood gases shows that the actual oxygen content is seriously diminished, and that the increase of corpuscles does not compensate for this loss. It should also be noted that the increase of red blood corpuscles at this stage is relative and not absolute. Later a true polycythemia may develop in certain cases which are slow in convalescence; it may be regarded as a compensation for chronic oxygen deficiency. (4) Digestive system.—Acute gastritis occurs in fatal cases, and chronic dyspepsia is one of the commonest sequela? of gas poisoning. (5) Excretory system. —The kidney are congested, as a rule, in cases which come to the post-mortem table. Albuminuria is found in poisoning with chlorpicrin. In goats dying as the result of gassing with this substance and with phosgene, a condition of acute necrosis of the kidney was found. This change is probably due to a circulatory deficiency and not to the direct effect of the gases themselves. Gases which interfere with the respiratory functions of the blood —Carbon monoxide. —This gas, though not used directly for offensive purposes, was a cause of casualties, being generated when camouflets in mines were blown, when high-explosive shells burst in a confined space, and from the discharge of machine guns in No. 2. 241 GALWEY GAS WARFARE. insufficiently ventilated pill boxes; from charcoal braziers in dug outs, and from the exhaust gases of motor engines in tanks. Carbon monoxide combines with the hemoglobin in the blood as does oxygen, but has about 240 times the affinity for hemoglobin that oxygen has. When blood is exposed to an atmosphere con taining CO and 02, the hemoglobin divides itself between the gases in proportion to their relative partial pressures. The gas acts as a poison simply through its exclusion of oxygen from the red-blood corpuscles so that want of oxygen develops —the degree of want of oxygen depending upon the amount of CO hemo globin present and upon the fact that when part of the hemoglobin is combined with CO the dissociation of oxygen in the tissues is slower than normal. The symptoms of the poisoning depend upon the degree of satura tion of the blood with the gas, and vary from giddiness and headache to loss of consciousness, respiratory and cardiac failure and death. The treatment is pure oxygen at once. This is given not for the purpose that oxygen is given in asphyxiant gas poisoning, but to drive the CO out of combination with the hemoglobin, since the amount which the hemoglobin combines with depends upon the partial pressure of CO and of 02 in the blood. Care should be taken that the patient does not rebreathe his own expirations. As soon, then, as the CO has been driven out the Oa may be stopped, though, on account of the damage already caused by the lack of oxygen, the patient may not recover consciousness at once or, indeed, may not recover at all. All are, no doubt, familiar with the cherry-red color which the Mood develops in the presence of CO. The box respirator does not protect against CO poisoning and in entering mines, etc., when it is present, it is necessary to wear an oxygen-breathing apparatus. Direct poisons of the nervous system. — Hydrocyanic acid is a di rect tissue poison, but the nervous system is peculiarly susceptible to its action. Concentration of the gas is of more importance than duration on exposure, i. e., it has practically no cumulative effect. When a cer tain concentration is attained the action is very rapid, but if the concentration is low it may be borne for a considerable time without ill effects. Syjnptom* follow each other in rapid succession —giddiness, con fusion, headache, indistinct sight, palpitation, and pain in the chest and over the heart, labored breathing, unconsciousness, convulsions, failure of respiration, and, finally, of the heart. In large doses death is almost immediate. 242 Vol. XVII. GALWEY —GAS WARFARE. The respiratory center is rapidly paralyzed — immediate treat ment, therefore, is necessary. The patient must be brought into fresh air, and if the respiration is stopped or gasping and weak Schafer's method of artificial respiration must be resorted to im mediately. This is the essential in treatment, and although other well-known methods of resuscitation may be applied time should not be wasted on them before artificial respiration is commenced. 6 243 LETTER WRITTEN BY HAMET CARAMALLI. HISTORICAL. JONATHAN COWDERT, SURGEON IN THE UNITED STATES NAVY, 1767-1852. PART II. By Capt F. L. Pleadwell, Medical Corps. United States Navy, and Lieut. Commander W. M. Kbrb, Medical Corps, United States Navy. In 1806 there 'was printed and sold by Belcher & Armstrong at No. 79 State Street in Boston a small book with the title "American Captives in Tripoli or Dr. Jonathan Cowdery's Journal in Minia ture." Evidently Doctor Cowdery contemplated a more extensive account of his experiences, for it is stated in the preface of this book : " He kept a regular journal from the time of his capture to the day of his release, in which he noted, as minutely as circumstances would admit, everything novel or remarkable and he has in contemplation to publish a volume to be entitled 'American Captives in Tripoli,' containing the particulars of the capture of the Philadelphia frigate ; general description of Tripoli with its adjacent country, its curios ities, etc., and a sketch of the customs and manners of its inhabi tants; to which will be added the journal at full length kept during his captivity, and an appendix containing the treaties and general relations between the United States and the Barbary Powers." As far as we know, this contemplated book was never published, but the following extracts from Doctor Cowdery's "Journal in Miniature " will tell the story of an interesting and romantic episode in American history. It is printed just as it was written over a hundred years ago, with the quaint phraseology, spelling, and punctuation in vogue at that time: The particulars of the unfortunate capture of the Philadelphia frigate, by the Tripolitans, have already been before the publick. She run on a bank abreast of tlie harbour of Tripoli, on the 31st of October, 1803, at 11, A. M. and kept up a brisk cannonade, with the pun boats of that regency, until 4 P. M. ; when, failing in their efforts to get her off, they surrendered to supertour force. The Philadelphia mounted 44 guns, and had 350 men ; she was afterwards got off by the Tripolitans, and moored in their harbour: but was destroyed by Capt. Stephen Decatur, jun. in a schooner, with three boats, a part of our Mediter ranean squadron, who boarded and burnt her up the night of the 18th of Feb. 1804, four months after her capture. On the capture of the Philadelphia, the Tripolitans demanded one million six hundred and ninety thousand dollars, for the release of our captured brethren ! they, however, have been very glad 243 244 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. to take 60,000 dollars for their release, and to enter into new bonds for future good behaviour ! This much promised, we now proceed to Dr. Cowdery's Journal; which he commences immediately after his capture. After the flag of the Philadelphia was struck, (says the Doctor), and the officers and crew were waiting the pleasure of their new masters, the Tripoli- tan chiefs collected their favourites, and, with drawn sabres, fell to cutting and slashing their own men, who were stripping the Americans and plundering the ship. They cut off the hands of some and it is believed several were killed. After this battle amongst themselves, was a little over, we were ordered in the boats to be carried on shore. One of their officers, whom I had taken by the hand, and who promised me his friendship, came to me, took me by the arm, and told me I must go. I asked him to let my boy go with me, which he refused. I then took hold of my small trunk, which contained my best clothes ; he gave me to understand that I could not take it, but should have every thing taken care of and restored to me. He took hold of my hand and hurried me over the side of ship, while his other hand was employed in rifling my pockets, from which he took about ten dollars. I had concealed some gold in my clothes, which he did not find. I then went down into one of their boats, from whence I was to pass into the next, which was almost full of our officers and men. I made all haste to get into it for I observed that the Turks in the boat where I then was, were stripping my messmate, Dr. Harwood, and the carpenter, Mr. Godby ; but I was soon stopped by three of the ruffians, who stood over me with drawn sabres and cocked pistols, and wrested my surtout from under my arm. Whilst they were picking its pockets, and quarrelling with each other for the booty, I sprung for the next boat, which was \vaitlng for me. In my way, I met a little fellow, who seized me, and attempted to take off my coat ; but I hurled him into the bottom of the boat, and jumped into the one which was waiting amongst my fellow officers, where I thought the Turks more ■civil. They then set off for the town, compelling our men to row the boat, and standing with drawn sabres over our heads. When we had got near the shore, they ordered our men to stop rowing. Two of them came to me and gave me a severe blow on the side of the head. They then searched me. and took a case of surgeon's instruments from my pocket. They took my pocket book, but finding it contained nothing but papers, they returned it. One took my silver pencil, and another the handkerchief from my neck. They then began upon Mr. Knight, sailing master, Mr. Osborne, lieutenant of marines, and all the officers in the boat, plundered their pockets and took the handkerchiefs from their necks. They then landed us at the foot of the Bashaw's palace, where we were received by a guard, who conducted us into the palace before the Bashaw. He viewed us with the utmost satisfaction, and had us conducted into an apartment where we found the captain and several officers, who arrived in another boat just before us. Here was a table set in the European style. The servants appeared to be Maltese and Neapolitan slaves. Here we supped, after which it was announced that another boat had arrived with our officers and men. who were before the Bashaw. Capt. Bainbridge requested me to go and look for Dr. Harwood, whom it was feared was killed. I found him with the car penter before the Bashaw, stripped of everything but their shirts and trousers. They afterwards informed us, that they were stripped in the boat where I lost my surtout; and when they got within a few rods of the shore, they were thrown into the sea, and left either to drown or swim ashore. The Bashaw's No. 2. JONATHAN COWDERY, SURGEON IN V. S. NAVY. 245 servant gave tlieiu dry clothes, and we were nil again conducted before the Bashaw,1 and formeti into a half circle. He was seated on his little throne, which was decorated in the Turkish order, and made a handsome appearance. He is a good looking man, aged about 35. He counted us, viewed us with a smile, and appeared highly pleased with us. We were then conducted by the minister of exteriour relations and a guard, to the house formerly occupied by the Ameri can consul— a very good house, with a large court, and roomy enough for our convenience. We were seated here about nine o'clock in the evening. Capt. Bainbridge got permission from the Bashaw to send for the Danish consul, who paid us a visit and offered every assistance in his power. We slept upon mats and blankets spread upon the floor, which was composed of tiles. November 1.—This morning the Danish consul, Mr. Nissen, paid us another visit. Capt. Bainbridge engaged him to furnish us with provisions and such other necessaries as we might want. Our dwelling was furnished In a plain style, and we were supplied with fresh provisions that were tolerably good. We were allowed to go to the front door, and to walk on the terrace or top of the house, which commanded a handsome prospect of the harbour, the sea, the town, the palace, and the adjoining country. Here we could see our ship on the rocks, full of Turks, and surrounded by their boats, and a constant stream of boats going to, and bringing off, the plunder of the ship. We could see these robbers running about town, with our uniform conts and other clothing on. The minister of exteriour relations promised to be friendly, and collect as much of our clothing and effects as he could, and return them to us. Nov. S.—The Bashaw sent for the carpenter to go on board the ship ; he went and found six feet water in the hold. The carpenter's crew and fifty men were ordered and carried on board to work at night. A gale of wind and heavy sea hove the ship off the rocks, and the carpenter returned. Nov. 4.—In the morning lieutenants Hunt and Osborne, and myself, were at the Danish consul's observatory, on the top of his house, upon a plain with and adjoining ours, which together made a large and handsome walk. We were looking at the ship with Mr. Nissen's glass, when our dragoman came and in formed us that the Bashaw had ordered us not to walk upon the terrace any more. We immediately returned to our house. 'The reigning Bashaw (Pasha) of Tripoli at this time was Yusuf Caramalll, who, about the year 1792, had usurped the throne by deposing his elder brother Hamet (or Ahmet) Caramalli. Yusuf had already done away with his elder brother Hassan, and Hamet after a wandering life had taken refuge among the mamelukes of Egypt. From this latter situation he was rescued early in 1805, and, with his followers, joined the expedition under Gen. William Eaton, formerly United States consul to Tunis. This expedition was undertaken for the purpose of bringing pressure to bear on the de facto Bashaw, Yusuf, securing recognition of our rights, and reinstating Harnet. A further reference will be made to this picturesque exploit, in which the city of Derne was carried by storm, an event commemorated in Whittier's poem Derne. The letter which is reproduced in this article is written by Ahmet Caramalll In more or less incorrect Italian and apparently contains Arabic terms. The following is a rough translation of it* contents: To the Very Honorable Captain Cheter, Mi veey dear Friknd : I believed that being far distant from the pleasant surround ings of Placenza you would no longer bear In mind our friendship of long duration. Nevertheless I send you my letters wherein I acquaint you of my good health, hoping that yours is the same. What has become of your notes used In medical work, which will be my salvation (Sanita). I hope, therefore, that you will not abandon me as I have always been your sincere friend. I remain, therefore, with a thousand greetings, and saluting you as a son. Your sincere friend, Ahmet Caramalli Bancian (t) SIracusa, December 20, 1806. 246 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. #01;. 5.—Our new masters came and closed up the passage which led to the top of the house; and a guard was set at the front door to prevent our going Into the street. The minister sent his chief secretary with a parole of honour, written in French, which we all signed. Nov. 6.—We found that we were not allowed to go out, notwithstanding our signing the parole of honour. The minister of exteriour relations sent us word that he had got eight of our trunks, which we might have for twelve hundred dollars. We did not take them, nor thank him for his hospitality. We pur chased new blankets, sent to us by the Danish consul. The English consul, Mr. McDonald, paid us a visit and offered us every assistance in his power. Nov. S.—The Jews purchased some of our clothing and offered it to us at an enormous price ; but we purchased little of it. The Bashaw sent for Captain Bainhridge and told him that John Wilson had informed him that Captain Bainbridge, before hauling down the colours, threw overboard nineteen boxes of dollars and a large bag of gold. Captain Bainbridge assured him that it was false, and gave him his word of honor, that there was no money thrown over to his knowledge ; but that the money in question was left at Malta. In the evening, the Bashaw not being satisfied, sent for the captain's servant, and ordered him to be flogged if he did not tell the truth concerning the money. The boy denied having any knowledge of it. After repeating the threat several times, and the boy insisting that he knew nothing about the money, he was acquitted. Wilson had turned traitor, and given the enemy all the assistance in his power. He now acts as overseer over our men. Nov. 9.— Our captain established a credit with the Danish consul who sup plied us with necessary provision, and with cloth for mattresses. A guard was posted at our door, to prevent our going out into the street, or purchasing any books or clothing. Nov. 10.—Several Turks came and informed Captain Bainbridge that the Bashaw had been told that Captain Rodgers who commanded the IT. S. frigate John Adams, treated the Tripolitan prisoners taken last summer, very badly, and they feared that we would suffer for it. We have plenty of pomegranates, dates, and oranges. The Danish consul visits us every day. Nov. IS.- —The minister of exteriour relations sent his dragoman to Captain Bainbridge and informed him. that if he would send an immediate order to Commodore Preble, to deliver up the Tripolitan prisoners captured by Captain Rodgers last summer, amounting to about eighty in number, we might remain where we were, but if lie did not comply, we should fare worse. Captain Bain bridge replied, that he could not command Commodore Preble, and therefore could not comply with his request. At 9, in the evening, a Tripolitan officer came armed with two pistols and a sabre, and said, To night nothing; to-mor- rou? the castle. We accordingly prepared for the castle. Nov. lh—Breakfasted early to be ready for our new habitation. At 9, A. M., a guard came and ordered us to the castle. We formed agreeable to rank, an:l marched to the castle. We were huddled into the most gloomy cell, among our men. where there was hardly room for us to stand. Here we spent the day without food, and were scoffed at by our foes until night, when, to our happy surprise, we were conducted back to our old place of abode. The min ister of exterior relations sent for Captain Bainbridge, and affected great surprise at our going to the castle, saying that he knew nothing of the measure, which we all knew to be false. He told Captain Bainbridge that we should remain where we were until he heard from his people, the prisoners, in the hands of the Americans. No. 2. JONATHAN COWDERY, SURGEON IX U. S. NAVY. 247 A'oi?. IT.—Visited our sick, who were quartered in a small house without a floor, near the palnce. and about half a mile from our lodgings. (As this was Doctor Cowdery's daily practice, we shall omit the repetition of it.) The Danish consul supplied the sick with fresh provisions, by the request of Cap tain Bainbridge. Nov. 20.—Tlie minister permitted us to purchase our clothes. We got but a few, and at a high rate. One of our men, by the name of Thomas Prince, turned Turk, and was admitted into the palace. Nov. 21. —After visiting our sick, I was permitted to go with our dragoman about the town to purchase medicine ; we found but a few articles. A man of 116 years of age came to me to cure him of deafness. Nov. 24- —The Bashaw refused to furnish necessary clothing for the sick, or anything for them to eat, hut sour filthy bread. Captain Bainbridge contracted with the Danish consul to supply the sick with beef and vegetables for soup every day. Nov. 27. —Our men complained of their hard usage, in being compelled to lie on the cold damp ground, to eat bad bread, to work hard, and to be bastinadoed by their drivers. Nov. 80.—One of our men in a tit of despair attempted to kill himself; but was prevented by the Turks, when in the act of cutting his throat. The wound did not prove mortal. I was permitted by the minister to call on the Spanish physician for medicine for Dr. Bidgley, who was then sick. December 5. —The Bashaw sent for me to prescribe for himself and two officers of his body guard, and ordered me to get such medicine as was neces sary of the minister, who had a medicine chest. Dec. 6.—Visited the sick at the palace, and found them all better. I was received and treated very politely. The minister sent for me to cure him of a blindness in the left eye. I prescribed for him with very little success. Dec. 7.— Visited the ambassador of Constantinople, who was affected with the intermitting fever. Pound my patients at the palace almost well. ««»*»*» Dec. 9.—Visited the Turkish ambassador and found him better. He asked many questions about America, and treated me with coffee. Dec. 10.—Visited the Turkish officer, where I found a captain of one of the grand Seignor's ships of war, who came to Tripoli to carry presents to the Grand Seignor. The Tripolitan captain who took the brig Philadelphia, Cap tain Morris, was also there. He was very inquisitive about our country and tur navy. Dec. 12.—Was called on by the general of Marine to visit his principal sec- etary. Before I was permitted to give any medicine the Turks, six in num ber, with Hamet, our dragoman, surrounded the sick man. and offered a prayer to Mahomet. The sick man then told me that if I would cure him he would be very thankful, and would speak to the Bashaw in our favour. Dec. 15.—The Bashaw had a schooner launched, which was built by the Spanish carpenters. She was tolerably handsome, and was calculated to carry six guns. When she was launched, three guns were fired from the batteries, and the consuls all hoisted their colours. At sunset, a firing from the batteries announced the commencement of the Mahometan Rhamadam. continuing a lunar month, in which they neither eat, drink nor smoke, while the sun is above the horizon, but feast at night. In walking through the town, to visit my patients, I found the mosque and principal houses illuminated, and the people rejoicing. Passing the. Coffee house with our dragoman, Lysle, a renegade Scotchman, who was now the Tripolitan admiral, called me in to drink coffee with him and was very polite. 248 JONATHAN COWDERY, SURGEON IN V. S. NAVY. Vol. XVII. Dee. 16.—Visited the Marine secretary, and found him in a state of great de- biiity. Could not prevail on him to take any medicine, or the least kind of nourishment. He said he would rather die than offend Mahomet by break ing the Rhamadam ; but he would take whatever I would advise him at night. Dec. 20.—The market was so poor that we could get nothing for dinner, but a shoulder of poor dromedary. January 1.— Was called to visit the Bashaw's child, about eleven months old. The Bashaw seemed much affected on my pronouncing the child danger ously ill ; and wished me to pay every attention to it, saying that anything he could afford would be at my service. Jan. 2. —Found the Bashaw's child better, at which he expressed great sat isfaction, and offered me a horse and servants to go to his gardens, about two miles from town. I preferred walking, and took our dragoman with me. As I passed out of the gates of the city. I saw a man's head sticking on a pole. On inquiry, I found that it was the head of one of the Bedouins, who, about a year before, killed a son in law of the Bashaw, who commanded the army, in collecting the taxes in the back part of h's dominion. About a quarter of a mile from the gate, the road passed through a burying ground full of graves. After this I came into a well cultivated country which was laid out in squares of from one to six or eight acres, each surrounded with date trees, interspersed with orange, fig. olive, lemon and other trees. On coming to Admiral Lysle's garden we found him there, and he invited me in. It was very beautiful. He loaded me with its fruits, and offered me access to it whenever I chose, and said I was welcome to anything growing in it. I concluded to postpone going to the Bashaw's garden, until another day. Jan. 8.—Went to the Bashaw's garden, where I met the minister and the prince, the Bashaw's oldest son. They politely conducted me through the gar den, which was ornamented with a great variety of fruit trees, loaded with fruit, particularly with oranges, lemons and limes. John Hilliard died in the evening. Jan. h. —William Anderson died. Jan. 12.—The Bashaw's eldest daughter was married to Selim, the Bashaw's chief Casteda or Treasurer. Wilson, who was one of our quartermasters, and lately turned traitor and Turk, received 500 bastinadoes for quarreling with the famous Lysle. Jan. Ik-—The minister of foreign affairs, Sidi Mahomet Dacize, visited our prison. The month's fasting (Rhamadam) ended this day at the change of the moon. The Tripolitans fired a salute from our ship which lay moored in the harbour, within sight of our window. Jan. 15.—The feast called By ram commenced. Every gun in Tripoli was fired in honour of the day. Every Turk put on his best suit, and there was a general rejoicing. Jan. 16.—Oapt. Bainbridge and lieutenant Porter, were invited and accordingly visited the Bashaw, with all the consuls. Jan 17.—The Byram ended this evening. The consuls, the ships in the har bour, and the castle displayed their colours during the three days. The rejoic ing was great, but neither elegance nor taste were discoverable. Jan. 18.—By permission visited the triumphal arch which was built at the time the Romans conquered this country. It is dedicated to Augustus Caesar; is very large, built of fine marble, and Is full of engravings and inscriptions In tolerable perfection. It stands near the niarinery. Jan 19.—The Bashaw's agent sent us a present of tea, coffee and sugar, and a lamb, probably to induce us to buy a quantity of old clothes taken from us, for which they asked 600 dollars. JONATHAN COWDERY, SURGEON IN U. S. NAVY. 249 Our diet at this time was two eggs and n piece of bread, with rain water for breakfast and supper ; poor beef or camel's flesh, bread, and sometimes boiled cabbage, with rain water for dinner. February 3.—Was conducted to the castle to visit the Kashaw. whom I found after passing several sentinels, about fifty fierce yelping dogs, and threi> heavy doors loaded with irons and bolts, which were opened for us by armed mamelukes. Prescribed for the Bashaw's disorder. Feb. 6.—The Bashaw sent for me to come to his room in the castle. He shook hands with me. received me with much politeness, and requested me to pay every attention to his family ns a physician. Feb. 10. —The Bashaw gave the officers permission to walk out into the town and country, but not to visit the consuls nor the batteries. Our dragoman. Haniet. was ordered to walk with us and direct us where to go. We went out six at a time. , Feb. 16.— Prescribed for the Bashaw's eldest daughter. Her husband offered me many civilities. At 5 o'clock. P. M. were informed that two English mer chantmen were standing in for the harbour. They proved, however, to be two vessels under the command of Oapt. Decatur. About 11, at night, we were alarmed by a most hideous yelling and screaming from one end of the town to the other, and the firing of a cannon from the castle. On getting up and opening the window which faced the harbour, we saw the frigate Philadelphia in flames. Feb. 17. —The Turks appeared much disheartened at the loss of their frigate. A strong guard was put at our door, and we were forbid going out. I was forbid visiting our sick. It was reported that an American schooner and three boats set fire to the ship. Two Turks escaped who told this news. They said that eight Turks had charge of the ship, and they supposed the other six were carried off by the Americans. Our dragoman informed us that we were to be removed from our present habitation into the castle. Feb. IS.—A guard of about twenty Turks was at our door. I asked permis sion to visit our sick and was refused. A gloomy aspect continued on the faces of the inhabitants at the loss of the frigate. Feb. 19.—Again asked permission to visit our sick, and was again refused. Feb. 20.— Permitted to visit the sick. —-Pound the town full of country militia and our guard doubled. Feb. 21.—Our prison was kept full of Turks, to guard us. The Bashaw, having got a little over his fright, consented to let us remain where we were. Feb. 21.—We were forbid sending letters to our friends, without first show ing them to the Bashaw or his ministers. The last letters we received, were broken open by the latter, before they were delivered to us. March 1.—We were conducted to the castle. March 2.— Found our habitation very dark and smoky, having no light but what came through a grated sky light. March 3.—Not allowed to visit the sick, and our dragoman was forbid carry ing letters to use. March .}. —Captain Bainhridge received a letter from the ministers, repri manding him on account of three men who floated ashore a few days after the burning of the frigate. The Turks pretended that they were murdered after they were made prisoners by the Americans. March 6. —In close confinement. Hamet. our dragoman, was taken from us The Bashaw suspected him of being too friendly to us. March 7. —The Tripolitans got the guns from the remains of our frigate, and mounted them on their batteries. In trying them, several of the gun carriages 250 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. broke down, and one of the gun.-* hurst and killed one Turk and wounded four. March H. —The Turks seemed much alarmed, and placed a strong guard at our door, for what reason we knew not. March 16.—The Bashaw sent word that I should have any thing I wanted, free of expense. March 17.—Ordered not to send our clothes out to wash. March 2/t. — I was taken out of prison to visit a mameluke's wife and child. The minister of foreign affairs paid us a visit", and said many clever things. March 26.—A truce was held between Commodore Preble and the Bashaw. From March the 28th to the 13th of April, I was violently afflicted with the dysentery, during which time the Bashaw expressed much anxiety, and offered me every assistance. April 1").—We felt the Syroc wind, which was very oppressive. April 2.1!.—John Morrison died, in consequence of a hurt he received a few days before while at work under the directions of his new masters. The Ba shaw permitted me, with two of my fellow officers, to go to his garden, con ducted by a guard of two Turks, armed with pistols and sabres. This precau tion, they pretended, was taken to prevent the wandering Arabs and Moors from robbing us ; but it was probably done to prevent our escaping to the squadron, then cruising off the harbour, in sight. May 11.—Our squadron appeared off the town. The Turks were at their quarters. They had twelve gun boats, armed, manned, and moored out in the harbour. May 16. —Ten of our officers took a walk to the gardens under escort of a guard. They returned with a variety of flowers and ripe apricots. May 20.—A party of us, under escort of four Turks, walked to the desert, about four miles from our prison. We ascended a large bank of sand, where we had an extensive view of the country. The deserts have a singular and grand appearance. They extend to Mount Atlas, which we could see at the distance of two day's journey. The sand is in heaps, like snow drifts in our country. There was not a house nor any other object to be seen; nor a thing growing to interrupt the sight ; but it appeared like an ocean of sand. On our return we visited several gardens, where we got oranges, lemons, apricots, and a variety of flowers. We were treated with sap of the date tree, which tasted much like mead. May 20.—A party of us, under escort as before, took a walk into the desert. On our return we dined in the Bashaw's garden, under the shade of orange trees. The dinner was prepared in the Turkish style and we ate with wooden spoons—it was simple and good. We visited several gardens, and were treated with as much respect as could be expected or desired from a foe, who held us as prisoners of war. On returning to town we saw two of our brigs at anchor off the harbour, seeming to defy all the force of Tripoli. June -}. —We are plentifully supplied with squashes and cucumbers. The Bashaw's eldest wife, called the queen, was delivered of her ninth child on the 18th of June. She was twenty three years of age. The first child was born when she was in her eleventh year. It is said to be common to marry at ten. June 27.—Mr. Hodge, our boatswain, Mr. Douglass, the sail-maker, and Mr. Fontaine, the first master's mate, were taken from the prison and set to work by order of the Bashaw. July 15.—The Bashaw, his wives and guards removed to their country seat at his garden. The season was very warm and our close confinement continued. We purchased figs, watermelons, muskmelons and cucumbers. No.I. JONATHAN COWDEBY, SURGEON IN V. S. NAVY. 251 July 28.—I was called to visit the Bashaw's eldest son, the Bey of Tripoli (termed the Prince of Wales of Tripoli, by the English Consul) at his palace, about three miles from town. I found him in a lofty and airy apartment, lying on a mattrass and surrounded by his attendants. I prescribed for him and was highly entertained in the Turkish style. July 29. —The Bey was well enough to return to Tripoli. He called at the door of our prison, which was unlocked and the bolts and bars unloosed. I was conducted to him when he expressed great satisfaction at having recovered his health, thanked me for my attention, and promised to alleviate our misfortunes, as far as was in his power. I was then sent back to prison. The Bashaw and Bey spend a day alternately in town, on account of the expected attack by the Americans. July 31.—I was carried with, my trunk, and bed, to the castle, where a room was provided for me, and the Bashaw informed me I must attend the Ameri cans and his family as a physician. August S.— The American squadron, under the command of Commodore Preble, consisting of one frigate (the Constitution), two brigs, three schooners, and seven gunboats, at about 2 o'clock, P. M. commenced an attack on the bat teries and gunboats of Tripoli. I stood on the top of the castle, where I had a fair view of the engagement. Three of the enemy's gunboats were captured by the Americans. Two Turks swam to the shore, and were carried before the Bashaw, who gave them a suit of clothes and a few dollurs. They said that many were killed on both sides. Aug. 5.—The American squadron nnchored off Tripoli, I was ordered to dress a wound of a mameluke, who had his hand shattered by the bursting of a blun derbuss. I amputated all his fingers but one, with a dull knife, and dressed them in a bungling rannner, in hopes of losing my credit as a surgeon in this part of the country, for I expected to have my hands full of wounded Turks in conse quence of the exploits of my brave countryman. Aug. 9. —At about 12 o'clock the alarm gun of Tripoli was fired. The Trl- politans all took their stations, and went through the Mahometan prayer, by kneeling and kissing the ground several times, with their faces toward the east, all with as much regularity as the exercise in a well-disciplined army. Their military manoeuvring was a scene of the utmost confusion. I got permission to go on the top of the castle, where I had a most extensive view of the sea and land, and saw the American squadron approaching the town. At about 1 o'clock the attack commenced, and the battle soon became vigorous, with a tremendous cannonading on both sides. I now beheld the melancholy catas trophe of the explosion of one of our gunboats. I saw the mangled bodies of my countrymen precipitated into the air. For a few moments a general silence took place, when the firing recommenced with unabated vigor. I saw shells explode, and set fire to the town in many places ; but the houses being prin cipally built of stone, mud and mortar, the fire did but little damage. The shells and shot, however, battered the town very much, and almost destroyed »me of the houses. The firing ceased at 4, P. M. when the ship John Adams joined the squadron. The Bashaw has a bomb-proof room in his castle, where he staid during the action. On hearing of the explosion of our gunboat, he ventured out to take a peep, with the precaution of having a ilarubetct or priest, to seal a black piece of paper on the top of his head, with a Turkish or Mahometan scrawl, with assurances that it would entirely secure him from all danger; but he soon returned to his cell. The Turks all wear a paper of this kind, sewed up In a little velvet bag, with assurances from the itarabeu t that it will protect them in the greatest danger. The Marabewt 108165—22 5 252 JONATHAN CO WDERY, SURGEON IN U. S. NAVY. Vol. XVII. gets a sum of money for these blessings. If a Turk gets wounded or killed, it Is supposed the blessed paper was too old, or not placed in a proper manner. In the time of action the Marabeivt gets upon some secure place and cries to Mahomet in the most dismal yells to let them conquer their enemies; and beckons to the vessels to run on shore or be destroyed. Such of our crew as were able, were put to work, and drove about like horses or mules. Aug. 10.—Lewis Heximer, who lately turned Turk, went by order of th« Bashaw, and told Capt. Bainbridge, the particulars of the two late actions. The Bashaw informed me that the late commander of the schooner Vixen, Lieut. Smith, was commodore of the gunboats in the late action, and was killed by a musket shot through his head. Our men complained of being drove and beat about at an unmerciful rate, In consequence of which they petitioned the Bashaw, in the following terms: " To his Excellency the Grand Bashaw of Tripoli: The petition of the whole of the American prisoners, most humbly sheweth :— " That your humble petitioners, when doing their duty with all their power, as they are commanded, are most cruelly beaten by our wardens, stoned, In sulted, and spit upon by the soldiers and others; required to carry burthens impossible for us to sustain, and chased and bruised, until we are, or soon shall be, unable to labour at all. " From the many acts of justice, kindness, and generosity we have experi enced from your Excellency, we cannot suppose that such conduct is authorized by your commands ; or that we should be punished for what is out of our power to perform ; or for the actions of others, which we have no agency in, and which we cannot prevent. " Returning your Excellency our sincere and humble thanks for your bounty and privileges heretofore shewn, and relying upon your goodness for protec tion, we therefore most humbly pray, that your Excellency would interpose your royal authority and grant us a speedy relief. And your petitioners, as in duty bound, will remain your Excellency's most humble, faithful and obedient servants." On the petition being explained to the Bashaw by Heximer, (or Hatnet Anverikan, his new name) the Bashaw forbid the Turks striking the prisoners. Aug. 11.—The Bashaw sent for me, and, agreeably to his orders,. I took a seat by his side. He began conversation about my country, and our squadron, which was then in sight, and consisted of eighteen sail- He said that for two dollars he could repair all the damages that the bombardment did to his town; that but one man was hurt by the shells ; that what he had been effered for the American prisoners was but fifty dollars per man ; that he would make them earn that sum in two months. He asked me what I thought my country would give for me. I told him I did not know. He said he would not take twenty thousand dollars for me; to which I replied, that I might then expect to re main in slavery for life. He patted me on the shoulder and said, I might then content myself to stay with him. I asked to go and see our men, but he refused, saying, that Moors and Arabs would kill me if they could catch me. Aug. 12.—Our squadron hoisted a flag of truce, sent in a brig and schooner and tired a gun. The Bashaw did not, and swore he would not, answer it; and said lie would not treat witli commodore Preble. A truce however was after wards held. Consul O'Brien wished to come on shore, but was refused. Aug. 13.—Another truce was held, when the Bashaw demanded one million of dollars for our ransom. One hundred and twenty thousand dollars were offered and refused. Aug. 17.—The Bashaw informed me that fifteen Americans were found drifted ashore at the westward of the town, and that one of them was an No. 2. 253 JONATHAN COWDERY, SURGEON IN U. S. NAVY. officer with an epaulet on the right shoulder. We supposed they were men destroyed by the explosion of the gunboat, in the lute engagement. I asked permission to go with two or three of our men and bury them, and the Bashaw told me I might go the next day. Our squadron lay at anchor off the harbour. The inhabitants had chiefly moved out of the town, through fear of another bombardment ; and the Bashaw ate, drank and slept in his bomb proof room. Several tribes of the back country inhabitants had lately come and offered their services to the Bashaw, —in all not more than one thousand men. Many of them had muskets without locks, but had a sort of match to put fire to them. They were almost naked, half starved, and without discipline. When (hey are going to battle or appear before the Bashaw, they run to and fro, shaking their rusty muskets over their heads, all crying Holouet Buoy (I am my futher's son.) Every tribe has a priest, or what they call Marabeict, whose badge is a small green flag, which is carried in his hand or stuck up at his tent. They pretend great skill in prophecy, in which the people put the utmost faith. They prophecy success in battle ; and for a small sum of money, ensure any one against wounds or death in fighting a Christian. They often go on eminences, and beckon and sing to the American vessels to run on shore. They prophecied that another American vessel was to go on the rocks, and the Bashaw fully believed it. Aug. IS.— Was not permitted to bury our dead. Our squadron stood out to Bea. At evening the Bashaw went to his country seat and the Bey came in to keep the throne till his father's return. They never both leave the castle at once. When the Bashaw leaves it, the gates are shut till his return, for fear of incursions upon the throne. In the evening, th« moon shining very brightly, the prince or Bey ordered out the band of music, which was very ordinary, and made Christians, Turks, Arabs and Guinea Negroes dance be fore him, according to the mode of their respective countries, at which he seemed highly diverted. Aug. 19.—Between 0 and 10 o'clock in the evening, Mr. Church, a respectable English gentleman was shot through the head in the street, on his return from visiting bis neighbours. Aug. 2k-—In the morning, between 2 o'clock and daylight, two of our small vessels- hove about thirty shells, as was supposed for the round fort, but they all fell short of the mark. Such attempts served rather to encourage than to intimidate the Tripolitans ; and the Bashaw was in high spirits on the occasion. Aug. 26.