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THE HARVEY SOCIETY 


THE 
HARVEY LECT 


Delivered under the auspi 


URES 


ces of 


THE HARVEY SOCIETY 
OF NEW YORK 


Previously Published 
FIRST SERIES. « 
SECOND SERIES . 
THIRD SERIES . 
FOURTH SERIES. . 
FIFTH SERIES 
SIXTH SERIES _. 
SEVENTH SERIES . 
EIGHTH SERIES . ; 
NINTH SERIES 
TENTH SERIES . 
ELEVENTH SERIES 
TWELFTH SERIES . 
THIRTEENTH SERIES 
FOURTEENTH SERIES 


1905-1906 


: 19006-1907 
. 1907-1908 


1908-1909 


. 1909-1910 
. IQI0-IgII 


IQII-19I2 
19012-1913 


. 1913-1914 
. IQI14-1915 


IQ15-1910 
IQ16-Ig17 
1917-1918 
1918-1919 


«<The Harvey Society deserves 
the thanks of the profession at large 
for having organized such a series 
and for having made it possible for 


all medical readers to 


share the 


profits of the undertaking.’’ 


— Medical Record, 
Crown S8vo. Cloth, $2.50 net, 


New York. 


per volume. 


J. B LIPPINCOTT COMPANY 
Philadelphia 


Publishers 


THE HARVEY LECTURES 


DELIVERED UNDER THE AUSPICES OF 


THE HARVEY SOCIETY 
OF NEW YORK 


1917-1918 
1918-1919 


BY 
Dr. W. T. PORTER Dr. E. K. DUNHAM 
Dr. LINSLY R. WILLIAMS Major ROBERT M. YERKES 
Pror. ALDRED SCOTT WARTHIN Dr. FREDERIC S. LEE 
Dr. HENRY C. SHERMAN CoLonEL FRANK P. UNDERHILL 
Pror. J. GORDON WILSON Dr. YANDELL HENDERSON 


Dr. STEWART PATON 


SERIES XIII and XIV l, 


y 
2s 
b 44 
= Ee 
Vey 
a 


PHILADELPHIA AND LONDON 


J. B. LIPPINCOTT COMPANY 


CopyYRIGHT, 1920 
By J. B. Lippincotr COMPANY 


PREFACE 


In medicine, as in many other departments of knowledge, 
notable advances have followed the intensive stimulation of re- 
search which the exigencies of the war have made necessary, and 
in some cases have facilitated through the unusual conditions 
existing. The problems of hygiene and of epidemiology at- 
tendant on the concentration of large bodies of men in camps and 
at the front, the treatment of the injuries received, the after care 
of the disabled, the restriction of food supplies, such new de- 
velopments as military aviation and the use of poison gases, the 
conditions existing in industrial establishments running at high 
pressure, these and many other questions have presented oppor- 
tunities for investigation which have been developed to the full. 
It is not astonishing, therefore, to find that of the lectures deliv- 
ered before the Harvey Society during the seasons of 1917-18 and 
1918-19 the majority were closely concerned with the war and its 
effects. How fruitful have been the labors of those who have 
addressed the Society both on military and non-military subjects 
is evident from a perusal of the lectures. 

The Society extends its thanks to the speakers who so gen- 
erously gave it their time and efforts under conditions when both 
were especially precious. Grateful acknowledgement is also due 
to the editors who have kindly permitted the reprinting of 
lectures which have already appeared in the pages of the fol- 
lowing journals: The American Journal of Syphilis, The Jour- 
nal of Industrial and Engineering Chemistry, Archives of 
Internal Medicine, Science, and to Mr. Paul Hoeber for permis- 
sion to reprint Dr. Paton’s lecture. 

5 


6 PREFACE 


An undesirable consequence of the war has been the necessity 
of publishing the lectures of the thirteenth and fourteenth series 
in a single volume, and the delay in its appearance which has 
resulted. It is also to be regretted that it has not been possible to 
secure for publication the lecture of Colonel Whitmore on 
‘‘ Infectious Diseases in the Army,’’ and that of Dr. Alsberg 
on ‘‘ Scientific Aspects of Current Food Problems.’’ 


Karu M. Voaet, 
May, 1920. Secretary. 


THE HARVEY SOCIETY 


A SOCIETY FOR THE DIFFUSION OF KNOWLEDGE OF THE 
MEDICAL SCIENCES 


CONSTITUTION 


I: 
This Society shall be named the Harvey Society. 


II. 


The object of this Society shall be the diffusion of scientific 
knowledge in selected chapters in anatomy, physiology, pathology, 
bacteriology, pharmacology, and physiological and pathological 
chemistry, through the medium of public lectures by men who are 
workers in the subjects presented. 


IIT. 


The members of the Society shall constitute three classes: 
Active, Associate, and Honorary members. Active members 
shall be laboratory workers in the medical or biological sciences, 
residing in the City of New York, who have personally con- 
tributed to the advancement of these sciences. Associate members 
shall be meritorious physicians who are in sympathy with the 
objects of the Society, residing in the City of New York. 
Members who leave New York to reside elsewhere may retain 
their membership. Honorary members shall be those who have 
delivered lectures before the Society and who are neither active 
nor associate members. Associate and honorary members shall 
not be eligible to office, nor shall they be entitled to a vote. 

Members shall be elected by ballot. They shall be nominated 
to the Executive Committee and the names of the nominees 
shall accompany the notice of the meeting at which the vote 
for their election will be taken. 

7 


CONSTITUTION 


VY: 


The management of the Society shall be vested in an execu- 
tive committee, to consist of a President, a Vice-President, a 
Secretary, a Treasurer, and three other members, these officers 
to be elected by ballot at each annual meeting of the Society to 
serve one year. 


¥. 


The Annual meeting of the Society shall be held soon after 
the concluding lecture of the course given during the year, at a 
time and place to be determined by the Executive Committee. 
Special meetings may be held at such times and places as the 
Executive Committee may determine. At all the meetings ten 
members shall constitute a quorum. 


VI. 


Changes in the Constitution may be made at any meeting 
of the Society by a majority vote of those present after previous 
notification of the members in writing. 


(9 4) 


OFFICERS OF THE HARVEY SOCIETY 


OFFICERS COUNCIL 


1917-1918 1917-1918 
E. K. DunuAm, President GRAHAM LUSK 
Rurus Cour, Vice President GEORGE B. WALLACE 
F. H. Pixs, Treasurer Freperic 8. LEE 


A. M. PappENHEIMER, Secretary  Pryton Rous 


1918-1919 1918-1919 
GraHAM Lusk, President GRAHAM Lusk 
Rurus Cou, Vice President JAMES W. JOBLING 
F. H. Pixs, Treasurer JOHN AUER 
Kari M. VoGEL, Secretary FREDERIC S. LEE 


The Officers Ex-Officio. 


ACTIVE MEMBERS 


Dr. JOHN S. ADRIANCE Dr. A. F. Coca 

Dr. F. M. ALLEN Dr. A. E. CoHN 

Dr. HucH AUCHINCLOSS Dr. Rurus CoLe 

Dr. JOHN AUER Dr. Ropert COOKE 
Dr. O. T. AVERY Dr. H. D. DaKIn 

Dr. GrorGE BAEHR Dr. C. B. DavenPoRT 
Dr. F. W. Bancrorr Dr. A. R. DocHEz 

Dr. S. R. BEnepict Dr. E. F. Du Bots 
Dr. Herman M. Biaes Dr. E. K. DuNHam 
Dr. Hartow Brooks Dr. WaAutTEeR H. Eppy 
Dr. Wave H. Brown Dr. W. J. ELSER 

Dr. Leo BUERGER Dr. Haven EMERSON 
Dr. R. Burton-Opirz Dr. EpHraim M. Ewina 
Dr. E. E. BurrerFrieLp Dr. JAMES EWING 
Dr. ALEXIS CARREL Dr. L. W. FAMULENER 
Dr. R. L. Crecru Dr. J. S. Ferauson 
Dr. P. F. Cuark Dr. C. W. FIELD 


ACTIVE MEMBERS—Continued 


. Morris S. FINE 

. Simon FLEXNER 

.N. B. FOSTER 

. ALEXANDER FRASER 

. Francis R. FRASER 

. F. L. Gates 

. A. O. GETTLER 

. H. R. GEYELIN 

. W. J. Gres 

. T. S. GITHENS 

. FREDERICK GOODRIDGE 
. T. W. Hastines 

._ R. A. HatTcHER 

. A. F. Hess 

. J. G. HOPKINS 

. Pauut E. Hows 

. JOHN HOWLAND 

. G. S. HuntineTon 

. Houtmes C. JACKSON 
. W. A. Jacoss 

. H. H. JANEWAY 

. JAMES W. JOBLING 
.D. R. JOSEPH 

. D. M. Kapuan 

. I. S. Kerner 

. CHARLES KRUMWIEDE 
. R. V. Lamar 

. R. A. LAMBERT 

. Freperic S. Ler 

. E. S. L’EsperaANcsa 

. P. A. LEvENE 

. 1. LEvIN 

. KE. Lisman 

. C. C. Lis 

. WarFretp T. LONGCOPE 
. GraHam Lusk 

. F. H. McCruppen 

. W. G. MacCattum 
. FRANKLIN C. McLEAN 


. Warp J. MacNrau 


. A. R. MANDEL 

. JouHN A. MANDEL 

. F. S. MAanpDLeBAUM 
. W. H. ManwakinG, JR. 
. S. J. MELTZER 

. ADOLF MEYER 

. G. M. MEYER 
.Epcar G. Minier, JR. 
. L. S. Minne 

. C. V. Morriuu 

. H. O. MoseNTHAL 

2, J. R. MuRLIN 

. Jd. B. MuRPHY 

. V. C. Myers 

. W. C. NosBie 

. Hipeyo Noagucui 

. CHARLES NORRIS 

. Horst OERTEL 

. Perer K. OLITsKy 

. EuGENE L. OPIE 

. B. S. OPPENHEIMER 
. R. OTTENBERG 

. W. W. PALMER 

. A. M. PappENHEIMER 
. Witiiam H. Park 

. F. W. PEasopy 

. LOUISE PEARCE 

. RicHarp M. PEARCE 
om Os BN ein 

. Harry PLotTz 

. FREDERICK PRIME 

. T. M. PrRupDEN 

. A. N. RicHarps 

. A. I. Rincer 

. C. G. Rosrnson 

. Peyton Rous 

. H. von W. ScHULTE 
. Orro H. ScHULTZE 
. E. L. Scorr 

. H. D. SENIOR 


ACTIVE MEMBERS—Continued 


Dr. E. G. STILLMAN 


Dr 
Dr 
Dr 


Dr. 


.C. R. Stockarp 

. I. Strauss 

.H. F. Swirt 
DouGLas SYMMERS 
. Oscar TEAGUE 

Py Bov ke LEERY 

. Wa. C. THRO 

. FREDERICK TILNEY 
. J. C. ToRREY 

. D. D. Van SLYKE 
. K. M. VoGEen 


. AUGUSTUS WADSWORTH 


. A. J. WAKEMAN 


ASSOCIATE 


. Ropert ABBE 

. F. H. ALBEE 

. PEARCE BAILEY 

. T. B. BarRINGER 

. F. H. Bartuerr 

. Smmon Baruch 

. W. A. BastTEDo 

. JOSEPH A. BLAKE 
. GEORGE BLUMER 

. A. BookKMAN 

. Davin BovairD, JR. 
. J. W. BRANNAN 

. JOSEPH BRETTAUER 


. G. E. BREWER 


.N. E. Britu 

. Wm. B. BRINSMADE 
. E. B. Bronson 

. S. A. Brown 

. J. G. M. Buttowa 


. Ss. R. Burnap 
. GLENTWoRTH R. BUTLER 


. C.. NB: Camac 
. Wan. F. CAMPBELL 


Dr. G. B. WALLACE 

Dr. Wu. H. WELKER 
Dr. CLARENCE J. WEST 
Dr. J. S. WHEELWRIGHT 
Dr. C. G. WiGGERS 

Dr. ANNA WILLIAMS 

Dr. H. B. WiLuiams 
Dr. R. J. WILson 

Dr. Wa. H. Woctom 
Dr. MartHa WOLLSTEIN 
Dr. Francis C. Woop 
Dr. JONATHAN WRIGHT 
Dr. Hans ZINSssER 


MEMBERS 


Dr. R. J. CARLISLE 
Dr. H. S. CARTER 
Dr. A. F. CHAcE 
Dr. C. G. CoaKLEY 
Dr. MartTIn COHEN 
Dr. WARREN COLEMAN 
Dr. WILLIAM B. CoLey 
Dr. C. F. Coiuins 
Dr. L. A. CoNNER 
Dr. C. B. CouLTEeRr 
Dr. E. B. CraGin 
Dr. Ftoyp M. CRANDALL 
Dr. G. W. Crary 
Dr. Epwarp CUSSLER 
Dr. CuHarues L. Dana 
Dr. THomMaAs DARLINGTON 
Dr. WILLIAM DARRACH 
Dr. D. Bryson DELAVAN 
Dr. E. B. DENcH 
Dr. W. K. Draper 
Dr. ALEXANDER DUANE 
Dr. THEODORE DUNHAM 
Dr. Cary EGGLEsTon 

11 


ASSOCIATE MEMBERS—Continued 


. Max Ernyorn 

. CHARLES A. ELSBERG 
. A. A. EPSTeIn 

. Evan M. Evans 

. S. M. Evans 

. KE. D. FIsHEer 

. RoutFe FLoyp 

. JOHN A. ForDYCE 

. Ropert T. FRANK 

. ROWLAND G. FREEMAN 
. WoLFF FREUDENTHAL 
. L. F. FrisseEth 

. H. Dawson Furniss 
. VirGiL P. GIBNEY 

. 5S. S. GoLpWwATER 

. M. GoopripGE 

. N. W. Green 

. J. C. GREENWAY 

. M. 8. Grecory 

. R. H. Hasty 

. GRAEME M. HamMonp 
. T. Stuart Harr 

. JOHN A. HartTweELL 
. R. S. Haynes 

. Henry Herman 

. W. W. Herrick 

. August Hoce 

. A. W. Houuis 

. H. A. Houcuton 

. Husert 8. Howe 

. Francis Huser 

. E. L. Hone 

. Woonvs Hurcuinson 
. LEOPOLD JACHES 

. ABRAHAM JACOBI 

. GEORGE W. JAcoBY 

. RALPH JACOBY 


12 


. WALTER B. JAMES 

. S. E. JELLIFFE 

. FREDERICK KAMMERER 
. Lupwiac Kast 

. JACOB KAUFMAN 

. F. L. Keays 

. Foster KENNEDY 

. C. G. Keruey 

. P. D. Kerrison 

. K. L. Keyes, JR. 

. ELEANOR KiILHAM 

. R. A. KINSELLA 

. ARNOLD KNAPP 

. LinnagEus E. La Ferra 
. A. R. Lams 

. ALEXANDER LAMBERT 
. SAMUEL W. LAMBERT 
. BoLestaw LApowskI 
. Berton LATrin 

. B. J. Lee 

. J. S. LEoPoLp 

. Ext Lone 

. WinuiAM C. Lusk 

. D. H. McApin 

. Morris MANGES 

. GEORGE MANNHEIMER 
. H. H. Mason 

. Frank S. Mepara 

. Victor MEurzER 

. WALTER MENDELSON 

. ALFRED MEYER 

. Witty MEYER 

. MicHAEL MICHAILOVSKY 
. G. N. MIuuer 

. JAMES A. MILLER 

. A. V. MoscHcowITz 
. JOHN P. MUNN 


ASSOCIATE MEMBERS—Continued 


Dr. ARCHIBALD Murray 
Dr. L. K. NEFF 

Dr. M. NIcoLu 

Dr. WautTer L. NILES 
Dr. VAN Horne Norriz 
Dr. WiLtLiIAM P. NorRTHRUP 
Dr. N. R. Norton 

Dr. A. T. Oscoop 

Dr. H. McM. ParIntTer 
Dr. ELEANOR PARRY 

Dr. STEWART PATON 

Dr. Henry S. PatrerRson 
Dr. CHartEes H. Peck 
Dr. FREDERICK PETERSON 
Dr. JAMES PEDERSEN 
Dr. G. R. PIsex 

Dr. SIGISMUND POLLITZER 
Dr. EuGEenE H. Poot 

Dr. Wu. J. PULLEY 

Dr. Epwarp QUINTARD 
Dr. F. M. RacKAMANN 
Dr. Joun H. RicHarps 
Dr. A. F. Riaas 

Dr. ANDREW R. RosInson 
Dr. JOHN Rocers, JR. 
Dr. J. C. RoPrer 

Dr. BernarD SAacHs 

Dr. E. F. Sampson 

Dr. T. B. SATTERTHWAITE 
Dr. R. H. Sayre 

Dr. Max G. Scurapp 
Dr. H. J. Scuowartz 

Dr. N. M. SHAFFER 

Dr. WiLuLIAM H. SHELDON 


Dr. 
Dr. 
Dr. 
. F. P. SoLtury 

. F. E. Sonpern 

. J. BENTLEY: SQuiEr, JR. 
. NORBERT STADTMULLER 

. ANTONIO STELLA 

. ABRAM R. STERN 

. Georce D. Stewart 

. R. G. StinuMan 

. Wo. S. STonE 

. A. McI. Strone 

. MILLS STURTEVANT 

. ParKrerR Syms 

. A. §. Tayor 

. JOHN S. THACHER 

. A. M. THomas 

. Wo. B. TRIMBLE 

. Pome Van INGEN 

. J. D. VOORHEES 

. JOHN B. WALKER 

. JOSEPHINE WALTER 

. JAMES S. WATERMAN 

. R. W. WEBSTER 

. JOHN E. WEEKS 

. HersBert B. Wiicox 

. Linsty R. WILLIAMS 

. MarGaret B. WILSON 

. G. Woousey 

. J. H. Wyckorr 

. CHaRLES H. Younea 

. JOHN VAN Doren YouNG 


H. M. SInver 
M. J. SITTENFIELD 
MartTIN DE Forest SmitH 


PERMANENT SUBSCRIBERS 


Dr. CHarues D. AARON 
Dr. A. D. BLACKADER 


Dr. 
Dr. 


CHARLES GOODWIN JENNINGS 
CxHarR Les G. ROGERS 


HONORARY MEMBERS 


Pror. J. G. ADAMI Pror. Franz Knoop 

Dr. Cart L. ALSBERG Pror. ALBRECHT KOSSEL 
Pror. J. F. ANDERSON Pror. J. B. LEATHES 
Pror. E. R. BALDWIN Pror. A. Maanus-LEvy 
Pror. Lewretitys F. BARKER Pror. Paut A. LEwIs 
Pror. F. G. BENEDICT Pror. THomas LEWIS 
Pror. R. R. BENSLEY Pror. JACQUES LOEB 
Pror. A. CALMETTE Pror. A. S. LOBWENHART 
Pror. WALTER B. CANNON Pror. A. B. MacaLttum 
Pror. A. J. CARLSON Pror. J. J. R. MacLeEop 
Pror. W. E. Caste Pror. EB. V. McCoLttuM 
Pror. CHARLES V. CHAPIN Pror. F. B. Mauiory 
Pror. Hans CHIARI Pror. L. B. MENDEL 
Pror. R. H. CHITTENDEN Pror. HANS MEYER 
Pror. Henry A. CHRISTIAN Pror. T. H. Morcan 
Pror. Orro COHNHEIM Pror. FrrepRICH MULLEB 
Pror. Epwarp G. CoNKLIN Pror. KARL vON NOORDEN 
Pror. W. T. CoUNCILMAN Pror. Frep G. Novy 
Pror. G. W. CRILE Pror. G. H. F. Nurrauu 
Pror. Harvey CusHING Pror. HENRY FAIRFIELD OSBORN 
Pror. ArtHuR R. CuSHNY Pror. T. B. OSBORNE 
Pror. Henry A. DONALDSON Pror. G. H. PARKER 
Pror. D. L. EDSALL Pror. W. T. PorTER 
Pror. JOSEPH ERLANGER Pror. J. J. PuTNAM 
Pror. WILLIAM FALTA Pror. T. W. RicHArDs 
Pror. Orro Foun Pror. M. J. RosENAv 
Pror. F. P. Gay Pror. Max RuUBNER 
Pror. J. S. HALDANE Pror. F. F. RussELL 
Pror. W. S. HaustTep Pror, FLORENCE R. SABIN 
Pror. Ross G. Harrison Sm E. A. SCHAEFER 
Pror. SvEN G. HEDIN Pror, ADOLPH SCHMIDT 
Pror. Lupwig HEKTOEN Pror. W. T. Sep@wickK 
Pror. L. J. HENDERSON Pror. Henry C. SHERMAN 
Pror. YANDELL HENDERSON Pror. THEOBALD SMITH 
Pror. W. H. Howe. Pror. E. H. StarLiIne 
Pror. G. Cart HuBER Pror. G. N. Stewart 
Pror. JOSEPH JASTROW Pror. C. W. STILES 
Pror. H. §. JENNINGS Pror. Ricuoarp P. Strone 
Pror. E. O. JorpAN Pror. A. E. TayLor 
Pror. E. P. Josuin Pror. W. S. THAYER 


14 


HONORARY MEMBERS—Continued 


Cou. F. P. UNDERHILL Pror. H. Gmron WELLS 

Pror. Victor C. VAUGHAN Cou. Eucene R. Wurrmore 

Pror. Max VERWORN Pror. E. B. WiLson 

Pror. A. D. WALLER Pror. J. GoRDON WILSON 

Pror. A. S. WARTHIN Pror. R. T. Woopyattr 

Pror, J. CLARENCE WEBSTER Pror. Sir ALMROTH WRIGHT 

Pror. Wu. H. WELCH Masor R. M. YERKES 
DECEASED 

Dr. Isaac ADLER Dr. Gustav LANGMAN 

Dr. SAMUEL ALEXANDER Dr. Eqpert LE FEvRE 

Dr. W. B. ANDERTON Dr. CHARLES H. LEwIs 

Dr. L. Botton Banas Dr. Siamunp LUSTGARTEN 

Dre. Cart BECK Dr. W. B. MarpPie 

Dr. J. B. BoRDEN Dr. CHARLES McBuRNEY 

Dr. T. G. Bropie Dr. GrorGE McNavuGHTON 

Dr. F. Tinp—EN Brown Dr. CHARLES S. MINOT 

Dr. S. M. BRICKNER Dr. S. Werr MitcHEeLL 

Dr. J. D. BRYant Dr. G. R. PoGure 

Dr. JoHN G. CuRTIS Dr. Wm. M. Pox 

Dr. AUSTIN FLINT Dr. C. C. Ransom 

Dr. C. G. GARSIDE Dr. Wm. K. Simpson 

Dr. Emit GRUENING Dr. A. ALEXANDER SMITIt 

Dr. FRANK HARTLEY Dr. RICHARD STEIN 

Dr. CHRISTIAN A. HERTER Dr. H. A. STEWART 

Dr. Puitie Hanson Hiss Dr. L. A. STIMSON 

Dr. EuGENE HoDENPYL Dr. WILLIAM Hanna THOMPSON 

Dr. Joun H. Huppieston Dr. WISNER R. TOWNSEND 

Dr. Epwarp G. JANEWAY Dr. R. Van SantvoorD 

Dr. THEODORE C. JANEWAY Dr. Henry F. WALKER 

Dr. Francis P. Kinnicutr Dr. RicHARD WEIL 

Dr. HERMANN KNAPP Dr. H. F. L. ZrmeEeu 


15 


CONTENTS 


PAGE 

Traumatic Shock: .0....56 5. Ati ake) aed 
Bee W. ty Poe eine Medical Schaal! 

Medical Problems and the War. . LY ETS Me a eel ee WE 

Dr. Linsty R. EN Medical Reserve Geen 
The New Pathology of Syphilis. . ste paar 81K 1 7 
Dr. ALDRED Scott Wiaciaba “University of Neicioa 

Food Chemistry in the Service of Human Nutrition................... 97 
Dr. Henry C. SHERMAN—Columbia University. 

The Results of High Explosives on the Ear . OS ee Ps CaP RM 7 


Pror. J. GORDON aT ican hea Bao 


Certain Aspects of the Application of Antiseptics in Military Practice... 161 
Dr. E. K. Dunnam—New York. 


Psychological Examination of the Soldier.......................05005 181 
Masor Rosert M. YERKES. 


The Human Machine in the Factory. . HE aie Sse te aie Ae eo ah eg aL 


Dr. FREpDERIc 8S. pa ee of ene aa Surgeons, 
Columbia University, New York. 


The Physiology and Experimental Treatment of Poisoning with the 
Lethal War Gases . SR Pirates oats sy carte a henotsha ih ater ataie cs ieee tte ate DE 


Galena P. eae 


m@he Physiolory, of, the Aviator. oss oe lease calf ks oe BS ocelot ares (OO 
Dr. YANDELL HENDERSON. 


Muman, Behavior i WAT; ANG (PEACE... 65 oa) sedis s/s/s wn eycicinm ee aje re cases, LEO 
Dr. Stewart Paton—Princeton University. 


17 


ILLUSTRATIONS 


PAGE 
Chronic syphilitic myocarditis. Unsuspected latent syphilis ....... 80 
Aneurysmal dilatation of left ventricle at apex .................... 80 
Unsuspected latent syphilis in middle-aged man .................. 80 
Sudden death in middle-aged man with history of “cured” syphilis.. 80 
Older process. ' Fibroid heart. Case of diabetes .........5......... 80 
Left ventricle wall from case of syphilis contracted 14 years previously 80 
Old “cured syphilis”; negative ER SE: cardio-vascular-renal 

symptom- complex TP Bere ER rao DG ANI SIAC ane ehAte .. 80 
Nearly healed fibroid area in left ventricle wall of old “cured 

SVP LIS Wuynsrectepeewaveweds etsustes secenclers aca asebaiehchaia chotherstebaistaicy AURA rere 80 
Completely healed, fibroid Ane 335.3 5s.) 2) chs -aiins(e telat Paley eyelet low | sao secs 80 
Tangential section of coronary vessel showing slight active syphilitic 

ARPETOLA GION) apis. fone tals wreMae agave latci sate auchaiet alates oyataveih si oreacte tastes 80 
Similar section, from same case, showing complete healing .......... 80 
Levaditi preparation of active latent unsuspected syphilis of left 

WEHERTOHS, WU Gb arc icis scat at snes acdeNer gobo erwuavaralane olndaleva icbohaiety eliareiavstate 80 
Levaditi preparation of chronic syphilitic myocarditis from case of 

MNSUSPECbed sy PTUs iy hf. cpelavareters cpste | okel neh slsi’e ole: eVeven sialleush ober stovanevel ste 80 
Case of diabetes, syphilis not suspected ................-..000005- 80 
Levaditi preparation of fibroid heart from case of diabetes, with un- 

BUA PEGLEG) KEV PETITE) | ihren sia7e't alot a/c wale eom, ore nine ald cho mt atalaabot oheretsl= 80 
iiypreal Gay PUVItie: INESAOFELGIS: <1eT: hu) 2k-\itinte syne a) ole Sich) «!atetetiete vere aici erele 80 
Portion of media and adventitia of aorta from case of latent unsus- 

TUS TYG GES DE ees BA SEr Cia aOioar sic McG hiCIS SIS i eubic: <iBte 80 
Pancreas from case of diabetes, with unsuspected syphilis and nega- 

ELVES AVVIASSCLINANMY Shi cfarensvalete aceustess seh auclatots eheret orien vararecbers teielon tbat 80 
Chronie syphilitic pancreatitis, with active areas, from case of 

Cigbevesh yee pee vel cc rower rece sete fei kec ra lelcehe adel emer et &) cteePMerenaney een cf = 80 
Chronic syphilitic pancreatitis. From tail of pancreas; same case as 

PALE CERATI | Wntetas Ls tatsysyal? ataye oy olgth 2 els als ayalin «i'd aataieVore “paiel oR Meietga ts a -ahoin as 80 
Higher power. Same case as preceding; plasma-cell infiltration .... 80 
Chronic syphilitic pancreatitis. Same case as in Fig. 18 ............ 80 
Same case as in Figs. 19-21. Area of active syphilitic inflammation.. 80 
High-power view of active area of plasma-cell infiltration seen in 

PREC RN ire iifarcins 2 cians on loi si sere) aheh ove! wiacere' siateln oe Siew akeleuetelatat rane. pshl 
High power, showing fibroid stroma and atrophy of acini ............ 80 
Area of severe change; fibrosis, destruction of pancreatic tissue and 

atypical regeneration of acini from pancreatic ducts ........ 80 


Colony of spirochetes in edematous, infiltrated area between lobules. 80 


Syphilis of the adrenal. Plasma-cell infiltrations in inner zone of 
i Hiohwaotyl Garvexe chivel on piyyehillln | \biietic cei ganoos tac colsonoee 80 


20 ILLUSTRATIONS 


Hiver.4rom case: of. Jatent syphilis... oe. sl. te Oe eee eee 
Active syphilitic orchitis. A constant lesion in all old cases of latent 

Sy OO DT ue Nr AA bee So EIGIOM Doo OG maw. CaG.eD ¢ paises eee 
Subacute syphilitic orchitis. Increase of stroma ..................- 


Chronie syphilitic orchitis. Complete fibrosis of testis, hypertrophy of 
Anterstrbial g Cells weer ieee jackals et carat eter enero eee erecta rane 


Syphilitic infiltrations in prevertebral tissues ...................... 


Small syphilitic infiltrations of plasma-cells around nerve trunk and 
vessels \In. root, .of ¢mesentery | o\2s0 -6s)-n) bes eso ee 


Section through the ductus cochlearis (Retzius) showing the generally 
accepted structurel of ithencochleame tas t-tests einen net 


Foot-plate of stapes (s) uninjured from case of concussion deafness .. 
Section through cochlea from case of concussion deafness ...........- 
Section through Ductus Cochlearis, from case of concussion deafness. 
Semi-circular canal and ampulla. From case of concussion deafness. . 
Macula Acustica (M. A.) of utricle, from case of concussion deafness. . 
Nerves passing through lamina cribosa at depth of internal auditory 


HUSA es hidcignao Seno micse.cuBG se bbObgCodoscniobaqoongessuice 
Same as Fig. 7 (X 130.) C. N. = Cochlear nerve, G. = ganglion at 
base of modiolus, Hey——shemonnhapeisae ities ae 
The distribution of intelligence ratings for typical army groups...... 


Relation of intelligence ratings to the success of students in officers’ 
training’ ;schoole'<asivi iy chistes 2 Re Se ee 


Relation of intelligence ratings to success of students in non-commis- 
sioned ‘officers’ ‘training’ schools 022. 10.75 sq cris ela es 


Proportions of low, average and high grade men in various important 
ALIAY, STOWE 05.0 s\sis:n: 9 oy nalts wing css sede ahs tal orto Eanes eer merce 


Median intelligence (scores) for groups of soldiers designated as 
“best,” “good,” “fair,” “poor,” and “very poor” with respect to 
MULEATY: (USCLULMESS 2 55/2 oshe, c.2ie os, He es setae sates Piste cele ane 


Distribution of intelligence ratings of “best” and “poorest” privates. 
Distribution of intelligence ratings for men of low military value.... 


Inequality of companies in an infantry regiment with respect to in- 
tellectuall/stren goth?) sn): areata eyatels: yeu sereaelencrerepeictere terete eee 


Inequality of regiments with respect to mental strength............ 


Difference appearing in the distribution of intelligence ratings in 
eighteen officers’ -training’ schools) /....<.(.5¢..4.. =: apeleeee 


The distribution of intelligence ratings for officers of different arms 
OL. “Che SERVICE « je jas 55s 5 e sup fala aeaieo isinyade in Ae lalate abaete a Seno ee 


Diagram of a scheme of mental classification in relation to differen- 
tiation of educational treatment. ..............-5 dene ensue 


Relation of intelligence ratings to occupations in the United States 


PATTI 06 5S ipis cs fan eluaehe’ Sonya e:'s ule SURES came ar Sle ee 
Relation of intelligence ratings to occupations in the United States 
yc) rer ee ron rete Mahe WEA AS NCS A SS Awa id Saline 
Diagrammatic representation of factors concerned in adjustments of 
hilman: ‘machine 00. a. se esc g aie Oar nee ee ere 


TRAUMATIC SHOCK * 


DR. W. T. PORTER} 


Harvard University. 


I 


HE history of traumatic shock during the past thirty years 
has been marked by hypotheses that have caused much 
confusion. These hypotheses give as the cause of shock (1) the 
exhaustion of the vasomotor centre; (2) the excitation of sen- 
sory nerves; (3) a hydrostatic fall in blood-pressure; (4) vibra- 
tion injuries; (5) direct wounds of the vasomotor apparatus; 
(6) hemorrhage. Some of these ideas are erroneous; others are 
imperfectly grasped. 

The hypothesis that shock is caused by exhaustion of the 
vasomotor centre, for long a mere speculation, was given finally 
a serious position by two much quoted studies. One of these 
studies was by a surgeon who enjoys deservedly a great reputa- 
tion; the other by physicians not less celebrated. Both were 
grounded on failures. The surgeon failed to obtain a satisfactory 
reflex rise of blood-pressure on stimulation of afferent vasomotor 
fibres in animals with experimental shock—the physicians in ani- 
mals with diphtheria. 

Against the first of these negative results, I brought the 
following positive experiment : 

At 9.15 a.m. on September 24, 1903, the stimulation of the 
depressor nerve caused the blood-pressure to fall from 67 to 
36 mm. Hg, a fall of 46 per cent. The animal then lay for eight 
hours with exposed intestines painted with nitric acid. All the 
signs of shock were present. The rectal temperature was 11° C. 
below normal. At the end of these eight hours of shock, at five 


* Delivered October 27, 1917. 

+ This review of my researches on shock has been brought to date 
(December, 1919) by including certain experiments made after this Harvey 
lecture was delivered. 

21 


22 HARVEY SOCIETY 


o’clock in the afternoon, the stimulation of the depressor nerve 
caused the blood-pressure to fall from 40 to 22 mm., a fall of 
45 per cent.* 

Since the depressor nerve can affect the blood-pressure only 
through the vasomotor centre, it is clear that the vasomotor 
centre is not exhausted in shock. 

Nor is it exhausted in the last hours of infectious diseases 
such as diphtheria and pneumonia. 

On December 20, 1913, the central ends of the divided vagus 
nerves were stimulated in a cat near death with pneumonia. 
The blood-pressure fell from 100 mm. Hg to 65 mm. This is the 
usual depressor fall obtained in normal animals. 

January 2, 1914, the central end of the sciatic nerve was 
stimulated in another cat near death with pneumonia. The 
blood-pressure was at 55 mm.; it rose to 125 mm., an absolute 
rise of 70 mm. This was even more than the usual normal rise.* 

A rabbit weighing 1400 grams received in the ear vein .004 c.c. 
diphtheria toxin at 1.05 p.m., January 18, 1914. The morning 
of January 20, the rabbit seemed listless. It was placed on a table 
and observed continuously from 9 a.m. As the day wore on, 
the rabbit could not hold up his head, nor regain his feet when 
laid upon one side. Finally, about 3.15 p.m., he lay prone, the 
head stretched on the table, and the respiration feeble and 
labored. At 3.30 he seemed so near death that he was placed 
on the operating board. Death at once followed; there was no 
corneal reflex, no respiration, no heart beat, the carotid artery 
seemed empty, and the rectal temperature was 32° C. The 
rabbit was completely insensitive. It was quickly tracheoto- 
mized and artificial respiration was established. Warm normal 
saline solution was injected into the external jugular vein. The 
heart began to beat, though feebly, scarcely raising the writing 
point of a membrane manometer, completely undamped. The 
carotid pressure rose to about 80 mm. Hg. Both vagi were now 
cut and the depressor nerve was stimulated. 

The carotid pressure fell on stimulation from 80, 70, and 
72 mm. Hg to 52, 40, and 45 mm., respectively; an absolute fall 
of 28, 30, and 27 mm. Hg, and a percentile fall of 35, 43, and 38.* 


TRAUMATIC SHOCK OS 


Thus, normal reaction from the vasomotor centre was obtained. 

This animal was not simply ill with diphtheria; he had 
died of it. 

The vasomotor centre is therefore not exhausted in shock. 
Nor is it exhausted in the infectious diseases, such as diphtheria 
and pneumonia, 

In truth, it is doubtful if the vasomotor centre can be 
‘* exhausted,’’ provided it continue to receive its minimwn 
blood supply. 

On February 9, 1909, at 10 a.m., I stimulated the depressor 
nerve with a current of 1000 Kronecker units; the blood-pressure 
fell 35mm. Hg. The stimulus was repeated at frequent intervals 
throughout the day. At 5.40 p.m. the same stimulus caused the 
blood-pressure to fall 42 mm. Hg. The observation could prob- 
ably have been continued some hours longer.* 

Experimental evidence shows that failure of the vasomotor 
centre is due to anemia rather than to stimulation. If the 
blood-pressure in the nutrient capillaries falls below the critical 
nutrient level—a very low level—the vasomotor cells are at once 
affected. Bulbar anemia may be a consequence of prolonged 
shock, especially when the bulb is allowed to be higher than the 
trunk—for a man with shock is a gravity animal and his cerebral 
circulation then depends chiefly on small differences in hydro- 
static level—but an injury after shock is not to be confused with 
au injury causing shock. 

In short, exhaustion of the vasomotor centre is a taking 
phrase, but it is nothing more. 


IT 


A second heresy of recent years was the notion that shock 
ean be produced by the stimulation of nerves. This idea was 
overthrown by experiments published in 1907. 