—At about 4 o'clock P. M. the fellow who murdered Mr. Church, was executed near the spot where the crime was committed. It had theretofore been a custom in this country, when a person had committed murder, to fly to a tomb of a Marabewt (or priest) where they were protected from justice, and a fee to a Marabeict would procure them absolution. This fellow fled to a place of this kind immediately after killing Mr. Church. The English consul, Mr. Langford. on being informed of the murder, addressed the Bashaw, and de manded justice. The Bashaw then found out by a boy, who accompanied the murderer when he committed the crime, the particulars of the affair ; and im mediately sent a file of men and ordered them to prevent any person carrying food or drink to the murderer. They watched him until night when the Bashaw sent his Marabewt, who coaxed him away, brought him to the castle and con fined him in irons. The next day the Bashaw called his divan, when it was de cided that the prisoner was guilty of wilful murder, and ought to suffer death. It appeared by the evidence and confession of the prisoner, that Mr. Church had lent a sum of money to a Spanish carpenter in this place:-— that Mr. Church had pressed him for payment ; and that the carpenter's wife hired the Turk to kill Mr. Church for forty dollars. The villain took his watch from his pocket 254 JONATHAN COWDERY, SUKGEON IN U. S. NAVY. Vol. XVII. after he had shot him. The boy who accompanied him and carried a lantern was bastinadoed with five hundred blows. The carpenter's wife was ordered to leave Tripoli. Aug. 27.—Our squadron stood towards the harbour. Aug. 28.—About 4 o'clock in the morning, I was awoke by a heavy and inces sant fire of cannon, and the whistling and rattling of shot nil around me. On getting up, I found that our gun-boats were close in, and were firing upon the town and batteries. Every gun in Tripoli that could be brought to bear, was returning the fire. The Tripolitan gun boats were close under the castle for protection. The firing continued until a few minutes after sun-rise, when one of the largest gun boats ventured out, with an Intention of boarding the nearest American boat. As soon as she got within pistol shot, the American discharged their piece, loaded with grape, and killed four and wounded two of the enemy, they then put about and retreated. At the same time, commodore Preble bore down and gave the batteries to the westward of the town two broadsides. The squadron then stood out and anchored off the harbour. The damage done to the town was considerable. A large vessel was sunk in the harbour and others damaged. Many men were killed and wounded. Aug. 29.—The Bashaw sent me to his palace in the country, to see his eldest son the Bey, whom I bled in the foot. He requested me to spend the day and dine with him, which I did. He endeavoured to have the dinner in the Christian style. It was set on a table, and consisted of a large dish of boiled rice and stewed fowls, out of which we both ate, he with a wooden spoon, and I with a silver one, without knife or fork. The prince's servant stood by him, and pulled the fowl in small pieces with his fingers, for the prince to eat. I -made use of my fingers and teeth to get mine in pieces. Our dessert was dates and water melons. Our drink was lngby, or the juice of the date tree, which we drank out of a large gold cup. He shewed me the garden, and took great pains to entertain me. Aug. SO. —A truce was held, I took a ride upon a mule about eight miles to the westward of the town, in company with my guide, Hamet, a Turkish officer, and several footmen. I there saw a boat, which drifted on shore, with a dead man, and several muskets and swords in it. The man appeared to have been shot through the body with a cannon ball, which hnd also pierced the bottom of the boat. The Turkish officer collected about twenty Arabs, who hauled the boat upon the beach, dragged the dead man out of it, stripped him entirely naked, and left him on the beach. I tried in vain to hire the Arabs to bury the body ; they said it was contrary to their religion to bury a Christian. I asked permission to get him buried by our countrymen, some of my fellow prisoners, but was refused. I found that our men, who were destroyed by the explosion of the gun-boat, on the 9th inst. lay in a state of putrefaction on the beach. They were scattered on the shore for miles, and were torn in pieces by dogs. The Bashaw had frequently promised me that these men should be buried ; but refused to let me take some of our men to go and bury them. September ?.. — At about 4 P. M. our squadron commenced another attack on the town in which eight of our gun boats drove sixteen Tripolitan gun boats under the battery on the east side of the harbour; while the Commodore bore down and gave the batteries at the west end of the town, several broadsides. Many of his shot came into the town, and castle. Two bomb-ketches were employed In heaving shells into the town, which did considerable damage to several houses, and entirely destroyed the house of the Spanish carpenter, the Bashaw's naval constructor. I observed the utmost confusion and random- firing among the Tripolitnns. It appeared they were almost out of powder. Two of their guns bursted, one of which was an eighteen pounder from the No. 2. JONATHAN COWDERY, SURGEON IN V. S. NAVY. 255 late Philadelphia frigate. The men, women and children ran out of the town in the utmost terror and distraction. .Sep*. 3.—Had been to see the prince in the country, and was returning about 10 o'clock in the evening, with the Bashaw and suit, when we saw a most extraordinary light or flash, and heard a heavy report. We all wheeled about, and made for the place we had left ; but the Bashaw soon altered his mind, and proceeded to town, while I went to the country palace and staid all night The explosion was a fire ship sent Into the harbour by Commodore Preble, which did but little damage. Sept. 5.—The Turks found ten dead men near the place where the vessel blew up, on the evening of the 3d instant. The Bashaw and his people had a thanksgiving to Mahomet on the occasion. Their ceremony was prayer in doleful tone, and singing, accompanied with the sound of an instrument made by drawing a skin over a hoop. Sept. 6.—More men were found, three of which appeared to be officers. By permission, I took our boatswain and a gang of men, and buried these bodies a little east of the wall of the town. All that I saw, who appeared to have been killed by the explosion, amounted to fourteen. The Bashaw's son-in-law told me that six more had been found drifted on the western shore ; but I could not ascertain the truth of it. Sept. 7.—John McDonah died of a consumption, with which he had Ion? been ill. Sept. 9.—The Bashaw took me with him, and his suit to his country seat where we spent the most of the day. About 5 o'clock P. M. we went to see the great Marabetct, or Mahometan priest, In whom the Bashaw had great faith, and thought he could foretell events. It was said by the Turks, that he fore told the stranding and capture of the Philadelphia ; that he got offended with the Bashaw and caused and foretold her being burnt. But I had beard nothing of these mysteries until a little previous to this. He now said that the com modore's ship, the Constitution, would never return to America ; that she would either be blown up, or run on shore ; and that the Bashaw would have success in his warfare with America. It appeared that this great prophet was a sojourner; and that he only came to Tripoli when the Bashaw was in want of a prophet. He was encamped on the sandy desert, at a tomb of an ancient Marabewt. The tomb had a house over it, with several rooms, and was en circled with several green trees. It was about two miles back of the gardens. We found this great Marabewt standing on a large mat, which was spread on the sand under the shade of a large mulberry tree. About thirty of his attendants stood back of him. paraded in form of a crescent. I was ordered to pull oft my hat; and all approached him from the west; the Bashaw, with «ome of his most truly attendants in front. When we came near to him we all dismounted. The Bashaw run to him, kneeled before him, and kissed his hand. The mamelukes followed his example. The Marabewt then sat down, and was followed by the Bashaw and his suit, forming a circle on the mat. During this time, I stood by my mule, about five rods from the scene, with my hat in hand. I was soon called and ordered by the Bashaw to take off my slides and feel the Marabewt's pulse. I left my shoes at the edge of the mat, or holy ground, and stepped on. I laid my hat on the edge of the mat in Preference to laying it on the sand ; but it was immediately taken off. I was then ordered to approach his holiness and kiss his hand. I felt his pulse; but before I had time to prescribe for him, he put his hand against me, and gave me to understand that I must go off the holy ground. Immediately stepped off; put on my shoes, took my hat, and went to my mule. The Bashaw called me back, and asked what I would do for the Marabewt. I recommended 256 JONATHAN COWDERY, SURGEON IN V. S. NAVY. Vol. XVII. bleeding: but the Marabewt, shook his head and gave me to understand that lie wanted nothing of the kelp (the Dog). I whs then told to withdraw, which I did, and took a walk round the tomb, which I found to be very ancient. The Bashaw spent about half an hour with the Marabewt, when he kissed his hand ; and we all returned to the country. The Bashaw apologised for the impoliteness of the Marabewt, and said that they had a foolish antipathy to all but Mohometans. October —None of our cruisers were to be seen from the top of the castle. The Tripolitau gun boats were disarmed, and the Bashaw's gunners were em ployed in drawing the charges from the cannon on the battery. Many of the guns now stood in the sand, as they did when Commodore Preble first attacked the town. On being fired two or three times, they recoiled into the sand so deep that they could not be worked, and were abandoned. The Bashaw told me that if he had three frigates, he would blockade America. He said he could do it as easily as a frigate and schooner could blockade Tripoli ! Oct. 26. —A great scarcity of grain. Our crew had no bread for three days. The Bashaw gave orders to all the market people, not to sell grain to anybody but his household. There was no bread to be had for money. A dispute took place between the Bashaw and the renegado Lysle, about the purchasing of some barley. Lysle was considerably intoxicated, and insisted on his right to purchase grain in the market. The Bashaw was highly affronted, and flew at him with all his might, struck him, and ordered his mamelukes to disarm him and put him in prison, which they strove to obey, and carried him off. The Bashaw, however, soon ordered him released, and then ordered his servant, who was supposed to be the cause of the quarrel, bastinadoed with five hun dred blows, which was Immediately put into execution. November 9. —The Bashaw had an epileptic fit, and his people thought he was possessed with the devil. They performed many ceremonies to cast him out, which they said succeeded. The Turks said they saw many ghosts the night before; and that a Marabewt drove the devil out of the Bashaw. December 6.— Our men suffer for the want of provisions. The Bashaw does not allow them either victuals or cash.—They get but a small allowance of bread, and that on the credit of their own country. They are beat unmerci fully and compelled to work hard every day. Dec. 7. —I was informed, that, through the Influence of many Turks, the Bashaw had given orders to Sarcey, our master, to treat the American prisoners with the utmost cruelty, In' order to induce the United States the sooner to make peace. He was impatient for his money. Dec. 10. —Our men all agreed not to work unless they were fed, and accord ingly when the wardens went to the prison and ordered them out, they all refused. The wardens whipped them until they were tired, and then went to Inform the Bashaw, who immediately ordered them bread and oil, and they went to work. Dec. 21.—At evening, the Bey. the eldest son of the Bashaw, was married to his first cousin, eldest daughter of the Bashaw who was driven out of Tripoli by the present Bashaw. The bride was said to be very handsome, and but twelve years old. Our boatswain, carpenter, sail-maker, and first master's mate, who had the liberty of the town for a few months, were put in close confinement with our other officers, on suspicion of attempting to raise the crew to take the town. Dec. 25. —The Bashaw's son-in-law, Selira, who had charge of the stores, was detected In selling a quantity of cordage to a Tunisian merchant. The Bashaw ordered him five hundred bastinadoes, but Selim fled to a Marabeict for protection, and escaped punishment. No. 2. JONATHAN COWDERY, SURGEON IN U. S. NAVY. 257 January 24.—Renegade Wilson, who pretended to be a great engineer, was ordered by the Bashaw to fire hot shot at a mark, but succeeded indifferently. The Bashaw, however, was highly pleased, gave Wilson eight dollars, and promised to reward hira in proportion to his exertions in his future warfare. Wilson engaged to teach the Turks how to throw bombs, hot shot, and hand grenades ; and to alter and improve the fortifications, etc. Jan. 25.—The Bashaw sent me to visit the wife of Alia Mameluke. She was once a wife or concubine to the Bashaw, who gave her as a wife to his favourite. She was sister to a wife of the Emperor of Morocco, about eighteen and very handsome. She was in child-bed travail, attended by a number of Jewish women. She was delivered of a son, her first child, to the great joy of all the Turks in the castle, male and female. It was proclaimed by a loud yelling, with clapping of hands to and from the mouth, by the women of the castle. Jan. 28.—The Bashaw was informed by Wilson, the renegade, that our crew were all armed, and about to rise upon the town. Search was made, and the report found to be false. But the Bashaw was much intimidated and an addi tional guard was placed over us. February J.—George Griffiths, one of our crew, having informed the Bashaw that he could build an air furnace, and cast guns, shot, etc., was furnished with a mason and nine of our crew, and set to work, with a promise he should have a hundred dollars for the first shot he should cast. After expending about five hundred dollars in the experiment, Griffiths this day attempted a blast in his furnace ; but with all the wood and coal that the Bashaw could furnish, he could not melt the iron, and the furnace cracked in several places. It afterwards appeared that Griffiths had no intention to cast any shot. Feb. 5.—While a number of our men were at work at the north corner of the castle, a large body of the wall fell, and killed Jacob Dowdesher. The only consolation we received from the Turks, was, that he was amak deric and sansafedah —that is D n his mother, he has got no faith, Romo Kelfi —He it a Christian dog. March 1.—An American frigate appeared off the harbour. The Turks were all at their quarters, and were manning their gun boats. The Bashaw was preparing an armament to go against some of his refractory tribes on the borders of Egypt. March 4-—Hassan Bey, the Bashaw's chief raameluke, was appointed to command the expedition towards Egypt, on the borders of the dominions of Tripoli. Hassan and his officers were attended by the Bashaw and several stand of colours to a ilarabewt about three miles from town to receive abso lution and assurances of victory in the intended expedition. A great part of our crew, and many Turks and Jews were employed In packing up ammunition, etc., for the camp. March 5.—Two frigates and a brig, supposed to be American, appeared oft the harbour. The people of Tripoli were preparing and moving their effects Into the country, expecting a siege by the Americans. March 12.— Swallows appeared. Apple, peach and plumb trees were in blos som, and peas in market. March 17. —Walking by the house called the American house, I perceived that It was full of Turks, and a strong guard was at the door. On inquiry, I found that they were the sons and nearest relations of the Bashaw's officers, who had gone in the expedition to the frontiers. The Bashaw kept these people as hostages for the fidelity of his officers, whom it appears, he was afraid to inist, least they might join in the rebellion and come against Tripoli. It was 258 JONATHAN COWDEEY, SURGEON IN U. B. NAVY. Vol. XVII. said that his highness had received a letter, stating that the Americans were making great preparations to attack Tripoli. A tent was pitched on the bat tery of the castle, and orders given to keep watch all night, and every night afterwards. Orders were also given to make every preparation to repel the Americans. March 18.—The Bashaw sent his son-in-law into the country for troops to protect Tripoli. March 19.—It was reported and generally believed that the Americans had been to Alexandria' in Egypt, where they had got the Ex-Bashaw * and four thousand Egyptians, and carried them to Syracuse* where they were to be landed to act in concert with the Americans against Tripoli. I perceived many private councils and long faces amongst the Turks. March 21.—A frigate and brig appeared off the harbour. The Bashaw told me he suspected commodore Barron was dead, as he had not heard from him for a long time. Not long before, he told me, that he had heard of the death of his brother the Ex-Bashaw. He seemed highly pleased at such news. Sev eral of the sons and dearest friends of his chiefs In the country, were brought into the castle, as hostages for their fidelity to the present Bashaw. Symptoms of dissatisfaction appeared amongst the people. March 22.—Two negroes were hung at the gate of the city for robbery. The Bashaw's son-in-law who had been sent into the country to collect troops to protect Tripoli, returned without success. The people refused to fight for the Bashaw, because he had made unusual demands for money, and even had stripped their wives of their jewels. For several days it had been reported that ten thousand troops were to muster on the beach near the town ; and his highness was to make a speech to encourage them to fight for him against the Americans and his brother. I prepared myself to see these troops; but to my disappointment not one of them appeared. April 7.—One of our cruisers appeared. A large gunboat was launched, which was built by the redegade West, who was one of our crew, and turned Turk. April IS.—The Bashaw received an unfavourable letter from his agent at Malta, concerning the armament of the Americans. The Spanish consul pre sented the Bashaw three hundred stand of arms and a number of pistols, and, it is said, advised him to keep up the war, and force the Americans to pay his demand. It was concluded that the Bashaw's women and children should stay at the castle during the summer. They said that if they must be taken, they would rather fall into the hands of the Americans than the Arabs. April IS.—The Bashaw declared, that If the Americans drove him to extremities, or attacked his town, he would put every American prisoner to death. April 19.—The Bashaw interrogated me concerning the force of my country ; -he asked me how many marines the United States kept In pay. My answer, for good reasons, was, ten thousand ! How many troops? he asked.—Eighty thousand, said I, are in readiness to march to defend the country, at any moment; and one million of militia are also ready to fight for the liberty and rights of their countrymen ! At this, his highness assumed a very serious look, and I returned to my room. • It has been mentioned that the ex-Bashaw, Hamet Caramelll, after falling to gain any advantages in his brother's forces, had withdrawn from Derne early in 1804, and gone to Egypt ■At this time the United States utilized the harbor of Syracuse as a base from which to operate against Tripoli. A naval hospital had also been established at Syracuse. No. 2. 259 JONATHAN COWDERY, SUBGEOK IN U. S. NAVY. April 27.—A very oppressive Syroc wind. Several companies of Arabs hail arrived within a few days : about three hundred horse and seven hundred foot. ' May 3.— The Bashaw and suit went very early this morning to the great Marabeict, of whom some particulars have been before mentioned. He was to continue with the Bashaw during the contention with the Americans. He now nssured the Bashaw that the American frigates would be destroyed ; and that the gunpowder of the whole squadron would be so damaged, that the Ameri cans would not be able to fire a gun. He agreed to attend the Bashaw, to keep the balls and shells from hurting him. He receives large sums of money from the Bashaw. May 1-J.—I received a note from capt. Bainbridge, stating the inconvenience which the officers laboured under by being in close confinement and by breath ing unwholesome air. I spoke to the Bushaw on the subject, and humbly solicited that our officers might be removed to the American house. The Bashaw replied, that the war between him and my country at first was about money; but now it was whether him or his brother should be the Bashaw; and that the Americans had bound themselves to his brother In such a manner that it was not in their power to make peace with him. But that his brother and the Americans were determined to take Tripoli and take off his head. He swore by the prophet of Mecca, that If the Americans brought his brother against him, he would burn to death all the American prisoners except me; that my life should be spared, because I saved the life of his child when very sick. He went off In a great passion, and mounted his horse. His mamelukes and guard, to the number of about forty, attended him, and they took a ride to his country palace. They returned about sun set, and the minister of exteriour relations and the Bashaw were in private conference. May 19.—A spy employed by the Bashaw, arrived from Malta and Syracuse. He brought news that the American squadron sailed for Alexandria in Egypt about twenty days before; that it consisted of 4 frigates, 3 brigs, 3 schrs. 24 gun boats, 6 bomb ketches, and several transports ; that they were to take on board the former, or Ex-Bashaw, and to proceed along the coast of Tripoli, and take the principal towns; and then to attack and take the town of Tripoli, and put it in possession of the Ex-Bashaw. The Bashaw and his people seemed much agitated at this news.' 'General William Baton waa born in Woodstock, Conn., on the 23d of February, 1764. Ar a boy he served for a short time in the Continental Army. He graduated from Dart- month College in 1790, wag cleric of the lower house of the Vermont legislature in 1791-92, and then reentered the Army as a captain, later serving against the Indians in Ohio and Georgia. In 1797 be was appointed consul to Tunis, where he arrived in February, 1799. While In Tunis he became acquainted with Ha met Caramalli, the rightful pasha of Tripoli, who about the year 1792 had been deposed by hlB brother Tusuf. When, In 1803, because he refused to comply with the extortionate demands of the bey of Tunis, Eaton was driven from tbat country, he returned to tie United States to urge American intervention for the restoration of Hamet Caramalli to the throne of Tripoli on condi tion of a permanent peace and no tribute, arguing that this would impress the Barbary States with the power of the United States. On reaching Washington he succeeded in exciting a moderate amount of interest In his project to cooperate with Hamet Cara malli, who in the meanwhile had taken up arms against his brother Yusuf, bad been defeated, and had early in 1804 withdrawn to Egypt. In May, 1804, Eaton was appointed Navy agent and placed under the orders of Com modore Barron. To the latter the Secretary of the Navy wrote, June 6, 1804 : " With respect to the ex-pasha of Tripoli, we have no objections to your availing yourself of his cooperation with you against Trjpoli. • * * In such an event you will, It Is believed, find Mr. Eaton extremely useful to you." Commodore Barron's squadron sailed for the Mediterranean in June, 1804, arriving at Malta in September, and the .following month Eaton was sent in the Argus to Egypt 260 JONATHAN COWDERY. SURGEON IN TJ. S. NAVY. Vol. XVII. May 21. —The Bashaw with his attendants rode into the counry. According " to custom he took with him on a mule, two hoxes. said to contain twenty thousand sequins, (forty thousand dollars). But I did not believe they con tained that sum. They were light. I had lifted them both ; and they were carried to and from the mule by one slave. Another mule was loaded with the At Cairo he lenrned that Unmet, with a fow of his followers, had Joined the Mamelukes, who were at war with the Ottoman Government, and was at that time besieged at Mlnieh, 150 miles or more up the Nile from Cairo. The prospect of getting into com munication with him seemed doubtful. En ton obtained nn audience with the Viceroy of Egypt nnd frankly explained the object of his visit. The Viceroy, delighted at an oppor tunity of ridding his country of an enemy, promised an amesty for Hamet and his followers and a passport through the Turkish lines. In the course of time Hamet and his followers nppenred at an appointed rendezvous. Eaton's plnn had been to embark with Hnmet on the Argus and to proceed from Alex andria to a point near Derne In Tripoli where they would meet Hamet's troops and cap ture the city, but it was thought best to go by land, chiefly because it was feared that Hamet's army would evaporate In his absence. He therefore formed his camp some distnnee to the west of Alexnndrin. Arrangements were made for the Argus to meet the expedition at the Bay of Bomba with supplies and reinforcements. Eaton entered into a convention with Hamet in which it was provided that the Gov ernment of the United States should reestablish him In the possession of his sovereignty of Tripoli and that' the expense Incurred by the United States was to be repaid by Hamet out of the tribute derived from certain other nations. Eaton's little nrmy was composed of about a dozen Americnns from the Argus, including Lieutenant O'Bnnnon of the marines and Midshipman Peck ; 25 cannoniers of various nationalities, with 3 officers ; 38 Greeks, with 2 officers ; Hamet nnd his suite of 90 men ; a party of Arabian Cavalry under Sheik el Tahib and another chief ; a number of footmen and camel drivers, altogether about 400 men, and a caravan of 107 camels and a tew asses. This expedition to Derne is of Interest because It was the first American force to operate on foreign soli. The story of the expedition Is splendidly told in Gardner W. Allen's " Our Navy and the Barbary Corsairs," from which the following Is quoted : " On March 8, 1805, the march was begun across the Lyblan Desert to Derne, a distance of between five and six hundred miles. For the greater part of the way the route lay within Right of the sea. Wnter was generally obtained from natural basins worn In the rocks by the streams during the wet season, and filled with rain water ; but there was often great scarcity of water and suffering for want of it. An advance of 15 miles was made the first day, and then on the following morning the owners and drivers of the camels became mutinous and demanded advance pay. In this they were encouraged by Sheik el Tahib, one of the Arab chiefs, who made trouble during the whole march. This difficulty caused a delay of a day and a half. Hamet was lrresolate and seemed to have no Influence with the Arabs. At last Eaton, finding argument fruitless, assembled the Christians ' and feinted a countermarch, threatening to abandon the expedition.* This had the effect of checking the mutiny, and the march was resumed. On the 13th a courier from Derne appeared and announced to Hamet that the Province was preparing to support him. This news caused rejoicing and a discharge of firearms, which alarmed the Arabs in the renr. who thought nn attack was being made. They thereupon at tempted to disarm and massacre the Christians escorting the caravan, but were restrained by one of their more prudent chiefs. " March lfi and 17. there was a cold rainstorm, and the Arabs again became mutinous. On the 18th, having advanced about 150 miles, Eaton learned that the caravan had been freighted by namet for this distance only. The owner.8 finally promised to proceed two days farther, upon being paid. This took nearly all the money Eaton had, and when they had received it, all deserted, part the first night and part the second, setting out on their return to Egypt. Sheik el Tahib nnd other chiefs now refused to proceed until news should be brought from Bomba that the United States vessels were there, and proposed to send a runner to ascertain the fact. Eaton ordered their rations stopped. These com plications consumed three days. The Arabs finally yielded, about hnlf the caravan was induced to return, and the march was resumed. " March 22, they arrived at a great plain, bordering upon the sea, inhabited by thousands of wild Arabs who had never before seen Christians or tasted bread. They had vast herds of camels, horses, nnd cattle, and countless sheep and goats. Hamet was here reinforced by 80 mounted wnrrlora, and a caravan of 90 camels was freighted: and later another force of Arabs, including 150 warriors, with their families, Joined the expedition. Xo. 2. 261 JONATHAN COWDERY, SURGEON IN U. S. NAVY. packages of the Bashaw's clothing. The Bashaw always wont thus provided, through (far that he might be served as he served his brother the Ex-Bashaw, who was denied to return to the castle when the present Bashaw usurped the throne. During the absence of the Bashaw, his eldest son, the Bey, had his amusement. He ordered two carpets spread on the south corner of the cnstle. On the 2flth a courier announced that a large force, sent by Yusuf Pasha, was marching from Tripoli to Dome. This canned another panic, Hamet hesitated and wavered, the camel drivers fled with the caravan, and Sheik el Tahlb deserted with pnrt of his tribe and a large number of other Arabs. Hamet begged Eaton to offer inducements for the Sheik to return. This Eaton refused to do and was glad to be rid of him, but he soon came back of his own accord. On the 28th Hamet's slender stock of resolution seemed to have oo»ed away completely, and he decided to abandon the enterprise and return to Egypt. Eaton kept or. with the baggage, and in two hours Hamet followed him. That evening all the Arabs that had Joined a few days before deserted, having been discouraged by Shiek el Tahl!>. An officer was sent back after them and returned with them the following afternoon. "The next complication was a quarrel between Sheik el Tahlb and another Sheik, which ended in the lntter's deserting with many others whom it was Important to retain on account of their influence with Arabs near Derne. Hamet went back to induce them, If possible, to return. ' From Alexandria to this place.' wrote Eaton, ' we have experi- inced continual altercations, contentions and delays among the Arabs. They have no sense <jf patriotism, truth nor honor ; and no attachment where they have no prospect ot gain, except to their religion, to which they are enthusiasts. Poverty makes them thieves and practice renders them adroit in stealing. The Instant the eye of vigilance is turned from an object on which they have fixed a desire, it is no more to be found. Arms, ammunition, and provisions most engage their furtive speculations, but sundry of our people have been robbed of their clothes and other articles. With all their depravity of morals they possess a savage independence of soul, an incorrigible obstinacy to discipline, a sacred adherence to the laws of hospitality and a scrupulous pertinacity to their religious faith and ceremonies.' After an absence of four days, Hamet returned with the Sheiks who lrad deserted. Meanwhile there had been more trouble with Sheik el Tahib, who demanded an increased ration. He became insolent, and Eaton threatened him with death If he attempted to incite a mutiny. He rode off with two other chiefs, hut a few hours later returned very penitent and took an oath to remain faithful thereafter. "On the evening of April 2, Eaton held a meeting of Hamet and all the Sheiks in his tent, and endeavored to impress upon them the Importance of union and perseverance, and they all ' gave pledges of faith and honor.' The force now consisted of between six and seven hundred fighting men, who with camel drivers and camp followers, including women and children, made a total of about 1,200. The next morning the march was resumed, hut after advancing only 10 miles the Arabs positively refused to go farther until a caravan bad been sent to an oasis five days' Journey inland for a supply of dates. Eaton flnallj agreed to this on condition that they should proceed the next day, being met at Bomba by the detachment sent after the dates. During the few days following there was much suffering for lack of water, but a good supply was found on the 8th. "On this day, also, occurred the most serious commotion yet experienced. Although there was only a six days' supply of rice and no other food, Hamet Insisted upon encamp ing and sending a courier to Bomba to look for the American ships. Eaton stopped the Arabs' rations. They prevailed upon Unmet to return to Ecypt and made a move to seize provisions. Eaton assembled the Christians and formed a line to resist this at tempt. After facing each other for an hour the Arabs dispersed. Supposing the tumult tranquilized, Eaton ordered the troops to pass the manual exercise according to his dally practice. In an instant the Arabs took an alarm, remounted and exclaimed. 1The '-hristlans are preparing to fire on us.' The Pasha mounted and put hlmseelf at their bead, apparently impressed with the same apprehension. A body of about 200 advanced in full charge upon our people, who stood their ground motionless. The enemy with drew at a small distance, singled out the officers, and with deliberate aim cried, ' Fire.' Some of the Pasha's officers exclaimed. ' For God's sake, do not fire. The Christians are onr friends.' • • * Eaton advanced toward the Pnsha, and cautioned him against giving countenance to a desperate act. At once a column of muskets were aimed at his breast. The Pasha was distracted. A universal clamor drowned Eaton's voice. He waved his hand as a signal for attention. At this critical moment some of the Pasha's officers and sundry Arab chiefs rode "retweeu the lines with drawn sabers and repelled (lie mutineers. Hamet repented of his rashness, ordered the Arabs to disperse, called Eaton his friend and protector, and promised to take up the march if rations were issued. This was done, •nd the next morning they moved forward. 262 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. On one of the carpets, the Bey and his attendants seated themselves, with a band of musiek, consisting of two men with tamborines, and one with a sort of drum. Murat, his uncle, and myself were seated on the other carpet. Three large negroes were brought and ordered to perform before the Bey. The musick then struck up and the three negroes commenced the negro dance, with "By April 10 there was 'nothing but rice and water for subsistence and that at half rations' for three days. No news from Bomba. Hamet was beginning to entertain the idea that he was being used by the Americans merely ' for the purpose of obtaining a peace with his brother,' a suspicion that proved to be not wholly unreasonable. A mutiny was organized among the cannoneers, of which Eaton was secretly Informed ; they were to insist on a full ration. The situation seemed critical, and Eaton took O'Bannon into his confidence. Early In the evening, however, before any outbreak took place, a courier arrived from Bombn with news that the ships had been sighted. Confi dence was now restored, and nothing more was heard of the mutiny. The last of the rice was Issued on the 12th. The next day Hamet had one of his camels killed, and exchanged another for sheep with the Arabs ; this gave the troops one full ration. For the next two days they subsisted on roots and herbs. On the afternoon of the 15th they reached Bomba, but found there no trace of a human being and not a drop of water : moreover, not a vessel was in sight. The Arabs now became mutinous and abusive. Eaton took the Christians upon a mountain, where they built fires and kept them burning all night. " The next morning at 8 o'clock. Just as the Arabs were preparing to leave In disgust a sail was sighted, which proved to be the Argus, Isaac Hull in command ; she had seen the smoke of the fires. Eaton went aboard at noon. He found a letter from the Commodore dated March 22, 1805, informing him that stores and provisions were sent and seven thousand dollars in specie, but that no marines could be spared. The camp was moved around the bay to a cistern of water which had been found, and in the afternoon provisions were sent ashore. Either here or later, at Derne, Midshipman Mann came ashore and rejoined Eaton. April 17, the Hornet arrived with abundance of provisions. They remained in camp recuperating until the 23d, when they resumed the march with ■ sufficient supply of provisions to carry them to Derne, a distance of about 60 miles. The next day another courier arrived, with the news that an army from Tripoli was rapidly- approaching Derne and would probably reach the place first. The Arabs were agniu seized with alarm and became mutinous. Sheik el Tahib, at the head of the cavalry, began a retreat. Hamet, as usual, was irresolute and despondent. After much persua sion and a promise of money, the sheiks were Induced to advance, and on the afternoon of the 25th they encamped on a height overlooking Derne. " The town was rcconnolti-red, and Information was also obtained from a number of shieks who came out in the evening to meet Hamet and assured him that two of the three departments into which the city was divided were loyal to him. The third department, situated along the water front and containing a third of the inhabitants, was devoted to the interest of his brother 1'usuf. This department was, however, the strongest in posi tion and in its defense, which consisted of a water battery of eight 9-pounders on the northeast breastworks, and walls of old houses on the southeast, and a 10-lnch howitzer on the terrace of the bay's palace ; the walls of the houses were also pierced with loop holes for musketry. It was likewise learned that the bey bad 800 fighting men, and that the Trlpolitan army was near at hand. On the 20tb Eaton sent in a flag of truce with a letter to the bey offering terms. His reply was : ' My head or yours.' Smoke signals were made, and in the afternoon the Nautilus appeared: The next morning the Arf/u* and Hornet hove in sight. The Nautilus and Hornet came close in. and sent a boat ashore with two field pieces. One of these was landed, but owing to the great difilculty and delay of hauling it up the steep and rocky precipice that bordered the bay, the other was left behind, as Eaton was very anxious to attack without any loss of time. " Eaton at once set about making his dispositions, and the attack was made that day, Apr. 27, 1805. The enemy began by firing on the ships. The Hornet, Lieutenant Evans, anchored within a hundred yards of the water battery and opened fire. The Aryus, Captain Hull, and Nautilus, Captain Dent, anchored about half a mile from shore, to the eastward of the Hornet, and opened on the town and battery. The breast works and a ravine at the southeast part of the town waB held by a considerable force of the enemy, and opposite this point, on an elevation, were posted the squad of marines, 24 cannoniers with the fieldpiece, and 36 Greeks, all under the immediate com mand of Lieutenant O'Bannon ; also a few Arabs on foot. Hamet occupied an old castle south-southwest of the town, with the Arabian cavalry drawn up in his rear. By 2 o'clock the action had become general, and 45 minutes later the battery was silenced by the fire from the ships, and most of the enemy In that quarter being driven No. 2. 263 JONATHAN COWDERY, SUBGEON IN U. S. NAVY. many ridiculous airs, whirling around, shaking their heads and roaring like mad bulls. This continued about hnlf an hour, when they appeared to be raving mad. They ran about, as if to tear in pieces every body they met. One of them made a leap at -me. but was prevented from reaching me, by the Bey, Murat and another Turk, who jumped between us. Two other Turks caught nut reinforced the party opposed to the Christian land forces. At this point the enemy's musketry fire was very hot. In the excitement the rammer of the fleldpiece was shot away and Its Are In consequence slackened. Eaton saw that his little force of undisciplined troops was falling Into confusion, and as the only hope of restoring confidence, he ordered a charge. The enemy fled from their defenses, firing from be hind trees and houses as they retreated. At this moment Eaton was shot through the left wrist by a musket ball. O'Bannon and Mann, with the marines, Greeks, and as many of the cannoniers as could be spared from the fleldpiece, pushed on toward the battery under a heavy fire from the houses. The way was cleared for them along the beach by the ships' guns. The battery was soon captured and the American flag was planted upon its walls. The guns, which were found rendy loaded and primed, were turned on the town, and with the help of the ships' Are the enemy were soon dislodged from their houses. The bey fled from his palace and sought refuge In a mosque, and Hamet took possession of the deserted residence. The Arabian cavalry flanked the flying enemy, and a little after 4 o'clock the whole town was In the hands of the assailants. The ships' boats were sent ashore with ammunition for the bat tery, and took off the wounded. One marine was killed and two wounded, one of them mortally; 11 others were wounded. Including Eaton and several Greeks. Practically all the fighting on this occasion was done by the Christians under Eaton's command, assisted by the ships' batteries. "May 1 the Hornet sailed with dispatches for Commodore Barron. The bey of Derne left the mosque, where he had taken refuge, and Bought asylum in the harem of an aged sheik, who, although a partisan of Hamet, could not be Induced to break the laws of hospitality by giving him up. The town was now fortified against the Trlpolltan Army, which was approaching. The enemy advanced slowly, and on the 8th occupied the ground held by Eaton's forces before the capture. They spent several days in attempts to corrupt the inhabitants of the town, who were vacillating between the two parties, fearing that If they adhered to Hamet they would be slaughtered In the case of his defeat The late bey Intrigued actively from his sanctuary, attempting to Incite a counter revolution In the town. At the head of 60 Christians, Eaton proposed to enter the house of the old sheik and seise the bey. This ccurse, however, was offensive to the Arabs, and Hamet begged that action be deferred until the next day. That night, May 12, the bey escaped to the Trlpolltan camp. " Eaton believed that the enemy before Denie would disperse, but they displayed more resolution than he gave them credit for. On the 13th, apparently encouraged by the bey's tales of disaffection towards Hamet, they mado an attack on the town which fell only a little short of being successful. In the morning they appeared on the heights back of the town to the number of about 1.200, Including Trlpolltnns. Arabs, and fugitives from Derne. After rcconnoitering, they attacked an outpost about a mile from the town, (onsistlnir of 100 of Hamet's Cavalry, who held their ground firmly until over come by numbers, when they were forceed to give way. They retreated Into the town, followed by the Tripolitans, who pursued as far as the bey's palace, now occupied by Hamet. Although exposed to the fire of the Argu» and Kautilug, as well as of the bat tery and small arms from the houses, they made a vigorous attack on the palace, deter mined, if possible, to seize the person of the pasha. Their success seemed imminent, and Eaton began to fear that the day was lost. His little force of Christians was too weak for a sortie from the battery, and he torned the guns upon the town. A fortu nate shot from n 9 pounder killed two of the enemy's mounted men. Immediately the undisciplined rabble beat a disorderly retreat, pursued by Hamet's Cavalry and har assed by the fire from the ships. On this day Hamet's people surprised Enton by an exhibition of courage and firmness of which their previous behavior had given him no reason to believe them capable. From deserters it was learned that the enemy had lost 28 killed and 50 wounded. 11 of them mortally. Hamet lost 12 or 14 killed and wounded. "The Tripolitans fortified their camp, abont 3 miles distant, and made preparations for another attack, but their leaders could not Induce the Arabs to Join In It. Eaton had the same difficulty. He wished to attack the enemy's camp, but Hamet and his people could not be prevailed upon to make the attempt. Eaton was beginning to feor a dearth «f provisions, as the enemy cut off all supplies from the country. The Xautilua sailed 264 JONATHAN COWDEBY, SURGEON IN U. S. NAVY. Vol. XVII. hold of the negro and held hlra, when I, by the advice of the Bey, went to the top of the north end of the castle, where I could see the sport in safety. During the frolick. I saw those negroes chase several Christians : and I was told that they often tear all their clothes off, and hurt them much by biting, etc. May 22.— I was informed, that, in u letter which the Bashaw received the May 18 with dispatches, leaving the Argus alone before Derne. Several times the euemy seemed about to attack, but they could never persuade the Arabs to expose themselves again to the Are o£ the Christians ; artillery they could not face. Eaton believed that if he had had money he could have bought a wholesale defection of these allies of the Tripolitans. ' We want nothing but cash to break up our enemy's camp without firing another shot.' On the 28th the enemy sent a detachment of 50 or 00, supported by cavalry, on a foraging expedition ; they descended a ravine and attacked a party of Arabs, but were driven back. June 1, the Hornet returned with dispatches from the commodore, dated May 19, announcing that peace negotiations were about to be entered upon, and that Derne must probably soon be e"acuated. June 10, the enemy, who had been largely reinforced by Arabs, made another attack and were (irmly resisted by Hamet's ■cavalry. The engagement which ensued lasted four hours. The Argun was occasionally able to use her long Im pounders when the enemy in their movements emerged from the hills and ridges, and one of Eaton's fieldpieces also gave some assistance. The Tripolitans were finally repulsed with a loss, according to deserters, of 40 or 50 kilted, and 70 wounded. Hamet lost between 50 and 60 killed and wounded. O'Bannon wished to lead out the Christians and take an active part in the fight, but Eaton was unwilling to leave the defenses unmanned, and, moreover, doubted If offensive operations would be justifiable in view of the peace negotiations supposed to be in progress. " June 11, the Constellation, Captain Campbell, arrived with orders from Commodore Kodgers, dated June 5, to evacuate Derne immediately, and announcing that peace had been concluded. It now became necessary to embark on the Constellation all the Chris tians, together with Hamet and his suite. This must be done secretly, moreover, as it was feared that the populace and the Arabs, enraged at being deserted, would attempt to revenge themselves by a massacre of those about to depart. Eaton was filled with disap pointment and mortification at this ignominious ending of the expedition which he had hoped would result in the capture of Tripoli. But he had now no choice but to yield to necessity. To divert the attention of the people, preparations for an attack on the enemy were made June 12. In *he evening patrols of marines were placed as usual to prevent communication between the town and the battery. The Constellation's boats came ashore and first took off the cannoniers and Greeks, with the fieldpieces and the 10-lnch howltier captured April 27. Then Hamet and his suite were embarked, and next the American officers and marines. Lastly, Eaton himself put off in a small boat, and had barely got clear ' when the shore, our camp, and the battery were crowded with the dis tracted soldiery and populace, some calling on the pasha, some on me, some uttering shriekB, some execrations. Finding we were out of reach, they fell upon our tents and horses, which were left standing, carried them off, and prepared themselves for Sight.' " The next morning the Arabs and many of the Inhabitants of Derne fled to the moun tains. The enemy had already retired, under the impression that the Constellation, had brought reinforcements to Eaton, A Tripolltan officer, a messenger from Yusuf Pasba, who had come from Tripoli in the Constellation, went on shore under a flag of truce, bearing letters of amnesty from the pasba ' to the people of Derne on condition of their returning to allegiance ;' but the people remaining In the town had no faith in Yusuf's promises, and in despair prepared to defend themselves to the last. This abandonment of Hamet's followers to the tender mercies of his brother was the most painful part of this whole transaction, but it is believed that no harm came to them and that Yusuf's promises in their case was fulfilled. " The Constellation sailed directly for Syracuse. From this point Eaton sailed for the United States In (he brig Franklin August 0, and arrived at Hampton Roads Nov. 10, 1805. " The situation of the unfortunate Hamet was by no means befitting to a royal exile. In a letter to Eaton, dated June 29, 1803, he acknowledges that everything had been done for him which he had any reason to expect, but suggests " some small assistance to enable me (o subsist myself and suite." Accordingly, by order of Commodore Rodgers, he was allowed .¥200 a month for the support of himself and his 12 or 15 dependents in Syracuse. A few weeks later he appealed to the President and to the people of the United States for relief. He was allowed for a time to suffer in neglect. In April, 1806, Congress appropriated $2,400 for his benefit, but it was not delivered to him until more than a year later. 'Hie allowance authorized by Commodore Rodgers was then stopped, lu the meantime, Feb. 18, 1S07, he had addresed a memorial to Con So. 2. 265 JONATHAN COWDEBY, SURGEON IN U. S. NAVY. evening before, it was stated that Hassan Bey and his array were taken in Derne, by the Americans and Sadi Haniet. the Ex-Bashaw. I was desired not to mention it, because it was a great secret ; and the Bashaw did not wish to let his people know it. I was also informed that the Bashaw called a council of his chiefs, and proposed to put all the American prisoners to death, but it was agreed to postpone this measure for that time. May 23. —Twenty-five of our men were sent with u cart for timber into the country. The wind from the desert was very heavy and hot. The men almost perished in the sand, which flew and drifted like a snow storm in our country. They stopped through fatigue, and asked their driver, who was a Turk, for liberty to drink at a well which was near them. The Turk replied, that they were Romo kelps, Christian dogs, and said they should have no water. He gave them all a severe beating with a large club, which he always carried with him to drive them with, and made them go on with the cart, which the poor fellows had to drag, loaded with timber, through the burning sand. They returned towards night almost perished. May 2$. —At night the Bashaw dispatched a boat with powder, musket balls and money for his troops, who were collecting to oppose the approach of his sress In which he says : " I will not, like the world, reproach the representatives of the American Nation with ingratitude. I rather implore their commiseration toward me; at least so far as to restore to me my family and to grant me a competence." In May, 1807, Dr. George Davis, who had been for some years charge d'affaires of the United States at Tunis, went to Tripoli as consul, and one of his first acts was to demand of the pasha the fulfillment of the third article of the treaty of June 4, 1805, which provided for the restoration to Hamet of his wife and children. It was now learned that Colonel Lear had agreed to a secret article of that treaty, allowing the pasha four years to comply with this stipulation. This fact had never been commu nicated to the State Department nor to Congress, although Eaton had stated his sus picion of some such secret agreement in a letter to the chairman of the Senate committee on Hamet's application. The President, in his message of Nov. 11, 1807, expresses sur prise at this affair, and says : " How It has happened that the declaration of June 6th has never before come to our knowledge can not with certainty be said. But whether there has been a miscarriage of it or a failure of the ordinary attention and correctness of that officer in making his communications, I have thought it due to the Senate, as well as to myself, to explain to them the circumstances which have withheld from their knowledge, as they did from my own, a modification which, bad It been placed In the public treaty, would have been relieved from the objections which candor and good faith can not but feel in its present form." Doctor Davis, however, prevailed upon the pasha to restore his brother's family without further delay, and this was done in October, 1807. Dec. 18, 1807, a committee of the House of Representatives recom mended further pecuniary aid for Hamet. In 1808 provision was made by the pasha for his brother's residence in Morocco, with a pension ; and in the following year, through the influence of Consul Davis, Hamet was appointed by the pasba to the government of Derne. Two years later he was again expelled by bis brother and fled with his family to Egypt, where he died. Upon his return to America, Eaton was received with marked distinction. The Leg islature of Massachusetts made him a grant of 10,000 acres of land in Maine. But he could never get over his chagrin and disappointment at the inglorious termination of his expedition, which he had hoped and believed would end with the capture of Tripoli, the restoration of Hamet, a brilliant victory for the United States forces afloat and ashore, and an honorable peace. The remainder of his life was embittered. Toward those who, he believed, had in any degree thwarted his plans, Lear especially, he was nnsparing of his reprobation. He therefore not unnaturally made enemies, and a reso lution to present him a medal was defeated In Congress by a small majority. He was embarrassed by long delay in settling bis claims nnnlnst the Government. Finally, in February, 1807, a bill passed in Congress authorizing the State Department to settle the accounts according to equity. Many years later his heirs applied to Congress for relief. The total expense of the Derne expedition was a little less than $40,000 ; Eaton would accept for his own services during this campaign only enough to cover his personal expenses. His relations with Hnmet continued cordial, and for some years they kept up a friendly correspondence. Eaton died in 1811 at the age of 47. 266 JONATHAN COWDERY, SURGEON IN U. S. NAVY. Vol. XVII. brother Hauiet, the Ex-Bashaw. The eldest son of Hamet, was confined in the castle by order of the present Bashaw. The Bashaw was so much agitated at the news of the approach of his brother, that he this day declared, that if it was in his power now to make peace and give up the American prisoners, he would gladly do it, without the consideration of money. His funds were so low, that his steward ran in debt for the supply of the kitchen. He gave his mamelukes and domesticks, and myself, but one meal per day.—The rich Turks in town took turns in supplying his few troops. He heartily repented for not accepting the terms of peace last offered by our country. May 26.—Three frigates in sight. At about 11, A. M. the smallest came near in, and hoisted the banners of peace. The Bashaw asked his head men of the town, who were with him in his gallery, whether it was best to hoist his white flag. All except one, the charge de affairs for Algiers, declared in favour of it, and of making peace if possible. They expressed great contempt towards the Algerlne consul for his advice, and said that whoever would advise the Bashaw not to hoist the white flag at such a critical moment must be his foe and not his friend. The Algerlne soon disappeared and left the castle. The Spanish consul soon after came to the castle; and the Bashaw sent him in one of his handsome boats, with Shous Hammad to the frigate. They returned at evening with the joyful news of a prospect of peace. There was a visible change, from gloominess to joy, in the countenance of all the Turks. May 27.— Both Turks and Christians were all anxiously looking out for the frigates. It was said that Col. Lear had promised to come on shore this morning and that the Spanish consul was preparing a dinner for the gentlemen who were expected to come with him. We were all agitated alternately by hope and despair. The terraces and every eminence in town, were covered with people of all classes and ages, who were looking for the wished for peace maker. But Dot a frigate nor a sail hove in sight during the day. May 28.—All looking out again for our squadron. A brig hove in sight in the morning, which we all at first thought was the flag ship. On discovering it was a brig, a gloominess again appeared on every countenance. The Turks began to think that the frigate had gone to fetch the whole fleet, which they heard consisted of sixty sail of different sizes. They thought that the flag of truce was only a plan of the Americans, to find out the force of Tripoli, eta But at sun set three frigates and a brig appeared, which revived our hopes. The Bashaw showed the greatest anxiety for peace. He was sensible of the danger he was in from the lowness of his funds and the disaffection of his people. May 29.—Three frigates and a brig bore down upon the town and displayed the ensigns and signals of peace, which were immediately answered from the castle. The Spanish consul, Fafah the Jew and several Turks went on board, and did not return until late at night, when it was reported that negotiations for peace were going on rapidly. Miiy 31.—The Spanish consul and Shous Hammad went on board to see the Commodore, and returned at night. The Bashaw sent me to inform Captain Bainbridge, that peace was agreed on, which I did to the great joy of, the officers. June 1.—The truce continued. Our men were still drove to hard labour, and our officers kept confined. June 2.—I received a letter from Captain Bainbridge stating that the terms of peace were agreed on. and that we should soon go on board the squadron. I immediately read this letter to our crew, who were so overjoyed that many of them shed tears. They were still drove to hard work, and many of them Hogged. No. 2. JONATHAN COWDEBY, SUBGEON IN U. S. NAVY. 267 June 3.— The articles of peace were signed, and salutes fired from the frigates and batteries. June 6.—I bid the Bashaw a final adieu, at which he seemed much affected. James Fenimore Cooper writing of the war with Tripoli, in his "History of the Navy of the United States of America," makes the following comments upon this naval campaign and its results : "It is not easy to express approbation of the terms of this peace. America had been contending for the usages of civilization, and the rights of nations, and the ransom was a direct abandonment of both. When we remember the force that was about to assemble before Tripoli, the season of the year, the fact that Derne was occupied by Hamet Caramalli, and the disposition that so generally prevailed in the squadron to renew the attacks on the enemy, we find it difficult to believe that better terms might not have been obtained. How far the course of the negotiator was compelled by his instructions, we have no means of saying, but the treaty was approved and rati fied. While many condemned it as unwise, all, however, rejoiced that it was the means of restoring so many brave men to their coun try. It is no more than liberal, moreover, to believe that the situa tion of these unfortunate officers and men, had a deep influence in inducing the Government to forego abstract considerations, with a* view to their relief. " Thus terminated the war with Tripoli, after an existence of four years. It is probable that the United States would have retained in service some officers, and would have kept up a small force, had not this contest occurred, but its influence on the fortunes and char acter of the Navy is incalculable. It saved the first, in a degree at least, and it may be said to have formed the last. Perhaps no serv ice, either in the way of ships or officers, ever had so large a propor tion of what was excellent in it, and so small a proportion of that which was defective, as the Navy of the United States, the day peace was signed with Tripoli. A stern discipline, a high moral tone, rare models in seamanship, active warfare, the means of comparison, and a spirit of emulation that is certain to carry the national character to the highest level, whenever the national energies can be permitted to exhibit themselves, had conspired to produce this end. The petu lant and always questionable proofs of private rencontres, which are so apt to sully the renown of infant services, had disappeared in a chivalry that seemed to have forgotten all but the country and her honor. Not a duel was fought during the command of Preble; the brave men assembled under his orders, regarded each other as brothers, and the honor of one appeared to be connected with the honor of all. An admirable esprit de corps was created, and the but ton, which bore the emblem of the common profession, was deemed a signal of the presence of a friend. Men had stood by each other 108165—22 6 268 JONATHAN COWDEBY, SURGEON IN V. S. NAVY. Vol. XVII. in moments of severe trial, and even the body of the Nation, which is so little addicted to the sentimental, or the abstract, began to regard the flag with open pride. In a word, the tone, discipline, pride, emulation, and spirit, that the Navy derived from this remote and, in one sense, unimportant war, prepared it for another and a severer trial that was at hand. The impression produced in the Mediterranean was also favorable, and the head of the Romish church is said to have publicly declared, that America had done more for Christendom, against the barbarians, than all the powers of Europe united." EDITORIAL. EDITORIAL STAFF. Lieut. Commander Lucius W. Johnson, Medical Corps, United States Navy. Lieut. Commander J. G. Ziegler. Medical Corps. United States Navy. Lieut. Commander W. M. Kerr, Medical Corps, United States Navy. Lieut. Commander J. J. O'Mallcy, Medical Corps, United States Navy. Lieutenant L. J. Roberts, Medical Corps, United States Navy. Lieutenant J. D. Benjamin, Medical Corps, United States Navy. Lieutenant E. Peterson, Medical Corps, United States Navy. SIB PATRICK MANSON. The death of Sir Patrick Manson, the distinguished parasitologist and teacher of tropical medicine, occurred on Sunday, April 9, 1922, at his house in London. The Lancet and the British Medical Jour nal for April 15 contain glowing tributes to his memory. He was born in Aberdeenshire on October 3, 1844, and was educated at Edinburgh and at the University of Aberdeen, where he graduated in medicine in 18G5. He spent the early part of his professional life in the East. In 1866 he went to Formosa to act as medical officer to a group of merchants and missionaries. Here he encountered diseases, espe cially beriberi and elephantiasis, which for the most part were unstudied in the medical schools of Great Britain, while their etiology was unknown to the entire scientific world. After practic ing in Formosa for five years he went to Amoy, in China, where he acted as medical officer to the Chinese maritime customs and was in charge of a large native hospital. In Amoy he saw many forms of elephantiasis, but could at first find no satisfactory solution of the problem it presented. During a visit to London in 1874 he heard for the first time of the discovery made by Timothy Lewis in 1872 that in the blood of a proportion of the inhabitants of certain dis tricts of India was to be found an organism which Lewis called the Viler' a sanguinis hominis. These parasites Lewis has encountered in association with elephantiasis. On his return to China in 1876 Manson discovered that these parasites were present in many dis tricts in a high percentage of the population. He spent the next two years in working out the life history of filaria. As the parasite showed no evidence of growth while in the blood or any features warranting the supposition that it was capable of reproducing itself, the inference was that it was an immature form. After much search L'G9 270 EDITORIAL. Vol. XVII. Manson found that this was the case, although the discovery had been anticipated by Bancroft as well as by Lewis. Turning his attention to the manner in which this organism entered the body it occurred to Manson that, as it was never found in any of the natural discharges, it could not escape spontaneously so as to pass from man to man without the aid of an agent capable of penetrating the skin and withdrawing blood. The mosquito appeared to him to be the most likely agent in the dissemination of falaria. To determine the frequency with which that parasite was present he examined the blood of a thousand natives with the help of two Chinese medical students. These assistants were employed in the hospital, one work ing in the daytime, the other at night. The one who worked at night brought Manson many specimens, the other seldom found a filaria. Investigating this point he found that in ordinary conditions of health, this filaria came into the peripheral blood stream about sun set, increasing in numbers toward midnight, but decreasing toward morning. This filaria periodicity suggested an adaptation of the habits of the parasite to the nocturnal habits of the mosquito. The next step was to determine whether the filaria was ingested with the blood which the mosquito imbibed and, if so, what changes occurred. An examination of the abdominal contents of mosquitoes which had fed at night upon a patient having filaria in his blood, showed the presence of the organism and its stimulation by the digestive juices to certain structural changes; its inclosing sack had been broken and discarded, while considerable growth had taken place, accompanied by the development of a mouth and alimentary canal. In later years, after months of research, it was demonstrated by Dr. G. C. Low, one of Manson's pupils in the London School of Tropical Medicine, that the filaria in its modified form leaves the stomach of the mosquito, reaches the thoracic muscles and finally the proboscis, in which locality it is ready to infect man. It was thus proved that certain kinds of mosquitos are carriers of this filaria and are agents in transmitting the diseases to which this parasite gives rise. In 1883 Manson returned to England where he worked for the first time with an oil immersion lens then recently perfected. While at home lie published a small book on filariasis. and in 1884 returned to China, where he confirmed his previous work with the better appa ratus now at his disposal and made his original researches into sprue. The years 1885 to 1889 were spent at Hongkong in general practice, where he founded a medical college for the Chinese. In 1890 he returned to England, and with his unrivaled personal knowledge of tropical medicine began practice as a consultant in London. He became physician to the Seamen's Hospital Society in 1894, and in 1897 was appointed medical advisor to the colonial office. In 1898 he delivered at St. George's Hospital a lecture on the No. 2. 271 EDITORIAL. need of the special study of tropical diseases, which resulted in the establishment of the London School of Tropical Medicine. Manson's knowledge of the life history of filaria was of value in clearing up the mystery surrounding the malaria parasite which had been discovered by Laveran in Algiers in 1880. Manson reasoned that this parasite like the filaria, to pass from man to man, must re quire the intervention of some blood-sucking insect as the mosquito. It had already been noticed that the malaria organism underwent certain changes, becoming flagellated when removed from the human body, and Manson concluded that these flagellated bodies were an early form of the extra-corporeal phase of the parasite. At Manson's suggestion the life history of the malarial parasite was worked out in India by Sir Konald Ross to the satisfaction of the scientific world, and two well known experiments conducted in Italy and in London demonstrated to the world at large the means of preventing malarial infection. The first of these experiments Avas the sending out to the most malarious port of Italy two observers, Dr. Louis Sambon and Dr. G. C. Low, who were to live among the malaria-stricken population, exposing themselves all day to the ordinary environ ment, but who were to retire for the night before sunset into houses specially protected from invasion by mosquitoes. These men re mained health}', while the inhabitants of the district were ill and often dying of malaria. The second experiment consisted of subjecting healthy subjects in London to the bites of infected mosquitoes col lected in the malarious parts of Italy. These men suffered from malaria fever two weeks after they were bitten, the parasites being found in their blood. " Sir Patrick Manson retired from active practice in 1913," we are informed by the Lancet, " and for a time traveled in Ceylon and South Africa noting hygienic problems. On his return he contin ued to take a deep interest in the conduct of the London School of Tropical Medicine and the progress of his special branches of science. He exercised great influence upon all who worked with him, for which nothing was too big or too smali for him to consider; his clinical acumen was sound, so that he made few mistakes. His habit of thought may be summarized in his own words written in 1909 to his son-in-law : ' Never refuse to see what you do not want to see or which might go against your own cherished hypothesis or against the views of authorities. These are just the clues to follow up. as is also and emphatically so the thing you have never seen or heard of before. The thing you can not get a pigeonhole for is the finger point showing the wa}- to discovery.' His own scientific hy potheses had a knack of turning out right —for example, his fore cast of the life history of Schistosoma haematobium in the fourth 272 Vol. XVII. EDITORIAL. edition of his manual of Tropical Diseases in 1907 ; also his sugges tion in 1903 of the two species of schistosoma proved true by Leiper in 1915. Younger men who came under Manson's influence remarked always that in outlook and in knowledge he remained eager and en thusiastic to the end. His interest in his work never flagged. Only 14 days before his death he visited the London School of Tropical Medicine and critically examined some microscopical preparations, showing his usual perspicacity in picking out the important points in each specimen and emphasizing the lessons they taught. Almost the last words he uttered expressed his hopes for the future of this school for which he anticipated a still wider field of work in coop eration with the Rockefeller scheme for the new Institute of Hy giene. " He married, in 1876, Henrietta Isabella, daughter of Capt. J. P. Thurburn, R. N.. by whom he had two sons and three daughters, one of whom is the wife of Doctor Manson-Bahr, the editor of the last edition of Sir Patrick Manson's famous Treatise on Tropical Dis eases." We learn from the British Medical Journal that " Manson was a devoted disciple of Izaak Walton and at one time used to fish in Scotland every year. In recent years he deserted the rivers of his native land for Ireland and took a place at Clonbur, County Galway, where he indulged his sport to his heart's content. After his retire ment from practice he retained his interest in the London School of Tropical Medicine and usually spent part of the winter in London. For many years he had been crippled by gout and rheumatism, but his mind remained vigorous." (w. m. k.) THE DEMAND FOK TRAINED LEADERSHIP IN SANITATION. On reading Capt. W. H. Bell's article on the Sanitary Inspector of the Community, which appeared in the July number of the Bulletin, we recall to mind the new types of technically expert in dividuals demanded by the expanding conception of health. It has been estimated that in the next 10 years the number of persons en gaged in public-health work in civil communities in this country must be doubled. The same ratio of increase will undoubtedly be noted in regard to naval sanitarians. In discussing the demand for trained leadership in public-health work George E. Vincent, presi dent of the Rockefeller Foundation, said : " Only in the last few years have opportunities for special public-health training been available in the United States. With exceptions almost negligible in number, American health officers have had no other formal training than that of doctors of curative medicine. They have gained what No. 2. 273 EDITORIAL. special competence they may possess in the hard, wasteful, and one sided 'school of experience.' That a few have attained the level of ' sanitary statesmen ' is an evidence of exceptional ability and char acter, not a vindication of rule-of-thumb, trial-and-error methods. The future of preventive medicine depends upon drawing first- class men and women into the profession and giving them efficient, modern, specialized training and supervised practical experience." (w. M. K.) ON THE USE OF THE SCHICK TEST, ANTITOXIN, AND TOXIN-ANTITOXIN IN THE PREVENTION OF DIPHTHERIA IN THE NAVY. The Schick test and the active immunization of individuals sus ceptible to diphtheria are procedures rapidly coming into more fre quent use. Important work in this direction has been carried out on a large scale among school children and those in orphanages and similar institutions. Particularly notable was the work of Park and Zingher, who administered immunizing doses of toxin-antitoxin mixtures to more than 52,000 nonimmune school children in New York City. The conclusion reached as the result of this work is that all children between the ages of 6 months and 5 years should receive immunizing doses of toxin-antitoxin, and that all children of school age found by the Schick test to be susceptible should be im munized by the same method. The conclusions in regard to the im munization of adults are less definite. In view of the fact that so large a proportion of adults have severe reactions following the im munization treatment. Doctor Park does not even urge nurses to submit to it. This work brings us face to face with the problem of diphtheria prevention in the Navy. To what extent, if at all, are we to make use of the Schick test, antitoxin, and toxin-antitoxin in the prevention of the occurrence and spread of diphtheria ? The Schick test and its purpose are well known. Descriptions of the usual method of immunization by toxin-antitoxin have appeared in previous publications of the Bureau of Medicine and Surgery, and it is unnecessary to give more than an outline of it here. Briefly, it consists of three subcutaneous injections, at seven-day intervals, of a 1 c. c. mixture of diphtheria toxin and antitoxin. If it should be thought desirable to immunize the personnel of the Navy it would lie advisable to do a preliminary Schick test on all individuals and immunize only those who are, by this procedure, found to be sus ceptible to diphtheria. It would also be necessary to apply the Schick test three to six months after the course of injections to determin" whether the individual had been rendered immune. Active immunity develops slowly, often requiring 8 to 12 weeks. In his follow-up work in New York City. Park found that three injections of toxin-antitoxin 274 Vol. XVII. EDITORIAL. mixture had produced an immunity in about 90 per cent of those who had been previously nonimmune. During the 11-year period ending December 31, 1920, the average aninual admission rate per thousand for diphtheria in the Navy was 2.22. The death rate for the same disease was 5.77 per 100,000, and the case fatality rate 2.6 per cent. The death rate for the United States in 1917 was 16.5 per 100,000. In Massachusetts in 1919 it was 15.4 per 100,000. These are representative figures. There are a number of reasons for the lower death rate from diph theria in the Navy as compared with the population at large. In the first place, the naval personnel is an adult population, and, as so con clusively shown by Park and others, most adults are immune to diph theria. The figures for New York and other city populations show about 12 per cent of adults susceptible as against 50 per cent of chil dren under 5. In rural communities the percentage of nonimmunes is somewhat greater, but in a mixed adult population the average figure would probably be not far from 20 per cent. Park believes that the repeated exposure of one living in the congested districts to the diph theria bacillus, resulting in slight, unrecognized, mild infections of the mucous membranes, leads to sufficient development of antitoxin to produce an immunity —the so-called natural or contact immunity. Living conditions in the Navy approximate fairly closely, as regards crowding, the densely populated quarters of our cities, and it is probable that after a few months of Navy life the number of non immunes should approach the city figure of 12 per cent. Another reason for the lower death rate for diphtheria in the Navy is the fact that the personnel is under constant medical super vision. Wherever numbers of men are grouped together a medical officer is readily available. Moreover, line officers cooperate with the medical officers during epidemics in seeing to it that the men report to the sick bay when the first symptoms develop. Control of the epidemic is thus facilitated, and in the case of diphtheria the early administration of antitoxin is made almost universal. As a result of the high degree of immunity of the naval personnel and the prompt steps taken to prevent diphtheria spread when a case develops diphtheria should not be a menace in the Navy. Rarely do more than a few cases develop on board ship in any so-called epi demic. In view of these facts the need of general immunization meas ures in the Navy is not as great as is the case among the population at large, and any method which introduces any seriously objection able features would scarcely be justified. That there are objections to the general administration of toxin- antitoxin in the Navy is indicated in the reports of medical officers who have used it extensively among the naval personnel. At the Naval Training Station, Great Lakes, 111., toxin-antitoxin immuniza No. 2. 275 EDITORIAL. tion against diphtheria was Carried out on a large scale. The work ers there found, as Park has found in New York, that the percentage of very sore arms and the constitutional reactions necessitating bed treatment is very great in adults as compared with the lack of reac tion in infants. A large proportion of those inoculated had to be admitted to the sick list for at least one day. Many others were inconvenienced to a greater or lesser degree. Aside from the damage to the Navy in " sick days," there is the added objection that any pro cedure which causes such inconvenience is bound to be unpopular and lessen the confidence of the naval personnel in immunization measures in general. This, of course, would be a great misfortune. There is another very important reason why most naval medical officers who have to do with the use of toxin-antitoxin on a large scale are not as enthusiastic over it as they were at the outset of their work. They have reached the conclusion that immunity, at least as revealed by Schick test interpretations in the Navy, is not constant. Large numbers of men who had given negative Schick tests on one occasion were tested several months later and a considerable per centage of them found to be Schick positive, i. e., susceptible to diphtheria. This could not be explained entirely by the personal factor on the part of those reading the tests, because the same medi cal officer made all the readings on both occasions, and any error, therefore, would tend to be constant. This observation was made at Great Lakes by Hughens and at Annapolis by Houghton. At An napolis, in the fall of 1918, all susceptible individuals were im munized by the injection of a toxin-antitoxin mixture furnished by the New York Department of Health. In the following spring an epidemic of diphtheria developed in this same group. The entire personnel was Schicked again, and of the 1,147 who had received toxin-antitoxin 22 per cent gave positive tests. One very striking example of the temporary quality of even active immunity was demonstrated by one individual who had a definite attack of diph theria in the spring of 1918, gave a positive Schick and received toxin-antitoxin in November, 1918, and developed diphtheria again in March, 1919. These facts brought out by medical officers in the Navy are of particular interest to the service, and although there may be certain instances where immunization by means of toxin- antitoxin among certain given groups is advisable its general use is probably not justified. In the control of a diphtheria epidemic, which actually exists, we have, of course, an entirely different problem. Toxin-antitoxin would be of no avail here because of the length of time necessary for the establishing of active immunity. Along with the usual pre ventive measures, many have advocated performing the Schick test on all contacts and the administration of prophylactic closes of anti 276 Vol. XVII. EDITORIAL. toxin to those who are found to be susceptible. The question of the phophylactic use of antitoxin in the Navy can not be answered by a sweeping statement, and it must be settled by the individual medical officer as the occasion arises. But, in order to avoid the false sense of security which such a method so often carries with it, its short comings should be realized. The immunity produced would be of very brief duration, quite possibly not outlasting the epidemic. The possibility of serum sickness must also be considered. Although serum sickness is seldom serious, its effect on the morale of the crew and their possible loss of confidence in such a sovereign remedy as diphtheria antitoxin, is not to be overlooked. In case it is not considered advisable to use antitoxin in epidemics, there is still the question as to whether those among the contacts who are immune, should be identified by the Schick test. It is con tended that, if the medical officer knows which men are immune, these immune individuals can be disregarded in the attempt at early identification of clinical cases of diphtheria. Under certain conditions, and where the medical officer feels confident of his ability to interpret the Schick test, this procedure may be advantageous. Before the crew can be tested and readings made, however, two or three days or perhaps more have elapsed. After all, the strict ob servance of the usual preventive measures is the procedure of prime importance in the Navy. The application of the Schick test can only be an accessory. These observations are made with the idea of presenting some of the new problems in the prevention of diphtheria with which naval medical officers have to deal. The questions involved can not be decided now. Much work and careful compilation of data is neces sary and it would be regrettable if the investigations along these lines should not be continued. In the meantime, we should realize the limitations of these procedures as applied to the Navy, and recognize that with us they are still in the experimental stage. (l. j. r.) ON QUININE AND MALARIA : EFFECTS AND MODES OF ADMINISTRATION. Quinine is still the drug par excellence in the treatment of malaria, although occasional reports of wonderful cures by other methods are sometimes seen, notably by the intravenous injection of arsphena- mine. As in the case of many other so-called specifics, the limita tions of quinine are being more and more appreciated. Lane in his critical review of recent malaria literature in Tropical Diseases Bulletin for February, 1922, brings out some very interesting find ings. It lias been long known that relapses in the malignant tertian type are less apt to occur than in the benign forms. Acton and his No. 2. 277 EDITORIAL. coworkers in Dagshai have also demonstrated this fact, showing that quinine cured the malignant cases but that the benign ones were wont to relapse. Wayne and Wenyon have independently shown that this selective action of quinine, so to speak, applies only to the asexual phase of the parasite. With regard to the game- tocytes the opposite seems to hold true. The quinine apparently has a specific action on the gametocyte of the benign tertian whereby its subsequent development in the mosquito is prevented, whereas the gametocytes of the malignant type do not suffer during quinine administration but retain their faculty of developing in the mos quito. Hence even if benign infection is difficult to cure with quinine, the danger of spreading the disease is practically nil while the patient is under treatment. The patient suffering from the malig nant type, however, is always a danger in this regard until complete cure has been established (i. e., as long as the gametocytes persist). With regard to the modes of administration the modern tendency is to give the drug by mouth to the exclusion of the intramuscular and intravenous routes. The latter method is indicated only when marked gastric disturbance is present or when other conditions (es pecially pernicious typos of the disease) render oral administration impossible or impracticable. The intravenous injection is con demned as a routine measure on account of the inherent dangers of such a procedure. In order to minimize as far as possible the dangers from the in travenous introduction of the drug, it is well to bear in mind that the procedure should be carried on with aseptic technic; the drug should be given in marked dilution and very slowly. The size of the dose should never exceed 15 grains and it is better to start with a smaller dose (5 to 10 grains). The dilutions should be \ grain of the drug to 1 c. c. of solution and the injection should be given at the rate of 1 c. c. per minute. The injection should be discontinued at once if there is any sign of the solution not entering the vein properly. In case of circula tory collapse, adrenalin will be found of great value. After the indications for intravenous injections have subsided, oral administration should be started. The intramuscular route has no advantages over the oral one. McLay in Macedonia (J. Roy. Army Med. Corps. February, 1922) obtained evidence that the malarial parasite disappeared more rapidly from the blood by oral than by muscular administration of quinine. The intense reaction, sometimes amounting to abscess formation, and the marked discomfort which it produces in the patient are too im portant disadvantages to make this method of administration even tolerable. 