In 1905, 1906, and 1907, the central ends of the sciatic nerve, 
the brachial nerves, the posterior spinal roots, the lumbar branches 
of the spinal nerves, the great splanchnic, the eceliae ganglion, 
the superior mesenteric plexus, the gastric branches of the vagi, 
and various parts of the abdominal sympathetic, were stimulated 


24 HARVEY SOCIETY 


for hours with strong induction currents, in animals anesthetized 
with ether. 

These numerous stimulations uniformly failed to give a signifi- 
cant fall in blood-pressure.*® 

An apparent exception must be taken to the conclusion that 
shock cannot be produced by the stimulation of nerves. It 
relates to a condition of great importance, namely the sensitization 
of the vascular apparatus. 

My first encounter with this condition was in 1894, where I 
found that ligation of the descending branch of the left coronary 
artery caused fibrillation in 64 per cent. of the dogs to which 
morphine and curare had been given and in only 8 per cent. of 
those in which morphine and curare were not employed.*° 

In working with the isolated heart, and especially with strips 
of ventricular muscle fed through a branch of the coronary 
artery, 1 have repeatedly been able to notice instances in which 
stimuli ordinarily limited in their results produced on these 
occasions profound and far-reaching reactions. Thus, in 1905 
I found that when the auricle of the tortoise heart is stimulated 
with a short series of induction currents at the rate of one a 
second, a tonus contraction is called forth. This contraction lasts 
usually about thirty seconds. Im one ease a similar stimulus 
caused a very strong tonus contraction lasting 64 minutes.’ 

In 1906, a rat was etherized and the carotid pressure written 
with a membrane manometer. A small quantity of very dilute 
curare solution was injected slowly into the external jugular 
vein. The blood-pressure was now 70mm. The difference between 
diastolic and systolic pressure was about 20 mm. On stimulating 
the brachial nerves the individual heart beats almost disappeared 
from the curve, the blood-pressure fell 20 mm., and the writing 
lever traced an almost unbroken line. On injecting warm saline 
solution, the heart improved and the difference between systolic 
and diastolic pressure rose to about 15 mm. An effort was now 
made to stimulate the central end of the already divided sciatic 
nerve. When the severed nerve was gently raised upon a thread, 
the heart again failed, and the above phenomena were repeated. 
Thirty-six minutes later, a saline injection was given, the heart 


TRAUMATIC SHOCK 25 


gradually recovered, the blood-pressure rose to 110 mm., and 
stimulation of the brachial and sciatic nerves caused a-rise of 
about 20 mm. Hg.® 

The following case occurred in the practice of a well-known 
surgeon. I quote his words: In operating on a sarcoma, ‘‘a 
mass of glands in the neck had been freely exposed by the high 
incision and was readily enucleated. Several large branches of 
the brachial plexus, however, were spread out over the growth 
and a secondary division of this portion consequently was necessi- 
tated. When this was done, the patient’s radial pulse immediately 
became impalpable. It continued thready and almost imper- 
ceptible during the remainder of the operation, which was rap- 
idly completed, and for almost twenty-four hours afterward.’’® 

Cases of persistent inhibition of the heart, similar to the one 
just cited, are often mistaken for true shock. 

These instances all relate to the heart. Since the heart is a 
modified blood-vessel, the sensitization of the heart would lead 
us to expect sensitization of the arteries. I have at present no 
experimental evidence of this. Yet there is clincial evidence of 
prolonged contraction or relaxation of the blood-vessels following 
stimuli ordinarily uneventful. Such is the tonie arterial contrac- 
tion in certain migraines, and the long relaxations in urticaria. 
But the evidence in hand, unquestionable for sensitization of the 
heart, does not as yet warrant the dogmatic inclusion of sensitiza- 
tion of the arteries among the sources of confusion in shock. The 
evidence does, however, point strongly in this direction. 

I do not diseuss at length the possible causes of sensitization, 
because such a discussion would be at present too speculative. 
There is here a great and fruitful field for research. 


III 


A third source of confusion is hydrostatic lowering of the 
blood-pressure. A simple hydrostatic fall of blood-pressure is not 
shock. When the intestines are exposed, the largest vascular 
area in the body dilates and the arterial pressure falls. If this 
low pressure continue long enough to impair the nutrition of 
the vascular apparatus, shock may occur. An admirable example 


26 HARVEY SOCIETY 


of the hydrostatic fall of blood-pressure is seen when a spinal 
injection of novoeain reaches the splanchnic nerve-cells. The 
arterial pressure falls to the shock level, but the fall is usually 
too transitory to cause shock.?® 

The shock so often observed in abdominal injuries is unques- 
tionably frequently due to this hydrostatic fall. The vasomotor 
apparatus of the intestines is remarkably sensitive to an invasion 
of the peritoneal cavity. When the vessels of this great area 
have dilated and the blood-pressure has fallen profoundly, the 
stimulation of the depressor nerve has little or no effect. What 
more natural than to conelude that the vasomotor centre is then 
exhausted? The following experiment shows what a pit here 
yawns for the unwary observer. 

On October 26, 1899, both splanchnic nerves were severed in 
a rabbit. Stimulation of the depressor had little or no effect 
upon the blood-pressure. The carotid blood-pressure was now 
raised to 75 mm. He by injecting normal saline solution, where- 
upon a renewed stimulation of the depressor nerves caused a 
fall to 88 mm. (49 per cent.) ." 

In these abdominal cases there is again the danger that cause 
and effect may be confused. If the dilatation of the splanchnic 
vessels finally brings the nutrient level of the vasomotor cells 
below the irreducible minimum, the vasomotor cells will be 
injured, but their impairment will be primarily an effect and 
not a cause. 


TV 


A fourth example of loose thinking is the confusion of vibra- 
tion injuries with shock. 

In experiments 3 and 21, performed in 1904 and 1907, a heavy 
blow on the skull caused the blood-pressure to fall 70 per cent. In 
five observations, the level reached by the descending pressure 
averaged 33 mm. Hg.'* This is about the level to which the 
blood-pressure sinks after the destruction of the spinal cord. 

Exploding shells, particularly those that burst within a 
dugout, sometimes shake the vasomotor cells so violently that their 
control of the blood-pressure is greatly impaired. Many such 
cases were communicated to me in 1916 at one of the great hos- 


TRAUMATIC SHOCK 27 


pitals in Amiens. The recovery from this shaken or shattered 
state depends naturally on the extent of the damage to the vaso- 
motor cells. In the experiments of 1907, the blood-pressure rose 
again in a few moments. In the soldiers at Amiens, recovery 
required in some cases several days. It is these vibration injuries 
which make shock in civil practice so difficult of study. 


Vv 

Vibration injuries may no doubt at times be severe enough 
to rank as wounds of the vasomotor apparatus, but it is convenient 
to reserve the latter rubric for cases in which the vasomotor cells 
or the paths connecting them are directly damaged by foreign 
bodies. When a shell fragment eniers the abdomen, such damage 
can never be excluded. It is, therefore, a constant source of error 
in any hypothesis of shock after abdominal wounds. 

No satisfactory instance of surgical wounds of the vasomotor 
cells or tracts can be presented here, but I wish to say a few words 
regarding experimental injuries in the bulbar vasomotor region. 
Annually, for many years, I have demonstrated an experiment 
not hitherto published. It consists in burning away parts of 
the floor of the fourth ventricle in the rabbit. A hole about one 
centimetre in diameter may be made in the region of the vasomotor 
centre without a significant fall in the blood-pressure. Some of 
the vasomotor cells certainly escape destruction, in spite of the 
wide ruin, and these cells continue to function successfully within 
a millimetre or two of the black calcined hole left by the destrue- 
tion of their companions. They are not inhibited. 


Vi 

I approach the subject of hemorrhage with a sigh. It seems 
almost hopeless to combat the prejudice of the profession with 
regard to hemorrhage in relation to shock. Military surgeons 
may be as invulnerable as those in civil practice. I remember 
a surgeon general in whose mental armor the high explosives 
of physiology did not leave a single dent. In his own trenches 
he was an excellent officer, but he was not good at going over the 
top. He had seen thousands of wounded, he knew that shock 
appears once in every hundred casualties, but he had not noticed 


28 HARVEY SOCIETY 


that among the other ninety-nine there were practically always 
men who had bled more than the shocked but who nevertheless 
had no shock. Every surgeon knows that from a pint to a quart 
of blood can be taken from a healthy young man without serious 
results. Every surgeon also knows that on the operating table 
the loss of a small quantity of blood may sometimes cause shock. 
Here is the source of the confusion. 

The relation of hemorrhage to shock is too complicated to be 
treated here, despite the generous limits of your patience. But 
five important facts may be offered as food for reflection: (1) 
Upon the field of battle hemorrhage is not a frequent cause of 
shock. (2) Above the critical level of the blood-pressure, blood 
may be drawn by the hundred cubic centimetres without shock. 
The ‘‘ critical level ’’ of blood-pressure in shock is that point 
below which the blood-pressure will not usually rise without assis- 
tance. With the Vaquez instruments used by me in France, the 
normal diastolic pressure was 97, and the critical level about 60, 
i.e., between two-thirds and three-fifths of the normal. Certainly, 
the normal diastolic pressure varies with the instrument employed. 
It is possible that the critical level shows a similar variation. 
(3) At the critical level, the loss of 50 cubic centimetres may be 
vital. (4) If the blood-pressure is at the critical level, the arteries 
are partly empty; to empty them still further may be mortal. 
There is, therefore, in these conditions a great difference between 
bleeding from an artery and bleeding from a vein, especially an 
abdominal vein. (5) Respiratory and nutritive metabolism, par- 
ticularly of the higher nerve-cell units, may be so affected that 
50 eubie centimetres of blood will only do the work of ten. The 
loss of blood is then a grave disaster. For the critical level 
varies with the condition of the nerve-cells and other tissues. 
A blood-pressure high enough to maintain a sufficient nutrition 
in normal bulbar nerve cells is too low to maintain life in cells 
which have already suffered from malnutrition. In that case a 
blood-pressure raised by the surgeon to a point above the usual 
eritical level will shortly sink again. Hence the importance of 
frequent readings of the blood-pressure until shock patients are 
clearly out of all danger. 


TRAUMATIC SHOCK 29 
VII 


Some of the sources of confusion which I have enumerated 
are especially operative in civil practice. In railway collisions, 
automobile accidents, falls from buildings, and in many other 
casualties brought to the civil hospitals, it is often impossible 
to exclude direct violence to the vasomotor cells. The perfect 
material is the young soldier, not too close to the exploding shell, 
wounded by a hot steel fragment, and seen within two hours, 
before infection has blurred the picture. There are great advan- 
tages in the laboratory study of shock controlled by such obser- 
vations on the battlefield. 

At the request of the Rockefeller Institute for Medical Re- 
search, I went to France to do such work. 

My first effort was to discover whether the conditions under 
which men live in the trenches predispose to shock. At Nieuport, 
on the Yser, I lived with the third regiment of the French, which 
there held the line. The effect of what is called the habitual 
bombardment was carefully observed. I went into the trenches 
to measure the blood-pressure. The trenches lay on the other side 
of the Yser. We crossed a pontoon bridge. Spare pontoons were 
anchored in the river, in case the bridge should be struck by a 
shell. We entered a communication trench. Here and there 
were signs, ‘‘Obligatory,’’ ‘‘Forbidden,’’ ‘‘In View of the 
Enemy,’’ where men had been killed often enough to show that 
a German sniper had marked that particular spot. 

Our trench is narrow and it is deep enough to protect the 
head. It winds through fields covered with long grass and 
poppies. These overhang the edge and brush our faces. The 
bottom of the trench is covered with a slatted walk about eighteen 
inches wide. We meet great pots of hot food, borne on a pole 
hung between two men. Happily, we are not fat; we slide by 
without being burned. 

Soon we are in the lines. Here are real defensive works, 
heavily timbered, and with space for many men. At frequent 
intervals are the burrows in which the men live. Telephone wires 
run near the bottom of the trench, on the side next the enemy; 
they are fastened to the earth with long wire staples. From time 


30 HARVEY SOCIETY 


to time we peep through an observation hole, but we do not stand 
more than two minutes in any one spot; always there are aero- 
planes and tower observers on watch, and we may get a shell. 
The shells are now flying over us, with a noise like the tearing 
of a great sheet. Presently, we reach the point nearest the 
enemy. It is near indeed; about the length of a tennis ground. 
I look through a periscope and there, as clear as in a clean 
looking-glass, are long mounds of earth and sandbags—the Ger- 
man ‘‘trenches,’’ one hundred and fifteen feet away. Apparently 
deserted, absolutely silent, they le heavily on the unkempt 
fields, mile upon mile. Their sinister quiet speaks louder than 
the screaming shells. 

The poilus are delighted with the blood-pressure apparatus. 
It is a game. Their faces are wreathed with smiles. They take 
oft their tunics, roll up their sleeves and are proud to be told 
they are ‘‘normal.’’ We keep our voices low and hug the front 
wall of the trench, but otherwise we might as well be in the 
Boulevard des Italiens, though now I think of it, that also is a 
dangerous place. 

The war at Nieuport was all in the day’s work. After two 
years, the daily round was the daily round, and it was noth- 
ing more. The habitual bombardment did not affect the 
blood-pressure. 

In this first summer, in spite of every effort, I sueceeded only 
in living under the habitual bombardment. In my second sum- 
mer, fortune favored me greatly. I took part in one of the battles 
at the Massifi de Moronvillers, under artillery fire said to be 
more violent than that in the great drive at Verdun. 

On May 22 I found myself about 300 metres from the crest 
of Mont Blond, one of the low summits in the Massif de Moron- 
villers, a long ridge which commands the plain beyond Chalons- 
sur-Marne. The strategic importance of this ridge is very great. 
In April it was still held by the enemy. The French offensive 
against the Massif began April 16. Owing probably to insuffi- 
cient artillery preparation, this first attack failed; little or no 
ground was gained, and the losses were very heavy. One ambu- 
lance, of which I knew, prepared for 3000 wounded ; they received 


TRAUMATIC SHOCK 31 


18,000. Since that date, the French had won all the ridge except 
that part above my station. On May 25, the French finished the 
job. It was a beautiful and interesting operation. I quote from 
a letter written on my knee during the last hours of the battle: 

‘* My poste de secours was dug by the Germans. It consists 
of a cellar about 8 by 10 feet, and 6 feet deep. The roof is proof 
against fragments, but not against direct hits.* A ladder leads 
to a cave, 7 by 8 feet, the floor of which is 15 feet below the 
surface of the ground. 

‘‘Yesterday afternoon, at three o’clock, the French began 
to prepare for storming the crest of Mont Blond—the white 
ridge just before my eyes. In an hour the Germans made up 
their minds that an assault was intended. The artillery fire, 
which was continuous before, now swelled to a torrent. Each 
side placed a barrage. The German barrage covered the little 
valley behind the crest. We were on the slope nearest the crest. 
The bottom of the valley was about 150 metres from us, conse- 
quently we were within the barrage. Between four o’clock and 
midnight, more than 10,000 heavy shells fell within a radius of 
1000 feet from our cave. I took the count from time to time 
with my watch. We were driven at once into our deeper refuge. 
The little stuffy hole was packed with men, knee to knee; stretcher- 
bearers, surgeons, my orderly, and myself. The three surgeons 
played bacearat. I sat on the edge of a plank and watched the 
game. We had an acetylene light. The shells fell all around, 
shaking the place and repeatedly putting out the light. The 
noise was remarkable. The air was filled with screams, hisses, 
and loud reports, followed by the slide of masses of earth. Many 
shells were so close that a strong push of hot gas was felt. At 
six o’clock the Moroccans took the ridge by storm. At midnight 
the bombardment slackened but did not cease. With the dawn 
the wounded came in a stream. They were laid in the upper 
room. The wounds were of all sorts. The worst was a completely 
erushed jaw, in a man with a dozen slighter wounds. One man 


*Two days after my departure, a shell entered the poste next mine, 
killing two surgeons and five of the stretcher-bearers. 


32 HARVEY SOCIETY 


had a hole through the temple into the brain—a hole two inches 
long and half an inch wide. Another had a smashed leg, a bad 
head, and in the thigh a wound the size of a small orange. I 
watched the blood-pressure carefully. Imagine a cellar with a 
plank floor covered with clay an eighth of an inch deep. A hor- 
rible tub full of bloody dressings. Two stretchers on the floor. 
Ten men in a space of 8 by 10 feet, shoulder to shoulder. Two 
candles. Sand-bag walls. The roof so low that I am always 
hitting my helmet against the beams. The air thick with the 
smell of blood, sweat, alcohol, iodine, vomit. Everywhere a smear 
of clay—the chalky clay of Champagne. The continuous scream, 
roar, crash of shells. A rain of small stones, dirt, pieces of steel. 
Every few seconds a profound trembling, as a shell strikes closer. 
Four men passing bandages and iodine in the half light, over 
backs, under arms. The eries of the wounded. The litter of 
bloody garments. The fresh cases, obliged to lie outside, under 
the fire, until the room is cleared. The brancardiers, bent under 
the load of the stretcher, slouching off with the dressed wounded. 
The dawn, the failing moon, the thick vapors and acrid stench 
of the barrage. The blasted hillsides smoking under the continual 
rain of death. Countless fresh shell holes all around us. The 
graves reopened. 

‘‘They are bringing down the dead. They lie sprawling on 
the slope just below us, half-sewed up in burlap, like pieces of 
spoiled meat.’’ 

In spite of these conditions, of which I have made a faithful 
report, the blood-pressure remained normal, not only in the 
unwounded men, but also in the wounded. Yet many of the 
wounds were grave. 

My previous observations at Nieuport, at the Mort Homme, 
and on the Somme, showed that the blood-pressure is not lowered 
under the habitual bombardment. These new observations show: 
(1) That the blood-pressure is not lowered under a barrage fire, 
said to be as violent as the worst in the great drive at Verdun; 
and (2) that shock probably is not immediate, but develops some 
time after the wound. 


TRAUMATIC SHOCK 33 


Vill 


In 1916, while stationed at the celebrated hospital in La 
Panne, I proposed to Doctor Depage the systematic treatment 
of shock upon a new plan.® 

It is true that the remedies employed had long been known; 
they were the inclined position, heat, and certain intravenous 
injections, such as normal saline solution and adrenalin. But 
up to this time, so far as I am aware, these remedies had not been 
based on systematic, repeated measurements of the diastolic 
blood-pressure. This is a matter of great importance. Treatment 
not based on repeated readings of the blood-pressure is not intelli- 
gent and it may be harmful. I found in the hospitals that the 
blood-pressure was not systematically taken—usually it was not 
taken at all. I did not see a single case in which the diastolic 
pressure had been observed. Now in shock the heart beats feebly. 
The systolic pressure falls more than the diastolic pressure falls. 
Conversely, when remedies are used they often raise the systolic 
pressure more than they raise the diastolic pressure. 

Conclusions drawn from the systolic pressure may easily err 
15 millimetres or more. But in shock the blood-pressure is at a 
critical level; a change of even 15 millimetres may be a matter 
of life or death. The error in using the systolic instead of the 
diastolic pressure may therefore do much harm. 