278 /ol. XVII. EDITORIAL. With regard to the oral administration of quinine, the method, em bodied in the Standard Treatment of this country so ably advocated by Bass, probably is as good as any. According to this method 30 grains of quinine are given daily during the period of symptoms and then 10 grains a clay for a period of at least 8 weeks. This method of administration is based on the fact that a marked difference exists between the clinical cure of the disease and the thorough disinfestation of the patient. Experience has shown that the latter is a fractional process and that even the daily adminis tration of 10 grains of quinine for 8 weeks is not always effective. A certain number of patients subjected to this method of treatment will continue to have relapses. But with each course of treatment the number of relapses grows smaller and smaller. The point to bear in mind, however, is that no person with malarial parasites should have less than 8 weeks of standard treatment, (e. p.) ON OBAL HYGIENE AS APPLIED TO HOSPITAL PRACTTCK. In conjunction with the Forsyth Dental Infirmary at Boston, the Massachusetts Homeopathic Hospital has taken up the work of oral hygiene and prophylactic treatment of the mouth in all cases ad mitted. The work as it is at present conducted consists in having the house officers list cases they wish treated, these cases then being ex amined and treated by dental hygienists from the Forsyth Dental Infirmary. These hygienists clean the teeth, give toothbrush drills, and massage gums, and then report the condition of the patient's mouth, suggesting any necessary further treatment. The results aimed at are several : During pregnancy the teeth are often neglected and allowed to decay. This, of course, can be pre vented by dental care. This factor of the care of the teeth during pregnancy is a very important one from the educational standpoint. If women in the obstetrical wards can be shown that it is desirable to care for the teeth during pregnancy, the loss of teeth will be pre vented and many diseased conditions which result from poor teeth and mouths infected with pyorrhea will be prevented. Another result is the instruction of children in the care of the teeth, in order that they may be started in the proper way. Faulty dental conditions are often at the bottom of digestive disturbances in chil dren. Another result is the prevention of bronchitis and pneumonia which sometimes occurs from the inhalation of septic material about faulty teeth during the course of ether administration. As a pre ventive measure it is highly desirable to have the mouth and teeth So. 2. 279 EDITORIAL. in the best possible condition prior to anesthesia. This is particu larly so in nose and throat work, in which it is most important that the oral cavity be as clean as possible before operative measures are undertaken. Focal infection of the mouth plays an important part in orthopedic conditions. Many cases of infectious arthritis clear up under dental prophylaxis and treatment. In medical cast's also the care of the mouth and prophylactic dental treatments are valuable. A clean mouth may have a tendency to prevent communicable diseases of the respiratory tract. Many of the vaguely indefinite digestive symp toms in adults may be alleviated by oral hygiene, because if the teeth are put in good conditions, they are more capable of functioning properly, thus rendering food in better form for digestion. Viewed from the standpoint of education, oral prophylaxis is ex tremely valuable because by means of such treatment the attention of the patient is called to the fact that teeth do need care, and if he is shown how to care for them himself after he leaves the hospital he is likely to carry on the work started there, (w. m. k.) ON ISCHIOKKCTAL AIISCESS. A recent careful review of 90 cases shows but a scant 25 per cent of complete cures, with a large number of unsatisfactory results. In order to incite bacterial suppuration within the ischiorectal fossa the organisms must be provided with a means of entry. This does not exist under normal conditions. Any mechanical factor that produces a tear or puncture of the mucuous membrane of the anal canal opens the pathway of infection. This break in the mucous membrane makes a short path for the organisms to the ischiorectal fat. This fat is of a very loose nature, subject to frequent trauma and low in resistance to bacterial infection. The relation of tuberculosis to ischiorectal abscess and fistula in ano has long been a debated question. G. S. Dudley writing in the American Journal of Surgery on ischiorectal abscess quotes many statistics to show that this association is rare and that not more than 2 per cent of anal abscesses and fistulas are due to that cause. The operation must be approached on the scale of a major proce dure. In preparation, castor oil catharsis is indispensable, since it not only empties the intestinal tract thoroughly but also there follows a period of two or three days during which defecation is not likely to occur. General anesthesia is the rule, since thorough manual dila tation of the sphincter is essential. This should be done gradually and gently. The anal mucous membrane is then inspected and palpated to locate the point of entrance of the infection. If no such 280 Vol. XVII. EDITORIAL. point can be found, the abscess is opened by an ample radial incision and a further search made for the point of entrance. The opening of the abscess is completed by a clean transverse incision through the external sphincter continuous with the radial skin incision. A single transverse division of this muscle is seldom followed by per manent loss of power. The wound is packed lightly with petrola tum gauze and a dry dressing applied. The first dressing is done after the first bowel movement, usually on the third day of convalesence, the gauze is removed and the wound irrigated, then repacked, (uw. j.) ON THE TREATMENT OF HIGH BLOOD PRESSURE. The control of hypertension has been attempted in many ways. None of them have been completely successful; some of them rest upon hearsay and tradition rather than upon clinical observation. For many years protein foods were considered to be at the root of the "blood-pressure evil." The dietary prescription of meat once a day or less and as few eggs as possible has been advocated until the meatless diet has become a popular slogan. There is no doubt about the fact that many of our citizens through an overindulgence in starchy foods are becoming obese and favoring the development of " high blood pressure " and " hardening of the arteries " by the very diet that is supposed to preA-ent these maladies. The feeding of pro tein, as meats or otherwise, will not tend to increase the blood pres sure of a hypertensive individual. The former idea that the retention of the end products of protein digestion act as irritants that stimulate the heart and the arteries to increased activity and raise the blood pressure can not be con sidered to be correct. Many of these cases do have a high blood pressure, but its cause must be sought in another direction. Dietetic therapy in these instances demands a lowered protein intake, but while ordering it we must be clear in our minds that we are doing it to relieve the kidney of its burden and not to diminish the hyper tension. Enough protein food should be allowed to maintain the body in an efficient condition, and nothing is to be gained by the rou tine restriction of meat, fish, or eggs. The starches have always been considered the most innocuous of foods; their final digestive products are carbon dioxide and water, which put no strain on any of the eliminative functions. The one drawback to an excessive carbohydrate diet is that it is prone to engender obesity in the individual. Many persons may become obese and exhibit no increase in their arterial tension ; others are not so fortunate. If the combination of obesity and increased blood pres No. 2. 281 EDITORIAL. sure does exist, a restriction of the starchy foods may bring relief. In individuals who are overweight, a control of the starchy food may be of distinct importance in regulating the blood pressure. What has been said in regard to the relation of starches to obesity and hypertension may be repeated for the fatty foods. The 'fats in themselves appear to have no other specific effect upon the level of the blood pressure. The effect of fluid intake upon blood pressure is practically nega tive when only such quantities of liquids are ingested as supply the normal needs of the body. When huge amounts of fluids are taken the arterial tension may be increased, but the normal allowance shows no changes, and it is not worth while to trouble patients in restricting the fluids with any idea of controlling the blood pressure. The only procedure that has been at all satisfactory in yielding a drop in blood pressure that may be regarded as a definite effect of therapeutic interference has been nervous relaxation obtained by longer or shorter periods of rest. It can not be said without reserva tion that rest and removal of nervous strain will lower pressure in every instance, but it is vital to regulate the business and family cares of hypertensive patients to eliminate nervous strain, and this requires an unusual amount of tact, cooperation, and forbearance on the part of all concerned. Drugs have failed to furnish us with the means of permanently reducing hypertension. This is the consensus of opinion at the present time of the best minds, and drugs are not being extensively used for this purpose to-day. H. O. Morsenthal, writing in the Medical Clinics of North America for January, 1922, on the treatment of high blood pressure, remarks that it is worth remembering that essential hypertension is a disease that occurs commonly and is, in its early stages, not associated with kidney involvement; that as the increased blood pressure persists certain secondary changes occur. These, in their order of vital importance to the patient, are : Cardiac hypertrophy, dilation and failure, apoplexy, and nephritis and uremia. One of the most im portant elements in the treatment of hypertension is the prevention of these sequelae. Aside from symptomatic therapy, there is in the majority of instances no specific effect to be expected from any form of treatment. Belief from nervous strain and rest for shorter or longer periods offers the best means of reducing the blood pressure and lessens the strain upon the heart and arteries, for a time at least. Diet as a whole or its various constituents, proteins, fats, carbohydrates, fluids, or salt have no direct effect upon the degree of arterial tension: indirectly the regulation of the various dietary factors so as to reduce weight, diminish the number of red blood cells, or bring about undernourishment may lower the blood pressure. 282 Vol. XVII. EDITORIAL. A careful general survey of the patient will indicate what other measures should be taken in regard to the teeth, gastrointestinal canal, genito-urinary tract, etc., which in some instances may be pro ductive of far-reaching results. The above represents the facts concerning the treatment of essential hypertension as we possess them to-day; there is much in the routine therapy of this disease that is traditional and that demands investigation before it can be successfully or conscientiously applied, (j. j. o'm.) ON NEUROPSYCHIATRY DISABILITIES. For purposes of description, neuropsychiatric cases may be di vided into four groups which differ from one another in the require ments of treatment. These are : 1. Injury or disease of nerve tissue. 2. The psychoneuroses (or neuroses). 3. The psychoses (or insanities). 4. Certain constitutional nervous deficiencies. Group 1 is comparatively small in size and relatively simple in its requirements. It includes such cases as gunshot and other accidental injuries to nerves and the damage produced by diseases of the nerv ous s}Tstem, such as meningitis, " strokes " of paralysis, etc. Uncom plicated disabilities of this kind can be adequately treated in 'general hospitals or relief stations. Group 2, the psychoneuroses, is by far the largest, but for hospi talization it should be extremely small. It includes the great ma jority of those conditions which were loosely and erroneously de scribed as " shell shock " during the war—the " nervous break downs," hysteria, neurasthenia, anxiety neurosis, psychasthenia. and the so-called functional diseases of the heart, stomach, and other organs. In essence, the neurosis is a " way out " of some intolerable con flict or difficulty. The feelings of stress, apprehension, and worry that belong to the conflict are interpreted by the patient as evidences of disease or injury, the origin of which is referred back to some accident or illness—gassing, influenza, overwork, etc., of the more or less recent past. The suffering is genuine and none the less real because the symptoms are ascribed to disease or injury. The treat ment of such cases must consist of discovering the conflict or diffi culty, convincing the patient of the real facts, and then helping him to find some more satisfactory method of dealing with it which is within his capacity. To place such a patient in a hospital is to con firm his belief in the existence of serious disease or damage. Fur thermore, it very effectually brings a cessation of the responsibilities No. 2. 283 EDITORIAL. and needs for adjustment that brought about the disorder. It is often extremely difficult to discharge such patients; it is a much simpler problem to keep them out of a hospital. Douglas and Singer, writing in Mental Hygiene for January. 1922, on the care of neurpsychiatric disabilities among ex-service men, are very strongly of the opinion that special hospitals for the treatment of psychoneuroses will eventually be found unnecessary, provided adequately staffed out-patient clinics are established. Group 3, the psychoses, in the great majority, must be treated, often for long periods, in a hospital. The fourth group of constitutional nervous deficiencies comprise (a) the feeble-minded, (b) the psychopathic personality (constitu tional inferiority), and (<?) the epileptic. The feeble-minded man who was accepted in the service is in prac tically all cases among the higher grades of defective. He is capable of placement in some activity, though the effort to carry this out may have to be repeated many times before a finally successful ad justment is secured. In attempting this placement and vocational training, it is essential that the capabilities of the man be very care fully studied. An unwise selection may result not only in the dis couragement of the patient, but also in greater disability than was present at first. Selection of vocation and environment should be made by an expert, with all the advice he can get from the physician who has really studied the patient. The psychopathic personality. — The psychopathic personalities present some of the most difficult problems of all. Such persons may show comparatively low intelligence, but they may also grade even above the average upon test. The essence of the defect lies in the personality. Often such persons are plausible and superficially shrewd, but they seem to be incapable of steady application and soon tire of any task. No State has yet succeeded in dealing with this group satisfactorily. The epileptic.—The epileptic in very many instances can get along in the community, especially where compensation and supervision through an out-patient clinic arc possible. In a certain proportion of cases, when the fits are frequent or the patient has difficulty in adjustment due to personality, segregation from ordinary society is advisable. The character of the institution to which he is sent should be that of a model community with its own industries, amuse ments, etc., rather than a hospital. In the opinion of Douglas and Singer the greatest need of the service at the present moment is for trained personnel. It is an unfortunate fact that neuropsychiatric medical officers, nurses, and social workers exist only in limited numbers, in no way commensu rate with the demands. To supplement the available supply and to 108165—22 7 284 Vol. XVII. EDITORIAL. prepare for the increased demand that will come with the opening of new hospitals and out-patient clinics, the establishment of a train ing center for medical personnel is highly desirable. This center must be accessible to university instruction and also to field facili ties. Any of the existing psychopathic institutes, if provided with out-patient clinic facilities, would be suitable and doubtless would be willing to cooperate. St. Elizabeths Hospital in Washington is being used for the purpose of training naval medical officers in this special line of work. Douglas and Singer, in their article draw attention to the frequent misconception existing with regard to the relation of occupational therapy and vocational training. Occupational therapy is not in any sense an effort " to make some thing." The purpose with which it is employed is quite variable, as the following classification will indicate. It may be prescribed (a) as a diversion; (b) because it brings into play certain muscles or joints which are functionally damaged; (o) to produce sedation or stimulation; (d) as an education in habits of application. The product of occupational therapy is the effect it has upon the patient. The articles produced in the process are. like the copy books of the child in the primary school grades, of no importance. Vocational training, on the other hand, is a training of the patient to carry out some technical operation and thus to give him a means of earning a livelihood. The product is, therefore, the patient placed in industry. Articles produced in this process must have a market value, and there is absolutely no place for the merely beautiful but fancy products, the value of which is personal and largely artificial, (j. g. z.) On Airplane Ambulances. Strange as it may seem a stretch of seacoast extending almost from Cape Henry, Va., to Wilmington, N. C, having a population of nearly 3.000, is quite devoid of medical attendance. One looking at a map of this region will note a series of sounds —Albemarle. Curri tuck, and Pamlico —extending along the coast and separated from the Atlantic by low-lying sandy islands. In places these stretches of sand are fairly wide and high, and have become sufficiently fertile to permit the growth of a few trees and underbrush; in other parts, for mile after mile, one encounters nothing but barren l eaches of sand. The storms of winter deal severely with this stretch of coast which mariners regard as treacherous as any seacoast in the world, often preventing communication with the mainland for days. The inhabitants of these desolate sand bars are mainly seafaring rolk connected either with the Coast Guard, the Navy radio stations, or the fishing industry. Among them up to the year 1918 there No. 2. 285 EDITORIAL. labored a physician who dwelt in the little village of Hatteras, but the influenza epidemic of that year cut short his career and no other physician has found these sand reaches sufficiently enticing to take his place. In the towns on the mainland there are doctors, but they are busy men. and a trip across the sound to the sand reaches, 5, 10, perhaps 20 miles away, can be made only in a great emergency. So it came about one day last winter when the young wife of a Coast Guard man had been in labor for 72 hours and required the services of an obstetrician, some one conceived the idea of asking the commandant of the fifth naval district by radio to send assistance to the suffering woman by airplane. In an hour a Navy seaplane with a naval sur geon and an obstetrical outfit was on its way to the lonely Coast Guard station near Cape Hatteras and both mother and child were saved. A few weeks later a Coast Guard man with pneumonia and a man with acute appendicitis were transported comfortably through the air to the hospital at Norfolk. Since then many people living in this isolated region have received medical attendance brought by airplane from the naval operating base at Hampton Koads. The average airplane is not suited for ambulance work because of its construction, and as the Coast Guard and the personnel of the Navy radio stations on duty along this coast are entitled to medical attendance, it is hoped that before long specially constructed air am bulances will be avilable for this service. The air ambulance has passed the experimental stage and is now in daily use in many parts of the world. Airplane ambulances hnve been used in the Air Service of the United States Army since early in 1918, and it is very evident from the following news item ab stracted from the Figaro, Paris, December 5, 1921, that the French Army is using airplane ambulances to an increasingly greater extent : " It appears that the ambulance airplanes of the Levant and in Morocco are growing rapidly in their emulation of each other, which is both admirable and profitable. Every day a new record is made by one or the other. '"A few weeks ago in Morocco they made a remarkable record by transporting 18 wounded men 80 kilometers ; now we hear that in the Levant they have just evacuated 44 wounded a distance of 100 kilo meters over the desert of Syria between Deir-t z-Zor. on the Euphrates at the southern border of our mandate, and Aleppo. This last opera tion is a record for transporting wounded by airplane. Moreover, the conditions under which it was done and the advantages gained merit attention. "After the victorious battles of the 24th and 26th of October, fought in the region of Deir-ez-Zor by Colonel Debieuvre against the war 286 Vol. XVII. EDITORIAL. like tribe of Ogueidats, who fought all the more fiercely against our troops because they had given a severe setback to the British in 1920, General Gouraud, high commissioner in Syria, gave orders on Octo ber 26 to Medical Inspector Emily, chief surgeon of the Army of the Levant, and to Major Denain, commanding the Air Service, to pre pare for the evacuation as rapidly as possible to Aleppo of the wounded we had during the course of these glorious combats. This work was rendered particularly difficult and dangerous, due to the fact that the 400 kilometers which separate these two places is an inhospitable desert, without landing places, occupied by hostile Bedouin tribes, with atmospheric conditions impossible to have a gas station at Deir-ez-Zor, which is 20 days from Aleppo by camel convoy. "A detachment, composed of all the ambulance airplanes in service with the Army of the Levant, was immediately organized at Aleppo under the command of Lieutenant-Pilot Vindreau and of the chief surgeon of the Air Service in the Levant, Doctor Liegeois. On Octo ber 25 a military surgeon, Doctor Chevalier, went to Deir by airplane to render the urgent surgical assistance needed. The same day five airplanes brought back 10 wounded, covering in a few hours the 800 kilometers for the round trip from Aleppo to Deir-ez-Zor and return, a very remarkable performance when the difficulties enumerated above are considered. " Evacuation continued the following days, and soon all the trans portable wounded —44 in all—were transported by air to the military hospital in Aleppo, making in three hours and a half and under very satisfactory conditions, as far as comfort was concerned, a trip which requires at least a week by motor ambulance, and by camel or cacolet (form of saddle for horse or male, carrying two men in a sitting position) more than three weeks over heavy roads. This would have been very trying on the wounded men. "Thanks to the airplane, Principal Surgeon Chartres. division surgeon of the second division, was able to go to Deir to superintend the evacuation and care of the wounded. Doctor Liegeois, who fol lowed and directed the operations from the medical standpoint, esti mates that, without counting the suffering that was avoided, five wounded men owe their lives to this method of evacuation. "The results are a great honor to the air service of the army of the Levant and especially to the pilots who, not satisfied with being courageous war pilots, have on this occasion given proof of their skill, endurane, and training by bringing safely into port all the wounded confided to them, in spite of the difficulties of such a long flight. '• It should be noted that in all the time that this means has been used for evacuation in the Levant, not a single wounded or sick man has been the victim of an airplane accident." (j. d. b.) CLINICAL NOTES. NOTES ON THE ORTHOPEDIC SERVICE, V. S. NAVAL HOSPITAL, CHELSEA, MASS.i By J. W. White, Lieutenant, Medical Corps, United States Navy. With the advent of the Veterans' Bureau patient, the orthopedic service at this hospital increased in activity so that now it handles well over twice as many patients as it did a year ago. A great many of the patients referred by the Veterans' Bureau are reconstruction problems following old war injuries and comprise such cases as re section of painful scars, reamputation for painful stumps, and osteotomy to correct deformities. Many of these patients suffer from some form of arthritis aggravated usually by some postural strain or some chronic condition existing previous to discharge and needing operative treatment, such as internal derangement of the knee joint, hallux valgus, free bodies in joints, and exostoses asso ciated with old fractures, etc. Inasmuch as physiotherapy, in some form, is indicated in the post-operative treatment of most of the sur gical cases, particularly where the operation is on or closely associ ated with joints, these cases are transferred to the Parker Hill Hos pital, a near-by Public Health hospital, which is equipped with a complete physiotherapy department, as soon as they have sufficiently recovered from their operation. They return from time to time for observation and further directions as regards treatment. A complete physiotherapy department is to be supplied to this hospital in the near future and the post-operative treatment can be better con trolled. The naval patients, to a large extent, are admitted for recent traumatic conditions, while it is seldom that a Veterans' Bureau patient is admitted with anything of recent origin. Men in training are the only ones strictly entitled to treatment for conditions not associated with previous service. In spite of the fact that routine treatments often are ill advised, we have devised some routine measures for conditions such as chronic back strain and foot strain, which we have found are the most diffi cult cases to treat satisfactorily. For the patients suffering from back pain, after satisfactory X-rny examinations of the entire spine ■From the Annual Sanitary Heport, U. S. Naval Hospital, Chelsea, Mass. 287 288 Vol. XVII. CLINICAL NOTES. have been taken to rule out organic disease, and physical examina tion is otherwise negative, hyper-extension in bed is employed until the patient is relieved from pain and muscular spasm. A snug fit ting plaster jacket is then applied and kept on for varying lengths of time. In the case of Veterans' Bureau patients, they are dis charged from the hospital wearing this jacket and the rest of the treatment is carried on at the Veterans' Bureau dispensary, where, upon removal of the jacket, the patient is supplied with a back brace to maintain the corrected posture for a longer period. Exercises are started to regain the normal mobility of the spine at this time as well. While this treatment is by no means satisfactory, we have by consid erable experience decided it is the most rational for this group of cases. Of course, where there is any indication of arthritis present, a thorough search for surgical foci is carried out and the indicated eradications are performed if practicable. As a rule, teeth have been found to be the main offenders. These patients all are on an anti- arthritic diet which is a balanced diet with as low a carbohydrate content as possible, as advised by Pemberton of Philadelphia. Patients with pes planus sufficiently severe to require hospitaliza tion usually show acute foot strain. A routine type of treatment is applied to these cases that do not require manipulation under an anesthetic. If full correction can not be obtained on admission be cause of muscular spasm, they are manipulated to a position of ex treme varus and are held in plaster for three or more weelcs. This is usually sufficient to correct the worst cases. There have been some cases where there was extreme bony deformity produced usually by the inward and upward deviation of the neck of the astragalus which were at the time treated conservatively but which will ultimately come to operation such as an astragaloscaphoid arthrodesis or some similar procedure. The routine treatment consists of absolute rest in bed, light massage and contrast baths. This is kept up until all evidence of foot strain has disappeared. The patient is continued in bed a few days longer, during which time exercises are started which he is to continue after being allowed on his feet, a few hours at first and then gradually increasing the time until he is up the normal time. These cases are all carried on our antiarthritic diet as de scribed above. When the patient is allowed up his feet are strapped in as extreme varus as possible and the contrast baths are discon tinued. This strapping is renewed frequently to retain the cor rected position. The exercises followed are those which tend to strengthen the muscles upon which the normal arch depends, for it is muscles and not ligaments that maintain correct posture not only in the feet but throughout the body. Symptoms are produced when any constant strain is put upon ligaments whose function essentially is to prevent abnormal extremes of motion. The form of support No. 2. 289 CLINICAL NOTES. used most frequently is the one devised by Whitman, of New York, which is corrective, almost forcing the patient to walk properly and yet preventing the ligamentous strain-causing symptoms. In feet where the deformity is extreme, this type of plate can not be em ployed and frequently the usual type of plate is used in the way of palliative treatment. In general, the use of plates of all sorts is dis couraged and relief from symptoms is hoped for as a result of muscle training, proper shoeing, and correct walking. While under treat ment at the hospital these cases are made to walk slightly " ding- toed." In the case of naval patients with definite evidence of acute flat feet, which, on examination show that there will be a predisposition toward recurrence, the policy of recommending them for medical survey is followed with few exceptions. These men can temporarily be relieved of symptoms, but with as little cooperation in following exercises and adhering to proper methods of walking as one gets in most flat-foot cases, they will soon be appearing at sick call again, particularly if they are put on some detail distasteful to them. A congenital flat foot is always predisposed to acute foot strain, and it is only by the patient's efforts that he can keep free from symptoms. By flat foot is meant everted foot and not the anatomically flat foot without eversion, which rarely causes symptoms. In naval patients that do show cooperation and are otherwise well adapted for the service, an attempt is made to return them to duty. They are retained at the hospital until they understand the proper exercises, continue to be free from foot strain and if thought advisable, par ticularly in the case of petty officers, are given Whitman plates to be worn to prevent the recurrence of their foot strain. Among the more interesting cases treated during the year may be mentioned a case of hematomyelia causing an almost complete trans verse myelitis at the level of the fifth cervical segment, following a fracture of that vertebra and with practically complete recovery in five months without operation; a case of multiple bone cysts which ultimately proved to be Von Recklingshausen's disease; and a suc cessful repair of a ruptured anterior crucial ligament of the knee. An interesting series of four fractures of the femur has been ob served, two supracondylar and two of the shaft. Malunion consist ing of outward anterior bowing occurred in the latter group, both due undoubtedly to premature weight bearing. In fractures of the shaft, it has been my experience that unsupported weight bearing short of six months is hazardous. In both of these cases, an osteotomy was performed at the point of malunion with the result that in one case the shortening was reduced from an inch and a half to three- eighths of an inch with practically perfect function of the knee, which latter element is always a serious problem to face after such 290 Vol. XVII. CLINICAL NOTES. long immobilization. The other case is still in his Thomas ring splint through which, via calipers in his shoe, his weight is supported, be ing now on his sixth month. His knee is receiving the usual baking, massage, and manipulation, and already there is about 30° of motion in it. This patient originally had the same shortening that was pres ent in the first case, but as the angulation was not so great and as there was more overriding he still has five-eighths of an inch shorten ing. His convalescence was considerably complicated by a hemolytic- streptococcic septicemia, originating in all probability from an old extensive war wound on his other thigh. Four days following the operation his left subdeltoid bursa was opened and several ounces of pus was removed, from which a pure culture of the above-named or ganism was obtained. Several days later a large phlegmon on the anterior aspect of his thigh containing 5 or 6 ounces of the same sort of pus discharged through the lower end of the operation incision well away from the site of the operation, which has never given any indication of becoming septic. For about three weeks following the operation his old war wound on his other thigh gave him consider able discomfort, and it was expected that it, too, would break down. It never progressed further than getting red objectively and subsided spontaneously. The patient, needless to say, was very sick, and the fact that he lost so much weight rather jeopardized the position of the fragments in the cast. The return of his strength has been slow and he did not get about as much during his fourth month in his cast as is usual in such cases. It is confidently expected that he will be returned to duty. The mechanical treatment of these cases is as follows, and may be said to be divided in three periods : The first period immediately fol lowing operation, at which time a plaster spica from well above the costal border extending down to the toes with the leg held in as cor rect position as is thought possible, consists of rest in bed for two months. X-rays are taken through the plaster to determine the posi tion a few days following the operation. If accurate alignment has not been obtained, the deformity continuing to exist is corrected by cutting a wedge out of the plaster at the appropriate point and of the calculated size and then approximating the edges of this wedge, leav ing a corresponding open wedge on the other side of the cast. More plaster bandages are then employed to hold this corrected position. This plaster is allowed to remain on for two months. It is then re moved and the leg is examined to see if there is union. X-rays are taken before another heavier plaster of the same extent is applied. After this plaster has thoroughly dried the patient is gradually got up on his feet. It is surprising to see how well one can get about with such an extensive cast. Activity is urged until this cast is removed at the expiration of the fourth month which completes the second No. 2. 291 CLINICAL NOTES. period. The patient is then put into a Thomas ring caliper brace ex tending down and inserted into the heel of sufficient length to take practically all the weight from the operated leg. Strenuous treat ment is then instituted to mobilize the knee which has been absolutely immobilized during the previous four months. Little difficulty is ex perienced with the ankle or hip. This brace is discontinued at the end of the sixth month, which completes the third period. One of the supracondylar fractures of the femur was a fresh case and I had him practically from the first. There was the usual marked posterior rotation of the lower fragment. Skin traction with ad hesive in a Thomas splint was employed with only increase in the deformity. This is what may usually be expected because of the loca tion of the points of origin of the gastrocnemius. Skelatile traction by the use of " ice tongs " applied to the femoral condyles reduced the malposition without difficulty in spite of the fact that there was an intercondyllar fracture as well. Unfortunately the tongs were only allowed on for three weeks, and after removal the inner fragment rotated slightly. This case was returned to duty four months later with a perfectly stable knee and over 90° of painless motion. The other supracondylar fracture was three years' duration with the usual unreduced lower fragment allowing 30° hyperextension at the knee and with If shortening when the knee is in full extension and 3 inches when fully hyperextended. His symptoms were due for the most part to knee strain, as might be expected. An oste otomy was performed at the point of malunion. Correction was maintained by the use of bone wedges taken from the tibia. The convalescence of this case was complicated by an attack of renal colic for which he underwent operation for the removal of a ureteral calculus. He has satisfactorily convalesced from the operation. At the present time he still has an inch shortening, but there is only the normal amount of hyperextension at the knee. These two cases demonstrate the importance of using skelatile traction in these supracondylar fractures. Very little discomfort was experienced from the tongs, and there was less discomfort than with skin traction. A small amount of osteomyelitis persisted on one side for about four weeks before the sinus healed. At no time was it painful and did not interfere in any way with his convales cence. Two cases of recurrent dislocation of the shoulder have been oper ated upon, and the revived Clairemont-Ehrlich operation has been adhered to. This consists in passing a good-sized muscle flap from the posterior portion of the deletoid. being careful to preserve its enervation and blood supply, from behind anteriorly through the quadrilateral space and attaching it to the coracoid process of the 292 Vol. XVH. CLINICAL NOTES. scapula. This forms, as can be readily understood, a sling which prevents any tendency toward a downward or forward dislocation of the shoulder. This is the only t}rpe that has any tendency to recur. One was a chief boatswain's mate and was returned to duty four months ago and so far has had no recurrence. The other case was a Veterans' Bureau patient and was only discharged a month ago and is too early to report (no recurrence has occurred four months after the above observation). He states, however, that he can abduct his arm with a perfect feeling of security and has little limitation in motion. We have at the present time a case of generalized ostitis fibrosa under observation. A multiojulated cyst was removed from the right tibia five months ago bacause the patient was experiencing local symptoms. He has a similar lesion in a corresponding point of his other tibia which causes no symptoms. Other lesions are present in the head of his left humerus and a large fusiform swelling in the mid shaft of his right numerous involves the entire shaft. This proved on exploratory operation to be fibrous replacement of bone typical of this condition. X-rays have been taken of all his long; bones and there is very little of the cortex of the pipe bones that is normal. In appearance, it resembles cancellous bone with the tra becular running longitudinally. He is being fed on a high calcium diet at the present time in the hopes that this might have some effect on his apparently deranged calcium metabolism. There is some question whether the conditions variously known as adult rickets, osteomalacia, Paget's disease, Von Keckingshausen's disease, and ostitis fibrosa are not all different manifestations of the same entity with which calcium metabolism is in some way associated. It is feared that if we operate on this patient at the present time there may be some difficulty in getting a graft to take properly. AVe have had various types of Pott's disease of the spine, from the very earliest to the extreme case with emaciation and double draining psoas abscess. Absolute recumbency usually in a plaster shell or some similar retentive apparatus and heliotherapy comprise the essentials of the treatment. No cases have been operated upon, as in our group there appeared to be insufficient indication. It is our experience and the consensus of opinion seems to be that oper ative treatment should be confined to a very limited number of cases where the disease has obtained little headway. In one of our cases, which incidentally is doing very well, there are three distinct foci of tubercular infection. There has been only one other case of bone or joint tuberculosis. This was an ankle in a case that physically was going down hill. Amputation was performed at the point of election, with improvement in general condition immediately fol lowing the operation. No. 2. 