Also new, to the best of my belief, was the principle that in 
the treatment of shock by injections, the diastolic pressure should 
not be raised to normal but only to a height 15 or 20 millimetres 
above the eritical level. I have seen the hasty injection of a litre 
of normal saline raise the pressure suddenly to 190 millimetres. 
Such a sudden rise is not free from danger. 

The essential points in this method of treatment are: (1) that 
the hospital shall be within a very few miles of the first line; 
(2) that the patient shall be taken directly from the ambulance 
to the trained shock specialist—minutes are precious; (3) that 
the trained observer shall not leave the case until the patient 
is out of danger; (4) that the treatment shall be based on repeated 
readings of the diastolic blood-pressure; (5) that the aim shall 

3 


34. HARVEY SOCIETY 


be to keep the blood-pressure 10 to 15 millimetres above the 
critical level. 

Here I must again declare, even at the risk of wearying you, 
that an understanding of the critical level is of the first impor- 
tance in the study and treatment of shock. If the blood-pressure 
just touches the critical level, a difference of 10 millimetres of 
mercury may be the difference between life and death. A few 
millimetres above this level, recovery will usually occur spon- 
taneously; a few millimetres below, death will follow unless 
skilled aid be at hand. It follows from this vital fact: (1) that 
procedures which at ordinary blood-pressures are not harmful, 
or are but slightly harmful, may kill the patient at the critical 
level; (2) remedies which raise the blood-pressure but 10 or 15 
millimetres will save the patient when this rise carries the blood- 
pressure from just below to just above the critical level. 

It is my experience that when the principles here set forth 
are neglected, the majority of the shock cases die. When the 
method is carried out with the necessary intelligence and devo- 
tion, by far the greater number get well. 


Ix 


In my first summer in France, in 1916, I was sent, among other 
places, to the Carrel Hospital in Compiégne. The surgeons there 
informed me that shock occurred most frequently after shell 
fracture of the femur and after multiple wounds through the 
subeutaneous fat. I have been able to verify this statement from 
my own observations at Mourmelon-le-Petit and elsewhere. 

Mourmelon-le-Petit is a small village in the plain of Chalons- 
sur-Marne. It is the seat of an ambulance de triage—a sorting 
station. To this station, which is within shell-fire of the German 
lines, were brought all the wounded from a number of postes de 
secours on the Massif de Moronvillers. At this triage, I saw 
more than one thousand freshly wounded. Aside from a few 
abdominal eases, in which there was probably direct injury to the 
vasomotor nerves of the abdominal vessels, the only shock was 
that caused by shell fracture of the femur or by multiple wounds 
through the subeutaneous fat. I do not make this statement to 


TRAUMATIC SHOCK 35 


exclude other causes of wound shock but to make clear the great 
frequency with which wound shock follows the two con- 
ditions named. 

In multiple wounds through the subcutaneous fat and in shell 
fracture of the femur, fat embolism is known to be present. 

On February 2, 1917, I proved that fat embolism was a cause 
of shock. Fat embolism had been studied experimentally for 
two and one-half centuries. The following facts had been estab- 
lished: (1) The fat in bones is in a condition peculiarly favorable 
to its entrance into the blood-vessels after fracture. (2) Large 
quantities of fat have repeatedly been found in the blood-vessels 
after fracture. (8) The entrance of fat into the blood-vessels 
begins immediately after the wound. (4) Frequently, if not 
always, there is fat embolism of the brain and other organs. (5) 
These facts have often been observed in men; they are equally 
true of animals in which fat is injected into a vein. 

Notwithstanding the very numerous clinical and pathological 
studies of fat embolism, there has been, heretofore, no attempt to 
demonstrate by measurements of the blood-pressure a causal rela- 
tion between fat embolism and the shock of the battlefield. Yet 
the following experiments will show that this relation can hardly 
be denied.** 

In the first experiment, February 2, 1917, about 3 ec. 
of the officinal emulsion of olive oil was injected slowly 
into the jugular vein. Very soon there was a fall in the 
carotid blood-pressure. It was recorded by a membrane mano- 
meter, which also recorded the force and frequency of the ven- 
tricular contractions. In two further experiments thick cream 
was used, and in the remainder the fat was neutral olive oil. 
The injection of from 2 to 4 c.c. of olive oil in a large cat has 
never failed to produce a fall of blood-pressure to one-half or less 
the normal level. Thus, on February 5, the diastolic blood- 
pressure fell quickly from 140 to 65 mm. Hg, and later to 
about 40 mm. In this cat the tracing showed that the fall in 
blood-pressure could not be ascribed to changes in the heart 
beat. The same is usually true when the injection is not made 


36 HARVEY SOCIETY 


too rapidly. The clinical picture is essentially similar to that 
of traumatic shock in human beings. 

When these experiments were first published efforts were 
made to discredit them as simple cases of embolism of the lungs. 
No one who had made the experiments would be likely to make 
this criticism. The symptoms of clinical pulmonary embolism 
are rarely present. Still more rare is failure of the heart from 
embolism of the coronary arteries. 

Embolism of the lungs is entirely excluded by the following 
experiments, which further provide an explanation of the mechan- 
ism of this variety of shock. 

July 29, 1918, a rabbit weighing 2 kilos was lightly eurarized 
and artificial respiration was begun. The carotid diastolic blood- 
pressure was 160 mm. He. The subclavian artery was ligated at 
its origin from the aorta and also at a point beyond the origin 
of the vertebral artery. The internal mammary branch was 
ligated, but two muscle branches were left open. By means of a 
cannula in the subelavian, one-fifth cubie centimetre of neutral 
olive oil was injected. Part entered the muscle branches and 
part the vertebral. In a few moments, the blood-pressure began 
to fall. In fifteen minutes, the diastolic pressure had fallen 
to 40 mm.*® 

The outstanding fact discovered in this and many similar 
experiments is that a minute quantity of fat will produce the 
characteristic fall in blood-pressure, and the concomitant symp- 
toms of wound shock, whenever the blood supply to the vasomotor 
region is interrupted by the plugging of its capillaries. In the 
experiment cited, the quantity of oil injected was one-tenth 
cubic centimetre per kilo. There is every reason to believe that 
less than this small quantity can be used with success. More- 
over, a part of this 0.1 ¢.c. per kilo was lost in the unligated 
branches of the subclavian artery; another part was lost in 
filling the subclavian and vertebral arteries between the point of 
injection and the bulbar cells; finally, some oil necessarily found 
its way into the capillaries supplying portions of the bulb other 
than the vasomotor region, for the vasomotor cells occupy but a 
very small fraction of the bulb. It follows that the amount 


TRAUMATIC SHOCK 37 


of oil actually used to produce shock in this experiment was 
exceedingly small. 

It must at once be recognized that the quantity of oil with 
which we have produced experimental shock by embolism of the 
vasomotor centre is far less than the amount which has repeatedly 
been found in the blood-vessels of human beings after fracture 
of the femur. 

A microscopic examination of sections through the vasomotor 
region, stained with Sharlach R, abundantly supports the con- 
clusion that minute quantities of fat may produce shock. When 
the amount of oil injected is relatively large (for example, in the 
eat, 0.4 ¢.c. per kilo) fat is readily found in many sections. When 
the fat injected is as little as 0.1 ¢.c. per kilo of body weight, 
the stopped capillaries are hard to find. Yet the physiological 
evidence is beyond question. The injected fat has gone only to 
the brain; all parts of the brain can be cut away without lowering 
the blood-pressure, if only the vasomotor centre be respected; 
hence the vasomotor region in our present experiments must 
have been injured. 

The demonstration of fat embolism of the vasomotor centre 
as a cause of wound shock is as follows: (1) Excluding abdom- 
inal wounds, in which a hydrostatic fall in blood-pressure may 
follow an invariable local injury to the largest vascular area 
in the body, the most frequent causes of shock in wounded sol- 
diers are shell fracture of the femur and multiple wounds of 
the subeutaneous fat. (2) In fracture of the femur and in mul- 
tiple wounds of the subeutaneous fat, considerable numbers of 
fat globules are found in the blood. (8) A quantity of fat much 
smaller than that known to circulate in the blood in the injuries 
most often followed by shock will produce shock when the 
nutrient vessels of the vasomotor region are stopped. 

It has seemed worth while to prove by two other methods 
that fat embolism shock cannot be explained by embolism of 
the lungs.?® 

The first of these methods produces shock by injections through 
the peripheral end of the carotid artery. This may excite sur- 
prise. Not long ago an experimenter of repute strengthened, as 


38 HARVEY SOCIETY 


he thought, the case for embolism of the lungs by failing to 
produce shock by the injection of oil into the peripheral end 
of the carotid artery. His failure to lower the blood-pressure 
by embolism of the brain seemed to him to leave the field clear 
for embolism of the lungs. 

The unsuccessful experimenter could hardly have forgotten 
that the vasomotor region is supplied by the basilar artery and 
not by the carotid. Probably he reasoned that the circle of 
Willis is an open road through which oil injected into the 
peripheral end of the carotid would easily reach the nerve 
centres in the bulb. That the circle of Willis is a generous anas- 
tomosis cannot be disputed. But the direction taken by a drop 
of oil entering this circle will not finally depend on the anatomi- 
eal relations. The vascular pressure is the warder of these gates. 
The circle of Willis is a balanced pressure ring, in which the 
pressure from the basilar area contends with that from each 
carotid area. So clear is this, that experiments would seem 
superfluous, were it not for the peril inherent in @ priori reason- 
ing. But the experiments are not less clear. 

If 1 ¢.. of neutral olive oil is injected into the peripheral 
end of one carotid in a eat weighing 4 or 5 kilos (both vertebrals 
and the other carotid artery being free), shock rarely follows. 
Obviously, the oil enters parts of the brain anterior to the bulb 
and does not plug the vessels in the vasomotor region. If, on the 
contrary, a clamp be placed temporarily (4 minutes) on one 
carotid while the oil is passing through the other carotid, shock 
usually does follow. 

Like the injection of oil into the vertebral artery, this experi- 
ment is doubly destructive against the hypothesis that shock 
is due to embolism of the lungs; for it leaves the lungs free and 
produces shock by the embolism of a particular region of the brain. 

The second of the two new methods compares two procedures, 
A and B, in each of which 0.5 ¢.c. of neutral olive oil per kilo 
of body weight is injected into the external jugular vein of eats. 
The rate of inflow is about 1 e.¢e. in 15 seconds. 

In series A, both carotid arteries were closed but both verte- 
bral arteries were free. Shock usually took place. 


TRAUMATIC SHOCK 39 


In series B, both carotid arteries were free but both vertebral 
arteries were closed. Shock seldom took place. 

Yet the lungs were emobilized equally in both series. In fact, 
the method in series A was identical with that in series B, except 
that in A the fat passing through the lungs into the general 
circulation could reach the brain through the vertebral arteries, 
whereas in B it could enter the brain only through the carotid 
arteries. Obviously, the state of the lungs being identical in 
both series, the difference in the result of the two series must 
be due to a factor outside the lungs. The experiments point 
clearly to embolism of the vasomotor region as the cause of 
the shock observed in series A, in which the vertebral arteries 
were open, 

The three methods detailed above lead to the same conclusion. 
Fat embolism shock is not explained by embolism of the lungs. 


x 


In dealing with surgical shock, it should always be borne in 
mind that life and death here depend on a relatively slight 
change in the arterial pressure. The diastolic pressure may fall 
from normal to the critical level with little or no danger—a 
further fall of even 10 millimetres may be fatal, unless skilled 
assistance be at hand. Conversely, in dangerous shock, lifting the 
diastolic pressure 15 millimetres will save life, as a rule. 

I have elsewhere insisted on the importance of the inclined 
position. In shock, the sufferer bleeds into his own abdominal 
veins. They take the blood from the heart and brain. The 
inclined position feeds the heart and brain by gravity. But 
gravity is slow and death draws swiftly on. Time may be gained 
by adrenalin and by injecting normal saline into the veins. Both 
tend to fill the heart; one by narrowing the arterial outlets, the 
other by adding to the volume of the blood. Neither is a logical 
remedy, for neither brings back the blood from the congested 
veins into the arteries and thus into the feeding capillaries. The 
veins store but do not feed. We should pump the blood from 
these fatal wells into the heart. Such is the logical ideal. 

The thoracic pump satisfies this ideal.1* 


40 HARVEY SOCIETY 


When the diaphragm descends in inspiration, the cavity of the 
thorax is enlarged. It is as if a squeezed rubber bulb were ex- 
panded under water; the surrounding fluid enters the sucking 
ball. So do surrounding fluids enter the chest. The air is sucked 
in through the trachea and blood is sucked in through the veins. 
In man, this suction may balance a column of mercury 30 milli- 
metres high, equal to a column of blood 15 inches high—a value 
one-third the total normal diastolic arterial pressure. Without 
this respiratory suction, a man of weak arterial tonus would 
faint every time he stood up. This potent force should be of use 
in traumatic shock. 

If the normal contractions of the diaphragm so aid the cireu- 
lation, its powerful contraction will aid still more. Powerful 
and frequent contractions are within our command. We have 
but to increase the carbon dioxide in the inspired air to eall forth 
deep and rapid respiration. The necessary amount of carbon 
dioxide is not injurious. 

The following cases of shock, observed at the Chemin des 
Dames in 1917, illustrate the value of the respiratory treatment 
in man: 78 

Case 1.—June 25, 7 a.m. Both legs amputated. Diastolic 
arterial pressure, 51 mm. When earbon dioxide was inhaled, 
until the quantity of air entering the chest was about doubled, the 
diastolic pressure rose to 60 mm. At 11 a.m. the patient was out 
of danger. 

Case 2.—June 26, 8.25 a.m. Two deep wounds in the back. 
Multiple wounds elsewhere. Diastolic pressure, 53 mm. _ In- 
clined position and hot normal saline in vein caused pressure 
to rise to 70 mm. Operation at 10.15 a.m., lasting a quarter hour. 
At 10.30 the diastolic pressure was 52 mm. An injection of 
adrenalin brought it to 57 mm. for a short time only. At 11.05 
the pressure was 53 mm. At 11.15 the respiration was deep- 
ened by inhaling carbon dioxide; at 11.20, diastolie pressure, 
60 mm.; 11.25 carbon dioxide was stopped and the pressure 
thereupon fell to 583 mm. At 11.35, the gas was again employed 
and the pressure rose to 61 mm. This man recovered. 


TRAUMATIC SHOCK 41 


From these cases it appears that increased respiration from 
the administration of carbon dioxide is of advantage in shock. 

In the observations at the Chemin des: Dames, the head of the 
wounded man was placed in a wooden box, the length, breadth 
and height of which were each about 35cm. The end for the neck 
was in two pieces. The lower piece was fixed and had a semi- 
circular opening for the back of the neck. The upper piece was 
movable. It had a semi-circular opening for the front of the 
neck. This piece slid down upon the neck like a guillotine. Cot- 
ton was placed between the edges of the openings and the skin. 
A hole of about 2 em. in diameter was made in each of the two 
sides of the box. Cotton was placed in these holes to regulate 
the amount of carbon dioxide and air. The carbon dioxide entered 
one of these holes. It came from a cylinder provided with a 
regulating valve. On its way it bubbled through a water bottle. 
The volume of gas employed was judged by the number of bub- 
bles per minute. Enough gas was used to double the respiration. 
The patient was in the inclined position, the feet 30 cm. higher 
than the head. 

XI 

This brief account of my researches, to which you have so 
kindly listened, may be summarized as follows: 

1. The vasomotor centre is not exhausted in shock. 

2. The vasomotor centre is not exhausted in infectious diseases 
such as diphtheria and pneumonia. 

3. The prolonged stimulation of sensory nerves is not a 
cause of shock. 

4. The heart and probably the blood-vessels may be sensitized. 
In this state, stimuli usually innocent may cause prolonged con- 
tracture or prolonged inhibition of the heart, simulating shock. 
It is possible, and even probable, that in these sensitized states 
such stimuli may cause prolonged relaxation of the arteries, in 
which ease the clinical picture of shock would be produced. 

5. Hydrostatic lowering of the blood-pressure may, if con- 
tinued, cause shock. 

6. Vibration injuries may temporarily reduce the blood-pres- 


42 HARVEY SOCIETY 


sure to the level at which it stands when the vasomotor system 
is destroyed. 

7. Hemorrhage is not a frequent cause of shock. Its danger 
depends on its relation to the critical level of blood-pressure. 

8. The critical level of the blood-pressure in shock is that 
point below which the blood-pressure will not usually rise again 
without assistance An understanding of the critical level is of 
the first importance in the study and treatment of shock. 

9. The blood-pressure was found to be normal in soldiers 
under habitual bombardment and during a heavy barrage. There 
is no evidence that such conditions predispose to shock. 

10. A successful treatment for shock at the front was devel- 
oped. This treatment was first of all systematic. It was based on 
repeated measurements of the diastolic blood-pressure, which it 
aimed to keep 15 to 20 millimetres above the critical level. 

11. Observations on freshly wounded men at La Panne, the 
Massif de Moronvillers, and the Chemin des Dames show that 
shock, excluding abdominal wounds, occurs most frequently after 
shell fracture of the thigh and after multiple wounds through 
the subeutaneous fat. 

12. Fat embolism of the vasomotor centre is proved to be a 
cause of shock. 

13. Increased action of the thoracic pump, brought about by 
the inhalation of carbon dioxide liberally mixed with pure air, 
will raise the blood-pressure from 15 to 20 millimetres in normal 
and in wounded men. When the blood-pressure is near the 
critical level this procedure is of advantage. 


REFERENCES 

* Boston Med. and Surg. Jour., 1908, exix, 455; also: American Journal of 
Physiology, 1907, xx, 501. 

? Boston Med. and Surg. Jour., 1914, elxx, 125; also: American Journal of 
Physiology, 1914, xxxv, 1. 

* American Journal of Physiology, 1914, xxxiii, 439. 

“American Journal of Physiology, 1910, xxvii, 282, fig. 3. 

* American Journal of Physiology, 1907, xx, 444. 

* Jour. Exp. Med., 1896, i, 49. 

* American Journal of Physiology, 1905, xv, 9. 

* American Journal of Physiology, 1907, xx, 448. 


TRAUMATIC SHOCK 43 


® Ann. Surg., 1902, xxxvi, 324. 

American Journal of Physiology, 1915, xxxviii, 108. 

% American Journal of Physiology, 1900, iv, p. 295, and fig. 4. 

2 American Journal of Physiology, 1907, xviii, 181. 

* Boston Med. and Surg. Jour., 1916, clxxv, 854. 

** Boston Med. and Surg. Jour., 1917, clxxvi, 248. 

* Boston Med. and Surg. Jour., 1918, clxxix, 273. 

*® Boston Med. and Surg. Jour., 1919, elxxx, 531. 

* Boston Med. and Surg. Jour., 1917, clxxvi, 699. 

* Boston Med. and Surg. Jour., 1917, clxxvii, 326. 

Further papers by the author dealing with shock: 

Boston Med. and Surg. Jour., 1908, elviii, 73; ibid, 1918, clxxviii, 657. 

Comptes rendus de l|’Académie des Sciences, Paris, Oct. 30, 1916, t. 163, p. 
492; ibid, July 23, 1917, t. 165, p. 164. 

Proceedings of the Institute of Medicine of Chicago, 1918, II, p. 24. 


MEDICAL PROBLEMS AND THE WAR* 


DR. LINSLY R. WILLIAMS, 
Major, Medical Reserve Corps. 


T would not be possible to describe all the medical problems 

which have arisen since the outbreak of the war in Europe 

or to give any detailed scientific description of scientific problems, 

but only a general view of some of the problems will be presented 
in an endeavor to show their variety and difficulty. 

Every modern nation has a Medical Service or Medical De- 
partment for the care of the sick and wounded. The duties of 
the service in each country are similar. They are, first, to keep 
the well from becoming sick; second, to care for the sick and 
wounded; third, to remove the wounded from the battlefields as 
rapidly as possible. It will be seen then that the medical prob- 
lems are those of hygiene and sanitation, the professional care 
of the sick and wounded and the organization and administration 
of the hospitals where the sick are cared for, the organization of 
an ambulance service to evacuate large numbers of wounded, to 
give them first aid and to transport them to zones of safety where 
the wounded ean be given skilled surgical treatment. 

The work of the army surgeons covers nearly all the varied 
types of medical, surgical and special work that occur in civil life, 
as well as a number of additional medical problems peculiar to the 
army. During peace times armies are comparatively stable as to 
numbers; new recruits are added to existing units in small num- 
bers. In some armies these recruits are isolated for two weeks to 
diminish the likelihood of outbreak of infectious disease. The 
men are quartered in permanent barracks. Sickness is small in 
amount and death rates are lower than in eivil life. With the 
outbreak of war the situation immediately changes. In the nations 
of Continental Europe where large standing armies have been 
the rule, all reserves are mobilized. For example, in the summer 


* Delivered November 24, 1917. 


44 


MEDICAL PROBLEMS AND THE WAR 45 


of 1914 the French Army consisted mainly of boys who had 
become 19 years old during 1912 and 1913. The mobilization 
order called for all classes of men who had become 19 years old 
from 1889 to 1912. About five million men were suddenly drawn 
from civil pursuits, all of whom had had two years of military 
service and who within a fortnight after the order was issued had 
joined their regiments and many of whom were on their way 
to battle. 

These men, young and middle-aged, came from all parts of 
France. Many had been exposed to contagious disease, many 
were carriers of infective disease, many with incipient or healed 
tuberculosis and many with parasitic diseases. For such an enor- 
mous number of men with such an immediate need for soldiers, 
physical examination to weed out the unfit is not possible nor 
is the administration of typhoid prophylaxis. Nor do comfort- 
able barracks and adequate facilities for the disposal of human 
waste spring up in a fortnight. Lucky the man who has a tent 
overhead and a blanket to wrap around him. Surprising, too, 
that food, clothing, equipment and rifles are ready. The ex- 
pected happens, forced marches, hard work, changed food, expos- 
ure to weather and communicable disease cause the weak to 
break down, undetected heart disease develops, the incipient tuber- 
culosis case becomes feverish, the lesion of the quiescent consump- 
tive becomes active, the typhoid carrier pollutes the water and the 
unprotected soldier develops typhoid and paratyphoid, and other 
infections follow. Contrast this situation with that in which we 
find ourselves now. In April we had a Regular Army of about 
125,000 men. Recruits have come in from 50 to 1000 a day, dis- 
tributed in a number of stations. National Guard organizations 
have been under constant though not extensive medical supervi- 
sion. New recruits are not the order in the National Guard and 
the units all come from the same locality. The National Army 
approaches more nearly the mobilization of Continental Armies. 
But, the National Army is not mobilized at once, but only five 
months after the declaration of war, and even then only five per 
cent. is mobilized at first. Meantime, barracks have been built, 
hospitals and infirmaries constructed, and a medical service organ- 


46 HARVEY SOCIETY 


ized, the majority of the new medical officers receiving two or 
three months’ intensive training. Potable water supplies are 
secured and distributed through water mains. Water carriage 
systems of sewerage disposal for the removal of human wastes are 
installed. All new recruits are carefully selected at home for 
physical fitness and re-examined at the cantonment on arrival, 
and typhoid and paratyphoid prophylaxis and vaccination against 
smallpox are performed immediately. Medical problems arise, 
however, even under these circumstances; men are gathered to- 
gether from different localities and placed in barracks in close 
proximity to each other, and there is constant danger of respira- 
tory infection, especially during cold weather, when adequate 
ventilation is uncomfortable. At the outset communicable diseases 
develop; scarlet fever, measles, cerebrospinal meningitis, mumps 
and chicken-pox being the most likely. Immediate isolation of each 
ease is feasible, as also quarantine of exposed persons. Separa- 
tion of immunes is not practicable as training must go on, but 
daily medical inspection is performed and early cases are imme- 
diately removed and isolated. Epidemics are therefore rare 
where the medical service is adequate. Epidemic meningitis 
offers a different problem, for the infective material is not only 
transmitted from the sick to the well, but also from the menin- 
gitis carriers to the well. A patient affected with meningitis is 
usually isolated and is a menace only to his attendants. Carriers, 
however, are not readily detected and the disease is usually spread 
by them. Individuals may carry meningitis germs for many 
months and infect many other individuals. Consequently it is 
of the greatest importance to detect and isolate carriers. If a 
company has 250 men and a dozen or more meningitis carriers 
are detected, steps should be taken to isolate these carriers from 
the normal individuals in the company. This procedure is diffi- 
cult, for it means the military rearrangement of companies, which 
is very discouraging to the line officers. The problem of treat- 
ment is also a difficult one, for it has been found that many sera 
for the treatment of cerebrospinal meningitis are ineffective. The 
researches of Dopter in France, Gordon and Flack in England, 
and Flexner in this country show that there are cases of menin- 


MEDICAL PROBLEMS AND THE WAR 47 


gitis in which the organisms differ immunologically from the 
ordinary intracellular micrococcus. Dopter has described a para- 
meningitis organism and Gordon and Flack a variety of organ- 
isms divided into four groups. Strains of all these organisms 
are now used for the production of meningococeus sera, and 
treatment with this serum accomplishes very satisfactory results. 
The detection of carriers remained a difficult problem until a 
suitable method and instrument for obtaining swabs from the 
nasopharynx was devised by West; this instrument consists of a 
curved hollow glass tube which contains a copper wire, around 
the top of which is a pledget of cotton. Both ends of the tube 
are sealed with a cotton plug and sterilized. In order to take 
the swab, the tongue is depressed, the cotton at the curved end 
of the tube is removed and the curved tip of the tube is inserted 
up and behind the soft palate, the copper wire is pushed out 
through the end of the tube, the vault of the nasopharynx is 
swabbed and the copper wire is drawn again within the tube. 
This method prevents the contamination of the swab with the 
mouth organisms. The material from the swab is then planted 
in special media and incubated. 


TREATMENT OF CARRIERS 


Many experiments have been carried on during the past three 
years, especially by English army surgeons, for the eradication 
of meningitis carriers. Different methods have been tried and 
excellent results are claimed for each method. Steam inhalations 
impregnated with some chemical have been the usual method tried. 
Chloramin-T, zine sulphate, and iodine have been tried, as also 
snuffling, gargling and spraying the nose and throat with weak 
solutions of potassium permanganate. Investigation of each 
method of treatment shows that the carrier state may persist for 
two or three months under any one of these treatments. Difficult 
as it may be, carriers should be detected, isolated and treated. 

The respiratory diseases, particularly pneumonia, are a com- 
mon accompaniment of camp life, particularly when men are 
housed in barracks or tents in winter. In winter ventilation is 
frequently difficult on account of lack of heat, and when off 


48 HARVEY SOCIETY 


duty men will collect around the stove and cough and expectorate 
or sleep in such close proximity that in coughing and sneezing 
the spray from one individual may be conveyed to the mucous 
membranes of another. The researches of the past few years by 
Cole, Avery and others have proven that the causative organism 
of pneumonia is not the same, but that the bacteria may be 
readily divided into at least four minor groups. A _ specific 
pneumonia serum has been developed which has proven to be 
very effective in two of the groups. The use of this serum offers 
technical difficulties, for it is necessary to determine the type of 
pneumonia before administering the sera. This is determined by 
injecting some of the sputum of the patient into the peritoneal 
cavity of a mouse and testing the growth obtained in the peri- 
toneum against serum from the different strains of pneumococci. 

The efficacy of pneumonia serum was proven during the winter 
of 1916 on the Mexican border, where a number of eases were 
suecessfully treated with pneumococcus sera. 

In both the French and British Armies special laboratory 
workers are assigned to the different camps and cantonments and 
detection, isolation and treatment of cases and carriers are being 
earried on satisfactorily. 

The isolation and treatment of pneumonia had not been under- 
taken in the French and British Armies last spring, but undoubt- 
edly will be in the United States Army after the work of medical 
organization has been completed. 


VENEREAL DISEASE 

No more trying problem exists than the prevention and con- 
trol of venereal disease. Whether venereal disease exists more 
frequently in the army than in civil life amongst males of the 
same age group is impossible to answer. When the Royal Commis- 
sion on Venereal Diseases began its investigations in England, 
in 1913, it found that no satisfactory statistics regarding the 
amount of venereal diseases existed, except the army statistics. 
It found that among a thousand men in the British Army at 
least fifty were admitted and treated for venereal disease, and 
in some posts, such as London and in India, there were over 


MEDICAL PROBLEMS AND THE WAR 49 


a hundred admissions per thousand men per year. No other 
statistics were available and the Army was forced to bear the 
brunt of criticism. During 1916 rumors were prevalent of the 
enormous increase of venereal disease in the British Army, par- 
ticularly among officers. Undoubtedly true numerically, but not 
proportionately. The Army increased from about a hundred 
thousand in 1914 to about four million in 1916, about fortyfold, 
but the number of cases of venereal disease did not increase forty- 
fold but only thirty-five times as many, and in the British Expe- 
ditionary Force in France the number of cases per thousand was 
less than in England. These rates, too, are far lower than the 
rates of the United States Army published in the report of the 
Surgeon General of the Army for the year 1915. Too much 
reliance, however, should not be placed on the amount of venereal 
disease, as inaccuracy frequently occurs in reporting these dis- 
eases. Whether the number of cases of venereal disease is 
greater in military life than in civil life cannot yet be answered, 
but the number in the Army is far larger than it should be and 
steps are being taken in the French, British and United States 
Armies to limit these diseases to a minimum. Army authorities 
must limit the amount of venereal disease and it cannot be done 
by one method. Venereal diseases are communicable and must be 
so considered ; segregated districts mean the maintenance of cen- 
tres of infection in the neighborhood of army camps. Fortu- 
nately this is forbidden in the United States by the Federal Law, 
which forbids the maintenance of houses of prostitution, the 
sale of liquor and gambling within five miles of camp. Federal 
authorities are enforcing this law. The substitution of various 
forms of recreation plays a large part in reducing temptation 
and the activities of the Young Men’s Christian Association, 
Young Women’s Christian Association, and the National Commit- 
tee on Training Camp Activities in this country play an important 
part in diminishing these diseases. The Army further punishes 
all soldiers who become affected with venereal disease by stopping 
their pay when unable to perform duty on account of illness from 
one of the diseases. Further, if the soldier fails to report for 
4 


50 HARVEY SOCIETY 


treatment after exposure to venereal disease and he subsequently 
develops venereal disease, the soldier’s pay not only stops, but he 
is court-martialed and punished by fine or imprisonment. While 
affected with venereal disease, he may not leave the camp or post. 
These regulations apply to officers as well as enlisted men. Early 
treatment or prophylaxis is given and for the same reason that 
antitoxin is given in diphtheria. The child exposed to diphtheria 
is protected from danger and similarly the soldier is protected 
from danger by early treatment. Prevention of venereal disease 
not only protects the soldier himself but protects his future wife 
and children, for it is unfortunately too true that not only in 
military but in civil ife many men affected with one of these 
diseases may later infect their innocent wives and children. 


SANITARY PROBLEMS 

As well as the problem of preventing communicable disease, 
there are the general sanitary problems of camp and cantonment 
life. These problems include securing a safe and adequate water 
supply, pure food, the practical methods of the disposal of 
sewage so as to prevent infection, the inexpensive and safe 
methods of disposal of human wastes, the appropriate methods 
for the disposal of garbage, either by feeding it to hogs, reclaim- 
ing the grease or by incineration, the spreading of manure 
upon distant fields, transporting it to suitable points for ferti- 
lizer or disposing of it by burning. The disposal of cans, waste- 
paper and trash offers another problem usually left to medical 
depariments to determine. Other problems are the prevention of 
overcrowding, the maintenance of adequate ventilation, proper 
cleansing facilities for bathing and for washing clothes. United 
States Army Regulations require all officers and enlisted men alike 
to wash their hands and face before meals and after attending to 
the necessities of nature. Facilities must be provided for this. 
Cleansing and airing of bed clothes is also a problem for the 
prevention of lice and other vermin. Suitable laundry facilities 
must be provided, not only for the soldiers’ use but for hospital 
linen and garments used by men in the hospital. 


ee 
ee e—EEE—————— 


MEDICAL PROBLEMS AND THE WAR 51 


ACTIVE CAMPAIGN AND COMBAT 


When forces take part in an active campaign and engage 
in battle occasionally, or constantly, as is frequently the case 
in the present war, all the medical problems of camp and canton- 
ment not only remain, but are intensified and made more difficult. 
The housing of troops in billets and tents makes the control of 
men more difficult, the ground is not of one’s selection, water 
supplies are usually limited in quantity and poor in quality. 
Drainage may be difficult if possible at all. These problems must 
then be solved by the Medical Department. The first-aid, trans- 
portation and care of the wounded alone is a problem of the 
first magnitude, attended with constant danger to medical officers 
and enlisted personnel. During the past hundred years the num- 
ber of killed and wounded in battle is somewhat greater, due to 
the improvement in firearms, and the total number of wounded 
has increased with the steadily increasing number of men engaged 
in battle. The number of casualties in a modern battle varies 
from 10 per cent. to 25 per cent. of the number of men engaged. 
Suppose 100,000 men engage the enemy and there are 20,000 
casualties, on the average one man is killed to five who are 
wounded ; 4000 killed, of the 16,000 wounded; 8 per cent., or 1080 
are mortally injured and cannot be transported; 20 per cent., or 
3200, must be transported, but are able to sit up; 12 per cent., or 
1920, are severely wounded and must be transported lying 
down; 28 per cent., or 4480, are able to walk a short distance 
to a dressing station; 12 per cent., or 1920, are very slightly 
wounded, have their wounds dressed promptly and return to the 
fighting forces. It is difficult in the present war to determine 
the actual percentage of men who are killed or wounded in battle. 
We read of an attack on a nine-mile front, perhaps twelve divi- 
sions amounting to 100,000, are engaged on this front; perhaps 
30,000 in the front line, 40,000 in the second and 30,000 in the 
reserve. The latter may never see any fighting and yet the 
advance could not be made without them. Artillery preparation 
may extend to the right and left of the nine-mile front occupied 
by fifteen more divisions which are never engaged but which may 
suffer losses from the responsive fire of the enemy’s artillery. 


52 HARVEY SOCIETY 


Tixaggerated stories have been circulated stating that the average 
duration of life of a soldier in the present war is but a few weeks. 
Perhaps this would be true if one assumes that the soldier is con- 
tinuously in the front line of trenches. This, however, is not 
true, for he takes his turn in the trenches and sometimes weeks 
or months may pass without any trench fighting for an individual 
soldier. A division actively engaged, consisting of 27,000 men, 
may have 15 to 25 per cent. of casualties, a brigade of 6000 men 
may have 50 per cent. or nothing, and a regiment may have 75 
per cent., or none, or be practically wiped out. In the Battle of 
Mukden one Japanese regiment had 68 per cent. of its number 
killed and wounded. If a regiment is said to be completely wiped 
out the ratio of killed and wounded remains about the same, 
and if of full strength this would mean 2400 men wounded and 
probably 1480, or 70 per cent., would be back in that regiment 
within six weeks. Notwithstanding the enormous losses in the 
battles of the present war, the proportion of killed and ratio 
of killed and wounded has increased but little over the Russo- 
Japanese war and never over the losses in some of the bloody 
battles of the Civil War. The number, however, has been enor- 
mous, and at the outset of the war neither France nor Germany 
had made plans for the evacuation of such vast numbers of 
wounded men, perhaps neither had realized the many millions 
of men who would be engaged in battle at one time. Wounded 
were sadly neglected, dumped into cattle cars and transported to 
distant points after the Battle of the Marne, lying on the bare 
floors for four, five, six, even seven days without medical atten- 
tion, and often without food or water. Many died en route and 
the suffering of those who survived was extreme. The adequate 
eare of the wounded in battle depends primarily on the organiza- 
tions developed for the evacuation of the wounded, which will 
permit of wounded soldiers being brought rapidly to points of 
comparative safety for temporary treatment and then to zones of 
safety where permanent treatment can be given. The organiza- 
tion now used by the French, English and United States Armies 
has been developed from the plan first employed by Doctor 
Lettermann, Chief Surgeon of the Army of the Potomac. The 


MEDICAL PROBLEMS AND THE WAR 53 


organization now fully developed consists of sanitary troops 
attached to regiments who act as stretcher-bearers and carry 
wounded to first-aid stations established by surgeons attached to 
regiments. Here bandages are applied and men with very trivial 
wounds return to their regiment. Wounded who can walk, but 
cannot fight, return to a designated dressing station in the rear and 
are there more carefully treated and then sent to the hospital. 
Severely wounded are helped by the regimental stretcher-bearers 
and earried back to a dressing station, in the present war situated 
usually in a dugout, where a station has been established by the 
ambulance companies and which is equipped similarly to an acci- 
dent ward in a civil hospital. Ambulances convey patients from 
this point to a field hospital, or if roads are good and distances 
not too great, to an evacuation hospital situated on a railroad. 
The evacuation hospital is a stationary hospital usually beyond 
shell-fire and patients may remain here if seriously wounded or 
are transported by rail to a more permanent and larger hospital 
some miles to the rear. 