293 CLINICAL NOTES. One of the most interesting fractures we have had was one involv ing both bones of the forearm, in which the fracture of the radius was located between the insertion of the pronators and suppinators. As is usual in fractures of both bones of the forearm, it was put up in mid-pronation and supination, as it is in this position that the bones are separated the widest. After union had taken place, how ever, only a few degrees of pronation and supination was possible. The fracture was cut down upon and it was noted that the union was immediately proximal to the insertion of the pronator radii teres. This explained the poor result. The upper fragment, to which the supinators are attached, was rotated into full supination, while the lower or distal fragment was rotated in just the other way, be cause both unopposed pronators acted upon it. An osteotomy was performed six weeks after the original break and the forearm put up in full supination. The end result warranted this procedure, as the patient was returned to duty and has almost normal motion at the present time. I0TES FROM THE GENITO-URINARY SERVICE, TJ. S. NAVAI HOSPITAL, CHELSEA, MASS.i By P. O. Nohthi.voton, Lieutenant, Medical Corps, United States Navy. The majority of the patients treated in the genito-urinary depart ment during the past year have suffered from gonococcus infection of the urethra and its complications. In the treatment of acute ure thritis, mercurochrome was used sufficiently diluted so as not to cause irritation. The strength varied from one-half of 1 per cent to 1£ per cent. The results obtained from the use of mercurochrome in the acute cases have been consistently better than the results obtained in simi lar cases with silver preparations. Posterior urethritis has been treated with diuretics, urinary sedatives and mild antiseptic irriga tions until the acute symptoms subsided ; then silver nitrate instilla tions and prostatic massage were begun. In the chronic case, the urethra was dilated and prostatic massage given twice weekly, and if the case did not respond to this method of treatment, a urethroscopic examination was made to determine, if possible, any demonstrable focus or cause for the persistence of the infection. Epididymitis has responded to palliative treatment, and the Hagner operation has been abandoned as we believe that it does not materially lessen the course of the infection and it increases the possibility of producing sterility. A large number of cases give a negative smear in a very short time after beginning treatment. However, an injection of silver nitrate solution will frequently increase the discharge and the gonococcus then can be found in the smears. When there is no discharge and the urine is clear for a week the patient is discharged to duty. ' From the Annual Sanitary Report, U. S. Naval Hospital, Chelsea, Mass. 294 Vol. XVII. CLINICAL NOTKS. The intensive course of treatment given to the syphilitic cases, provided there are no contraindications, consists of six intravenous injections of arsphenamine and six intramuscular injections in doses of 0.1 gram mercury salicylate. Arsphenamine 0.3 gram is given for the initial dose and 0.6 gram in each subsequent treatment. Follow ing the sixth treatment a blood Wassermann is done and a spinal fluid examination made. Arsphenamine is given by the gravity method. The number of reactions both local and constitutional have been lessened, since we abandoned the syringe method. We attribute this to the fact that in giving the solution with a syringe it was ad ministered too fast and many cases of extravisation occurred with un necessary hardening of the veins. At lea t ";0 per cent of our cases show some reaction, the most constant symptoms being nausea, vomit ing, watery diarrhea, and malaise which usually clears up within 12 hours. Our patients lose weight under treatment and some as much as 10 pounds during the period of a course. There has been one fatal ity following the administration of arsphenamine. This patient was admitted with secondary syphilis May 9, 1921, Wassermann four plus. Administration of arsphenamine 0.3 gram on May 17, no reaction. Urinalysis on May 22 showed nothing ab normal. Arsphenamine 0.6 gram on May 24. A few hours later the patient complained of nausea, vomiting, and diarrhea. The following day he was markedly shocked and purpuric but reacted favorably to stimulants. Two days later jaundice and bleeding from mucous mem branes of nasal cavities and gastrointestinal tract developed. Urin- i.lysis revealed marked destruction of the kidneys. Patient died June 8,'l921. It is believed that, though probably arsphenamine is more active therapeutically than neoarsphenamine, its contraindications are not always found out on examination and it is administered with a greater risk to the patient. Spinal fluid examinations have been made routinely in the follow ing instances : (a) In all cases at the end of an intensive course of arsphenamine and mercury therapy, irrespective of the blood Wassermann reaction. (b) In cases of early syphilis showing symptoms of central nerv ous system involvement. (c) In all cases showing mental or nervous symptoms, irrespective of the blood Wassermann reaction. Many cases showing early involvement of the central nervous sys tem, clinically, and with characteristic spinal fluid changes, will respond to intravenous therapy, hence intraspinous treatment is not given unless there are persistent symptoms or signs after a course of intravenous therapy. No. 2. 295 CLINICAL NOTES. Neurosyphilis requires more intensive treatment than syphilis ■which does not affect the nervous system. The following method advocated by Fordyce has been used in all intraspinous treatments. The blood having been removed from a vein is centrifugalized, serum pipetted off, and centrifugalized again to insure complete re moval of any red cells. To 10 c. c. of this serum fa to 1£ milligram of arsphenamine, according to indications, is added. This mixture is incubated at 37° F. for 40 minutes and inactivated to 56° F. for one-half hour, and is then administered. The advantages of this method over the use of autosalvarsanized serum according to the Swift-Ellis method are the administration of a definite quantity of arsphenamine, the addition of a definite amount of the drug in a small quantity of serum, and the convenience of preparing several doses with the serum from one patient. There have been no reac tions following this method of treatment save an occasional head ache which was attributed to the puncture. This can usually be pre vented by keeping the patient in a recumbent position for 24 hours. MEB.CUR0CHH0ME-220 AS A GEBMICIDE IN OPHTHALMIA NEONATORUM. By C. C. Gboff, Lieutenant, Medical Corps, United States Navy. The following cases of ophthalmia neonatorum are reported be cause at the time of treatment, 1920, mercurochrome-220 had not been used in the service, so far as I am aware, in this condition. This remedy seemed to shorten the duration of this disease, but has the disadvantage of staining the lids and face deeply, yet not permanently. The fact that it seemed to shorten the duration of the disease may commend its use to eye men in the service. Case 1.—B. W., white, male, age 11 days, was seen February 2, 1920, two days after the discharge first appeared. Examination revealed acute purulent ophthalmia neonatorum with edena of the lids and much pus in the right eye. The cornea was clear. A smear showed pus cells with gram negative intracellular diplococci. The child was delivered by a country physician who neglected to instill silver nitrate into the eyes. After cleansing with boric acid solution, a 2 per cent solution of mercurochrome was ordered every two hours. A small quantity of boric acid ointment was smeared around the margin of the lids after the instillation of the mercuro- chrome. This seemed to make for a longer retention of the solution in the eye. To be absolutely sure of preventing infection 1 drop of 2 per cent mercurochrome was used in the normal eye three times a day and a shield applied. February 5 : The right conjunctival sac was almost entirely free from pus. The edema was much less and the gonococci were much fewer in number. '296 Vol. XVII. CLINICAL NOTES. Treatment was ordered to be continued for a week longer. February 12 : There was a slight serous discharge but no cocci were found. Boric acid instillations were ordered. February 27: Eye apparently normal. Case £.— Gr. E. F., colored, female, age 13 days, was seen January 14, 1920, four days after discharge first appeared. The mother stated l"the accoucher dropped something in the babies eyes but its eyes were red and inflammed looking about one week after it was born." Examination revealed acute purulent ophthalmia neonatorum of right eye with left eye. weeping copiously. The lids of the right eye and conjunctival sac were markedly swollen, sclera injected and cornea beginning to look dull. A smear showed numerous pus cells with gram negative intracellular diplococci. The eyes were cleansed with boric acid, saturated solution, and a 2 per cent mercurochrome solu tion was ordered every half hour for six applications. This seemed to be slightly irritant, and a saturated solution of boric acid was then alternated every half hour with the mercurochrome solution during the night. January 15 : Twenty-four hours later the cornea was beginning to lose its dull appearance and the march of infection seemed to have- been halted. Instillations were now ordered every two hours. The left eye was receiving instillations of mercurochrome every three hours from the first examination. January 19: The free pus in the conjunctival sac of the right eye had almost disappeared and the left eye was apparently normal. Boric acid ointment was now applied to the edges of the eyelids of the right eye. after instillation of mercurochrome to insure retention of solution. The left was still receiving instillations of mercuro chrome three times a day to prevent reinfection. January 24: The edema was now much less and a smear showed the gonococci to be much fewer in number. January 31 : There were no gonococci present but a slight serous discharge was present. Instillations of mercurochrome were con tinued and saturated boric acid, camphor water and zinc sulphate were instilled every three hours alternating with the mercurochrome. February 12: Eye apparently normal. Because of frequent instil lations of mercurochrome a condition similar to argyria was looked for. but no permanent staining resulted. AN UNUSUAL CASE OF FOREIGN BODY IN PHARYNX. By S. B. Fordes, Lieutenant, Medical Corps, V/nittd States Navy. The following unusual case of foreign body in the pharynx is reported, as it serves to exemplify the difficulties sometimes encoun- FOREIGN BODY REMOVED FROM THE LARYNX. No. 2. 297 CLINICAL NOTES. tered in arriving at the etiological factor in patients admitted to a hospital in a comatose condition. The patient was a white male, age 35 years, unconscious on admis sion ; no history was obtainable. Physical examination.—Temperature was subnormal, pulse was 126 and of fair volume. Respirations were 12 and very labored, with great inspiratory and expiratory dyspnea. There was an ex treme degree of cyanosis. His skin was cold and covered with per spiration. The odor of alcohol could be detected on the breath. The pupils were equal in size but dilated, and did not react to light. The patient's condition was rapidly becoming worse and he was practically in a moribund state. Examination of the upper respiratory passages revealed a foreign body in the oropharynx extending from the level of the tip of the uvula clown to the epiglottis. The lower portion rested directly on the anterior surface of the epiglottis, forcing it down over the upper laryngeal orifice. Kemoval of the foreign body was effected with some difficulty owing to its tremendous size. It was found to be a piece of roasted meat weighing 37 grams. The dimensions were as follows: Length 10.2 cm., width 3.2 cm., and thickness 3.8 cm. The illustration will give some idea of the size and shape of the foreign body. A distinct odor of alcohol could now be detected on the breath, therefore gastric lavage was done with a warm solution of sodium bicarbonate. Several particles of undigested food were recovered. An excess of solution was allowed to remain in the stomach and the patient was returned to the ward. Clinical course. —The dyspnea and cyanosis rapidly disappeared and the patient returned to full consciousness within 15 minutes from the time of removal of the foreign body. He had no recollec tion of any of the circumstances surrounding the attempted inges tion of this large bolus of food. His condition was perfectly normal the next morning. Later a history was obtained from a relative who stated that the patient while partaking of the evening meal suddenly fell over un conscious. He volunteered the information that they had imbibed several drinks during a period of three hours prior to dinner time. A physician was called and he pronounced the case one of acute alcoholism. This case well emphasizes the fact that the diagnosis of acute alco holic toxemia should not be arrived at too rapidly and that a thor ough physical examination should be made, thereby eliminating all possible etiological factors, before attributing the comatose state to alcohol alone. NOTES AND COMMENTS. The following editorial comment on the question " What is an epidemic ? " appeared in the issue of the New York Medical Journal for March 1, 1922 : " ' The disease is epidemic' ' The disease is not epidemic' ' The disease is epidemic' Year after year we hear these statements from health officials, uttered not in succeeding breaths, perhaps, but in breaths of succeeding days. They remind one of the harlequin who rushed upon the stage with a bundle of papers under each arm. When asked what was in one bundle, he replied, ' Orders ! ' and when asked about the other, answered, ' Counterorders ! ' What is an epidemic, or when is an epidemic? If health officials do not know, who does know ? "An epidemic disease is not different in nature from the same dis ease when not called epidemic. Scarlet fever is scarlet fever and influenza is influenza. If there is any difference in the infectious agent, it is only a matter of more or less of its native qualities. There is nothing new about it. If there is any difference in those infected, it is again only a matter of more or less resistance. There is again nothing new or original in their state. There is an altered relationship between host and parasite, but there are all degrees of alteration. In other words, the law of relativity holds in infectious diseases as elsewhere. What is now an epidemic of smallpox was a normal state of affairs a century ago. " There is no drawing the line between epidemic and nonepidemic disease, and there would be a more rapid advance in health matters if we were to do away with the words ' epidemic ' and ' endemic,' or use the word ' epidemic ' for all communicable diseases. We seem perfectly content, at least the public does, when a disease is not pro nounced epidemic, but when that name is applied by official author ity or, more often, by popular decision, there is suddenly much alarm and much precaution taken to avoid the disease and to pre vent its spread. And yet, in its ordinary every day, every year run, the communicable disease carries off some fourteen times as many lives as in the briefer days or years when it is pronounced epidemic. The disease, then, in nonepidemic form, whatever that may mean, is fourteen times as much to be dxeaded as when it is called epidemic, whatever that may mean. 108165—22 S 299 300 Vol. XVII. NOTES AND COMMENTS. " It is high time for health officials to cease quibbling about the existence of epidemics and turn their attention to the stimulation of greater interest in the ordinary incidence of communicable dis eases. Let the public consider any number of cases an epidemic. We should be thankful if their public health consciousness has reached such a developed state that they are readily alarmed." The Division of Venereal Disease of the United States Public Health Service contributes the following on gonorrhea. A review of 1921 literature: " Syirvptomatology. —Sagot has collected the reports of 45 cases of gonococcal endocarditis, including one observed by himself and Halle. He concludes that gonococcal endocarditis may be benign or vegetative ; that the benign form is more common than is generally supposed, and is a probable cause of chronic cardiac disease ; that the vegatative or ulcerative form has the character of an acute septicemia with cardiac symptoms and is usually fatal ; that the danger of septicemia increases with extension of the disease to the deeper genito-urinary organs, but bears no definite relation to the severity of the primary infection. " Kivaz describes a case of the rare complication of gonorrhea keratodermia blenorrhagica. The patient was treated with perman ganate irrigations and a polyvalent vaccine. The condition cleared up about two months after its first appearance. " Citron reports a case of gonococcal septicemia which was cured by subcutaneous injection of 50 c. c. of meningococcal serum. He refers to cases reported by other observers which benefited by men ingococcal serum — acute gonorrheal affections of the internal genital organs in women by Le Masson, and gonorrheal arthritis by Barlee. and concludes that this serum is indicated in all severe cases of gen eral gonococcal infection. Weill and Colaneri report another case of gonococcal septicemia. Symptoms of septicemia developed in a man during the acute stage of gonorrheal urethritis. Treatment by intramuscular injections of electrargol and afterwards by antimeningococcic serum and an auto- vaccine has no effect. Patient died a month after symptoms of septi cemia commenced. Valentin remarks on the frequency of relapses in gonorrheal vul vovaginitis in children. In his 161 cases the chief source of relapse was found to be the rectum. " Diagnosis. —Norris and Mickelberg give an analysis of 794 ex aminations of films (Gram's) from women presenting clinical evi dences of gonorrhea. They believe that clinical evidence is of No. 2. 301 NOTES AND COMMENTS. greater value in diagnosis than staining methods. Minor details of technique are given. " Prophylaxis. —Schumacher prefers alburgin to protargol, hego- non, or other silver preparations, as it contains a high percentage of silver, and can, therefore, be used in weaker solution. A 1 per cent solution is considered a sufficient prophylactic against the gonococcus. As in the case of mercury, solutions of silver salts must contain silver ions in order to be effective. Schumacher points out that perchloride of mercury acts as a prophylactic against both the spirochete and the gonococcus, and can hence be used alone. The chief objection .to general use is its poisonous property. He therefore suggests the use of 10 per cent solution of albargin as a general prophylactic, and holds that the silver ions have also a bactericidal action against the spirochete. " Treatment—Phelip claims good results from silver ionization in the early stages of gonorrheal urethritis. He gives method of treat ment used. " Haxthausen quotes the investigation of Eizenberg and Okolska (Zentralbl. f. Bakt.N 1st Abt. Orig., 1913, 69. 312) as having shown that the action of certain disinfectants can be greatly increased by the addition of even small quantities of alcohol. He compares the results of his 100 cases of acute uncomplicated and mild complicated gonorrhea treated with a solution of protargol (0.5 per cent) and alcohol (5 per cent) with Jersild's (Ugesk. f. Laeger., 1913, 961) re port on 116 cases treated with a watery solution of protargol followed by a watery solution of silver nitrate later in the disease. Hax thausen finds this comparison favorable to his treatment. " In a subsequent paper, Jersild, who has treated 14 cases of gonorrhea of the urethra in women and of vulvovaginitis in children with alcoholic solutions of protargol and has compared the effects with those obtained in 20 other cases treated with a watery solution of protargol, has nothing good to say of the former method. '"Mann advocates acriflavin for the irrigation of gonorrhea. "Oettinger and Deguingand report on eight cases of gonorrheal arthritis treated with antigonococcal serum. The results obtained by intra-articular injection were much more rapid and effective than when the serum was injected subcutaneously. " Scherliess claims good results with hot-water irrigation in gonor rhea in soldiers. He gives his treatment used in 200 cases with only three failures. " Lindblad has tested the value of milk injections in gonorrheal diseases of the eyes by a statistical comparison of the results obtained at the Sabbatsberg Hospital before and after the introduction of this treatment, which for the past year and nine months had been adopted in every case of gonorrhea of the eyes. Author concludes that this 302 Tol. XVI r. NOTES AND COMMENTS. treatment is beneficial in some cases but it does not deserve extrava gant praise. " Terrien, Debre, and Paraf have studied the effect of antigonococ- cal serum by experiments on the rabbit. From the results obtained the authors are of the opinion that antigonococcal serum, to be effec tive, should be injected into the actual focus of disease. This, how ever, does not apply absolutely to the effects of serotherapy in the human subject. "Sagot regards subcutaneous or intravenous injection of anti gonococcal serum as the most promising form of treatment in cases of gonococcal septicemia. He mentions the experiments of Debre and Paraf with. this serum in animals. " Reenstierna reports favorable results from the treatment of gonorrheal complications by a combination of antigonococcus serum and a temperature-rising agent. " Sezary discusses the variable results of antigonococcal vaccino therapy. In conclusion he remarks that we must not expect too much from vaccinotherapy. Its role is to stimulate and reenforce the reaction of immunity, but this reaction may be slow and insuf ficient. " Boyd has investigated the value of vaccines in acute gonorrhea. Comparing 270 cases treated with vaccines with 200 control cases treated without them, it was found that the vaccine had no effect on the course of acute gonorrhea. " Demonchy advocates the use of vaccines in acute gonorrheal urethritis. From his experience he concludes that intravenous in jections of antityphoid vaccine give the best results. He thinks that the specificity of the vaccine plays only a secondary part in the treatment of the complications of gonorrhea and that the therapeutic results are not proportional to the dose injected. He advises small doses repeated not later than five or six days. " Weill reports favorable results from the subcutaneous injection of hydrocele fluid in cases of gonococcal epididymitis complicated with hydrocele. Three cases are reported, in the first of which two injections of 10 c. c. were given, in the second one of 5 c. c, and in the third one of 3 c. c. The first case improved most rapidly, and Weill considers that the therapeutic effect is proportional to the quantity of liquid injected. Weill also obtained improvement in two other cases of gonorrheal epididymitis by injections of hydrocele fluid from the first case —hetero-plasmo-therapy. " Cumming and Glenn recommend vas puncture and injection of collargol in cases of acute and chronic seminal vesiculitis. Their method of treatment is given. As the result of an experience with 55 cases the authors conclude that this is an effectual method of treatment of gonorrheal infection of the seminal vesicles; that it No. 2. 303 NOTES AND COMMENTS. should be combined with the usual treatment for associated condi tions of urethritis and prostatitis; that vas puncture is contraindi- cated in cases with acute anterior urethritis or acute epididymitis; that while not a certain cure, it leads to improvement in most cases, and to cure in some. " Tests for cure of gonorrhea. —Fraser warns against overtreat- ment and overinstrumentation. He concludes that there is no abso lutely certain test for cure, but gives a scheme which he considers practical and sufficient. With regard to the complement fixation test, he thinks that more knowledge of the different types of gono- eocci and a more sensitive antigen are required before the test can be rendered reliable. " Volarelli, who has investigated the tests for cure of gonorrhea from the results of 172 cases, considers that the best test consists in provocative injections of gonococcal vaccine, together with bacterio logical and cytological examination of the secretion. " Herrold has attempted to establish a more definite standard of cure in gonorrheal infections in the male by improved methods for cultivation of the gonococcus, and by study of the value of provoca tive and serological tests. He concludes that cultures of prostatic and seminal secretions and the first urine sediment furnish the most reliable means of determining whether a gonorrhea is cured." Surg. Commander E. L. Atkinson, R. N., writing on " Imme diate Surgery with the Royal Marine Artillery Howitzer Brigade in France, 1916-1918,'' in the Journal of the Royal Naval Medical Serv ice for January, 1922, reviews his experiences during a period of service in France from May, 1910, to June, 1918, during which time between three and four thousand wounded came under observation and treatment. He describes in detail the dressing station used dur ing the Somme offensive in 1916. It was a small dugout, located roughly, 3,600 yards from the front line, and provided room for five stretcher cases and a wooden table for dressings and examinations. Lighting was by means of a small acetylene lamp, supplemented when necessary by oil lamps and candles. Heating was secured by an im provised stove made from a l()-gallon gasoline drum, with a stovepipe made of biscuit tins. The entrance to this dressing station, to pre vent the entrance of gas, was fitted with double curtains of blankets soaked in a saturated solution of hyposulphite of soda. A goodly supply of shell-wound dressings, splints, and stimulating food was kept on hand. Two-gallon primus stoves were used for the steriliza tion of instruments. Instruments for immediate use were kept in trays containing 1-20 phenol. Hypodermic and seruni syringes and a supply of morphine in solution were kept sterilized. Iodine, was 304 Vol. XVII. NOTES AND COMMENTS. kept prepared for application. A large supply of ammonia ampules were provided for cases of gas poisoning. There was constant de mand for agate urinals. This station proved satisfactory, but in the Battles of Arras and Ypres and in the retreat in 1918 any available shelter was occupied. In an advance or retreat one had to rely entirely upon shell and field dressings and upon what field equipment could be carried. Ambu lance patients forwarded from an advanced dressing station were tagged with a description of the injury, identification, treatment, morphia, and antitetanic serum given. Fragments of high-explosive shells and shrapnel bullets were re sponsible for the majority of the injuries received. Shock varied in degree and in time of onset according to the temperament of the in jured man, to the severity of the injury, and the duration of previous exposure. In men lightly or moderately severely wounded the first symptoms are a feeling of chilliness and a desire for warmth, fol lowed by drowsiness. In the more severe cases —independent of th< degree of the wounds — the onset is almost immediate. There in pallor, sweating of the face and hands, the heart beating rapidlj, and the breathing labored. Cases of mild degree respond to any appropriate stimulant, such as aromatic spirits of ammonia, hot drinks, and warmth. The sitting position, with the arms pressing the knees firmly against the abdo men, was found beneficial. In moderate cases the horizontal posi tion, with 10 minims of ether hypodermically and a large 4-inch flannel bandage compressing the abdomen, produced good results. Hot drinks in small quantities were given when the symptoms began to subside. Ether hypodermically acts quickly and efficiently. No benefit was derived from the use of strychnine. Hemorrhage from shell wounds varied with the character of the projectiles. These wounds were generally punctured or lacerated, and bleeding from them in most cases was controlled by packing with lint soaked in sterile saline and a firm pad and bandage. Morphia, one-half grain hypodermically. assisted in the control of bleeding. No attempt was made at the advanced dressing station to tie bleeding vessels; a tourniquet was applied and the patient evacuated as Boon as possible to a casualty clearing station. In cases where a tourniquet was required a special note was attached at the time of application and the ambulance orderly told to report on arrival at the clearing station. In the early treatment of wounds the clothing was first cut away and the wound itself was covered with gauze soaked in hypertonic saline (4 per cent). The skin immediately around was cleansed with swabs soaked in gasoline. The gasoline having been removed with clean swabs, the surrounding skin was painted with tincture of No. 1. 305 NOTES AND COMMENTS. iodine or with picric acid. If the iodine or picric acid gets into the wound great pain results. After the removal of fragments and dirt the wound was cleansed with 1-2,000 bichloride of mercury so lution, washed out with saline solution, and packed, if necessary, with saline gauze. The results of this method were very satisfac tory. Cranial wounds were generally in a very dirty condition, the pa tient in collapse and bleeding severely from the scalp. When suf fering from embarrassed respiration efforts were made to clean out the fauces, draw forward the tongue, and, if necessary, secure it with a stitch fixed by adhesive plaster to the cheek. The injured man was placed in a sitting position and, if shock was profound, ether was given hypodermically. The scalp was shaved and painted with iodine. The wound was then examined, any obvious bone frag ments removed, and saline gauze, wool, and protective applied. In thoracic wounds a sudden, large intra-pleural hemorrhage pro duces profound shock and embarrassment to respiration, which is complicated by coughing. Such large hemorrhages, however, were rare. The immediate indication was absolute rest in a sitting pos ture and cessation of movement, which is generally impossible in the field. Aspiration of a hemothorax was adopted in cases where the fluid reached a level causing embarrassment. In the writer's experience, abdominal wounds produce less shock than in other regional wounds. Bullet wounds of the abdomen do not cause protrusion of gut. They are best cleaned and left alone, morphia administered, and the patient evacuated as soon as possible. Wounds of the abdomen caused by shell fragments usually cause more laceration, and necessarily more protrusion of gut. When there was protrusion without obvious injury to the gut, morphine was given and the wound cleaned and the gut replaced under chloroform anesthesia. If the gut was injured an attempt was made to pack off the wounded gut from the peritoneal cavity. In wounds involving joints the best practice in the field is the removal of any visible foreign body, but not to explore for the frag ment causing the wound. Rupture of the membrane tympani was exceedingly common from the near explosion of large shells. All six of the laboratory workers of the United States Public Health Service who have been studying tularemia, a disabling sick ness of man which has been known, particularly in Utah, for the last five years, have contracted the disease, two of them being infected in the laboratory in Utah and the other four in the Hygienic Laboratory in Washington. Such a record of morbidity among investigators of a disease is probably unique in the history of experimental medicine. 306 Vol. XVII. NOTES AND COMMENTS. Two of these workers are physicians, one is a highly trained scien tist, and the others are experienced laboratory assistants. One of them contracted the disease twice, once in the laboratory in Utah and again, two years and five months later, in the laboratory in Wash ington. In these workers the disease began with a high fever, lasting about three weeks, and was followed by two months of convalescence. The disease has few fatalities, its chief interest arising from the long period of illness which it causes in midsummer, when the farmer? of Utah are busily engaged in cutting alfalfa and plowing sugar beets. The studies into the cause and transmission of the disease show it to be due to a germ, Bacterium tvlarense, which is conveyed by six dif ferent insects : The blood-sucking fly, Chrygops distalu; the stable fly, Stomyox calcitrans; the bedbug, Cimex lectularius; the squirrel flea. Ceratophyllus acutus: the rabbit louse, Haemodipsus ventricogus ; and the mouse louse, PolypJax serratus. Only the first four of these are known to bite man. It appears possible that the germ may also enter through unbroken skin ; for instance, that of the hands. Carbon monoxide poisoning is one of the most widely distributed and most frequent of industrial accidents, says the United States Pub lic Health Service. The gas is without color, odor, or taste. It is an ever-present danger about blast and coke furnaces and foundries. It may be found in a building having a leaky furnace or chimney or a gas stove without flue connection, such as a tenement, tailor shop, or boarding house. The exhaust gases of gasoline automobiles con tain from 4 to 12 per cent of carbon monoxide, and in closed garages men are not infrequently found dead beside a running motor. A simi lar danger may arise from gasoline engines in launches. The gas is formed also in stokerooins, in gun turrets on battleships, in petroleum refineries, and in the Leblanc soda process in cement and brick plants. In underground work it may appear as the result of shot firing, mine explosions, or mine fires ; or in tunnels from automobile exhausts or from coal or oil burning locomotives. Carbon monoxide exerts its extremely dangerous action on the body by displacing oxygen from its combination with hemoglobin, the coloring matter of the blood, which normally absorbs oxygen from the air in the lungs and delivers it to the different tissues of the body. Oxygen will replace monoxide in combination with hemoglobin whenever the proportion of oxygen in the lungs is overwhelmingly greater. Therefore — 1. Administer oxygen as quickly as possible and in as pure form as is obtainable, preferably from a cylinder of oxygen through an inhaler mask. NOTES AND COMMENTS. 307 2. Remove patient from atmosphere containing carbon monoxide. 3. If breathing is feeble, at once start artificial respiration by the prone-posture method. 4. Keep the victim flat, quiet, and warm. 5. Afterwards give plenty of rest. Among the members of our profession who have had a life of adventure few names are more familiar, says the British Medical Journal for February 18, 1922, than that of Thomas Dover (1660- 1742), who took his B. A. at St. Mary's hall, Oxford, and the M. B. from Caius College, Cambridge, and became a captain in a bucca neering expedition, in which capacity he in 1710 rescued Alexander Selkirk, whom Defoe made immortal as Eobinson Crusoe. Eventu ally Dover began the practice of medicine in London, where he be came known as " the quicksilver doctor " on account of his cure for asthma and many other ills—namely, " an ounce of quicksilver daily, to be taken at what hour the patient pleases, and a spoonful of the gas of sulphur in a large draft of spring water at 6 o'clock in the afternoon and at bedtime." In his well-known collection of bio graphical essays, An Alabama Student (1908), the late Sir William Osier gave an attractive account of this " physician and buccaneer." with many details about his popular work, The Ancient Physician's Legacy to His Country, " designed for the use of all private fami lies." To the February number of The Bookman's Journal and Print Collector, which we are given to understand is the only peri odical in the world devoted exclusively to the collecting of books and prints, Dr. Philip Gosse, the son and grandson of leaders in literature and zoology, respectively, contributes a brightly written sketch of Dover's adventures as a pirate, based mainly on a rather rare book, A Cruising Voyage Bound the World. This book was begun in 1708, and, according to the title-page, contains " Remark able transactions as the taking of Puna and Guayaquil, of the Aca- pulco ship and other prizes ; an account of Alexander Selkirk's living alone four years and four months on one island, etc., 1721," by Capfr. Woods Rogers, who commanded the expedition of two ships—the Duke and the Duchess —fitted out by the merchant adventurers of Bristol at the instance of William Dampier, the famous circumnavi gator, freebooter, naturalist, and hydrographer. Dampier. then 56 years of age, went as pilot, and Dover, who was practicing in Bristol, was chosen as second in command, not because he had any knowl edge whatever of the sea or ships, but, strange as it may seem, on account of his bad temper ; for it was shrewdly argued by the mer chant adventurers who were financially interested in the expedition that Dover's vile temper would render him so unpopular that he 308 Vol. XVII. NOTES AND COMMENTS. would not have any followers should he attempt to break away from the main party—a danger that had led to the failure of previous expeditions in which a popular second in command had been per suaded by a discontented party to go off on a separate cruise. As may be imagined, the voyage was not free from quarrels over the distribution of the spoils. After sacking Guayaquil the English sailors stored their plunder in the churches and spent the night there to guard it, but their sleep was much disturbed by the smell of corpses recently buried as the result of an epidemic of " plague." Next day they returned to the ships, but within 48 hours 180 of the crew of one ship were down with the plague; here Dover stepped in and ordered the ships' surgeons to bleed every sick man to a hundred ounces, and to give large drafts of dilute sulphuric acid ; it is recorded that this drastic treatment was justified by the recov ery of all but eight patients. The editor of the British Medical Journal makes the following comment on "the destruction of vitamins" in the issue of that periodical for February 11, 1922 : " The two facts of greatest practical importance about vitamins are, first, that a certain minute supply of these substances is essential for animal life, and, secondly, that they are very easily destroyed. It is most necessary to bear this second characteristic in mind, for the actual existence of vitamins can only be demonstrated by the disastrous effects produced by their absence from the diet or their presence in it in insufficient quantities; indeed, since vitamins occur naturally in nearly all fresh foodstuffs, it is probable that their existence would never have been suspected had they not been such unstable bodies. "An abundant supply of vitamins exists in all fresh vegetable foods, and considerable quantities occur in milk and in meat, pro vided that the latter are obtained from animals fed on fresh foods. A normal adult living on an ordinary diet containing a reasonable proportion of fresh vegetables is, therefore, certain of obtaining a plentiful supply of vitamins. Unfortunately these indispensable food constituents are, as has been said, very readily destroyed. All three vitamins are rapidly destroyed by heating in the presence of air or oxygen. Hopkins showed that the fat-soluble vitamin A in butter was completely destroyed by heating the butter to 120° C. for four hours if oxygen was bubbled through the butter, although practically no destruction occurred if the butter was heated without aeration. The experiment established the important fact that this vitamin, though fairly resistant to heat, is readily destroyed by oxidation. Zilva found that the antiscorbutic vitamin C was com No. 2. 309 NOTES AND COMMENTS. pletely destroyed by boiling for an hour in the presence of oxygen, but that no destruction occurred when it was boiled for two hours in an atmosphere of carbon dioxide. The destruction of vitamins depends largely upon the length of time for which they are heated in the presence of air. Hess, for instance, showed that little destruc tion of vitamin C occurred when tomatoes were heated to 100° C. for 15 minutes, but that four-fifths of the vitamin was destroyed when the tomatoes' were heated to 100° C. for an hour. Similarly, it has been shown that a greater destruction of the vitamin C present in fresh milk occurs when it is heated to 60° C. for half an hour than when it is boiled for a minute. The reaction of the fluid containing the vitamin is also of importance, for vitamins are much more readily destroyed in an alkaline than in an acid fluid. The fluid ne^d only be feebly acid. The antineuritic, water-soluble vitamin B is more resistant than vitamin C, but it also is readily destroyed by boiling in an alkaline fluid in presence of air. "A fair proportion of all three vitamins in fresh vegetables appears to survive all ordinary cooking ; but prolonged boiling, such as occurs in making stews, destroys nearly the whole of vitamin C and prob ably most of vitamins A and B. The vitamins in milk are unfor tunately very unstable; ordinary pasteurization destroys practically the whole of vitamin C and a considerable amount of vitamin A. " The extraordinary difficulty of retaining vitamins in preserved foods is in large measure due to the fact that vitamins slowly oxi dize on keeping. Vitamin A is the easiest to preserve, for it appears to be fairly stable when dissolved in oil, and it can be kept in cod- liver oil for months and probably for years; it also survives for many months in tinned meat. Vitamin B can be preserved in the dry state, and whole-meal flour and unpolished rice retain their con tent of this vitamin for long periods. The preservation of vitamin C, the antiscorbutic vitamin, is by far the most difficult problem. This is well known ; efforts have been made for the last hundred and fifty years to find some satisfactory way of obtaining a concentrated, portable, and stable preparation of the antiscorbutic element in fresh fruits or vegetables. The problem is of the greatest importance to the Navy and to explorers; in special circumstances it may be of first-rate importance to the Army also. A stable preparation of vitamin C is essential for the prevention of scurvy when fresh vege tables and fruits are not obtainable. Lemon-juice was introduced as an antiscorbutic in the eighteenth century, and its use reduced the mortality in the Navy enormously. Lemon juice is very rich in vitamin C, and the acids present help to preserve the vitamin. Un fortunately, in the nineteenth century lemon juice was discarded for lime juice, which has only one-quarter the vitamin content of the former. Lemon juice, however, is not a really satisfactory vehicle 310 Vol. XVII. NOTES AND COMMENTS. for the preservation of vitamin. C. Bassett-Smith found that com mercial lemon juice lost all its vitamin content rapidly; he showed, on the other hand, that dried lemon-juice tablets retained their vitamin for at least a year. Harden and Robison found that dried lemon juice kept in a desiccator for 15 months at room tempera ture only lost 50 per cent of its activity. Hess ascertained that tinned tomatoes retained their vitamin C content with little loss for three years. He also found that if perfectly fresh milk was dried by a suitable process and stored in sealed tins its vitamin C content was preserved for many months. The simplest way of transporting vitamin C is by the use of dried peas; they contain little of the vitamin when dry. but produce large quantities when allowed to germinate. By the use of germinating peas an abundant supply of vitamins can be obtained by explorers or troops in sterile countries. It is important to realize that although dozens of different methods of food preservation are known, yet the few examples mentioned above are practically the only methods by which vitamin C can be preserved for any length of time. " Individuals living under normal conditions may suffer from vitamin lack, owing to an improper diet from which all vitamin- containing foods have been eliminated. All that is needed in such cases is the addition of such foods to the diet. The following foods are particularly rich in A'itamins: Cod-liver oil contains about 240 times as much vitamin A as butter, yeast is the richest source of vitamin B, and fruit juices contain a large amount of vitamin C (ierminating seeds contain large amounts of both vitamin B and C. while green vegetables and tomatoes contain large quantities of all three vitamins. An abundant supply of all the vitamins can there fore he obtained simply by the addition to the diet of cod-liver oil and the fresh vegetables mentioned. " Certain workers claim to have produced concentrated prepara tions of vitamin B, but no methods are known by which eithei vitamin A or vitamin C can be obtained in concentrated form. Any attempt at chemical treatment produces a rapid destruction of the vitamins. As already pointed out, it is a matter of great difficulty to devise any means by which vitamin C can even be preserved, and its concentration is at present impossible. It is extremely easy to obtain an abundant supply of vitamin C by the use of fresh foods, but it is very difficult to retain more than a fraction of this vitamin in any form of preserved food. Xo substance is known which contains more vitamin A than cod-liver oil. and, as has been said, it is only in the case of vitamin B that any success has attended the repeated efforts that have been made to purify or to concen trate vitamins. No. 2. 