SURGICAL PROBLEMS 


During the early period of the present war patients were 
removed as promptly as possible to a point far in the rear of the 
fighting lines. This soon brought up another medical problem. 
Contrary to expectation, nearly every wound became infected, 
and every effort to prevent this failed. How can infection be 
prevented and how can infection be cured after it has once 
developed? Early treatment by having hospitals nearer to the 
front, and cleansing wounds and cutting away damaged parts 
has nearly solved the first part of the problem and deep irrigation 
of wounds devised by Carrell with the use of Dakin’s solution or 
similar solutions if properly carried out has largely solved the 
latter part of the problem. Problems of a surgical nature have 
been many and varied. When to operate and how much lacerated 
tissue to remove, problems of plastic surgery, resection of nerves, 
early incision and closure of joint injuries or late incision and 
drainage, surgical apparatus for the transportation and treat- 
ment of fractures, the treatment of burns, the detection, location 


54 HARVEY SOCIETY 


and extraction of foreign bodies and special problems of surgical 
treatment for injuries of special parts of the body are all matters 
requiring study. The hardness of the fighting, the intensity of 
shell-fire, the hardships of trench life, the exposure to cold and 
wet, the difficulties of providing adequate food, clothing and 
shelter have all brought up a number of additional medical prob- 
lems. Chilblains, frost-bite and frost-bite gangrene, all of which 
are designated as ‘‘ trench feet,’’ have incapacitated tens of thou- 
sands of soldiers in Europe at one time. Exposure and, some few 
think, infections, have produced many cases of albuminuria, in 
some instances nephritis being caused. Similar outbreaks have 
been described by Civil War surgeons during the period of trench 
life occurring during the siege of Petersburg, Va. 


NERVOUS PROBLEMS 


The many neurotic and hysterical conditions incident to the 
strain of civil life have been intensified in the terrors of trench 
life and many cases of traumatic hysteria, hysterical paralysis, 
and neurasthenia have developed and latent epilepsies, dementia 
preecox and other mental abnormalities have been brought to 
light, many of these conditions being loosely described as ‘‘shell- 
shock,’’ even in cases which have never heard shell-fire. Inability 
to change personal clothing has resulted in a pest of lice which 
in the eastern countries has resulted in widespread epidemics of 
typhus fever, notably in Serbia in 1915. Difficulty in securing 
adequate and safe water has compelled the soldiers during an 
advance to drink water from shell holes and ground springs, 
frequently polluted with dead bodies and excretions from the 
living. This has caused outbreaks of dysentery, diarrhea and 
typhoid fever. Even as late as midwinter, 1915, the French 
and English colonial troops were not fully protected against 
typhoid and paratyphoid fever. 

With the development of disease of such varied types it was 
only natural that civilian physicians of experience should urge 
that specialists should receive commissions and investigate their 
special problems, and in army medical services which previous 
to the war contained only surgeons who were assumed to know 


MEDICAL PROBLEMS AND THE WAR 55 


all the branches of medical science, now nearly every recognized 
specialty is represented, with results of untold value. These 
efforts have resulted in a better understanding of the diseases in 
question by the surgeons and medical officers. Special wards and 
special hospitals have been developed for the more adequate and 
thorough treatment of different disease groups. Special hospitals 
now exist for surgical injuries of the head, plastic surgery, genito- 
urinary surgery, injuries of the eye, convalescents, heart disease, 
nervous diseases, insanity, contagious diseases, venereal diseases, 
and in England and France special hospitals for women and chil- 
dren. The perfection of the organization and the method of ad- 
ministration, coupled with the solution or partial solution of many 
of the surgical problems have resulted in a marked improvement 
in the care of the patients and a diminution in the length of time 
necessary for a cure and has increased the percentage of wounded 
able to return to their fighting units from 30-50 per cent. early in 
the war up to 60-80 per cent., or even more, at the present time. 


THE PROBLEM OF AFTER-CARE 


The enormous number of sick and wounded necessarily leaves 
a large number of men partially or wholly incapacitated from 
injury or disease. The care of these cases has become a national 
problem in the combating nations. This problem is partly a 
medical problem and partly a sociological and industrial problem. 
The medical problem includes hospital provision for patients with 
surgical injuries, needing prolonged treatment for correction of 
deformities, for preparing stumps for artificial limbs, for fitting 
artificial limbs, for eye injuries, for the tuberculous, mental and 
neurological conditions, cardiac cases and other chronic ailments. 
Orthopedic care and provision for the blind are the two most 
important of the problems, for the tuberculous, the insane 
and other chronic disease conditions can be more readily cared 
for by existing hospitals. The sociological and industrial prob- 
lem includes the technical training of disabled men to fit them 
for new positions or for their former trade if practicable and to 
secure new positions for them. A brief review of what has been 
done in Great Britain and France will be of interest in illustrating 


56 HARVEY SOCIETY 


these problems. In Great Britain it has been found that from 
5 to 10 per cent. of all the wounded become permanently disabled. 
The total number of disabled soldiers is therefore very large. 
Sir George Murray, in a report to the Local Government Board 
for England and Wales, published in 1915, estimated that there 
would be at least 16,000 disabled soldiers and sailors discharged 
from service monthly by the end of the year. The magnitude 
of the problem was not realized at first and existing private 
agencies endeavored to care for the disabled men. National 
institutes for the blind and deaf, polytechnic schools, societies 
of arts and crafts, and nearly every other agency, private or 
public, in both France and England, offered their services to care 
for the blind and deaf, to re-educate the crippled, and to secure 
employment for those who were able to work. 

In 1915, France bore the heaviest brunt of the fighting for the 
Allies, and in consequence had a far greater number of wounded. 
The enormous increase of cripples placed a heavier burden on 
the various private institutions than they could carry. The 
French Government then appointed an Interministerial Commis- 
sion to study the problem, and this commission recommended that 
subventions be granted to certain existing institutions, that new 
institutions be established, that disabled soldiers be given the 
opportunity to learn a new trade when it was not possible for 
them to pursue their previous vocations, and that facilities be 
provided for maintaining the soldier while he was learning a 
new occupation. The War Department established special hos- 
pitals known as ‘‘Centres of Apparatus’’ in a number of the 
eighteen Army regions in France which were outside of the fight- 
ing zone, to which soldiers could be sent while still under treat- 
ment at the existing military hospitals and where they could 
secure an artificial limb or the necessary orthopedic apparatus. 
Many soldiers were provided with artificial limbs, but it was 
learned that in many instances the soldier disearded his artificial 
limb in an endeavor to work without it. Many French surgeons 
doubted the usefulness of providing artificial limbs for the sol- 
diers, stating that they were too cumbersome and not suitable for 
the ordinary working man. Other physicians realized that the 


MEDICAL PROBLEMS AND THE WAR 57 


real reason for the artificial limbs not being used was that the 
stump had not been properly prepared to receive an artificial 
limb, that the limb had not been properly fitted, and that the 
wearer had not been sufficiently educated in its use. This latter 
opinion prevailed, and about a year ago the centres of apparatus 
were abolished and military orthopedic hospitals created in their 
stead in each Army region, where stumps could be properly 
prepared for artificial limbs and the necessary training given. 
One of these military orthopedic hospitals is situated at Bor- 
deaux and the surgical work there is under the direction of 
Major Gourdon. A brief description of this hospital will illus- 
trate the purpose and usefulness of these institutions. Instruc- 
tions have been issued to the Chief Medical Officer in each Army 
region to transfer to the military orthopedic hospital all ampu- 
tation cases, all patients crippled from wounds, and all others 
who would require apparatus or orthopedic treatment. Upon the 
arrival of the patient at the orthopedic hospital a complete 
physical examination is made and also a special orthopedic 
examination, which includes functional tests to determine the 
physical capacity of various musele groups. Careful records 
are made of the examination, including charts and diagrams of 
the wounded part, an X-ray photograph, and in some instances 
a special plaster cast is made of the crippled limb. Appropriate 
treatment is then commenced, electricity and massage being quite 
generally used until the limb is in a suitable condition to receive 
an artificial leg or special apparatus. This treatment may last 
for one or more months, but as soon as the patient is able to be 
up and about he begins to receive special training in some branch 
of work which he has chosen for his future career, although every 
endeavor is made to return the soldier to his previous occupation 
and varied facilities for training are provided so that he can 
nearly always work at his former trade. 

The vocational school for this region is also in Bordeaux and 
situated but a short distance from the hospital. Soldiers who 
live in the city receive their discharge from the hospital but 
continue at the school. This school provides a complete commer- 
cial course including stenography, typewriting, commercial arith- 


58 HARVEY SOCIETY 


metic, correspondence, bookkeeping, and also special courses in 
French and English. There are also opportunities for learning 
tailoring, shoe-repairing, bookbinding, tinsmithing, forge and 
metal work, toy manufacture, drawing, industrial design, pottery, 
and the manufacture and repair of artificial limbs. Courses are 
also offered in the repair and operation of automobiles and for 
training assistants in the use of plaster-of-Paris and photography. 
The work is under the direction of competent instructors who 
have had wide experience in these fields. Major Gourdon lays 
great stress upon the functional re-education of impaired muscles. 
Each patient is carefully studied in order to ascertain how much 
power remains in his wounded limb and appropriate exercises 
ave prescribed in order to increase its usefulness. 

Professor Amar, of the Society of Arts and Crafts, has for 
years studied the efficiency of the workingman and has suggested 
a method for re-educating a disabled limb. Professor Amar pre- 
seribes a complete physical and functional examination of the 
crippled limb, the functional training of the limb without any 
apparatus in order to increase the muscular efficiency or to 
increase the sensitiveness of the stump if an amputation has been 
performed, and finally to re-educate the affected arm or leg with 
the artificial limb or apparatus attached. Major Gourdon firmly 
believes in Professor Amar’s teaching and has carried out this 
plan with remarkable success. He also believes that it is of 
great importance to secure as teachers men who have learned a 
trade after having lost a limb. Major Gourdon has been ably 
assisted in the re-educational training of the armless men by a 
young woman whom he found begging in front of the Cathedral 
at Bordeaux. The girl had lost both her hands in an explosion 
at a munitions factory, and Major Gourdon offered to teach her 
how to use her arms and artificial hands. After a number of 
months of training she was able to dress herself, to sew, em- 
broider, weave baskets, and do many other useful occupations 
without the artificial hands as well as with them. The sensitive- 
ness of her stumps had been so increased that blindfolded she 
could distinguish small weights which varied only one or two 


MEDICAL PROBLEMS AND THE WAR 59 


grams. She became so proficient in her work that Major Gourdon 
employed her as instructor for the men who had lost an arm. 

When the soldier is ready to leave the school, employment is 
secured for him, either through a central employment bureau 
which has been established in Paris or through a local employment 
bureau established in this region, and he is given a certificate 
on discharge stating that he has completed so many days of train- 
ing. He may also return to the school for additional training at 
any time when he so desires, and he may also come back to the 
hospital as frequently as may be necessary to have his artificial 
apparatus kept in repair and receive such adjustment as may 
be necessary. 

As soon as a soldier is discharged from the hospital he receives 
his pension and all expenses for his re-education are paid by 
the Government and the apparatus is furnished him also without 
expense. Institutions similar to this now exist in every section 
of France so that any soldier who has been crippled may receive 
the proper treatment and apparatus, re-education, pension, and 
appointment. Unfortunately nearly every soldier is strongly 
tempted to return home at the earliest possible moment, and if 
he can work at all at almost any occupation, he is needed at 
home, for France sorely needs workmen on her farms and in her 
factories and the soldier must consider the immediate necessity 
as well as the future welfare of his family. Many soldiers, there- 
fore, do not receive the re-education which would be of inestimable 
value to them, to their families, and to their country. This is 
a situation which cannot be wholly obviated with the existing 
conditions in France. 

The present efficient organization for the care of disabled 
soldiers and sailors in England has been the outgrowth of work 
originated through efforts of private philanthropy. One of the 
earliest, efforts made was to provide artificial limbs and for this 
purpose a special hospital was established at Roehampton, in the 
outskirts of London, through the efforts of Lady Falmouth, Lady 
Harcourt and Lady Kenderdine, and the hospital was designated 
as the Queen Mary and Alexandria Hospital. Difficulties at once 
arose, for it was found that it was not feasible to secure the 


60 HARVEY SOCIETY 


manufacture of a sufficient number of artificial limbs in England, 
and American manufacturers were called upon to furnish an 
additional number of these limbs. This is a sad commentary on 
the United States, for it brings home the fact that the production 
and manufacture of artificial limbs was far greater in the United 
States than in England to meet the demands created by industrial 
accidents. It was very shortly realized that the artificial ihmbs 
were not giving satisfaction to their wearers and for the same 
reason that existed in France. The British War Department then 
established a special hospital at Brighton to treat the stumps 
and to prepare them for receiving the artificial limbs. While 
undergoing this treatment at Brighton and having a new leg 
fitted at Roehampton, time hung heavy on the hands of the 
British soldiers and it was appreciated that habits of idleness 
would be inculeated in the soldiers, which would seriously impair 
their future ability to gain a livelihood. Treatment workshops 
were then established at Roehampton entirely at the expense of 
Lady Wantage. During the month, while the soldier was being 
fitted for his limb, he was given opportunity to receive work 
for treatment which would increase the suppleness of his 
muscles, and an opportunity was given to try himself out in 
some occupation. 

Roehampton accommodates about four hundred patients, but 
as the number of patients waiting admission increased, there was 
delay at Brighton, and although additional accommodations were 
provided at Brighton, yet the length of stay was prolonged. 
Appeals were then made by the surgeon at Brighton for oceu- 
pation of the soldiers and training workshops were established 
there by Queen Mary. 

The steady growth of this work and the intense specialization 
of it required the services of the best orthopedie surgeons in 
Great Britain, and Colonel Robert Jones, an orthopedic surgeon 
of Liverpool of international reputation, was placed in charge of 
all the orthopedic work in Great Britain. There were many other 
soldiers disabled from wounds who had not lost a limb, yet who 
were in great need of special orthopedic treatment. Wounds 
which had left behind them a stiffened joint, a misshapen limb, 


MEDICAL PROBLEMS AND THE WAR 61 


or a paralyzed hand or foot from an injured nerve, required the 
services of these special surgeons. 

A military orthopedic hospital was then established in Liver- 
pool under the direction of Colonel Jones and shortly afterward 
a similar hospital was established at Hammersmith in London. 
At these hospitals special facilities were provided for electro- 
diagnosis to test the functional efficiency of injured limbs, also for 
giving massage, and some time later a plant for hydrotherapeutic 
treatment was installed to give douches and baths, which are so 
helpful in relieving stiff joints. Before these hospitals were 
opened the necessity for maintaining treatment workshops in 
connection with the hospital was fully appreciated and when the 
hospitals commenced their work, facilities were provided for ear- 
pentry work, tailoring, shoe-repairing, painting, fret-saw work, 
grinding of surgical instruments, electrical work, plumbing, brick- 
laying, cigarmaking, leather work, and repairing and manufac- 
turing of splints and orthopedic apparatus. 

The prime object of these workshops is to provide natural 
exercises for functionally impaired joints and muscles, rather 
than to give this exercise by means of highly specialized apparatus 
such as is given by the Zander method of physical training, 
which is so tedious and uninteresting to the average individual. 
These training workshops also keep the man from acquiring 
an idle disposition and teach him practically that he still has a 
sphere of usefulness. The success of these two institutions 
which have been in operation for nearly eight months, and the 
insufficient accommodation provided by them, have demonstrated 
the necessity of establishing new institutions in the large urban 
centres and new hospitals will be opened shortly in Dublin, 
Cardiff, Birmingham and Glasgow. A similar institution near 
Edinburgh will be enlarged. 

In order to secure the satisfactory use of an artificial limb 
it has been found necessary to manufacture artificial limbs on 
the grounds of the Roehampton Hospital and to train the men in 
the use of their newly acquired member before giving them 
their discharge. By this method the artificial limb can be 
properly fitted, suitable adjustments made, and the soldier trained 


62 HARVEY SOCIETY 


in its use before he leaves the hospital. It has been found most 
efficacious to have the men trained by discharged non-commis- 
sioned officers who have lost a limb and who are successfully using 
an artificial one. The men with artificial legs are trained by a 
man who is wearing an artificial leg and the men who are wearing 
an artificial arm are likewise trained by a man who is wearing an 
artificial arm. It is astonishing to see what satisfactory results 
are obtained by the use of these artificial limbs. A man with an 
artificial leg can readily learn to hop, jump or dance quite grace- 
fully and to be apparently as active on his feet as he was before. 
The men who have lost an arm have been very much assisted 
by a very ingenious man who is working at the hospital who had 
lost an arm in an industrial accident some time prior to the war. 
This man has been able to devise a number of ingenious and 
simple devices which are attached to an artificial arm, so that a 
man with one of these appliances can readily learn to perform 
a large number of special tasks. Some of the soldiers have been 
taught by this man to wield a sledge hammer, ride a bicycle, play 
golf, hold a book and to acquire many other similar accomplish- 
ments. By means of a universal pincer attachment any small 
object can be readily picked up, the pincers being opened by shrug- 
ging the shoulders to which a strap is attached, which runs down 
to the pincers, and the pincers are closed by means of a spring. 
Upon the discharge of a soldier from Roehampton or from a mili- 
tary orthopedic hospital, he has an opportunity to continue his 
training in a polytechnic or vocational school, many of which exist 
in Great Britain, and all have been opened to the work of re-edu- 
eating the disabled soldier for civil life. These technical schools 
offer courses in a wide variety of subjects, commercial work, 
stenography and typewriting, arts and crafts and mechanical and 
industrial trades in their branches. At the Regent Street Poly- 
technic Institute one can readily see the results of this system. 
Men who had previously been unskilled laborers have been taught 
to become efficient mechanics, carpenters, tinsmiths or electricians, 
in from three to six months. Employment has been secured for 
them and they are able to earn two to three times as much as they 
could prior to the war. So many men have shown such marked 


MEDICAL PROBLEMS AND THE WAR 63 


aptitude for learning a new trade and have become skilled in 
so short a time that the country has realized that it does not take 
an apprentice from three to seven years to become a skilled 
mechanic and has also learned the astonishing fact that the only 
highly technical skilled trade is that of farming. It has not been 
found possible to teach a man to become a farmer in any reason- 
able period of time. 

It is only natural that a soldier will ask many questions 
before commencing a period of re-education which may last three 
months or sometimes even a year, and so many questions of a 
similar character have been asked that each soldier is now given 
a copy of a number of questions and their answers so that he can 
be reassured about the financial condition of his family. Every 
soldier of Great Britain who has a wife or other dependents has 
a separate allowance granted to his wife or other dependents 
during his absence. This separation allowance is continued while 
the soldier is in the hospital and also during the period of his 
vocational training. Many soldiers naturally desire to return to 
their homes as soon as they are discharged from the hospital, 
but every soldier is urged to take a special course of training 
unless it is possible for him to return to his former employment, 
which is ascertained by special agents by communication with 
his former employer. A further stimulus is given to the soldier 
by automatically beginning his pension on the day of his discharge 
from hospital, by organizing special hospitals for housing and 
boarding the soldier during his period of re-education and by 
granting him a pension of 5s. a week during this period. A 
soldier, then, will receive during his re-education period his 
pension, board and lodging, vocational instruction and an extra 
pension of 5s. a week from the Government. In addition to this 
his wife, children or other dependents also have their separation 
allowance continued. If a soldier is wounded in France he is 
treated at various hospitals until he reaches a base hospital. If 
he has a serious injury which will require a long treatment, he 
is transferred to a general hospital in England as soon as pos- 
sible. If, on the other hand, his injury is not very severe and 
requires only short treatment, he is quickly returned to his unit, or 


64 HARVEY SOCIETY 


if a longer period is required he is transferred to a general hos- 
pital in Great Britain and then to a special orthopedic hospital, 
or if he has lost a limb, to the hospital at Brighton. From 
Brighton he is ultimately transferred to Roehampton, and 
whether in the military orthopedic hospital or at Roehampton 
application is made for his discharge and pension three weeks 
before he is expected to leave this hospital. Upon his discharge 
from the hospital the pension commences, which is granted in 
two forms: If his disability be functional and a complete cure is 
anticipated, he may receive a gratuity or an allowance which 
may be increased or diminished, depending upon the extent of 
his disability, and if he has served for a considerable period of 
time in the Army he also receives a supplementary service pen- 
sion. Pensions for functional disability may only be temporary 
and may be increased or diminished, but pensions for permanent 
disability, if once allowed, remain fixed at the amount origi- 
nally granted. 

The pensions ministry has created a large number of local 
committees in various parts of Great Britain, and prior to the dis- 
charge of a disabled soldier from a hospital, he is visited by an 
agent of the Local Pensions Committee of the district in which 
the hospital is located. If the soldier returns to his home situ- 
ated in the district of another committee, all the facts relating 
to his ease are transferred to the local committee. The dis- 
charged soldier may then carry on his vocational training, either 
in the district in which the hospital was situated or he may be 
transferred to his own home and receive his vocational training 
in that district. In either event he remains under the super- 
vision of the local Pensions Committee. This supervision has 
the following functions: First, to see that appropriate outdoor 
treatment is provided for the soldier if he is in need of it, the 
adjustment and repair of artificial limbs or other apparatus, 
and maintaining the soldier in continuous employment, if that 
be possible. 

The principle laid down by Sir Henry Norman, reporting 
to the Prime Minister on the result of his investigations on the 
after-care and re-education of disabled soldiers and sailors in 


a 


MEDICAL PROBLEMS AND3THE WAR 65 


France, was that hospitals and re-education centres should be, 
““few and good, rather than poor and many,”’ and this principle 
has been firmly adhered to. The concentration of a large group 
of disabled soldiers makes it possible to give a larger variety of 
courses of training and applies not only to those with disabled 
limbs but also to those who have been blinded in battle. The 
re-education work for the blind in England has been earried on 
entirely by private agencies, particularly by the National Insti- 
tute for the Blind. The successful re-education of the blind 
soldiers would perhaps not have been possible were it not for 
the fact that the most energetic and efficient member of the 
Board of Directors of the National Institute was Sir Arthur 
Pearson, who became blind shortly prior to the war. Largely 
due to Sir Arthur’s efforts a large school, known at St. Dunstan’s 
School for the Blind, was established in Regent Park, and to this 
school all blinded soldiers are urged to come. This is made 
easier because all the blind soldiers receive hospital treatment at 
the Chelsea Hospital for the Blind in London, and while in the 
hospital they are visited by agents of St. Dunstan’s School, some 
of whom are blind themselves and can readily explain to the 
blinded soldiers the advantages of the institution. There are 
now nearly five hundred pupils at St. Dunstan’s, which is sup- 
ported by grants from the Prince of Wales’ Fund and by 
volunteer contributions. Accommodation for officers has been 
provided by Sir Arthur Pearson in houses near his own home in 
London, and he also has as guests in his own house a certain 
number of these blinded officers. 

Sir Arthur has laid down three cardinal principles for the re- 
education of the blind. First, no sympathy shall be expressed 
for any blinded soldier. He must be told that he has a life of 
usefulness before him, that he must learn to be blind, and that 
he can be taught to learn a trade which will make him self- 
supporting. Second, instruction must be given by blinded per- 
sons, particularly by those who have become blind in adult life. 
And, finally, blind pupils must be given short periods of work. 
This last principle Sir Arthur realizes well himself, for although 
he has been over the grounds of St. Dunstan’s many times and 

5 


66 HARVEY SOCIETY 


readily notices any unevenness or turn in the path, yet when 
he showed the grounds to the Prinee of Wales he could not 
explain the work to him while walking, as each of these tasks 
required complete concentration for the blinded person. 

At St. Dunstan’s every soldier is required to learn typewrit- 
ing and is given a typewriter on his discharge. He is also re- 
quired to learn to read Braille so that on his discharge he can 
surely be able to read books and to write his own letters. The 
vocational training given to the blind soldiers includes a variety 
of special trades, and the proficiency attained by some of the 
blind soldiers is truly remarkable. Carpentry and joinery are 
taught and some of these men become very skilled in cabinet work, 
in making bookcases, picture frames, and other similar small and 
useful articles of furniture which command a ready sale. Classes 
are given in shoe-repairing, mat-making, basket work and poultry 
raising. It is hardly believable that a blind man can pick out a 
hen from twenty different varieties and tell immediately which 
variety it is, or that he can select a special type of poultry food 
from a large number of samples. The men, however, are not 
encouraged to learn poultry raising unless they have a wife or 
some other member of their family who can assist them in regu- 
lating the temperature of the incubators and who can also assist 
in marketing the products. 

All of the trades taught are those which can be carried on at 
home and each one of which is also sufficiently lucrative to enable 
the soldier to be self-supporting from what he earns and from 
what he receives from his pension. 

Pastime occupations are also taught in weaving rugs, mak- 
ing network bags, hammocks and other similar articles. These 
various courses take from four to six months and a course in 
massage is also given which requires one year. Many men have 
completed the course in massage and have passed the examination 
required by England before they are allowed to practice. 


THE NEW PATHOLOGY OF SYPHILIS * 


DR. ALDRED SCOTT WARTHIN 
University of Michigan. 


N an analysis of 4880 autopsies performed at Bellevue Hospital 
during a period of ten years Symmers + found anatomic evi- 
dence of syphilis in only 314 cases, or 6.5 per cent. In a similar 
study made by myself of 750 autopsies at Ann Arbor during the 
last ten-year period evidence of syphilitic infection was found 
in 300 cases, or in 40 per cent. of the entire autopsy material. 
Nothing could better illustrate and emphasize the points which 
I hope to establish in this paper than the wide discrepancy 
between these two studies. This is made all the more striking 
when the character of the clinical material in the two hospitals 
is considered. In a great city hospital like Bellevue, in a great 
city like New York, with patients derived chiefly from the poorer 
classes, the incidence of syphilis would naturally be thought to be 
much greater than in a state hospital, like the university hos- 
pitals in Ann Arbor, in which the clinical material is drawn 
chiefly from the rural population of the state, representing the 
better elements of the middle class farmers, village storekeepers, 
mechanics and laborers. Is the latter rural population syphilized 
to a greater extent than the poorer working classes of New York? 
In 139 autopsies made at Ann Arbor in 1916-1917, fifty-six cases 
showed evidences of active syphilis, in 1915-1916 out of 79 autop- 
sies there were 30 cases, and in 1914-1915 out of 58 autopsies 
there were 25 cases, and for the remaining years the incidence 
was 40 to 50 per cent. annually. Does this mean a greater total 
incidence of syphilis in Michigan than in New York? 
I believe that this striking difference in findings is chiefly 
dependent, not upon the clinical material, but upon the different 
pathologic criteria employed in these two studies. If we turn 


* Delivered December 8, 1917. 
+ Journal of the American Medical Association, 1916, Ixvi, 1457. 
67 


68 HARVEY SOCIETY 


to Symmers’ paper we find that the criteria employed by him 
were chiefly anatomic. His diagnoses were based upon the fol- 
lowing lesions: Aortitis in 55.7 per cent. of cases, aneurism in 
25.6, chronic interstitial orchitis in 39, lesions of the nervous 
system in 35.6, of the liver in 33.4, of the skin in 33.4, indurative 
atrophy of the base of the tongue in 25, osseous lesions in 14.9, 
of the respiratory tract in 10.5, of the lymph-nodes in 6, and of 
the gastro-intestinal tract in 2.2 per cent. It is very evident 
from Symmers’ paper that many of the findings not classed as 
gummata were in reality gummatous processes and should have 
been classed as such. For example, hepar lobatum always means 
healed gummata of the liver. He takes no note of syphilis of the 
heart muscle, the pancreas or adrenals, or of the occurrence in 
the most varied tissues of small inflammatory infiltrations asso- 
ciated with the presence of the Spirochete pallida. In short, his 
diagnoses have nothing to do with the spirochete and the most 
common lesions produced by this organism; but are based chiefly 
upon the gross pathologic anatomy of pre-spirochete days. 

The pathologic anatomy of syphilis is still ruled by the dicta 
of the gross pathologic anatomists of the latter half of the last 
century. The statements in our textbooks concerning the pathol- 
ogy of this infection in its latter stages are based almost without 
exception upon the occurrence of the gumma, and syphilis of an 
organ is said to be frequent or rare according to the frequency of 
gumma of that organ. The gumma was practically the only 
anatomic lesion of syphilis recognizable by the early pathologic 
anatomists. Morgagni’s knowledge of the gross pathology of 
syphilis (lwes venera) consisted almost wholly of observations 
upon gummatous lesion of the bones, aneurism of the aorta, and 
changes in the lungs and kidney. He speaks particularly of 
never finding changes in the liver in bodies affected with the lues 
venera. As it was not until the years 1831-1837 that syphilis was 
separated from gonorrhea and soft chancre by Ricord, there was 
no advance made in the pathology of syphilis in the first thirty 
years of the nineteenth century. 

It is a very strange fact that Rokitansky, the father of modern 
gross pathologic anatomy, in the thirty thousand autopsies said to 


THE NEW PATHOLOGY OF SYPHILIS 69 


have been performed by him, should have added nothing to the 
knowledge of the pathology of syphilis. With a pathologie 
material drawn from a highly infected population his observa- 
tions upon the gross pathologic anatomy of syphilis are amaz- 
ingly few. Ulcers near the nails, necrosis and hyperostoses in 
bones, and inflammations of fibrous structures, and possibly 
eummata, constitute his apparent knowledge of this disease, as 
shown by his great work on gross pathologie anatomy. Virchow, 
likewise, in his ‘‘ Cellular Pathology,’’ 1858-1860, barely mentions 
syphilis and, at that, not in connection with any essential patho- 
logic feature of the disease. Nevertheless, in 1858 * he clearly 
distinguished the simple inflammatory (irritative) and the gum- 
matous lesions of syphilis, and showed for the first time the part 
played by this disease in producing inflammatory conditions 
of the most varied organs and tissues. This article really laid 
the foundation for the modern knowledge of the pathology of 
syphilis obtained since the spirochete was discovered. But his 
separation of syphilitic lesions into the two types made little 
impression upon the syphilology of the next forty years. In 
Waener’s ‘‘ Textbook of Pathology’’ (1862-1876), emphasis of the 
syphiloma (tuberculum s. gumma syphiliticum, tumor gum- 
mosus, gummy tumor) as the essential pathologic lesion of syphilis 
ruled completely the minds of both clinicians and pathologists 
up to nearly the close of the century, and still remains the chief 
part of the pathology of syphilis in our textbooks. This narrow- 
ing of the conception of the pathology of this disease was largely 
due to the very valuable and comprehensive article by Baiimler 
on syphilis in the von Ziemssen’s Handbook (1874). The chapter 
on the general pathologic anatomy of syphilis in this article con- 
cerns itself chiefly with Wagner’s conception of the syphiloma ; 
and Baiimler’s monograph has been the fount of inspiration 
for the majority of textbook articles on syphilis written since 1875. 

As the relationship of tabes and paresis to syphilis became 
more evident during the next two decades the conception of 
‘*postsyphilttie, metasyphilitic,’’ and ‘‘ parasyphilitie’’ proe- 


MAGS 


* Ueber die Natur der constitutionell-syphilitischen Affectionen, Arch. 
i. Path. Anat. u. Phys., xv, 217. 


70 HARVEY SOCIETY 


esses arose in explanation of this relationship. Fournier (Les 
affections parasyphilitiques, Paris, 1894) was chiefly responsible 
for the use of this term and for the view that a large number 
of pathologic conditions bore a definite relationship to syphilis, 
but were not syphilis and were not necessarily caused by it. 
Paresis, tabes, aortic aneurism, arteriosclerosis, a variety of con- 
ditions of the nervous system, leucoderma, leucoplakia, and many 
other affections were regarded as parasyphilitie affections. The 
association of a typical form of aortitis with aneurism, paresis, 
tabes, and other parasyphilitic conditions gradually led to an 
acceptance of its syphilitic origin and nature. Nevertheless, up 
to the discovery in 1905, of the Spirochete pallida, the gumma 
remained the one specific histopathologic lesion of syphilis. 

With the discovery of the etiologic agent of syphilis it was to 
be expected that a change would be wrought in our concepts of 
the pathology of the disease, and that expectation was soon ful- 
filled. Parasyphilis has disappeared as the various parasyphilitic 
affections have been shown to be active syphilis with living spiro- 
cheetes still present in the affected tissues. The term is now a 
misnomer. To the pathologie criteria of the disease there have 
been definitely added during the last decade the characteristic 
lesions of the central nervous system and syphilitic mesaortitis. 
The Harvey lecture by Fordyce, in 1915, on ‘‘Some Problems in 
the Pathology of Syphilis,’’ expresses very fully the generally 
accepted knowledge of the pathology of syphilis of the present 
day. He recognizes that ‘‘in all stages and in all organs the 
lesion begins in the perivascular lymph-spaces as a lymphocytic 
and plasma-cell infiltration;’’ but he still says that ‘“‘the type 
of lesion of the tertiary period is the gumma.’’ He advances 
the pathology of syphilis only by the full recognition of the 
syphilitic nature of the nervous lesions and mesaortitis. Of the 
pathology of latent syphilis in other organs and tissues he has 
this to say: ‘‘ Aside from gummatous involvement of the viscera, 
little is known of the effects of the infection on the various 
organs.’’ My investigations and their results begin here in the 
demonstration that the gumma is not the type of lesion of late 
or latent syphilis, and that the viscera are involved in all cases 


THE NEW PATHOLOGY OF SYPHILIS 71 


of latent syphilis, not by gummatous processes, but by specific 
inflammatory processes, eventually fibrosis, usually mild in char- 
acter, but acquiring pathologic importance because of their pro- 
gressive character. 

As soon as the Levaditi method of demonstrating the Spiro- 
chete pallida in sections was published, I began investigations as 
to its occurrence and distribution in the tissues, and my atten- 
tion was first drawn to congenital syphilis because of the greater 
ease of demonstrating the spirochetes in the tissues of such eases. 
As a result of such studies important facts concerning the inci- 
dence of Spirochexte pallida in the heart muscle of congenital 
syphilitics have been added to our knowledge, as, for example, 
the constant presence of spirochetes in the hearts of cases of 
congenital syphilis dying before or at birth, the occurrence of 
focal fatty changes in the myocardium due to the colonization 
of the organism, and of a specific type of interstitial myocarditis 
due to the same cause. The essential lesion in congenital syphi- 
litic myocarditis was shown to be edema of the interstitial tissues, 
often giving reactions for mucin, infiltration with lymphocytes 
and plasma cells, and fibroblastic and angioblastic proliferations. 
Spirochetes were found to be constantly present in such lesions, 
often in enormous numbers. That spirochetes could be present 
in great numbers in the tissues of congenital syphilis without 
producing tissue changes was also shown. 

From the study of the lesions of congenital syphilis it was a 
natural step to that of the pathology of acquired syphilis. 
Similar lymphocyte and plasma-cell infiltrations, associated with 
spirochete localization, were found in the tissues, and organs 
of known eases of acquired syphilis, aortic aneurism, tabes, 
paresis, ete., as well as in cases not recognized clinically as 
syphilis, but it was not possible to demonstrate the presence of 
spirochetes so readily or in such a large proportion of cases, owing 
to their smaller numbers and widely scattered distribution, Never- 
theless, the demonstration of the organism was successful in such a 
large number of cases (75 of the 300 cases), as to make the specific 
syphilitic nature of these lesions certain. In the progress of 
these studies the specific inflammatory lesions of spirochexte 


72 HARVEY SOCIETY 


localization have been found in the myo-, endo-, and pericardium, 
the aorta, pulmonary and other large arteries, nervous system, 
liver, pancreas, adrenals, testis, prostate, prevertebral and mesen- 
teric tissues. These lesions vary greatly in size, from minute ¢ol- 
lections of few cells to larger infiltrations just visible to the naked 
eye. Every stage of development, from the early active lesions 
to complete healing and fibrosis, was observed ; but no cases were 
found in which there were no active lesions. Complete healing 
throughout the body was never observed. The marked tendency 
of the lesions to undergo fibrosis and healing with the formation 
of dense hyaline scar tissue was a striking feature and regarded 
as evidence of the relatively avirulent character of the organisms. 
Spirochetes may be found in all stages up to nearly complete 
healing, but were never found in the dense fibroid areas. A 
detailed description of these lesions of latent syphilis will now 
be given. 


THE MICROSCOPIC PATHOLOGY OF LATENT SYPHILIS 
Nervous System.—The central nervous system was examined 
in only a small percentage of the material, the head much more 
frequently being opened at autopsy than the spinal column. 
No especial study was made of either brain or cord, and the 
changes noted in these were only those found in the ordinary 
routine of microscopic examination accorded all tissues and 
organs obtained at autopsy. The most constant changes were 
those found in the meninges. In practically every case of latent 
or clinical syphilis autopsied some degree of thickening of the 
meninges was noted. The dura was constantly more adherent and 
thickened. No active syphilitic foci were, however, ever found in 
this membrane. Focal thickenings of the leptomeninges were 
found in practically every case. These varied in all possible 
degrees. They were most common over the parietal convolutions, 
and along the median surfaces, being most easily seen over the 
sulei. They more frequently involved the arachnoid than the pia; 
but the focal thickenings very frequently represented fibroid 
areas involving both pia and arachnoid. Thickening of the wall 
and more or less obliteration of the meningeal vessels were usually 


THE NEW PATHOLOGY OF SYPHILIS 73 


found associated with the localized fibrosis. In the great major- 
ity of the brains examined these meningeal focal thickenings were 
small, usually pinhead in size, and sharply circumscribed. Only 
in clinical cases of paresis, tabes, cerebral syphilis, cerebral 
gumma and ‘‘toxic psychosis’’ were they larger, more diffuse 
and more marked. Transition stages from these small focal lesions 
to the larger ones were found. The great majority of these 
foeal fibroses of the leptomeninges were healed inactive areas, 
plasma-cell infiltrations and fibroblastic infiltrations being found 
only in the more active cases of syphilis. They appear in the 
latent cases to represent old and early lesions in the history 
of the individual infection. The occurrence of active lympho- 
eyte and plasma-cell infiltrations in the meninges in old latent 
eases of syphilis seemed, however, to parallel the degree of activ- 
ity of the lesions found in the heart, aorta and other tissues. 
Precisely the same lesions in the meninges occurred in the non- 
paretic and non-tabetic cases of syphilis as in those showing 
a clinical paresis or tabes, the only difference being one of degree. 
Active meningeal lesions have been found more frequently in 
young adults with congenital syphilis than in the old eases. 
Similar lesions occur in the meninges of the cord; and, as in the 
ease of the cerebral meninges, the degree of these meningeal 
changes usually corresponded to the severity of the lesions in 
other organs and tissues. The meninges of the cord usually showed 
the most marked changes in cases of tabes and paresis, but a few 
exceptions to this were found in latent cases. The meningeal 
changes noted by me associated with syphilis, both latent and 
clinical, correspond in general with those described by LeCount 
and other writers as characteristic of meningeal syphilis. The 
foeal chronic leptomeningitis regarded by some writers as the 
result of chronic alcoholism, would appear from my experience 
to be the result of syphilitic infection rather than of alcoholism. 
It is true, that some of my most marked cases of meningeal fibrosis 
were both alcoholic and syphilitic ; but precisely the same menin- 
geal changes occur in those eases without a history of alcoholism. 