311 NOTES AND COMMENTS. " In spite of the fact that ordinary fresh foods are the simplest, cheapest, and richest sources of vitamins, the public apparently demands to be supplied with vitamins in the form of medicinal products. A large number of preparations are on the market which claim to contain vitamins. Some of these preparations are so far satisfactory that the prepared article has been proved to contain vitamins, although even in these cases a few ounces of green vege tables would probably contain more vitamins than large quantities of the preparation. In the case of certain manufactured products, however, it is simply stated that the preparation is made from sub stances very rich in vitamins. This statement means nothing, for. from the facts mentioned in this article, it is obvious that even if a preparation is made from a raw material rich in vitamins, it does not follow that the finished article will contain any vitamin at all when it reaches the patient. " We have endeavored to state the known facts as plainly and directly as possible, and invite manufacturers to take note of them. They may be unwelcome, but they are, we believe, incontrovertible.*' NURSE CORPS. DREAMS. By an Old Dreamer. Much has been written on the subject of dreams, and some of these writings have been pernicious nonsense even though emanating from high authority. But why let the voice of authority dominate our reason without giving it the " once over " on our own account j The imagination, literally the making of pictures, is a faculty of the mind, and a very entertaining faculty at that, which goes on alike whether we are awake or asleep, and the pictures which are made are for our delectation. The normal physiological exercise of any bodily function gives a pleasurable sensation ; thus while we are asleep with consciousness partially suspended or disassociated, but never completely obliterated, the reins of imagination are loosened. Without the restraining influence of other faculties of the mind, such as the logical, the moral, the cautious, the imagination literally plays and paints its fantastic pictures for the amusement or consternation of the latent consciousness. The instinct of play, while universal, is strongest in youth. Sleep rejuvenates, not only in a physical sense, but also gives to- one the mind of a child by submerging the barriers of sophistication. Sometimes dreams terrify rather than amuse, in which case the latent consciousness generally says : " See here, young person, I'll not stand for that, you know," and emerges from the too violent shock. In such cases it usually happens that consciousness proceeds to reflect upon this picture too vividly painted. Wide awake, it re members with horror the vision of the executioner wearing that curious red mask, standing just under the scaffold. How black his beard looked showing below the mask ! Why did he not wear a black mask, then his beard would be red, like Uncle George's —why it is " Uncle George "—and lo, one is asleep again, and " Uncle George " this time puts the noose around one's neck and gives it a tug—and again consciousness emerges and the painting is suspended. It is a characteristic of the dream to recur to the same subject and present it in many different aspects, and this specimen dream is related to indicate the transition between sleep and wakefulness, also to show that the imagination may continue to follow the same figment unin 313 314 Vol. XVII. NURSE CORPS. terruptedly in both states, back and forth, repeatedly playing with the image and changing it in color and form, though retaining the motive which in this case gave the consciousness a shock of horror. Sleep, as a part of life, is curiously undervalued by most of us, if one may judge from popular habits and daily routine of the general pleasure seeker. All that the young realize about sleep is that it is a part of the daily life to be postponed as long as possible, although usually prolonged at the further end. To the young and healthy sleep is " lost time," and they would discredit the fact that it is supposed to be a pleasurable part of one's existence. And yet children are adept dreamers; the imagination paints rare pictures for the young both waking and sleeping. Thankful we may be that the sophisticated theorist can not impute to the age of innocence his idea of the sub ject matter of dreams. And the child is no martyr of repressed de sires, or I know not the child ! To those of us who have experienced the sensations of life and have realized the numbing effects of sophistication, then is the re sponse deeper than recognition of the poetic beauty of the lines : "Above thy deep and dreamless sleep, The silent stars go by." Such a degree of disassociation of the conscious mind as expressed by " deep and dreamless sleep " is perhaps the fullest pleasure the cup of life contains. Sleep may be dreamless. Just as in the case of the Cape Cod cap tain, while we are awake " we sometimes sit and think and some times we jest sit": so, while we are asleep the imagination, may rest, or, as high authority declares but can not prove, the disassociation is so great that memory does not register. Various physiological states account for this—such as the amount of blood in the brain and the degree of fatigue or excitement which preceded sleep. A high pillow will tilt the head forward and lessen the blood supply, and this has been found to lessen the number of dreams. The influ ence of the digestive functions upon dreams is too well known to require comment. From such stimuli of the body arise the hints which start the imagination on its wild excursions. After allowing for all such causes, however, it certainly leaves a vast horde of ideas unaccounted for. Transitions are instantaneous and without appar ent connection ; nor can acts or thoughts of the wakeful hours give the clue to the flash of memory which revives something long for gotten. A creative faculty is sometimes manifest; one may compose verse, devise an invention, or plot a story. Not infrequently do we hear of individuals who have writing materials at the bedside so that ideas which sleep creates may not be lost to waking consciousness. This No. 2 315 NURSE CORPS. power of innovation is strong evidence that all dreams are not sug gested by external stimuli. The cause of such unsuggested dreams is the well-recognized but entirely mysterious power of the imagina tion of making spontaneous mental combinations. When such com binations are the most varied they result in inventions, and the indi vidual is called a genius. In dreams also genius is at work. All this is subject matter of common observation, and it requires no elaborate theory to elucidate. If perchance one dreams that it is thirty degrees below zero, and that it changes to sixty degrees below, and some one knocks at the door and asks if one is going skating, it requires no great mental feat to perceive that one dreamed because one was cold. A psychoanalysis may explain that the dream of zero weather means the repressed desire for another blanket ; but the de sire does not remain repressed after one has sufficiently come to con sciousness to make even a reflex movement toward the foot of the bed where the extra coverings hang ; yet it is the repressed desires of the awakened existence which this theory would have as the cause of our dreams. Surely there is no place for that explanation in the case of a sensation of the body occurring while we are asleep. It would be absurd to deny that to a certain number of dreams this psychoanalytical explanation is applicable, but can not this be over- advertised? Is there not a Zurich school of analysis as well as a Viennese? As a matter of fact, what are these desires which we so persistently repress in our waking hours as to afford material for our nightly volume of dreams? The majority of us adults are under the impression that the human animal is not given over to practicing self-control, and one can not credit him with much in the way of repression. " Lead us not into temptation, for if you do, assuredly we shall yield." would seem an honest prayer for the majority of the human adults. That the general color of our dreams may be influenced by the general color of our lives is not denied, but a closer relationship of cause and effect between the acts and thoughts of the day and our dreams at night other than that of the broad general emotions, anxiety, sorrow, pain, and their opposites, does not always occur. A patient suffering from a chronic ailment may have depressing dreams of death or of varied calamities. His thoughts during the day may not have embraced a single one of the specific elements of his dream, but (shall we say subconsciously) they determine the field in which his imagination rambles at night. And so the study of our dreams may give a hint to the character of our lives, whether we are placid or morbid, spiritual or sensuous. But in spite of "high authority" may not we who are merely plod ders on the road of life state that we do not think that they can give 108165—22 9 316 Vol. XVII. NURSE CORPS. more exact or explicit information? Certainly knowledge of our selves so obtained is not in the least comparable in value to that afforded by a study of our waking hours, and. also, one would hate to acknowledge that the stuff one's dreams were made of were made in Austria. THE ROLE OF THE NURSE TN CURE AND PREVENTION. Speaking of the role of the nurse in the cure and prevention of disease George E. Vincent, president of the Rockefeller Foundation, in his review of the foundation's activities in 1921 sa37s : " The modern hospital and doctors and surgeons are largely de pendent upon the trained woman nurse, who has made an invaluable contribution to curative medicine. Public health administrators are recognizing the visiting or health nurse as equally indispensable to the success of public and personal hygiene. Already maternity and child welfare nurses, school nurses, tuberculosis nurses, and several other specialized types have taken their places in private health systems and in Government departments. One State has announced as its goal the appointment of a health nurse for every 2.000 of the population ; another has fixed the ratio at 1 to 3.000. " Questions as to the exact function of the bedside nurse, the kind and length of training she should receive, have been under discus sion for some time. The advent of the health nurse raises similar problems. How far should her education coincide with that of the hospital nurse? In what should consist her special training? How much time should the entire course occupy ? Should there be differ ent grades of both bedside and health nurses ? Is there a place and function for a lay worker or a health visitor? In 1919 the founda tion, invited a group of persons who are most familiar with nurs ing problems to a conference which nominated a survey committee under whose auspices a competent expert has been making a study of the subject in all its phases. A report is promised in the summer of 1922. The expenses of the survey have been met by the founda tion. "During 1921 the International Health Board contributed toward short courses for New York State nurse training. Four nurse train ing centers in France were aided not only to train visiteuses <Phy- giene but to improve in certain hospitals standards of ward nursing and administration. The Cavell-Depage Memorial School of Nurs ing in Brussels will be an integral part of the reorganized hospital 8nd medical school to which the foundation is contributing a large sum. The International Health Board is cooperating with the new Government hospital in Rio de Janeiro in establishing good stand ards of nursing under the leadership of American trained nurses. No. 2. 317 NURSE CORPS. The foundation supports a nurse training school in connection with the Peking Union Medical College. A survey of nurse training in Great Britain and on the Continent, to be begun early in 1922, has been authorized." NOISE. A recent publication has stated that scientific investigations have shown that "there are few more active robbers of our energy and strength than noise. Whistling, whether it be the effort of the passing boy, the shriek of the railway engine, or the blare of the police alarm, is only a type of the many noises with which the in habitants of all towns are cursed. These noises are really a serious menace to the health and happiness of all communities. Those of us who live in cities believe that we become accustomed to the din, but this is not entirely correct. What we think is a process of becoming accustomed to noise is in fact a state of active resistance to it. We ignore by refusing to hear, but this can not be done without expending more energy than we can afford." This nerve energy which transmits outside sounds to the brain may be likened to the electric energy which operates a telegraph system or the familiar house electric bell. In all these cases the striding of the message, be it the noise from ear to brain, the code from operator to tape, or the push button to bell, uses up a given quantity of nerve or electric energy, tending to ultimate exhaustion of the nerve centers or batteries. Our nerves of hearing expend some of their energy transmitting sounds to our brains; when we make an effort to refuse to hear an unnecessary waste of nerve energy goes on. It is claimed the amount of this waste is measurable. The intense effort required for not hearing is accompanied by a rise in the pressure of the blood stream on the walls of the arteries, and an ingenious mechanism attached to the pulse measures this increased pressure of a column of mercury. It is thus our total available stock of energy is reduced and we have not enough left to bring our " not hearing " faculty into play and noise becomes a torture. One of the most persistent criticisms made of our naval hospitals is the amount of noise the sick are forced to endure. Heavy boots, slamming doors, rattle of dishes, loud talking, scraping of metal furniture—all these have been enumerated. To the query, "Why do you not report these disturbances ? " there is but one answer, " I have tried, but I am regarded as a crank." Outside the hospitals city authorities have tried to help in the suppression of noise by notices of " Zone of quiet," but few could assert that these signs have restrained any motorist from blasting his horn or any motorcyclist from cutting out his muffler. The boat proceeding up the Sound 318 Vol. XVII. NURSE CORPS. passes a hospital at the waters edge; the wall bears a 3-foot sign, " Quiet— Xo unnecessary noise," but at this particular point the boat sends forth a siren whistle. Employers of labor now recognize that time and energy are wasted from the fatigue engendered by the noise of machinery and manual operations, and it is believed that more active measures will be taken to control unnecessary and preventable noises. When one is very ill, one fully realizes how great must be the stock of energy required to intercept noise. It is not work that kills but the continuous drain of nervous energy entailed by our efforts not to hear distracting din. Even if one does not entirely agree to this statement, one can not gainsay the retarding effect of noise in cases of sickness, and such united and per sistent efforts as can be made to promote quietude in our hospitals will result in greater good to the patients and increased efficiency on the part of the personnel. BOOK NOTICES. Publishers submitting books for review are requested to address them as follows: The Editor, U. S. Naval Medical Bulletin, Bureau of Medicine and Surgery, Navy Department, Washington, D. C. (For review.) Books received for review will be returned in the absence of directions to tbe contrary. KCV1HWERK. Lieut. Commander W. M. Kbrk. Medical Corps, United States Navy. Lieut. John Harper, Medical Corps, United States Navy. Lieut. L. J. Koberts, Medical Corps, United States Navy. Still am I busy books assemblynge, For to have plentie it is a pleasant thynge In my conceyt, and to have them in hande, But what they mene do I not understande. (Medieval book collector.) Pboteji* Therapy and Nonspecific Resistance, by William F. Petersen, M. D., associate in pathology, University of Illinois, College of Medicine, Chicago, III. The MacMillan Co., New York, 1922. A book on this subject is timely. For the past six or seven years clinical data has been accumulating which indicates that it is neces sary for us to broaden our views in relation to biologic therapy. For the past 30 years the idea of specific immunity has so dominated medical thought that it is difficult for us to think in terms of non specific protein therapy. The fact of the existence of a nonspecific reaction, however, has been established, and its application in the treatment of disease is becoming more and more widespread. There fore, because of the opportunity it offers of keeping us abreast of the times, it is very fortunate that the author has made available such a complete and judicious resume of the subject. The book is divided into three sections, the first dealing with " The method," the second with " Theories," and the third with " The clinical results." In the first section the author gives a sketch of the early history of nonspecific protein therapy, followed by an enumeration and brief discussion of the various nonspecific agents 319 320 Vol. XVII BOOK NOTICES. which have been used. He then describes the so-called nonspecific reaction, taking up in detail the rather marked effect which the intravenous injection of 25 to 50 million dead typhoid bacilli has on the physiological balance of the body. The last chapter of this section deals with the focal reaction in response to nonspecific protein injections. In the section on " Theories " the author dis cusses briefly those advanced by various writers to explain the mechanism of the nonspecific reaction. This is followed by a rather extensive discussion of his own views on the subject. He has formulated what appears to be a very plausible theory explaining the probable mechanism of the reaction. In considering the clinical results of nonspecific protein therapy the application of this form of treatment to various diseases is taken up. The methods of procedure are merely outlined and dosages either not mentioned or merely suggested. We are given a brief summary of the forms of non specific therapy used and the results obtained in the diseases in which it has attained any application worthy of note. The final chapter on indications and contraindications contains information with which everyone should familiarize himself before attempting to use this form of therapy. One of the most valuable features of the book is the extensive bibliography which it contains. There has been published a surprisingly large mass of literature on nonspecific protein therapy and allied subjects, and the author has gone to a great deal of trouble in compiling this bibliography for the benefit of those who may wish to refer to the original sources. The volume under discussion will undoubtedly disappoint those who have been looking for a ready reference book to which they might turn for definite well-developed methods of treatment by means of nonspecific agents. Nonspecific protein therapy, however, can not at present be carried on by rule of thumb, and this book serves an entirely different purpose than that of an outline of treat ment. As the author says in his preface : " The summarizing of our present knowledge in this particular field has seemed of some pos sible value, not with the idea of popularizing a new therapeutic measure but rather in stimulating interest in a direction that seems to offer decided possibilities of advance. I have therefore merely indicated some of the methods at present employed in nonspecific therapy without effort to define precise modes of application or indications for therapeutic use. On the other hand I have endeavored to present the possible theoretical basis and some of the collateral fields of application as fully as our present knowledge will permit." With an understanding of the author's point of view in the presenta tion of this subject one can more readily read the book with appre ciation. In dealing with so new a subject it has been necessary to No. 2. 321 BOOK NOTICES. include reference to, and in some cases relatively lengthy discussions of, methods and theories which may later have to be discarded. The average reader will be inclined at times to be skeptical of the value .of some of the material used. But if we bear in mind that the author's purpose is to present a subject in which he wishes to stimu late further investigation this material is seen to be essential. It must not be thought, however, that this book is not written for the practicing physician. As the author states: "It was the clinic that directed that attention to this form of therapy." It is a method of treatment, and, therefore, must of necessity be handled by those caring for patients. The use of protein therapy is outlined in the case of some of the diseases with enough definitenoss to enable one proceeding cautiously and with judgment to carry out with safety in certain selected cases some of the methods described. The final paragraph indicates the spirit of caution and yet the enthusiasm with which the author has attempted to present his subject. He says: " Needless to say, nonspecific therapy does require judgment, careful attention, and bedside study on the part of the physician perhaps in greater measure than any other therapeutic procedure. It should never be a routine ; to be useful it must be an individualized therapy, with dosage and preparation and time of application varied to the disease, its intensity, its duration, and the resistance of the patient, So used, nonspecific therapy should prove to be one of our most use ful measures both in acute infectious diseases and chronic inflamma tory lesions." The enthusiasm embodied in this last sentence may be unwar ranted. But even though some may not be willing to accept all that the author claims for nonspecific protein therapy, this book is undoubtedly a distinct contribution to medical literature, (l. ,t.r.) A Textbook of General Bacteriology, by Edwin O. Jordan, Ph. D., professor of bacteriology in the University of Chicago and in Hush Medical College. Seventh edition. W. B. Saunders & Co., Philadelphia, 1922. In the new seventh edition of this well-known work the author has made a thorough revision with the addition of 52 pages of subject material. The chapters on the methods of studying bacteria, the hemophilic bacteria, and spore-forming anerobes have been rewritten and enlarged. Extensive revision has been made in the chapters dealing with the streptococcus and pneumococcus. Typhus fever has been revised and placed in the appendix under the chapter dealing with infectious diseases of doubtful origin or unknown causation. The spirochaetal diseases have been brought up to date and grouped under a separate heading. A commendable feature of this edition is the effort on the part of the author to get away from the present loose and unsatisfactory bacteriological nomenclature by using, so far as practicable, the 322 Vol. XVII. BOOK NOTICES. nomenclature proposed by the committee of the Society of American Bacteriologists. Objections to adopting new names for old ones will be heard mainly on the ground of confusion, but it is a well-known fact that wherever confusion has reigned, the establishment of order always results in temporary greater confusion, (j. h.) Bacteriology, General, Pathological, and Intestinal, by Arthur Isaac Ken dall, B. S., Ph. D.. Dr. P. H., professor of bacteriology in the Northwestern Medical School, Chicago, III. Second edition. Lea and Febiger, Philadel phia and New York. 1921. The author is to be congratulated upon the appearance of an edi tion that has been thoroughly revised and, where needed, rewritten. This edition, similar to the first, is divided into 5 section and 32 chapters: Section I—General bacteriology; Section II—Pathogenic bacteria; Section III—Higher bacteria, molds, yeast, filterable viruses, and diseases of unknown etiology; Section IV—Gastro- in testinal bacteriology; Section V—Applied bacteriology. In nearly every chapter extensive changes and additions have been made, in accordance with the advance in the science of bacteriology in recent years, prominent among which is the chapter on anerobic bacteria. The subheadings, spacing, and print are excellent. Illustrations are few but good. References are extensive, and the revision has been accomplished with practically slight increase in size—30 pages. The reviewer believes that this newer edition will prove even more popu lar than the preceding one. (j. h.) A Textrook of Bacteriology, by Hans Zinnscr. M. /)., professor of bacteriology. College of Physicians and Surgeons, Columbia University, New York City; with a section on Pathogenic Protozoa, by Frederick F. Russell, colonel, Medical Corps, V. S. Army. Fifth edition. D. Appleton and Co., New York City, 1922. This work is a new edition in every sense of the term, as it brings all the subject matter up to date. Consistent without advancing knowledge of certain pathogenic organisms, the chapters dealing with the pneumococcus, streptococcus, meningococcus, influenza, and anerobic bacilli have been extensively revised or rewritten. Those familiar with the extensive literature concerning these subjects will appreciate the brief, yet complete, manner in which the author has summarized the results of the numerous investigations. The same applies to the chapters dealing with spirochetal infec tions, diseases caused by filterable virus, and diseases of uncertain etiology in which yellow fever, Rocky Mountain fever, typhus fever, etc., have been revised in accordance with our present knowledge of these diseases. The section on pathogenic protozoa by Russell has been completely revised, is thoroughly up to date, and contains many excellent illus trations. No. 2. 323 BOOK NOTICES. A commendable and outstanding feature of the work which will be appreciated by the laboratorian, clinician, and public-health worker alike, is the successful effort on the part of the authors to correlate laboratory knowledge with clinical and preventive medicine by the inclusion of a wealth of clinical and epidemiological data. (J.H.) Modern Italian Surgery and Old Universities of Italy, by Paolo De Yecchi, M. D., F. A. C. S. Paul B. Hoeber, New York, 1921. Before the war American students of the medical sciences went to France, to Germany, or to Austria to visit the great clinical centers which existed in those countries, but they never went to Italy to visit the hospitals or to learn from Italy's medical teachers. The achievements of Italy in medicine and surgery during the war have been so great and the country is so interesting that the American medical man, with an inclination for a trip abroad, might well profit by a visit to her sunny shores. It is with the idea of familiarizing American surgeons with the Italian School of Surgery in the hope that they will visit Italy "not only as a pleasure resort or as a center of antiquities, but as a new country and a new seat of educa tion " that Doctor De Vecchi has written this readable book. In spite of the antiquity of the Italian peninsula, Italy, as we know her to-day, is a new country. Only 62 years have passed since Giuseppe Garibaldi, with 1,000 volunteers, landed in Sicily and started a revolution which ended the domination of the Bourbons and resulted in the unification of Italy. Yet during that short time the Italian people have learned to rely on their own capacities and to depend on their national unity, in which lies their strength, power, and ability to develop their own resources to their utmost extent. Among the surgeons of modern Italy who have achieved promi nence may be mentioned Edoardo Bassini, of Padua, who devised the well-known operation for the cure of inguinal hernia ; Francesco Rizzoli and Alessandro Codivilla, of Bologna, who are noted for their work on orthopedics ; Enrico Bottini, of Pavia, who has made valuable contributions to the surgery of the prostate gland ; Edoardo Porro, of Milan, whose name is associated with his special uterine operation; Antonio Carle, of Turin, and G. F. Novara, of Genoa, who have contributed to the surgery of the intestines; Francesco Durante, of Rome, who has devised an iodine treatment of bone tuberculosis ; Raffaele Bastianelli, also of Rome, who has extensively contributed to the surgery of the thorax and kidneys; Davide Gior dano, who has contributed to the surgery of the kidneys: Giuliano Vanghetti who experimentally devised a successful method of utiliz ing the muscles of a stump to actuate artificial limbs ; and Antonio Ceci. of Pisa, who, applying the principles of this method to the human subject, attained a much more satisfactory prosthesis than 324 Vol. XVII. BOOK NOTICES. ever before achieved. There are a host of other men who, while per haps not quite so prominent, have attained distinct renown. These men Doctor De Vecchi introduces to his readers as he conducts them, in the pages of this book, through the Italian universities. In the book will be found an excellent review of Italy's medical and surgical achievements during the war, an account of the work of reconstruction and of orthopedic surgery in Italy. The latter half of the book is devoted to an account of the Italian universities and their relation to modern Italian surgery. " There are at present 17 universities in Italy all under the control of the Government, with a complete course of medicine and surgery of six years' duration. Each is administered by the same standard and regulations, and provided with a staff of professors and instructors elected by a special board after public examinations, or by the exhibition of some special scientific studies or contributions which would entitle the candidate to the responsible position of teacher." The number of universities in Italy far exceeds the needs of the country. Before the unification of Italy, when the land was di vided into small kingdoms and principalities, the existence of a uni versity for each State was justified, especially for political reasons. It is unfortunate that some of these centers of learning have not been consolidated, as such a concentration would strengthen the uni versities retained and would provide large clinics, promote more uniformity of work, and would undoubtedly attract more attention from the outside world. Educational centers in Turin, Rome, Naples, and Palermo might well supply the demand, but certainly such a consolidation would deprive the visitor to Italy of the charm of the universities in the smaller cities of Bologna, Modena. Parma. Padua, Pavia, Genoa, Pisa, and Siena, which Dr. De Vecchi de scribes. (W. M. K.) Ephraim McDowell, Father of Ovariotomy and Founder of Abdominal Surgery, by August Sclmchner, M. D., F. A. G. S. J. B. Llppincott Co.. Philadelphia, Pa., 1921. This is a remarkable book, the biography of a surgeon who in the early years of the last century laid the foundation of modern abdominal surgery. Biographies of men who have achieved success in any line are always fascinating. A natural curiosity exists con cerning such persons. We like to read of their everyday life, their habit of thought, and of their accomplishments. A certain lapse of time must follow the death of one more or less entitled to fame be fore the story of his life can properly be written, because his contem poraries are so close to him that they can not view the details of his life with the proper perspective, and if they do write of him they are apt to set down merely a series of facts, some of which are rela tively unimportant. So. 2. 325 BOOK NOTICES. The contemporaries of Ephraim McDowell could not possibly realize the intricate and marvelous development of abdominal sur gery which was the logical outcome of his discovery that the peri toneal cavity could be successfully invaded under proper precau tions; nor could they have understood the factors which forced him to explore fields which surgeons practicing in the great medical centers of that time dared not enter. Ephraim McDowell practiced in Danville, Ky., when it was a small frontier town. His practice extended for miles around. This was before the days of roads or stage coaches, and his visits to his patients were made on horseback at times through trackless regions. Some of these calls meant absence from home for a week or more, especially when a surgical operation was involved. Doctor Schach- ner gives a delightful review of the frontier life in Virginia and Kentucky, and indicates its influence upon McDowell and his surgi cal work. On December 13, 1809, McDowell was asked to see a Mrs. Jane Todd Crawford, who lived in the wilderness some 60 miles from Danville. He found her to be suffering from a large ovarian tumor, a condition which up to that time had been considered inoperable. Realizing the possibility of relief only through surgery he induced Mrs. Crawford to make the journey to Danville, where he success fully removed the diseased organ. When we realize that this was the first time this operation had been performed and the fact that it was done without the aid of anesthetics, antiseptics, trained help, or any operative accessories, save the simplest domestic utensils, wre can understand the dramatic possibilities of the occasion. To Doctor McDowell apparently this operation was but an inci dent in his daily life and it is possible that he did not realize its full significance, as seven years passed before his friends could pre vail upon him to publish an account of three such cases which he had successfully operated upon. When he .did publish his modest account of the first ovariotomy it exposed him to the ridicule and sarcasm of some of the foremost surgeons in England. Doctor Schachner ably reviews the entire controversy and defends McDowell from those who attempted to dispossess him of his justly earned and richly deserved honors. Ephraim McDowell came more or less in contact with many im portant personages of his day and Doctor Schachner has woven into his tale delightful sketches of such men as John Bell, of Edinburgh, and Philip Syng Physick, of Philadelphia. He concludes the volume with a very readable sketch of Mrs. Jane Todd Crawford, whom he aptly styles the heroine of the first ovariotomy, (w. m. k.) QUERIES. Medical officers are invited to submit queries and to present their problems to the Bulletin, which, being in a position to draw on varied and extensive sources of information such as are not available elsewhere, will use every means of securing authoritative opinion. All queries will be answered by mail; and the replies, if of sufficient general interest, vrill also be published in this column. To the Editor: Please publish in the Query section of the Bulletin some good methods for the destruction of lice on the body. Lieutenant, Medical Corps, U. S. X. The following outline found in " Sanitary Entomology," by W. D. Pierce, will be found useful: Control of lice on body. A. Crab louse.— (1) Kerosene emulsion soap: The soap is made by boiling 1 part of soap chips in 4 parts of water and then adding 2 parts of kerosene oil, or 4 parts of gasoline. This jellies when cold, and 1 part of this soap jelly is added to 4 parts of warm water, making a good liquid soap at very small cost. This is followed by vermin jelly: Texas fuel oil. sp. grav. 0.86 b. p. 250 to 350° C -._ 50 parts. Crude vaseline 20 parts. Soft soap 30 parts. The cutting or shaving of pubic or axillary hairs is to be avoided because of the discomfort caused. Powders such as N. C. I., etc., should not be used in the pubic regions. B. Head louse.—Wash head with equal parts of kerosene and vinegar or 25 per cent acetic acid for one-half hour, keeping the head covered with a towel. The vinegar separates the eggs from the hairs, while the kerosene kills them. Use a fine-toothed comb to remove the eggs and lice. Wash the head with warm water and soap containing kerosene (Xuttall). C. Body louse.— (1) Bathe, using liquid kerosene soap emulsion; (2) disinfect and disinseet clothing, possessions, etc. 328 Vol. XVII. QUERIES. In absence of facilities for the above—insecticidal powder (Moore) - Superior to N. I. C. Fumigation: Entomologists prefer cyanide. In " Investigation of the Louse Problem," by W. Moore and A. D. Hirschfelder, the authors give the following summary of the problem : 1. Lice and their eggs are destroyed by the ordinary laundering processes used in the washing of cotton and khaki goods ; for woolens slight alterations in the methods of washing are necessary. 2. Chlorpicrin may be used for fumigation of garments, accom plishing the desired results in a short period of time, with a small quantity of the chemical, without the use of high temperatures. 3. The sachet method of controlling lice is ineffective or very expensive. 4. Louse powders may be used with success but, being a wasteful method of applying an insecticide, are not recommended. 5. Impregnation of the underwear is the most promising method of louse* control between lousings. Active chemicals of very low volatility are necessary to prove effective for the longest period of time. Halogenated phenols, such as dibrommetacresol, dichlormono- brommetacresol, and their sodium salts, dibromcarvacrol, and di- bromxylenol were found to be the most promising under laboratory conditions. To the Editor: I was interested in reading the communications regarding tlie treatment of burns which "Ambustio " submitted for publication in the last number of the Buixktin as evidence to support his contention that picric acid is not a proper agent to use in the treatment of burns. I believe the reaction against the use of picric acid set in because it was feared this chemical might be a factor in the production of shock. In this connection the following extract from an" editorial which appeared in the Journal of the American Medical Association, February 25, 1922. is offered as a commentary on the fact that shock may be produced in burns by other agents than picric acid, which I have found to be an extremely useful agent in certain types of burns. " Cannon 1 has recently summarized the best-known features of wound shock as characterized by a low venous pressure; a low or falling arterial pressure ; a rapid, thready pulse ; a diminished blood volume ; a normal or increased erythrocyte count and hemoglobin per centage in peripheral blood ; a leukocytosis ; an increased blood nitro gen; a reduced blood alkali content; a lowered metabolism; a sub- Creosote Sulphur- Talc 1 c. c. i gr- 20 gr. Commander. 1 Cannon, W. B. : Studies in Experimental Traumatic Shock, IV, Evidence of a Toxic Factor In Wound Shock, Arch. Surg. 4 : 1 (Jai.), 19^2. No. 2. 329 QUERIES. normal temperature ; a cold skin, moist with sweat ; a pallid or gray ish or slightly cyanotic appearance ; thirst ; rapid respiration ; often vomiting and restlessness; and anxiety, changing to mental dullness and lessened sensitivity. Many of these features, he adds, may appear at once or as soon after the reception of the wound as the observations can be made, or they may develop only after the lapse of several hours. At one time it was urged that the widespread effect in the organism induced by severe trauma might be due to nervous impulses. Numerous investigations, however, have made such a theory untenable. It matters little for the outcome of the trauma whether the injured parts are denervated or not; in truth, there is no clearly demonstrable essential relation between the production of shock and an excessive stimulation of the central nervous system. Equally true is the now-recognized fact that the low blood pressure initiated by severe injury is not primarily due to a loss of vasomotor tone or any comparable sort of exhaustion. As Cannon has con vincingly pointed out anew, if the low blood pressure resulting from local trauma is not due to loss of blood into the injured region, or to reflex vasodilation, or to depression or exhaustion of the vaso constrictor center, or to fat emboli, or to acapnia, the connection between the local damage and the general bodily state may reason ably be looked for in the remaining great connecting system—the circulation. "In harmony with this conclusion there has arisen a theory of a toxemic cause of wound shock, based on evidence for the existence of a toxic factor liberated in the injured tissues. Striking analogies between the physiologic effects of certain occasional tissue compo nents and the phenomena of surgical shock have been presented by Dale 2 and his associates in England. Poisonous protein derivatives, products of partial digestion, of bacterial action, and tissue manipu lation readily produce a fall of blood pressure attended with a series of changes in which ' dilation of the capillaries and pooling of blood within them, poisoning of their endothelial walls so that they are abnormally permeable, escape of plasma through these walls into the tissue spaces, and consequent concentration of the corpuscles are the main features.' Championing the importance of these fea tures characteristic also of traumatic shock, Cannon has presented a convincing review of clinical as well as purely experimental evidence for traumatic toxemia, citing in particular the notable contribu tions of the French surgeon Quenu.3 They show, among other in- * Dale and Laldlaw : Memorandum upon Surgical Shock and Some Allied Conditions. English, Medical Research Committee, February. 1017. Dale, Laidlaw, and Richards: Traumatic Toxemia, English Medical Research Committee, Report Series 26, March, l'JIO, P. 9. 'Quenu : Rev. dc ehlr. 56: 204, 1918. 330 Vol. XVII. QUERIES. teresting observations, that anything which delays or checks absorp tion from the injured region delays the development of shock: but if there is a sudden removal of the check serious results follows. " If shock is actually the outcome of an intoxication, presumably by protein derivatives set free from areas of tissue destruction, some of the manifestations of severe burns become more easy of interpre tation. As Cannon concludes, in harmony with other experts in this field, the present conception seems to be that not only the shock following burns, but also the delayed shock consequent on severe trauma, is properly placed in the same category with some forms of general depression of bodily functions and defective circulation due to the setting free of toxic material in the body." To the Editor: Is there any way of rejuvenating dried-out adhesive plaster? I.IErTKNANT. Unroll the plaster, and, without stripping off the muslin covering, wipe over with a gauze sponge wrung out of cottonseed oil. Warm over a radiator or in a sterilizer for an hour and the result will be all that could be desired. THE DIVISION OF PREVENTIVE MEDICINE. Lieut. Commander R. F. Jones, Medical Corps, United States Navy, In charge. Notes on Preventive Medicine for Medical Officers, United States Navy. INSTRUCTIONS TO MEDICAL OFFICERS. STUDIES ON VENTILATION OF CLOSED COMPARTMENTS. Conducted in the laboratories of the Naval Medical School, by Lieut. Commander R. F. Jones, Medical Corps, V. S. Navy, and Lieut. J. E. Henry, Medical Corps, U. S. Navy. BRIEF DISCI SSION OX MODERN VIEWS OF VENTILATION. The problem of supplying air in sufficient quantity and of proper quality to an occupied space must take into consideration, first, physical properties—temperature, humidity, and air movement — which control the cooling power of the air upon the surface of the body: second, chemical constituents; and third, the variability from time to time of the physical properties already mentioned. Inasmuch as the cooling or heating power of the atmosphere surrounding the body governs to a large extent the physiological function of heat elimination, the physical properties of air should be given first con sideration. The chemical purity of the air is also an essential; but, contrary to the former belief of sanitarians, the physical properties are of far greater importance than the chemical. The importance of the third factor—viz. the proper range of variability in the physical properties of air supplied for human consumption—has not perhaps been fully realized. Yet a variation in these properties undoubtedly stimulates the human mechanism, giving tone to the vasomotor sys tem, exciting muscular activity, and thus assisting the proper func tioning of glandular, respiratory, digestive, and vascular organs. I. Cooling power of the air.—The comparison of the human body to a furnace is, in many ways, an apt one. However, the ordinary furnace is kept at no particular temperature and a variation of many degrees is unsually unimportant, whereas the human body is .a special furnace that must constantly be kept at a temperature of about 98.6° F. and a variation of so little as li° from that temperature will cause 108165—22 10 331 332 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. discomfort. Through centuries of hardships in the past the human body has been admirably trained to resist cold but it has been shown that only to a limited extent can it resist heat. Therefore, one of the biggest problems in ventilation is to avoid overheating, which in reality is more injurious than the reverse — unless it be in the case of the very young, the very old, or invalids. Through various physiological processes the body is continuously eliminating heat to maintain itself at a standard temperature of ap proximately 98.6° F. Some of the more important of these processes are the dilation of the cutaneous capillaries to allow the exposure of a larger volume of blood to the cooling air about the body surface, the accelerated heart action to increase the rapidity of flow and con sequently the amount of blood that can get to the surface in a given time, and the secretion of perspiration and its evaporation. On the other hand, the body, when necessary, may check to a degree the amount of heat that it will give off. It can also provide extra heat when elimination from outside causes is great by increasing its fuel consumption. In addition, in our civilization, man successfully pro vides against too much loss of body heat by warm clothes and by artificially heating the air of his living apartments. In fact, since this is so often overdone, we have to deal with overheating in our ventila tion systems more than with underheating. In general then the prob lem of ventilation is to surround the body with air of such physical properties that the heat loss will be just sufficient to maintain body temperature at 98.6° F. without having to call too much on those auto matic devices by which a person can increase or decrease his heat elim ination. If the physical conditions of the surrounding air take the heat away from the body too rapidly or too slowly the body protects it self against heat loss or heat gain by those means with which nature has provided. If it does not readily succeed these mechanisms have a heavier and heavier strain put upon them, and if they finally fail the body suffers the consequences of a decreasing or increasing body temperature (98.6° being the standard). The oppressive feeling, the drowsiness, and other discomforts associated with a warm, close room are the results of too little cooling power of the air (physical property) and not to an increase in the C02 in the air (chemical property). This was proved some years ago by Flugge. He placed men in a closed cabinet and allowed them to breathe and rebreathe the air contained therein until they were very uncomfortable. He then in troduced fresh air to them through tubes without changing the con dition of the air that surrounded their bodies. They got no relief at all, although they were getting air which contained little carbon dioxid and about 21 per cent of oxygen. He then allowed men out ,N'c.2. 333 DIVISION OF PREVENTIVE MEDICINE. side of the cabinet to breathe the air from within the cabinet through tubes while their bodies were surrounded by fresh outside air. They experienced no discomfort, although they were breathing the foul air of the cabinet which contained an excess of carbon dioxid and other expired impurities, as well as a decreased amount of oxygen. The excessive heat and humidity that were generated in the cabinet by the bodies of the men were the causes of the discomfort (physical changes) and not an increase of carbon dioxid and other impurities (chemical changes) . As the heat and humidity in the compartment rose the cooling power of the air, of course, grew less and less until the body could no longer eliminate enough heat to keep itself at 98.6° F. As a consequence the body temperature began to rise, and as it rose the discomfort became more and more marked. Men outside not in contact with this heat and humidity did not have a consequent rise in their body temperatures and were, therefore, entirely com fortable, although they breathed the cabinet air. The cooling power of the air upon the body is dependent on : (1) Radiation. —This is dependent on the difference between the temperature of the body (98.6°) and that of the surrounding air. The colder the air the greater the radiation. Hence, the importance of the temperature regulation of the air. (2) Convection and conduction. —Air movement and temperature of the air are both involved. Currents of air (which need not be drafts) replace frequently the aerial blankets of warmed air about the body with cooler air. The frequency of replacement (air move ment) as well as temperature of the replacing air, then measure the amount of heat that is taken away from the body by convection. High humidity at a temperature of 65° F. and under favors heat loss by convection and conduction, whereas at 70° or over it prevents heat loss by hindering evaporation of perspiration. (3) Evaporation. —This depends on three things —temperature, air movement, and water-vapor tension of the air. The higher the temperature of air the more moisture it will hold and the greater will be its capacity to evaporate the perspiration that covers the skin. In stagnant air evaporation of perspiration would soon cause the body to be surrounded by an aerial blanket of almost completely saturated air, and as a result no more evaporation could take place. Air movement would remedy this and would replace this blanket surrounding the body with air not so nearly saturated with water vapor, and, therefore, capable of permitting evaporation. The drier the air or the lower its water-vapor tension the greater its evaporation capacity. 334 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. To summarize, the cooling power of air upon the hody is de pendent on : (1) Radiation, affected by— (a) Temperature of surrounding air. (2) Convection and conduction, affected by— (a) Air movement. (b) Temperature of surrounding air. (c) High humidity at less than 65 ° F. (3) Evaporation, affected by— (a) Air movement. (5) Temperature. (r) Water-vapor tension (determining the amount of mois ture which the atmosphere is still capable of absorbing). To attain, then, the proper air movement, water-vapor tension, and temperature and to have proper variations in them is the aim of the modern ventilation engineer. It is better in our ventilation work to think of humidity in terms of water-vapor tension or as grains of moisture contained in each cubic foot of air rather than as relative humidity. For example, air of 25 per cent relative humidity at a temperature of 55° F. dries the skin and mucous membranes in an unpleasant manner: but if the same air is maintained at 25 per cent relative humidity and is raised to 85° F.. it has an agreeable effect upon the skin and mucous membranes. The explantion of this is that at 55° F. air can hold only 5 grains of moisture per cubic foot when fully saturated. Twenty-five per cent relative humidity, then, gives only 1} grains of moisture per cubic foot of air, which is too dry for the skin and mucous membranes. The vapor tension of such air is about 2.8 mm. of mercury. At 85° F. the capacity of the air is about 12.5 grains per cubic foot and with 25 per cent relative humidity it would con tain over 3.1 grains per cubic foot and have a vapor tention of about 7.9 mm. of mercury as compared with 1.25 grains and 2.8 mm. of mercury for the same relative humidity (25 per cent) at 55° F. It is readily apparent that if all these factors contribute to the cooling power of the air. and if this is of such prime importance in ventilation, an instrument that could register cooling power would be of immense value. It would, indeed, indicate the effects of many causes— some of which, such as air movement, are not readily meas ured-—in ow. figure. Such an instrument has been devised and is known as the katathermometer. A description of it follows. Many hundreds of observations with it have convinced the authors of its great value, practicability, and accuracy. Its inventor has intro duced another instrument for the same purpose, but adapted more particularly for popular use. This he calls the comfimeter. A de No. 2. 335 DIVISION OF PREVENTIVE MEDICINE. scription of it also follows. Many observations have been made with the comfimeter by us, but judgment on it is reserved until it has been more completely studied. The katathermometer. —The katathermometer is an instrument devised by Leonard Hill to measure the cooling power of the atmos phere exerted on its surface at body temperature (36.5° C). It is in reality an alcohol thermometer with a relatively long cylin drical bulb 4 cm. long by 2 cm. in diameter and a stem 20 cm. in length, graduated between 95° and 100° F. To use the instrument, it is immersed in water at a temperature not over 80° C, until the column of alcohol (colored red) is raised above 100° F. and overflows into and half fills the overflow reservoir. The thermometer is then taken from the water and suspended in the air. A stop watch records the number of seconds required for the column to fall from 100° F. to 95° F. Each instrument has a factor determined for it at the factory, which, when divided by the number of seconds consumed in falling from 100° F. to 95° F., will give the cooling power of the air in mi He-calories per square centimeter per second exerted on its surface ■At 98.5° F. Two readings are commonly taken, a wet and a dry. To get the wet kata reading, the bulb is covered with a knitted cot, immersed in hot water and held in the air. The cooling effect of evaporation enters into this reading. The dry kata observation is obtained by immersing the bare instrument, drying it. and holding it in the air. The rate of cooling of the surface of thi* instrument (and by analogy, of the surface of the human body) depends on convection, evaporation, and radiation. The dry kata cooling power depends almost entirely on convection and radiation, since the surface of the instrument is not covered with a wet cover and is purposely wiped dry. The wet kata reading depends on all three factors; the differ ence between the wet and dry gives the cooling power from evapora tion alone. It should be remembered that this instrument measures the power o* the atmosphere to cool its own surface when the temperature of that surface is 98.5° F. If the atmosphere has a certain cooling power on objects at this temperature the rate of cooling of the sur face of such objects will depend on their character as .well as the cooling power of the atmosphere. In the case of the skin, the rate would depend on such things as the amount of clothing, the amount of moisture produced by the body, and the structure of the skin and tissues under it, as well as the cooling power of the air around the body. 336 Vol. xvn. DIVISION OF PREVENTIVE MEDICINE. The experiments performed by the authors seemed to indicate that the cooling power of air should not be less than 15 wet kata and 6 dry kata for sedentary occupations. The instrument appears to accurately measure the cooling power of air, and, since the comfort of man depends so much on the control of his heat elimination, it is very important to know just how much heat a surrounding medium can take from him. This is probably the most important single factor in the realm of ventilation. The katathermometer, or some modification of it, has probably come to stay. The comfimeter. —Comfimeter observations in these experiment-) are recorded for what they are worth. No opinion has yet been formed as to the value of this instrument, but data is being gathered for this purpose. Leonard Hill is the inventor of this instrument also, and in a letter he makes the following preliminary remarks. He has informed us that he will soon publish a paper on this subject. In order to keep comfortable conditions in rooms by determining the cooling power by convection or radiation —convection depending on the temperature and movement of the air— I have designed wl instrument, which I call a " Comfimeter." This takes the place of the katathermometer for ordinary civilian use. The katathermometer requires to be heated in water, and the cooling rote measures as the meniscus drops from 100° to 95° F. The warm ing of the katathermometer and the time measurements are against its popular use. The comfimeter is an instrument which can be read at any time just as the ordinary dry bulb thermometer; it consists of a cylindrical metal box 18 cm. high and 10 cm. in diameter, in which is inserted an 8 candlepower carbon filament lamp, the lower part of the box being removable for this purpose. On the top of the box is fixed a metal cone, which in its turn forms a union with a chimney 25 cm. long and 2J cm. in diameter. There are some holes in the lower and upper part of the box for the purpose of ventilation. An ordi nary dry bulb thermometer is introduced into the chimney so that the bulb hangs within it to a depth of 9 cm. The thermometer rests on the top of a chimney by means of wire which is twisted around its stem in a suitable fashion. There are two disks of gauze through which the stem of the ther mometer passes to give it a central position within the chimney. The candle- power lamp acts as a constant source of heat and the box and the chimney are cooled by radiation and convection. Under satisfactory conditions in ideal summer days, with the windows open, the comfimeter standing on the table in my room indicated a temperature of about 30° C. In a close room, heated, with hot-water coils on and the windows shut, the comfimeter indicated a temperature of 40° C. If the comfimeter be sheltered from wind by a screen of cotton material placed around it. it will Indicate in place of, say, 30° C, u temperature of about W C, while the dry bulb thermometer standing within the same screen will only vary a degree or two as the result of screening. These figures show how sensitive the comfimeter is to the cooling power of the wind. It must, of course, be given time to get in equilibrium with the environmental conditions. When the comfimeter indicated 30° C. the dry katathermometer gives a cooling power of about 7 mille-calories per square centimeter per second. So long as schools and factories are kept with the comfimeter indicating some where about 30° C. fresh conditions suitable for work will be obtained. No. 2. 337 DIVISION OF PREVENTIVE MEDICINE. In another letter of January 22, 1922, he states: We have been investigating the behavior of the " Comf." against that of the " Kata " recently. We use the "Comf." as made by Siebe Gorman (Ltd.), 187 Westminster Bridge Road, London, with measurements, blackened sur face, orifices, and thermometer arranged according to instructions given to this firm. The lamps we use are 8 British candlepower carbon filament ones supplied to us by Edieswan & Co., Queen Victoria Street, London E. C. This firm picks out lamps for us which take the same number of watts. It does not matter whether the current be, say, 100 or 200 volts, but it does matter that the voltage should be steady. It does not matter if the voltage swings up and down a little as leads come on and off, and average, say, 100, but it matters considerably if the voltage Is 95 or 105 in place of being 100. Given the right lamp and voltage, the " Comf." in air of rooms with no sensible draft gives readings which can be graduated against the " Kata " quite well. The " Comf." is not meant to be used in sensible drafts. The paper dealing with it we are now preparing for the press, and when ready we shall probably send it to the American Journal of Industrial Hygiene. II. Purity of air.—In the past, physiologists and sanitarians be lieved that the bad effects of close, ill-ventilated rooms were due to increased carbon-dioxid content and decreased oxygen. This was a plausible theory. Acting on it, sanitarians set a standard of so many parts of carbon dioxid per 10,000 as a maximum, which should not be exceeded, and required sufficient air turnover to keep it at or below that figure. By doing this they overcame the discomforts due to poor ventilation, for they were getting rid of other conditions at the same time they removed the carbon dioxid. The experiments of Flugge and others definitely proved that the harmful effects had not been due to the carbon dioxid or other im, purities but to the physical effects of air on the surface of the body. Many clung to the idea that emanations from the body were respon sible for some of the ill effects, but no acceptable proof of this has ever been offered. Of course, in submarines and other occupied closed compartments, carbon dioxid will soon reach dangerous con centrations and the oxygen will be reduced very rapidly unless pro vision is made for purifying the air. Body odors —for esthetic reasons, if for no others —are not tolerated in any good system of ventilation. But ordinarily, if air be obtained from a good source and is free of gases, smoke and dust, we do not have to concern our selves with its chemical composition. If pure at the source, the turn over necessary to take care of the physical properties prevents any serious vitiation. In fact, long before any such acquired impurities could have any effect conditions would have become intolerable from other causes. III. KaNOE OF VARIABILITY IN THE PROPERTIES OF THE AIR.—When all has been said and done about ventilation, nothing is better or healthier than window ventilation properly handled. This system permits of the best range of variability. A hothouse plant, constantly 338 Vol. XT11. DIVISION OF PREVENTIVE MEDICINE. subject to the monotony of unnatural and unvarying warmth and humidity, is fragile and delicate, full of sap and lacking in fiber. Yet, if the temperature, humidity, and air movements are given con stant variation without going to foolish extremes a much more hearty and virile plant can be raised even in a hothouse. Monotony tends to stagnation and disintegration, whereas variety stimulates and freshens. By widening the range of variability we stimulate and keep active all the functions— the circulation is quickened, waste products burned and removed, muscular activity is increased and every gland and organ in the body is made more healthy and active. Variety is literally the spice of life. EXPERIMENTS. The studies submitted herewith deal mainly with the physical con ditions of air in closed occupied compartments. In some of the ex periments the chemical aspects werfe^also considered. The conditions dealt with are unVsual, such as might exist in submarines or compartments into which and from which no air can be taken. The conclusions are. therefore, applicable to such problems only and would probably be of little value in ordinary ventilation. From the evidence obtained it would seem that relief from the acute distress resulting from extreme physical and chemical condi tions in such compartments is entirely feasible and that men may be made comfortable in such places by reconditioning the air for short periods without injurious effects. Whether long confinement in them would be possible without danger is another question. P^xperiment I was performed to show, first, the rise of carbon- dioxid and fall in oxygen within supposedly safe limits in a closed occupied compartment; second, how temperature and humidity may lie satisfactorily controlled at the same time by means of cold coils and fans. The experiment was done three times in order to give a good check on the work. Experiments II to VII were performed to show the effects of air motion (electric fan) and cold running water in coils on air condi tions in a closed occupied compartment. The chamber used was a double- walled cabinet of special construc tion and so insulated as to allow a minimum escape of heat, gases, or sound. The dimensions were 7 by 7 by 5.83 feet. After proper deductions for furniture and other contents, there was a net capacity of 278.8 cubic feet. There wore 44 lengths of water coils, each 33.5 inches b,y 1 inch in diameter (outside measurement). The inside diameter of the piping was j inch. The fan was a 16-inch Westinghouse. It was always run at first speed. No. 2. 339 DIVISION OF PREVENTIVE MEDICINE. f g I J- = £ •v 2 c — I 1 s s 1 s s a.-^^ s=.c'.; =rE « c © S '- -c Z O * C °- « c HI 3>3 C.I- OC — —(C at —ci 8 ! s ?£g ii,-:,-:' —.—,{N : C r- ss£ sr.. .ti 5 ^re—o E t e J Q.C.6. * p£I? csci co CO •4- C o < I a •—I H O x o To show rise of C03 and fall in 03 within supposedly safe limits in a closed occupied compartment, etc — Continued. EXPERIMENT I (C). Per cent of O,. 20.9 19.3 18.6 17.3 16.9 16.2 Per cent of CO,. 0.04 1.7 2.5 3.51 3.8 4.4 Comfi- meter reading. 39.8 40.6 35.1 35.3 31.2 28.3 27 Dry kata cooling power. 1.9 1.5 2.9 1.8 5.9 7.4 7.6 Wet kata 9.9 10.2 18.5 25.1 cooling power. 7 8 23 Dry kata tune (seconds). 275 347 183 291 90 71 69 Wet kata time (seconds). 53 75 52 66 29 23 21 Grains of moisture per cubic foot of Bir. 7.13 10.67 12.21 15.04 9.57 6.84 6.08 Relative humid- ity. 57 79 86 94 87 72 64 Dry bulb. 84 87 88.5 92.6 80.5 75.5 76 Wet bulb. 72 81.5 85 91 77. 5 oas 67 Time. 1 1.30 2 2.30 3 3.30 4 Remarks. Warm, men perspiring; respiration 18.2; no fan; no cooling coils. Hot, men perspiring freely; respiration 19.2. Fan on at 1.52. Afforded some relief; close, heavy; heavy perspiring; respiration 22. Hot, uncomfortable: respiration 23.2. Three men complained of headache. Water on at 2.46. Relief felt in a few minutes; respiration 22.4. Matches would not burn. Respiration 23.1. Quite cool; headache relieved. Cold, chilly; suggestions to turn fan oil; respiration 25. OUTSIDE CONDITIONS. 3.21 3.96 30 36 79.5 80 00 62 1 4 35 37 im in-. 15. 1 14.3 3.4 3.2 (1) Five men were used, entering at 1 p. m., emerging at 4 p. m. (2) Net capacity of cabinet 278.8 less space occupied by men themselves. (3) Water passed through coils at rate of 40 liters per minute. (4) Temperature of water as It entered and left the coils: Time. 2.51 p. m. 3.16 p. ra. 3.36 p. m. 3.56 p. m. Inlet. 6.3° C. 4.1° C. 4.0° C. 4.1° C. Outlet. 6.9° C. 5.1° C. 4.8° C. 4.6° C. Notes. Comfort fair. Do. No. 2. 341 DIVISION OF PREVENTIVE MEDICINE. 21 1 1 — BINET J* 3 - u.e i . m I " 4 M ! o az < PERCENT OF CO, ■ at « 1 i 1 ■ S 5 8 e 8 om eo ■am N i X V EXPERIMENT 1(e) SHOWING PERCENTAGES OF CO, AND 0a IN ATMOSPHERE OF A CABINET OF 26S CUBIC FEET CAPACITY WHEN OCCUPIED BY S MEN FOR 3 HOURS. N Conclusions, Experiment I. 1. Five men in 265 cubic feet of air raised the carbon dioxid to 4.5 per cent in about three hours. They lowered the oxygen to about 15 or 16 per cent in the same time. 2. These limits for that length of time caused no distress to men not engaged in manual work, when humidity and heat were controlled. 3. Before the carbon dioxid reached 4.5 per cent and oxygen 16 per cent, when the heat and humidity were not controlled, the com 342 VoL XVII. DIVISION OF PREVENTIVE MEDICINE. partment became oppressive if not unbearable as a result of the heat and humidity emanating from the bodies of the men. 4. Carbon dioxid and oxygen conditions and body odor conditions to some extent are susceptible of control by method practiced in sub- EXPERIMENT 1(c). EFFECT OF COOLING COILS AND AIR MOTION (COMBINED) ON UNFAVORABLE TEMPERATURE AND HUMIDITY CONDITIONS WITH FIVE MEN CONFINED IN AIR-TIGHT CABINET OF 265 CU. FT. CAPACITY FOR 3 HOURS. marines. Heat and humidity in submarines are probably taken care of by cold water on the skin of the ship and precipitation of moisture on the inside. .r>. Since no such escape of heat and moisture from air within closed compartments in the center of a large ship is possible, un No. 2. 343 DIVISION OF PREVENTIVE MEDICINE. doubtedly some consideration will have to be given to these factors in caring for air conditions under such circumstances. 6. This experiment showed that fans up to a certain limit will give great relief; this limit being approximately the body temperature (98.5° F.) and very high relative humidity. The effects of convec tion and evaporation from a fan would then cease to operate. 7. When the above limits had been approximated in the experi ments, cold water was run through coils, thus giving a cooling unit as well as a surface for precipitation of moisture. The fan was left on and rapidly passed the moist, hot air over the cold coils. 8. complete relief was obtained in this way. 344 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. P c t c - 3 If 12 ■5 " No. 2. DIVISION OF PREVENTIVE MEDICINE. i S3 Comfl- meter reading. Remarks. Uncomfortable, but easily bearable. Fn Moisture on colls at 2,35. More comforts Small drops on coils at 2.55. Still uncomfortable but bearable. No dripping. Some (tripping. . Still uncomfortable. Almost com/ortable. Hi ?<£>oe*<e«cr^ac l-ieieiNficici lit wcooooooon ssiasjJssJs Wetkata time (seconds). 53333333 Grains of moisture per cubic foot of air. 8SS388SS - ftp . Jlift.'lb 8SgS8833 #. ?- • # • ■ • > * Ui • ^ > * . ■ • * s e SS3S3S51 1 ouoouoo 3 u. t. t* t, u. u. f^c c o e « o c jSBBaSE .£~g.«PS|;Sg38S Oui>^ oi c«e*5eo co 346 vol. xvn. DIVISION OF PREVENTIVE MEDICINE. Conclusions, Experiment III. In 1 hour and 45 minutes there were marked improvements. These were mainly due to (a) lowering of temperature (7° in wet bulb and 19.5° in dry bulb temperature), and (b) improved dry kata con ditions, as seen in columns 2. 3, and 9. 2. Readings of the comfimeter decreased very slowly. 3. Wet kata conditions did not change greatly. No. 2. 347 DIVISION OF PREVENTIVE MEDICINE. 348 DIVISION OF PREVENTIVE MEDICINE. Vol. XVII x -o 2 mzH in u ■• <o n 5 o M » m oo x F O X X o I HILLECALORIES PER SO.C.M.PER SECOND GRAINS H20 PER CU.FT. OF AIR. s owo><oroG!S£i! 2 3 8 8!* w I'M • \ \ 11401 ■ I ne Ml KID *M ):4< i s o « o I m S• ■ n ■ A S 5 O 1 ■> r4*f » sX _ I c ■ S:5B, \ p 4:10 o ••> «d i3 ;8 i k a !s a i* 8 ■ 1 ■ X t t:m 3a ?J > * i w It II i * |S P c Conclusions, Experiment IV. 1. In 30 minutes, from 1.48 to 2.18 p. m., better conditions were obtained than was obtained in Experiment III with cold running water in coils in 1 hour and 45 minutes, from 2.25 to 4.10. In other words, with high temperature and low relative humidity, air motion and cold coils together were over three and one-half times as effective No. 2; DIVISION OF PKEVENTIVE MEDICINE. as cold coils alone. The added efficiency obtained from a fan de pends, of course, on its size, speed, and position with relation to the amount of air passing directly over the coils. 2. Although air motion itself does not take out heat and humidity (Experiment II (b)), it does force the air over the coils many times more rapidly than it would naturally pass over them, thereby getting much more rapid action from the coils. 09 i O To show the effect of air motion (electric fan) on high temperature and high relative humidity. EXPERIMENT V. [Observations made with fan off.] Remarks. Very uncomfortable. Uncomfortable. Comfi- mcter reading. 43 41.5 Dry kata cooling power. .95 1.7 Wot kata cooling power. 4.4 7.5 Dry kata time (seconds). 555 310 Wet kata time (seconds). 121 70 Grains of moisture per cubic foot of air. 13.34 11.74 Relative humid ity. 85 87 bulb. 92 87 Dry Wet bulb. 87.5 83.5 Time. 2 Notes. (1) Observer entered cabinet at 1.45 p. m. and left it at '2 p. m and entered again at I p. m. Allowance, therefore, should lie made for increase of humidity and temperature due lo his presence for 30 minulcs. Allowan'-e also should be made for some dilution of air when he left and reentered the cabinet during the experiment. (2) When observer entered at 4 p. m. the comfimeter registered 33.2 (fan had been on). In 15minutes it registered 41.5° (fan off). ('onc/iHiorti, Kiptriinrnt V.— (1) With a high temperature and high relative humlditv actual physical conditions were little changed by brisk air motion. (2) With high relative humidity a fan can do little for comfort by evaporation since the air is almost saturated. With high temperature it can do little by convection, because removal of the warm aerial blanket about the body and its replacement by air almost as warm as the body helps very little. (3) Comparison of (a) and (b), Experiment II, shows that comfort conditions were much improved with high temperature and low humidity when the fan was on, due prin cipally to possibilities of evaporation. No. 2. 351 DIVISION OF PREVENTIVE MEDICINE. w able. M Water turned on. Soon more comfort Uncomfortable, but slight improvemei Do. Do. Do. Do. | Do. it. 1 | Almost comfortable. Do. Comfi- metcr reading. 42.5 41.9 41.2 40 40 39.5 39.2 39.1 39. 1 1|| ■^tiO».-H—« 'f5 <© St.- at>C00 "3CO»C'OO lis .-i o>ci o -~o r4cs o 5 o (seconds). Dry kata time if Is uns of isture cubic ot of lir. Relative humid- ity. iOiOiO bulb. Dry Wot bulb. S7 77.5 74 70.5 69.5 87.5 06.5 65 84.5 Time. i en-~ 1 g GciddddddtJ § . 8 § % 1 ^^^^ I °Sg3| «l3ogt . BB6ESESE |".|n«s ci re :c -* HvS^c^k 4>o»ol 352 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. To show the combined effect of air motion (electric fan) and cold running water in coils on high temperature and high relative humidity. EXPERIMENT VII. Remarks. Soon very comfortable. Mois ture on colls at 10.22. Felt improvement almost at once. Drops on oolls at 10.28;dripping from coils at 10.30;very com fortable at 10.38. Notkb. 1. Water running Bt rate of 40 liters per minute. , 2. Temoeratures of water: Time, 10.25a. m.; ingoing, 8.0° C; outgoing, 6.3" C. 3. Observer remained in cabinet throughout the experiment. Time. Wet bulb. A. M. 10.21 82 10.3» 63 Dry bulb. Bt Ti Rela tive hu midity 68 Grains; of mois ture per cubic foot of air. 10.9 5.04 Wet kata time (sec onds). 75 23 Dry kata time (sec onds). 65 coollngjcoollng Wet kata power. 24 Dry kata power. 1.2 Comfl-j meter ] read ing. 44 27.8 Xo. 2. 353 DIVISION OF PREVENTIVE MEDICINE. Conclusions, Experiment VII. The following table shows that in 15 minutes (10.21 a. m. to 10.36 a. m.), with worse initial conditions, better results were obtained with both fan and cold-water coils than were gotten in 105 minutes (2.15 p. m. to 4 p. m.) in Experiment VI with cold water alone. Time. Wet bulb. Dry bulb. Relative humid ity. time, (seconds). Wet kata time, (seconds). Dry kata Wet kata cooling power. Dry kata cooling power. Com- flmeter reading. Experiment VII: 10.21 a.m 82 89 75 75 451 7 1.2 44 15 minutes later.. 63 73 58 22 65 24 8 27.8 Experiment VI: 2.15 p. m 77.5 85 72 55 212 9.6 2.5 41.* 105 minutes later. 64.5 74.5 59 42 147 12.6 3.6 39.1 The combination of water and fan as run accomplished the same work as the water alone in less than one-seventh the time. HEALTH CONDITIONS OF THE NAVY. Health conditions of the Navy are better than they have been at any time during the past five years. The annual admission rate for all causes from January 1 to July 8 being 589 per 1,000 per annum, as compared with 776.27 for 1918, 676.02 for 1919, 778.99 for 1920, and 625.65 for 1921. The morbidity rate for all causes for the four- week period ending July 8 was 385 per 1,000 per annum ; for diseases only, 340 per 1,000 per annum; and for injuries and poisons, 45 per 1,000 per annum. With the exception of malaria, there have been very few com municable diseases reported during the past four weeks. The fol lowing table compares the admission rates for certain diseases for June, 1922, with the average admission rates for that month for the previous four years. Annual admission rates per 1,000 for certain communicable diseases, current month of June, 1922, in comparison icith the mean annual admission rates, month of June, for the four-year period 1918-1911, inclusive. Disease. June, 1918-1921. June, 1922. Cerebros inal fever 0.13 2.37 2.53 21.70 24.30 4.21 11.07 4.34 2.29 .15 4.02 .19 0 Diphtheria 0.88 1.68 6.81 14.31 1.28 .99 2.27 .30 3:H .10 354 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. It will be noted that the morbidity rates for measles and mumps are exceptionally low; this is no doubt due to the fact that few recruits have been inducted into the Navy during the ;past few months. Although the admission rate for malaria is lower than the average, it is believed that this rate should be further lowered. Very few admissions for malaria are being reported from stations in the United States, except Quantico, or from ships serving in and around United States ports; the vast majority of the cases were reported from San Domingo and Haiti. The annual admission rate for venereal disease for the four- week period ending July 8 was 96 per 1,000, which is considerably lower than the annual admission rate for 1919, 1920, or 1921. The progressive average rate for venereal disease for 1922 is now 107 per 1,000 per annum. PREVENTIVE MEDICINE EDUCATIONAL MATERIAL. The Bureau of Medicine and Surgery has forwarded to all ships and stations within the past month a set of posters dealing with general, personal, and social hygiene. It is requested that medical officers inform the Bureau of Medicine and Surgery if the material now being supplied to ships and stations is of sufficient value to continue such an educational campaign. If such posters are re ceived favorably by the commanding officers and medical officers of ships and stations, new sets of posters dealing with the pre vention of diseases and accidents will be forwarded to ships and stations from time to time. In order to keep a constant flow of material it will be necessary for medical officers to furnish the Bureau of Medicine and Surgery with sample posters and, if pos sible, with actual photographs of conditions existing at sea or at naval stations. If each medical officer of a ship would forward to the burean one such poster a month or, in fact, even one a year, ample material would always be available to provide a steady flow of posters. Many accidents and diseases occur in the Navy each year which could be prevented. It is not so easy to obtain photographs showing how disease occurred and how it may be prevented, but it is a very simple matter to obtain photographs of the place of the accidents and consequences therefrom. Such photographs when placed upon posters attract attention and lead men to read the lessons contained thereon. The next set of posters to be forwarded to ships were obtained from the National Safety Council. Many of these are excellent, but No. 2. DIVISION OF PREVENTIVE MEDICINE. 355 unfortunately they do not depict the life and environment of the bluejacket. It is considered that it would be far better if the Navy Department could make their own posters instead of having to call on civilian organizations. Such posters, however, will demonstrate to the medical officers the extent to which civilian manufacturing establishments are progressing along these lines. In addition to posters, the Bureau of Medicine and Surgery is hav ing made a series of lantern slides which may be used at the regular motion-picture shows while reels are being changed. Such slides will be self-explanatory and will not require a lecture by the medical officer in conjunction with them. If the medical officers so desire another set of slides will be made for lecture purposes. Here, also, it will be necessary for the medical officers throughout the Navy to furnish the Bureau of Medicine and Surgery with new ideas and necessary material for producing such slides. "Within the next month a 12-reel motion-picture film, entitled " The Science of Life," will be forwarded to the commander in chief of the Atlantic Fleet, the commander in chief of the Pacific Fleet, and to the naval training stations, Hampton Boads, Va., and San Francisco, Calif. Later, such a film will be forwarded to the com mander in chief of the Asiatic Fleet. Medical officers afloat who desire to show this film may obtain it by forwarding a letter to the commander in chief of their respective fleets. This film has been produced by the Bray Productions (Inc.)*, New York, N. Y., in co operation with the United States Public Health Service, the United States Army, and the United States Navy. The first four or five reels may require some explanation, inasmuch as these reels were produced largely for high-school students, but the remaining reels are self-explanatory. The following subjects are covered in this motion picture : General biology. Protoplasm, the beginning of life. Reproduction in lower forms of life. Interdependence of living things. Reproduction in higher forms. Communicable diseases. Reel 5 Parasitism. Plants and animals that live at the expense of other plants and animals. Heel 6 How disease is spread. Reel 7 How to prevent disease. Reel 8 How the mosquito spreads disease. Reel 9 The fly as a disease carrier. Reel 1 Reel 2 Reel 3 Reel 4 356 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. Personal hygiene. Reel 10 (M) Personal hygiene for young men: (a) Importance of understand ing reproductive function in man. (6) Avoidance of venereal dis ease, (c) Consequences of venereal disease. ACCIDENTS AND INJURIES AMONG CIVIL EMPLOYEES AT NAVAL ESTAB LISHMENTS DURING 1921. An endeavor has been made to analyze the accidents and injuries occurring among civil employees at naval stations, reported in the annual sanitary reports for the year 1921. As the basic data from several navy yards and stations were obviously incorrect in many in stances and the totals for "location of injury" and "cause of accidents" did not balance, no accurate conclusions can be drawn from such an analysis. However, it is believed the medical officers acting in the capacity of industrial physicians may obtain useful information from the following tables : Table I compares the number and type of injuries occurring at certain navy yards and shore stations : Reel 11. Reel 12. (Personal hygiene.) General hygiene for men and women. No. 2. 357 DIVISION OF PREVENTIVE MEDICINE. 3 O ISO) joqmn \ "3KG en duiu ■—o ©~ir- iv. >Ijejuni \ -« ©~ © OOGjgi-id •aniri J90| jaqmn.v ~i6 «s © O o- ~«coO eo~© ~© 0 5 «o-*^j^O *©T£~ ~S o o o o •©©© O O O OOOflOO O © 06 |HHO PO"■•"5" © o a> o ~ Fg o n jo O 0030 o o© © © ©"^ ©~ ~« ©~ O M 0UIT1 ISO] jaqnin\ ©7|| o ST" ■amp ISO] j,H!imi\- 2 s= C4 —C 2 5 oo ■o»n =i ™3 © -m—© ae- 1 " 3g 38 1 S 0DJ11 O S ©~ o» ■-Hill! S3SBD[«*>X J* | *sastt>imox - © - -i c cr:- "~55 (6 ©~ oo as o © © 2° ° USI •euiri j.kiumik; ■suni lsoi ia<)mn\ r-- tg O OO ■~ "5N ^ — 8 S3 ° S°a"sffi-' —. o ~o" oo •«©© © noVnx © o'us^ o B PT" 8 8 N oo ;gno s=cg- 3 3 " ="238- SSfg" ~M 5 o o O © "(5 SS 31? Is! own 8 O m O 358 Vol. XVII- DIVISION OF PREVENTIVE MEDICINE. It will be noted that the naval station, Mare Island, Calif., had an average of 7,411 civil employees; the navy yard, Philadelphia, Pa., 7,775; and the navy yard, Washington, D. C, 6,388, and that the total number of injuries for the naval station, Mare Island, was 6,062; the navy yard, Philadelphia, 6,134; and the navy yard,. Washington, 3,331. More than likely, the reason the navy yard, Washington, had fewer injuries than either Mare Island or Phila delphia, all of which are comparable as they employed approxi mately the same number of men, was due to the fact that this was the only navy yard or station which employed a safety engineer. Table II shows the frequency of various types of injury, the parts of the body injured, and the cause of the accident as well as the total number of injuries for civil employees, the number of men who lost time, the average number of days absent of cases that lost time, and the average days absent of the total number of cases for various types of injuries. No. 2. 359 DIVISION OF PREVENTIVE MEDICINE. | piloi jo tuasqv 8 £ SBS=SS3SSSS JSOl )BI() S^BpaSBJOAV | I 1 >. 3 >> *o eo I MM VB%oj, ■("319'sanmj 'sprou) sagag pire ppnbtq 8 s iggiHIPF •' ■ : : Ffg : : :« : • . • * • la . . . '•Mummi pub ssaj^ M X iO<0SO00© ;2 sj t; —s saunpem auipuug N r; « X K . •sau^qoBiaguidBqg •sipa jnomdmba n.»u,i •pBojjmi jo saptuj, '(POOA pm |991S) SJSAIIS PUB i ' \ •sjoox •s[jbi pan sdijS 1BIOX ■)ooi PUBH •smjv g ES8»£S2" — o r- x r- « —— — — " 2 ?Sg2S--gS'-°'-2 8 S eIP*SSS9§ O r- 04N n e*—I M ■uouropqv j Jo50.©. ~g c* n «5« O'd ~5 Nt^eo ; i 91 « if ffi — a 360 DIVISION OF PREVENTIVE MEDICINE. Vol. XVII. It is fully realized that there are many apparent inaccuracies in Table II, particularly when it is compared with Table I, most of which are due to the fact that the report from the navy yard, Ports mouth, N. H., is included in this table, whereas it was not considered in Table I. There are also a few inaccuracies due to faulty basic data. However, this table does show the injuries most frequently encountered in navy yards and stations, the parts of the body most frequently injured, and the principal causes of accidents among civil employees. Since the instructions relative to the preparation of statistics of accidents and injuries among civil employees did not reach the medi cal officers concerned until the latter part of the year, they could not be expected to have the necessary basic data with which to prepare the form in the annual sanitary report. For the year 1922 every medical officer should have the necessary basic data and tables from stations should be correct. If so, the tables published by the Bureau of Medicine and Surgery next year will be of immense value not only to the medical officers in the field but to various civil industrial concerns. MENTAL HYGIENE AND DELINQUENCY.1 By WiLLiiM Healy, M. D., Judge Baker Foundation. At present mental hygienists are endeavoring to get before legis lators, people in charge of institutions, judges, probation officers, and others who handle delinquents an understanding that an important proportion of delinquency is directly related to abnormal function ing of the mind. But it was not many years ago that the reverse was true ; we can read case histories of 10 years ago and find reformatory heads insisting to psychiatrists that certain individuals were insane, although as the result of some professional examination they had been declared sound mentally. We could give many instances of this, showing a point of view that differs widely from that taken by modern psychiatry. A very striking though short paper appeared in the "British Medical Journal" in 1906, written by a certain Justice Rhodes, who plumped the question at the medical profession concerning whether the crime situation in England was not one for prime consideration by that part of the medical profession which had to do with mental diseases rather than one to be decided merely through legal methods. He very pertinently asked what could be the meaning of the fact, for instance, that of 186,000 convictions in 1906, upward of 10,000 ' Reprinted from The Commonwealth, Massachusetts Department of Public Health, by permission of Eugene B. Kelley, H. D., commissioner of health. No. 2. 361 DIVISION OF PKEVENT1VK MEDICINE. of those convicted had been sentenced more than twenty times before. In all common 6ense, was this more likely to be a matter that could be remedied by continuation of these same legal methods, or was it a matter for the deeper understandings that might come through medico-psychological studies of these individuals? And concerning recidivism itself, the repetition of offense, one may recognize at once that this is one of the cardinal points of the problem of delinquency. The individual who, taken in hand by the law, does not profit by his experience, even by punishment meted out to him, what can be his mental make-up? The figures of recidivism for this country can not be given, because as yet we have developed no sort of general or nation-wide study, not even statistical, of our most expensive problem of delinquency and crime. But if one looks up the facts of any of our metropolitan institu tions for criminals, one finds that they readily approach the figures found in the " Blue Book of Crime and Statistics " in Great Britain, or the carefully worked-up statistics that are available from other countries. The implications of recidivism, or the failure of the law to successfully cope with a repeated offender, are of vast sig nificance for us in America. Twenty or thirty years ago almost the only explanation offered for the career of the delinquent or criminal was comprised in the term "degeneracy." The criminal man was the degenerate man; and under the influence of the positivist school, volume after volume was produced descriptively setting forth the characteristics of the delinquent man, woman, and child, as if one were dealing with a certain species or subspecies of human beings. But in the really remarkable developments of the last two decades all this has been changed. Much more has been learned of the nature of mental disease, and vastly more, particularly through psychological studies, of the nature of mental defect. And these two principal divisions of mental abnormality, mental disease and mental defect, are being studied every day more and more in their relation to delinquency and crime. Now there is no need whatever for exaggerating the extent of the correlation between mental abnormality and delinquency. It must be confessed at once that enthusiasts have indulged in rash and ridiculous statements in connection with their earliest studies, par ticularly with the first introduction of the use of mental tests. And there have been people, including lawyers, who have been willing to state that " crime is a disease " and ergo the criminal is a dis eased man. But all such sweeping generalizations are worth little. Judging by the most careful and consistently undertaken studies, the fact regarding mental defect and its relation to delinquency and crime seems to be that among young delinquents there are very many DIVISION OF PREVENTIVE MEDICINE. Vol. XVII. more times the number of mental defectives than is to be found among the general population. The definite percentage varies for different places, of course, and naturally is greater in institutions, when, under probation, the brighter ones are selected as offering the most promise of doing better outside of institutional walls. But under any circumstances, taking cases just as they come in any one of the large juvenile courts, it will be found that at least 10 per cent of the delinquents are mentally defective. We have made very careful studies of several thousand youthful offenders in Chi cago and Boston, and our conservative estimate is that at least 25 per cent of these must be regarded as abnormal mentally. Of this 25 per cent, by far the largest number are to be classified as mental defectives. It is unnecessary to more than mention the classic studies of family groups in this country where mental abnormality and delinquency were closely related —the Jukes family, with the recent restudy of this family, the story of the tribe of Ishmael — an Indiana family, and the Kallikaks as studied by Goddard. The size and importance of the problem is clearly apparent from all this. The percentage of delinquents or criminals who are suffering from definite psychoses varies widely. Figures as published are unfor tunately particularly dependent upon the inclination of the ob server toward some given theory, but in situations where judgments are conservative we still see that there is a very considerable rela tionship betwen actual mental disease and the commission of an antisocial offense. Statistics might be quoted that range from the 2 to 5 per cent of mental disease, which we ourselves have found among young offenders, to the large percentage of even some special mental disease which some observers claim to have found in par ticular court or institutional groups of older criminals. A much wider viewpoint has recently been taken —and very cor rectly taken, I believe —by the exponents of the modern ideas of mental hygiene. It is not only the frank psychoses, the " real cases " of mental disease, and the plain cases of mental defect that are im portant for the students of mental health, but also many other matters that are to be properly classified as unhealthy functioning of the mental life, and matters that pertain to peculiarities of the structural make-up of the mental powers in a given individual, even though there be no feeble-mindedness. By studies in this field we come across the facts of, as well as the causes for, intense dissatisfaction, grudge formations, impulsations and even obessions, mental conflicts, jealousies, emotional outbreaks, urgent desires, and other affairs of the mental life as originating from within or from without, any of which directly cause or directly underlie tendencies toward delinquency. Surely these are matters No. 2. 363 DIVISION OF PREVENTIVE MEDICINE. of the highest importance for therapeutic endeavor under the head ing of mental hygiene. They are matters of the greatest social as well as personal concern. They require study which is only com petently undertaken by persons with a wide range of knowledge of what is available in psychology, normal and abnormal, and of what bears on the given situation in medicine. We have many instances of minor abnormal mental manifestations such as occur during the course of disease, as in chorea, or during a period of life, as in adolescence. School dissatisfactions leading to delinquency—" the kindergarten of crime "—are based upon special disabilities for learning and many other factors in the whole school situation. We have the production of unfortunate mental states as the result of reactions to irritating conditions in home or school life or in employment. And in connection with recreations, or even with reading, we sometimes find the development of a most unhealthy type of ideation. In many ways undesirable mental habits are formed as the result of experiences or inner tendencies. Some of the very deepest emotional upsets are to be observed in normal or even unusually intelligent individuals as the result of untoward happenings experienced at particularly susceptible periods of their fives. Any and all of these, we know from the study of many cases, are conditioning elements at the foundation of careers of delinquency and crime. Observation also shows the immensely fruitful field that there is in all this for the therapeutic approach that the term mental hygiene implies. It is a work for trained specialists with open minds, who know not only the phenomena of mental disease as such, but who are also students of personality, characteristics, and trends, of psycho logical capacities and incapacities that are quite beyond the implica tions of " an intelligence quotient," who are students of all that goes to make the individual (always through the mental life itself) ex hibit unfortunate antisocial tendencies. There are adjustments that can be made with the greatest hope of success in ways that are not at all contemplated by the alienist as implied in his dictum " insane or not insane," " feeble-minded or not feeble-minded" (which amounts to institutional care or not institu tional care), or by the work of the modern psychiatrist, though he deals more carefully than ever with definite psychoses. There may be much more to it for professional work as our science develops. AVe hope for much more, whether it be by glandular therapy, or by study of toxins affecting brain cells, or through other investigations from a physiological or psychological standpoint. But, even as it stands now, the direct, proper, and main avenue of approach to the prob lems of delinquency and crime is through the field which has come to be designated mental hygiene. 108165—22 12 364 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. ASPECTS OF MENTAL HYGIENE RELATED TO ALCOHOLISM AND DRUG ADDICTION. Any one who has even half studied human inebriety must have reached the conclusion that many alcoholics are defective or insane. And one may hold this opinion without being in the least an ex tremist. Neff well writes : " It has quite often been said that all in ebriates are more or less insane or mentally defective, but it is our opinion that when all inebriates of all social grades are classed to gether it will generally be found that the majority are neither de fective nor insane." This statement is merely preliminary to the recognition of a very practical fact for treatment, namely, that a considerable proportion of drunkards are by virtue of mental ab normality not responsive to treatment. Taking cases of habitual and periodic drinkers who have been re peatedly arrested, Anderson found in his court work that 56 out of 100 had a decidedly inferior level of mentality. He considered 37 of them clearly feeble-minded, 7 were insane, 7 were epileptic, and 32 of them showed evidences of an innate psychopathic constitution. This is probably a fair sampling of the chronic offenders in a metro politan court where many arrests are made for drunkenness. No other statement is needed to show the relationship of mental health problems to the social scourge of alcoholism. That another feature is added in very many of these cases through alcoholic mental degeneration, the result of definitive poisoning of brain cells, goes without saying. Drug addiction is an issue before the country at present as never before. In connection with the problem of drug addiction, prob ably the student of mental hygiene is more concerned with the results of the drug itself upon the mental powers than with the original constitutional weakness of those who become drug users, in this respect being a variation from the problem of alcoholism. The fact that some observers working in courts have found evi dences of a considerable proportion of mental abnormality, either defect or psychotic tendencies, is not so significant as in cases of inebriety, because nearly all of these drug users as they appear in court are delinquent individuals involved in other antisocial be havior than the use of drugs. They are either innately so abnormal mentally or have become so deteriorated that they place themselves in situations where they readily come under the ban of the law. Comparatively few of their arrests are for breaking the drug law. As a matter of fact a vast number of drug habitues never come in contact with the law because, of course, their use of the drug does not entail such socially offensive behavior as does drunkenness. The problems of mental hygiene, however, are involved in prac tically every case of habitual drug using even if there is no drug No. 2. 365 DIVISION OF PREVENTIVE MEDICINE. psychosis or any innately defective mental constitution. This main fact constitutes one of the great points of attack in treatment. Mental dissatisfaction itself, for example, whether through ill health or other stress, is one of the prime reasons for entering into and continuing the drug habit. Anyone who would merely attempt to get an understanding of why human beings respond to such artificial stimuli or satisfaction must take into account the facts of mental life. As in the case of the relationship of mental hygiene to delinquency, we see here again the fact that mental health means much more than freedom from a definite psychosis, just the same as bodily health means much more than freedom from specific and well-known dis eases. The student of health must take into account the functioning of the organisms upon levels of efficiency, adaptation, and satisfac tion to the individual —facts that are not usually dwelled upon in textbooks of pathology, either of mind or body. MENTAL HYGIENE AND PROSTITUTION. The studies and reports, some of them very extensive, of the earlier vice commissions which, 10 or 12 years ago. first undertook the diffi cult task of public enlightenment concerning prostitution had very little to say concerning the mental personality of publicly immoral women. The swing from the nonrecognition of the problems of mentality involved to the most exaggerated statements concerning the amount of feeble-minded and psychopathic conditions to be found among these women was the natural swing of the pendulum. The real situation seems to be about as follows : Of course, no one who knows the facts would presume to argue that such immorality entered into by women as a gainful occupation is highly correlated with mental incapacities of any kind. The only studies of mentality that have been made are of those women who have been so foolish that they did not avoid the notice of the police or other preventive agencies, or, more rarely, of some groups of those who have been openly and notoriously plying their trade and have been willing to be studied. Even the superficial investigations of vice commissions show that a vast amount of prostitution is engaged in by women who are sharp enough to keep out of public notice and to avoid showing any evidences of law breaking. There is no reason to believe that these women differ in mentality from the average run of the popu lation. But through the study of women who are easily accessible, be cause of open immorality or being under arrest, we get a picture that demonstrates clearly a very considerable correlation between mental abnormality and such " caught offenders." In the opinion of the Massachusetts Vice Commission, about half of the women 3G6 DIVISION OF PREVENTIVE MEDICINE. Vol. XVII. seen were to be considered as mentally defective. It is of local interest that Anderson, taking 100 women who were seen in his laboratory in the Boston municipal court, found that about half of them represented pathological mental types, among which feeble mindedness ranked highest. But here again we have the fact that many of them evidently came to attention as violators of the law because they were alcoholics or drug habitues. Indeed, some of them had already begun to show deterioration from these poisons. The point of the whole matter is that no individual or general social therapeutic or preventive treatment of prostitution can be considered, even in terms of common sense, without reckoning on the highly practical human factors of mental conditions as they most necessarily affect prognosis. The problems of illegitimacy are to some extent the same as those of prostitution. Here again it is clear that the brighter individuals take care of themselves and of their offspring in ways to avoid public notice. But a study of cases of illegitimacy as they come to public agencies reveals a very considerable percentage of mental abnormality among the mothers. Probably the best source of in formation for readers of this bulletin is Kammerer's " The Un married Mother." MENTAL HYGIENE AS RELATED TO VAGRANCY AND DEPENDENCY. It is easy to understand that the vagrant or tramp very frequently indeed is a psychopath. The fact of his lack of success or of find ing satisfaction under ordinary conditions, when, as is usually the case, he has a fairly good physique, is evidence of something ab normal in his personality. Of course there are economic reasons, fairly clear at different periods, which must be taken into account in estimation of the causes of wandering or vagrancy. But the study of the ordinary or habitual tramp in this country as well as in Europe, where an important literature has developed concerning the subject, reveals a considerable list of mental troubles in the background of the tendency toward a vagrant life. One mental disease in particular has received considerable at tention as relates to vagabondage, and from observation of indi vidual cases we have no doubt that this disease (dementia praecox) plays an unusually large part in the situation. In the fellowship of tramps—and it sometimes exists to the ex tent that there are tramp colonies —degenerate practices are very frequently carried on which may well develop a tendency toward deterioration, toward living at a lower level than the innate mental constitution of these men would warrant. Apropos of social prevention of the ills that such irregular living implies, it is most interesting to note that in communities where No. 2. 367 DIVISION OF PREVENTIVE MEDICINE. feeble-minded youths and cases of mild psychoses have been taken care of early in greater proportion, there is very much less evidence of vagrancy or tramp life. The problem can be solved —it is solved to a greater extent in Massachusetts, through better cure of the mentally abnormal, than in most States in this country. Much can be done by early attention to the real needs of the. feeble minded, the mentally diseased, the epileptic who lias mental dis turbances, and the psychopathic inferiors. We can find evidence of it in the better control in certain localities of tramp life, pros titution and delinquency. Constructive measure!-: undertaken arc related not only to the welfare of these individuals themselves, but also to their progeny, for, of course, dependency results from the nonsupport and the desertions that are connoted by alcoholism, pros titution, and vagrancy. And much more is involved (ban the eco nomic situation resulting in State care and placing out of children; we have only too frequently the matters of actual disease in these children, physical and mental, which are most costly to our civiliza tion. There is thus every argument for assailing in the most direct way those burdens of our social life which come under the head of delinquency, alcoholism, drug addiction, prostitution, illegiti macy, vagrancy, and dependency through an approach to them which can only be gained by knowing their intimate relationship to the facts of mental hygiene —through understanding what each of these means in terms of departure from mental health. NOTES FBOM THE NAVAL BASE, HAMPTON EOADS, VA. Newly eidisted recruits began to arrive at the naval training station on the 20th. As has been the custom for the past year or more, all of these men have been very thoroughly reexamined physi cally by a medical officer; including an examination of urine, which is not customary, I think, at other training stations. This procedure has brought to light more than a dozen men, having albumin per sistently present in their urine. These men, of course, have been held up, transferred to sick quarters and placed under observation. The functional efficiency of their kidneys will be determined, and, if found necessary, they will be surveyed. Other defects, principally heart disease, have been found in various recruits. Surveys have already been held upon those who are not physically fit for the service. We are proceeding on the assumption that the Navy re quires only men as nearly perfect physically as it is possible to obtain. 368 Vol. XVII. DIVISION* OF PREVENTIVE MEDICINE. SANITATION DIVISION. The work of mosquito prevention has been vigorously carried on during the month, and all breeding places, both on the naval oper ating base and the Virginia Terminal property, have been kept thoroughly covered with larvaecide. The prevailing heavy rains have made the work of mosquito prevention quite an undertaking: but by directing most of the time and attention of the division to ward this particular work, the situation has been kept well in hand. Instead of the routine inspections that have been carried out liere- tofore, inspections have been made to determine the probable breed ing places of mosquitoes and flies. All places that were, or could possibly become, breeding places for these pests have been covered with larvsecide. NOTES FROM THE UNITED STATES NAVAL TRAINING STATION, SAN FRANCISCO, CALIF. The general admission rate for the month of May was 634 per 1,000 per annum as compared with 899 per 1,000 per annum for April. There were but two admissions for communicable diseases: one with diphtheria and one with tuberculosis. About 20 per cent of all hospital corpsmen are found to be car riers of the organisms of Vincent's angina, usually with minute lesions of the gums. The same condition applies to the personnel of the Hospital Corps training school. Active treatment of lesions, disinfection and in appropriate cases isolation is practiced. NOTES FROM THE NAVY MINE DEPOT, Y0RKT0WN, VA. During the month of May a bacteriological examination of the water supplied to this station was made and it was found to contain B. coll. No chlorine was being used at this time, as the supply bad been exhausted. Upon investigation of the watershed it'was found - that a number of laborers were working around the group of springs supplying the water mains, and that there was a small amount of pollution of the hillsides around the springs. Rigid regulations were instituted at once to prevent further contamination, a supply of chlorine was secured from a neighboring Army camp, and every one concerned was advised by a station notice to boil the water before using it for drinking purposes. No. 2. 369 DIVISION OF PREVENTIVE MEDICINE. INSTRUCTIONS TO MEDICAL OFFICERS. Circular letter. FEMcC-EFL 124842(103). Serial No. 195-1922. Washington, D. C, June IS, 1922. To: All naval hospitals. Subject : Report of board for consideration of standardized forms. Reference: (a) Bureau's letter No. 124842(103) of February 14, 1922. Enclosure: Report of board. No. 124842(103), June 6, 1922. * 1. The recommendation of the board contained in the attached report Is approved. 2. The new forms will be put Into effect when the stock of old forms at the supply depot have been exhausted. F. Li. Pleadwell, Acting. FEMcC-EFL 124842(103). Washington, D. C, June 6, 1922. From : Board for consideration of standardized forms. To : Chief of Bureau of Medicine and Surgery. Subject : Report of board. Reference: (a) Bureau's letter No. 124842(103) of Nov. 30, 1921. (6) Bureau's letter No. 132-1921, of Oct. 16, 1921. (c) Board's report of Jan. 30, 1922. (d) Bureau's letter No. 124842(103) of Feb. 14, 1922. 1. In response to reference (rf) seventeen reports were returned from the commands to which reference (c) was referred. Nine of the reports received expressed concurrence with the hoard's recommendations. 2. The following is an abstract of the criticism received and grouped under each form considered : (a) N. M. S. Form No. 10.—" Recommended that the following be added Im mediately after absentee report (reverse side) : Mast report. Name : rate : offense : date, etc. : Remarks. This gives the commanding officer daily information as to all mast reports, awaiting-actiou cases, etc. (I'earl Harbor.) "Daily personnel report, which should contain more than twenty-one wards" (Great Lakes). " This form as submitted is incomplete in that summary does not show num- Ikt of patients died, deserted, in confinement, on leave, or absent without leave. Summary should also show number of hospital corpsmen on duty, in confine ment, on leave, or absent without leave."- (Norfolk.) " It is recommended that ' Changes in staff ' be made a seperate report in stead of being printed on the back of the ' Personnel report.' The data for the changes in staff and the absentee report is, at a large hospital, more efficiently handled at a desk other than the one handling the personnel report, and. due to the delay often occasioned by definitely determining the absence of an indi vidual, the distribution of the personnel reimrt would be unnecessarily de- • layed." (New York.) (6) N. M. S. hospital Form No. 3.—"Horizontal lines are not practicable in that copies seldom agree with original when inserted on typewriter, due to faulty printing. An unruled page, allowing names to be typewritten single spaced, will permit listing of twenty or more nnmes instead of ten as on sug gested form, an item of interest to large hospitals. Space allotted to listing of service records, health records, and pay accounts should be reduced, thus permitting long names to be written in full followed by service number. Num bering of lines is not necessary." (Norfolk.) (c) lia-ggage cheek. — " In order to render this check more difficult to change or counterfeit in the case of loss, more important as a means of identification 370 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. to the owner and to better serve Its purpose as a baggage check, it is recom mended that both the tag and its stub be numbered consecutively in conspicuous type." (Newport.) " Recommended •that first action section of stub have space for patient to sign ns receipt. Stub to be filed by baggage man for future reference in case a claim is made for baggage or missing clothing after patient has left hospital. " U. S. Naval Hospital " All personal property received this date " Witness : " Bagroom keeper." (Pearl Harbor.) " The advantages of this form believed to be of a doubtful nature. Experi ence at this hospital has demonstrated that only constant watchfulness on the part of the corpsman detailed in baggage room will prevent thieving, and it appears that the loss of baggage check and consequent finding of it by another person would tend to give the finder access to baggage not his own were he inclined to be dishonest. The above remarks are based on the assumption that the possession of the detached part of the tag will gain access to baggage indi cated on the check. It is suggested that the service number or some other form of a check appear on the original check (not on the duplicate) that can be furnished only by the bona fide owner of the baggage." (Charleston.) (d) Change of diagnosis. —"This office recommends adoption of attached standardized forms with alteration of " Notice of change of diagnosis " to read as follows, due to the fact that patient might be carried with a diagnosis other than the one with which admitted to hospital : Diagnosis changed j ^^'.m ' (Annapolis.) " Recommended space be provided for approval by executive officer in smaller hospitals, or by supervisors of medicine or surgery in the larger hospitals. Eliminates mistakes (technical or otherwise) by junior inexperienced medical officers and keeps immediate superiors familiar with status of patients under their supervision. Authorizes personnel office to make necessary record changes." (Pearl Harbor.) "A similar scheme in the form of a memorandum has been tried out in this hospital and has not met with success. A book kept in the record office and accessible to medical officers is believed to give results and such book is now being used as an experiment in this hospital. Too often the card fails to reach the record office and only a constant check of health records insures the form ' F ' card being closed out and a new one for the new diagnosis opened. The book is believed to provide a more stable record." (Charleston.) (e) Operations scheduled. —" It is believed that if space were provided on this form to show the ward to which patients to be operated on are assigned, it would aid in proper distribution of the several copies where more than one ward is concerned." (Charleston.) " Suggested that the word ' anesthetist ' be added to the heading anesthetic. In most hospitals where there are several anesthetists, the above additional information assures equal distributiofi of this duty and gives necessary pre paratory information." (Pearl Harbor.) " Operations scheduled " should contain several more spaces for names." (Great Lakes.) "That all new forms recommended in paragraph 7 be adopted except (b). It is believed that the ' Operations scheduled ' in its present form could be omitted or modified for the following reasons: " First. Emergency cases could not be planned in advance. " Second. Operating surgeons must be allowed leeway as to what anesthetic is to be used, as the case comes to operation. " Third. With a senior operator and several assistants, it is impossible to tell in advance which assistant would be given the opportunity to do routine work as the need for post-operative watching of a patient, and other condi tions will modify the schedule. " Fourth. Under present conditions most operating surgeons are men of sufficient experience to be trusted with the details of the work they are doing, and I believe all hospitals now have in effect some form of official approval of work planned, but not in such detail as indicated. No. 2. 371 DIVISION OF PBEVENTIVE MEDICINE. •' Fifth. A schedule such as proposed would be constantly changed, either by additions or omissions, depending upon changed condition of patients. It would soon, of necessity, degenerate into a perfunctory, useless formality. " Sixth. Many times the ' Professional assistant to the executive officer ' or the executive officer has followed a case more carefully than the command ing officer, and the determination to operate, or not to operate, can be better decided by him than by the commanding officer. As a matter of fact, a majority of ' approvals ' are in the nature of taking the recommendation of the ' Professional assistant to the executive ' or the operating surgeon. " Seventh. In most cases it would be as important for the commanding officer to give his approval for instituting radical treatment in medical cases as in the ordinary run of surgical eases. The question of venesection, the use of oxygen, and the more powerful forms of medication, are not ordi narily referred to the commanding officer for approval in advance, nor do I believe the average run of surgical cases need approval." (San Diego.) The following are the views of the board regarding the above comments : (a) N. M. S. hospital Form No. 10.— Inasmuch as the regulations require that a special report book be kept, which report book contains entries of all disci plinary refractions, further entries regarding this subject are deemed out of place on this form. In order that more space for wards be allowed without increasing the size of the form, it is recommended that the horizontal lines be eliminated from the form as originally proposed. This will permit any probable number of wards to be enumerated. The present form, if correctly made out, would show the disposition of all personnel in the body or' the report. It is, therefore, recommended that no addition be made to the " summary of patients," since the aggregate of change in personnel of the day is believed to be sufficient for requirements. A com plete dally summary for hospital corpsmen is believed to be unnecessary, as daily changes are infrequent and a weekly report is already in existence. The recommendation of the New York hospital as to dally changes in staff would necessitate a new form, which Is not recommended. (b) N. M. S. hospital Form No. 3.—The board concurs In this recommenda tion and recommends its adoption. (c) Baggage check.— The proposed form provides for a storage number. Receipt of patient for baggage is covered by Form " G " when his signature Is obtained on discharge or transfer, Form " G " should be filed in his jacket, thereby being made available for any future correspondence covering the sub ject. The board believes that the duplicate checks should be in the custody of the ward nurse and not carried by the man concerned on account of possibility of loss. The nurse Is in a better position to identify the man than the bag room keeper. (d) Change of diagnosis. —The recommendation of Annapolis Hospital is concurred in. If a hospital demands that this report be signed by the executive officer or supervisor o>f a department, this may be accomplished by having the proposed report initialled by the officer concerned. It is the apinion of the board that while several hospitals are now using this form (which is believed to be adequate and its adoption recommended for this reason), nevertheless it would appear that the best procedure would be to return the health record at the time the change is made to the record office so that it may be checked by officers concerned and the record office. A book for this purpose is not recommended. (e) Operations scheduled. —The form as proposed is for the official notifica tion and approval of an operation by the commanding officer and does not abridge any of the prerogatives of the operating surgeon with respect to pro fessional judgment. Other suggestions not concurred in. 4. Copies of all forms recommended are appended. F. E. McCuix-otjgh, Captain (M. C), 17. S. N H. W. Smith, Commander (U.C.), U. 8. A". H. L. Gail, Chief Pharmacist, U. S. X. 372 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. Circular letter. WJCA:ESK 129733(04). Serial No. 196-1922. Washington, D. C, June 29, 1922. To: All naval hospitals. Subject : Occupational therapy work for Veterans' Bureau beneficiaries ; re port of. Reference: Letter from Assistant Director, U. S. Veterans' Bureau #BWC: HW : It : lO.Hosp. Sec. 1. In order that the United States Veterans' Bureau may have a complete record of all occupational therapy work done by U. S. Veterans' Bureau bene ficiaries in U. S. naval hospitals, you are requested to forward, on the first of each month, a report covering this work for the past month. 2. It is understood that the committee composed of representatives of the Ann}-, Navy, Public Health Service, Soldier's Home, and the U. S. Veterans' Bureau have adopted a new form for reports on this type of work. United States Veterans' Bureau form Med. 1870 will be used until such time as the newly adopted forms are received. 3. All of these reports shall be forwarded (in duplicate) by the commanding officers to the Director, U. S. Veterans' Bureau, via the Bureau of Medicine and Surgery. F. L. Pleadwell, Acting. Circular letter. WSG/T 132586, 132641. Serial No. 197-1922. Washington, July 12, 1922. ■To: All naval hospitals, U. S. naval medical supply depots, and U. S. Naval Medical School. .Subject: (a) An act to readjust the pay and allowances of the commissioned and enlisted personnel of the Army, Navy, Marine Corps, Coast Guard, Coast and Geodetic Survey, and Public Health Service, approved June 10, ]922. (6) An act making appropriations for the naval service for the fiscal year ending June 30, 1923. and for other purposes, appro ved July 1, 1922. References : {a) ALNAV TWENTY-EIGHT, 4230-1230 of June 30, 1922. Enclosures: (A) Copy of above (a) (H. R. 10972). (B) Copy of above (6) (H. R. 11228). 1. The bureau encloses herewith copies of the two acts above mentioned, and directs that they be made available for all members of the staff, including hospital corpsmen engaged on office work ; the acts are supplemental to one another, and should be considered together. 2. An accurate knowledge of appropriational matters is essential to the proper allocation of charges; that this knowledge is not so widespread throughout the Medical Department as it should be is evidenced by the large number of invoices received in the Bureau of Supplies and Accounts on which the wrong appropriations of the Bureau of Medicine and Surgery are debited. 3. The strictly bureau appropriations are found on pages 19 and 20 of the naval act. 4. The appropriation " Care of hospital patients " will continue under the immediate and direct control of the bureau, but wider no circumstances will any charges be placed against it, except directly by this bureau. 5. Legislation relating to "Passenger-carrying automobiles" will be found on pages 20 and 21 of the naval act. 6. The value of commuted rations stopped on account of sick in hospitals is fixed by the naval act for the fiscal year 1923 at seventy -five (75) cents (page 17): this rate for three meals will govern the charges made against the pay of civilian employees for subsistence; it will also be the rate of charge in the duty officer's mess; the charge for less than three meals in all cases will be twenty -five (25) cents per meal. 7. The pay and allowances of members of the Nurse Corps are defined in sections 5, 6, and 13, of the " Act to readjust the pay and allowances." exce-m that the naval act (End. B), page 17. provides for "subsistence in kind at hos pitals and on board ship in lieu of subsistence allowance of female nurses'" ; No. 2. 373 DIVISION OF PREVENTIVE MEDICINE. the Assistant Secretary of the Navy in Alnav twenty -eight (ref. a) directs that at hospitals and aboard ship nurses ••shall be subsisted in kind as here tofore." E. It. Stitt. Circular letter. HWS :MFD 125221 (71). Serial No. 198-1922. Washington, D. C, July 13, 1922. To : All medical officers. Subject : Training of flight surgeons. 1. A large number of medical officers will be needed for training in aviation medicine and subsequent duty as flight surgeons. 2. The training period will consist of a course of instruction of approxi mately four months' duration either at Washington, D. C, or at Mineola, L. I. 3. Any medical officer wtio may desire to identify himself with the specialty of aviation medicine is requested to make early application to the bureau, en- <dosing a report of a physical examination such as is prescribed for pilots. E. K. Stitt. VITAL STATISTICS. The "Monthly Health Index," which is published on the 15th of each month, contains the statistical data for individual ships and shore stations. The statistics appearing in this Bulletin are sum maries compiled from those published in the " Monthly Health Index." Annual rates, shown in the succeeding statistical table, are ob tained as follows : The total number of admissions to the sick list or the number of deaths reported during the period indicated is multiplied by Zfg- or -3S<^ or 12, depending upon whether the period includes four or five weeks or a calendar month. The product is then multiplied by 1,000 and divided by the average complement. E. R. Stitt. Table No. 1.—monthly report of morbidity in United States Navy and Marine Corps for the month of June, 1922. Average complement All causes: Number of admissions Annual rate per 1,000 Diseases only: N umber of admissions Annual rate per 1,000 Injuries and poisons: Number of admissions Annual rate per 1,000 Communicable diseases exclusive of venereal disease: Number of admissions Annual rate per 1,000 Venereal disease: Number of admissions Annual rate per 1,000 Entire Navy. 121,590 4,709 464.73 I," 402.95 628 01.78 373 37.01 Forces afloat. 81,224 2,331 344.36 2,004 aw. ta 4X.31 142 20.>J> 1,024 ; 6X5 101.06 101.20 Atlan tic Fleet. 258 109.39 Pacific Fleet. 28,301 29,920 359^98 S49 3SS.23 968 320.98 757 336.09 838 39.01 92 52. 14 130 AU shore sta tions. Atlan tic stations in United Slates > Pacific stations United States. 191 76.60 2,378 700.91 2,079 618.02 299 SS. 8S 231 58.67 339 100.77. 1,034 495.57 49 23.48 135 64.70 6,004 185 366.09 S 20 39.58 Marine Corps. 21,480 852 475.97 714 415.64 108 60.33 134 74.86 160 89.38 1Does not include ninth naval district. Note.— Asiatic and unassigned ships not reported. 374 Vol. XVII. DIVISION OF PREVENTIVE MEDICINE. Table No. 2.— Number of admissions reported by Form F cards fiyr certain dis eases and annual rates per 1,000 for the month of June, 1922. Diseases Injuries and poisons. . Total. Class III. Appendicitis, acute Autointoxication, intestinal. Cholangitis, acute Cholecystitis, acute Colitis, acute Constipation Enteritis, acute Gastritis, acute catarrhal Gastroenteritis Hemorrhoids Pharyngitis, acute Ulcer of duodenum Ulcer o( stomach Forces afloat, Navy and Marines (complement), 81,224. Number ofadmis- sions. Total. Class VII. Varicocele.. Class VIII. Chicken pox Diphtheria German measles Influenza Measles Mumps Pnoumonia , broncho Pneumonia, lobar Scarlet fever Smallpox Whooping cough Total. Class IX. Dysentery, bacillary. Dysentery, cntamebic Typhoid fever Total. Total. Class XI. Tuberculosis (all forms) Class XII. Chancroid Gonococcus infection Syphilis Tjtal 2,004 327 2,331 Annual rate per 1.IKKI. 296.05 48.31 Forces ashore, Navy and Marines (complement), 40,366. Number of adrais- Annua 1 rate per 1,000. Total (complement), 121,590. Number of admis sions. ,079 299 . 603. 16 i 88.88 4,083 626 Annual rate per 1,000. 402.95 61.78 464.73 as 3.84 46 13.67 72 7.11 u 1.63 20 5.95 28 2.76 32 3.25 22 6.54 44 4.34 7 1.03 4 1.19 11 1.09 2 .30 5 1.49 7 .69 7 1.03 19 5.65 26 2.57 11 1.63 15 4.46 26 2.57 6 .89 7 2.08 13 1.28 21 3.10 49 14.57 70 6.91 31 4.58 24 7.13 55 5.43 9 1.33 18 5.35 27 2.66 1 .15 4 1.19 5 .49 1 .15 n 1 .10 22.90 230 68.37 ?.<, 38.00 17 2.51 16 4.76 33 3.26 4 .59 I .30 5 .49 1 . …