Foeal infiltrations of lymphocytes and plasma cells were found 
in both brain and cord in eases not regarded clinically as paresis 


74 HARVEY SOCIETY 


or tabes. These infiltrations were perivascular and were some- 
times associated with proliferative changes in the vessel, at other 
times not. The character of these minute scattered lesions is pre- 
eisely identical with those found in the brain and cord, in paresis 
and tabes, the differences being only those of number and degree. 
In two eases diagnosed clinically as ‘‘toxic psychosis’’ these 
lesions in the brain were so numerous as to suggest a pathologie 
diagnosis of early paresis. Two other cases without nervous 
symptoms gave similar microscopic findings. In one ease of sec- 
ondary syphilis dying from salvarsan poisoning the brain showed 
scattered perivascular plasma-cell infiltrations. 

The question is raised by these findings as to their frequency 
in syphilis and their relation to the symptoms of paresis and 
tabes. Is every case of syphilis, to a slight degree, at least, a 
paretie or tabetic? There can be no doubt that pathologically 
there are borderland cases just as there are clinically such; and 
my experience would lead me to believe that probably every case 
of old syphilis will present in the brain and cord the same seat- 
tered perivascular infiltrations of lymphocytes and plasma cells 
found in all other organs and tissues. Such infiltrations represent 
simply the local reaction to the presence of spirochetes ; and their 
relation to paresis and tabes may be simply one of degree, with 
reference to the number of infecting organisms, the degree of 
intoxication produced, and the resulting destruction of nerve 
tissue and functional disturbance produced. 

Minute infiltrations of lymphocytes and plasma eells are of 
frequent occurrence in and about the spinal ganglia, the spinal 
nerves and the large peripheral nerves. No spirochete studies 
have been made of these, and their syphilitic etiology is assumed 
because of their identity with known syphilitic lesions in other 
organs and tissues, and their constant association with such. 

Similar infiltrations are also very common in and about the 
sympathetic nerves and ganglia, particularly in the solar plexus 
and periadrenal plexus. Fibrosis, atrophy, and pigmentation 
of these ganglia have been observed in connection with such infil- 
trations. In three cases of Addison’s disease due to syphilitic 


THE NEW PATHOLOGY OF SYPHILIS 75 


fibrosis and atrophy of the adrenals, the adrenal and solar plexus 
showed especially marked syphilitic infiltrations. 

The tendency of the nervous system to spirochete localization 
and to focal reactions of lymphocytes and plasma-cell infiltra- 
tions would appear from our material to be less than that of the 
heart, aorta, and other tissues, but this impression may be due 
entirely to the smaller number of cases in which the central ner- 
vous system was examined, and to the more superficial study 
accorded, it. The routine examinations reveal, at least one very 
important fact, that such minute lesions as occur in other organs 
in syphilis are found also in the nervous system when no clinical 
symptoms of its involvement are present. 

Heart.—The heart in every case showed microscopic lesions 
characteristic of spirochete localization; and in this organ more 
frequently than in any other has the spirochete itself been 
demonstrated by the Levaditi method. The cardiac lesions in the 
eases in which syphilitic infection was known to exist, and in 
those in which it was not suspected are identical. They vary 
greatly in degree. To the naked eye the hearts of the cases 
included in this autopsy material showed as a rule dilatation, 
hypertrophy, atrophy, and fibroid patches in the wall of the left 
ventricle. In many eases no fibroid changes were visible to the 
naked eye, and-the occurrence of fibrosis and active infiltrations 
was determined only by the microscopic examination. The por- 
tion of the heart most frequently involved was the anterior wall 
of the left ventricle near the apex, the adjacent portion of the 
septum and the posterior left ventricular wall near the mitral 
ring. In eases of congenital infection the right ventricular wall 
may be chiefly affected. It must be emphasized that the deter- 
mination of cardiac syphilis is essentially microscopic; when no 
myocardial changes can be seen by the eye the microscopic exam- 
ination may reveal the most extensive lesions. This is especially 
true of the more acute and active cases. 

The essential lesion of cardiac syphilis is an interstitial myo- 
carditis characterized by infiltrations of lymphocytes and plasma 
cells along the vessels between the muscle fibres. These infiltra- 
tions are usually patchy or diffuse, very rarely focal or cireum- 


76 HARVEY SOCIETY 


scribed, thus differing from streptococcus myocarditis. The infil- 
trations vary in degree, but usually are slight, the cells often 
being arranged in close single file between the fibres. To a super- 
ficial glance there appears to be only a slight increase of the 
interstitial nuclei. Polynuclears are few in the infiltrations, and 
eosinophiles are not present. The cells of the infiltrations are 
probably chiefly histogenetic lymphocytes and young formative 
cells. Large epithelioid fibroblasts are very common, especially 
in the older, healing areas. Giant cells are rare. (See Figs. 
1, 2 and 3.) 

The entire heart wall from epicardium to endocardium, inelud- 
ing the papillary muscles, may be involved in the infiltrations; 
but in the average case they lie nearer to the endocardium, often 
just beneath it, or in the middle layer of the myocardium. In 
acquired syphilis they rarely begin on the epicardial side, as they 
frequently do in congenital syphilis. In the most severe cases 
larger areas of infiltrations are grouped around the coronary 
arterioles. These may reach such a size as to suggest miliary 
cummata (see Fig. 4). Caseation, however, does not occur in 
these larger infiltrations. In two cases only were true gummata 
found in the myocardium. These were associated with the diffuse 
-plasma-cell infiltrations. 

In the more acute, severe and active cases the stroma of the 
infiltrated areas in the myocardium is edematous, often giving 
a slight reaction for mucin with specific dyes. In the older healed 
areas the stroma becomes fibroid and hyaline. In the great 
majority of cases the myocardium shows healed fibroid areas in 
association with the active infiltrations (Figs. 5 to 8). In many 
eases the fibroid areas predominate, and search may be necessary 
to show the presence of active infiltrations. This is true especially 
of the older unrecognized cases. In every case, however, such 
active areas have been found, and no completely healed cases have 
been seen. <A progressive fibrosis of the myocardium always 
takes place. In acquired syphilis the fibroid areas are always 
larger on the endocardial side; but in some eases they have 
extended completely through the myoeardium. When this is the 
ease, both endocardium and pericardium are thickened, and the 


THE NEW PATHOLOGY OF SYPHILIS 77 


latter usually shows a localized adhesion. These marked changes 
practically always occur just above the apex, in the anterior wall 
of the left ventricle; aneurismal dilatation of the weakened wall 
at this point is not uncommon; rupture of the wall may take 
place as in two of our eases. More frequently, however, throm- 
bosis occurs on the thickened endocardium overlying the fibroid 
patch, and death usually results from the progressive thrombosis 
of the left ventricle, or from embolism. In thirty of our cases 
thrombosis of the left ventricle over an area of syphilitic infiltra- 
tion or fibrosis of the ventricular wall was the cause of death. 
In the great majority of the cases of latent syphilis the left 
ventricle was dilated, and such dilatation was either the chief or 
an accessory cause of death. The ‘‘fibroid’’ heart is the ultimate 
outcome of all cases of latent syphilis. (See Figs. 7 to 11.) 

In the congenital and active acquired cases spirochetes are 
fairly easily demonstrated between the heart muscle fibres. In 
the older eases, with fibrosis more or less well advanced, the 
demonstration of the spirochete becomes a task requiring patience 
and determination, spread often over days or weeks. They are, 
nevertheless, more easily found in the heart than in any other 
organ or tissue, so far as our experience goes. (See Figs. 12 to 15.) 

The parietal and mitral endocardium appears resistant to the 
spirochete to a much greater degree than that of the aortic 
valves. In no case have I been able to demonstrate the occurrence 
of syphilitic changes in the mitral valves. Secondary strepto- 
coecus or staphylococcus endocarditis with mitral stenosis or in- 
sufficiency was in a number of cases, particularly those of 
congenital syphilis, the immediate cause of death. The heart 
of congenital syphilis seems to give a local predisposition to 
secondary infections. Sclerosis of the coronaries may or may 
not be associated with syphilitic myocarditis. In my material 
marked coronary sclerosis was rather a rare finding ; the coronary 
involvement was perivascular rather than primarily vascular. 
Even in a number of the angina pectoris cases the coronary 
sclerosis, as far as the larger branches were concerned, was not 
marked, although these cases all showed marked fibrosis of the 
myocardium. Thrombosis of the coronaries was not observed 


78 HARVEY SOCIETY 


in any case. The smaller terminal arterioles and capillaries are 
obliterated and destroyed by the perivascular infiltrations and 
proliferations, while the larger coronary branches rarely show 
much sclerosis, except in the cases showing a general arterio- 
sclerosis. A striking feature of the fibroid areas is the dilatation 
of preéxisting capillaries or veins or a new formation of such in 
the fibroid areas. Often such areas appear cavernous or sinu- 
soidal, because of the large blood spaces present having practically 
no wall but that of the lining endothelium. These appearances 
are probably the result of a compensating circulation in newly 
formed capillaries. In younger scars the new formation of capil- 
laries is very striking, and this vascular proliferation appears to 
be one of the distinct features of syphilitic myocarditis. 

The heart muscle itself in all of the cases presented varying 
degrees of hypertrophy with simple and brown atrophy, fatty 
degeneration, and necrosis, all of these changes usually being 
present in the same heart. In the immediate neighborhood or 
periphery of the infiltrations the heart muscle fibres often showed 
no changes at all; in other cases fibres extending through the 
lesions showed only hypertrophy. I have previously shown that 
colonies of spirochetes may be found in heart muscle appearing 
perfectly normal. While this is most common in eases of con- 
genital syphilis, it is also found in late acquired syphilis. It is 
evident that the toxic action of such spirochetes upon the muscle 
fibres must be very slight indeed. The intensive study of these 
cardiae lesions tends to emphasize more and more the mild and 
slowly progressive nature of the latent syphilitic infection. 

The clinical features of these heart lesions can not be presented 
in detail here, and for the present only generalizations can be 
given. While a history of symptoms is wanting in some cases, 
the great majority of the cases included in this material pre- 
sented symptoms of cardiac weakness, and circulatory disturb- 
ances. A very large number of the cases were frankly those 
presenting the cardio-vaseular-renal complex. The termination 
of the case was frequently cardiae dilatation. Shortness of 
breath, palpitation, precardial pains, anginal attacks, irregularity 
of pulse, swelling of ankles, dizziness, general weakness, ringing 


es oa. = ee 


THE NEW PATHOLOGY OF SYPHILIS 79 


in ears, ete., were the most common subjective symptoms. All 
of our cases of angina pectoris were syphilitic. The blood- 
pressure may be high or low; the cases are about evenly divided 
in this respect. The disturbances of rhythm are very prominent 
and of every variety; the most interesting cases studied in the 
Clinie of Internal Medicine coming to autopsy belong to this 
material. ‘‘Functional’? murmurs were common. The final 
clinical picture in all was that of an insufficient heart—a heart 
that could not do its work properly. The majority died a cardiac 
death; as shown by the hypertrophy and dilatation of the heart, 
and the chronic passive congestion of lungs and other organs. 
The chief pathologic findings at autopsy were those of a myo- 
eardial insufficiency (‘‘fibroid heart’’) without (in the great 
majority of cases) accompanying valvular lesions. 

Aorta.—The aorta, when examined microscopically, showed 
in every ease of old syphilis characteristic syphilitic infiltrations 
in its media and adventitia. To the naked eye the changes may 
be very slight or marked. The gross appearances may be those 
of so-called senile atherosclerosis or of the type now generally 
recognized as syphilitic aortitis, or the two gross pictures were 
frequently combined in the same ease, particularly in older 
patients. While the lesions in the majority of cases are most 
often, seen in the beginning of the aorta and in its arch, they are 
often most marked in the abdominal aorta; and, in a few cases, 
were confined to this portion, so far as the gross appearances 
were concerned. The process is very common about the mouths 
of the aortic branches. 

It is certain, from my experience, that the gross appearances 
are no absolute criterion of the aortic condition. When the gross 
appearances of syphilitic aortitis are present the pathologic diag- 
nosis of syphilis may be given at the autopsy table without hesi- 
tation; but when the picture is that of atherosclerosis, no positive 
exclusion of syphilis can be made without a microscopic examina- 
tion. The aorta may present no changes, or very slight ones, 
to the naked eye, but the microscopic investigation may show 
characteristic plasma cells along the vasa vasorum of the media 
and adventitia. This is true of all the early stages of the diseases. 


80 HARVEY SOCIETY 


In the few cases of secondary syphilis examined at autopsy the 
aorta showed slight changes (‘‘fatty degeneration of the in- 
tima’’), or none at all, yet microscopic study showed extensive 
infiltrations along the vasa vasorum and around the small vessels 
in the prevertebral tissues. This is the early active stage when 
the demonstration of spirochetes can be most easily carried out. 
The cases recognizable by the naked eye as syphilitic aortitis are 
old cases; and the demonstration of the spirochetes in these be- 
comes increasingly difficult. This is particularly true when to the 
syphilitic aortitis there are added the changes of atherosclerosis 
due to age or other etiologic factors. In the great majority of old 
cases the gross appearances of atherosclerosis are combined with. 
and conceal those of syphilitic aortitis. For this reason a nega- 
tive gross diagnosis of syphilis of the aorta is of no value, in the 
absence of a thorough microscopic study. 

The microscopic features of this form of aortitis are now so 
well known that they will be but briefly discussed here. Small 
infiltrations of lymphocytes and plasma cells are found along the 
vasa vasorum of the media and adventitia, usually most marked 
around the vessels of the latter, and diminishing in degree as the 
vessel passes up into the media. Perivascular proliferation, 
fibrosis and obliteration of the small vessel then follows. (See 
Figs. 16 and 17.) The resulting disturbances of nutrition of the 
vessel, wall are first seen in the intima and the inner portion of 
the media, in the form of fatty degeneration, atrophy and necrosis 
of the cells of this portion of the vessel, with weakening and 
thinning of the wall, followed later by fibrosis and hyaline change. 
The involvement of the media progresses steadily outwards, and 
because of the greater involvement of the media locally there 
results local thinning of the vessel wall and microscopie ruptures 
of the elastic fibres. Such changes naturally predispose to the 
development of aneurisms. In simple uncomplicated syphilitic 
aortitis the fibrosis of the intima is less than in atherosclerosis, 
and there is less tendency to secondary atheroma and ealcifica- 
tion. The two forms of aortic disease are, however, combined 
in the majority of cases, and the microseopie picture presents the 
characteristics of both processes. In some cases the changes in 


Se 
Sh. Seb ce 
ee Me 


sou OP ge Oe RNS a 1% 


he 


+ = TY 
Fig. 1.—Chronic syphilitic myocarditis. Unsuspected latent syphilis. Sudden death. Male, 
aged 52 years. Dilatation of left ventricle. Wall of ventricle showed diffuse plasma-cell infiltra- 


tions. Spirochetes present throughout these infiltrations. 


2 7 = uJ “ : meen ees a ; AS F bia ae eS: 3 
is aS Bers eRe? Ges 


Fig. 2.—Chroniec syphilitic myocarditis. Male, 45 years of age. Sudden death. Syphilis not 
suspected by clinicians; aneurysmal dilatation of left ventricle at apex. Diffuse plasma-cell 
infiltration of papillary muscles and wall of left ventricle at apex. Spirochetes present. 


Pee Rt E Le ae Oe “Pee BOS Cob st 2! ee ae wep? 
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Fig. 3.—Chronic syphilitic myocarditis. Unsuspected latent syphilis in middle-aged man. 
Sudden death. More severe process than in preceding. More marked plasma-cell infiltrations of left 


ventricle wall above apex. Spirochetes. 


aL RRR SS 7 BE RE VO OED [ae 
oe 3 ar EN cs 2 Meee. NOS SS A, ,o*$ oa 
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Fig. 4.—Chronie syphilitic myocarditis. Sudden death in middle-aged male with history of 
*“cured ’? syphilis. More active process; plasma-cell infiltrations more diffuse with larger focal 
infiltrations approaching miliary gummata. Abundant spirochetes. 


Fig. 5.—Chronic syphilitic myocarditis. Older process. Fibroid heart. Case of diabetes ; 
unsuspected latent syphilis. Small active area in left ventricle wall in healing stage. Few 
spirochetes. 


; ‘ f . Ayr ‘ 
> 3 ey ne co thes : a ee ‘ ; ri 


Fig. 6.—Chronic syphilitic myocarditis. Left ventricle wall from case of syphilis con- 
tracted 14 years previously. Suicide. Fibroid areas in heart with active plasma-cell infiltrations. 
Few spirochetes. 


Fig. 7.—Chronic syphilitic myocarditis. Old ‘‘cured syphilis’’; negative Wassermann; 
cardio-vascular-renal symptom-complex ; dilated, fibroid heart. In areas showing nO more active 
plasma-cell infiltration than in photographic spirochetes found in small colonies. ’ 


-; 
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; 4 
: =i 
+ 
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Be Se | 
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Fig. 8.—Chronie syphilitic myocarditis. Nearly healed fibroid area in left ventricle wall 
of old ** cured syphilis.’’ Slight plasma-cell infiltrations. Few spirochetes found after prolonged 
search, 


Fig. 9.—Chronic syphilitic myocarditis. Completely healed fibroid area. In such hyaline 
connective tissue without plasma-cell infiltration spirochetes have never been found. 


Fig. 10.—Tangential section of coronary vessel showing slight active syphilitic infiltration. 


Fig. 11.—Similar section, from same case, showing complete healing; fibrosis without 
plasma cells. 


Leyaditi preparation of active latent, unsuspeated syphilis of left ventricle wall. 


Fig. 12. 
Many spirochetes between muscle fibres. 


hit 


Fig. 13.—Levaditi preparation of chronic syphilitic myocarditis from case of unsuspected syphilis. 
Spirochetes at border of fibroid patch. 


Fig. 14.—Levaditi preparation of chronic syphilitic myocarditis. Case of diabetes, syphilis 
not suspected, negative Wassermann. After prolonged search small colony of spirochetes found in 
small area of plasma cells at border of fibroid patch. 


. 


Fig. 15.—Levaditi preparation of fibroid heart from case of diabetes, with unsuspected syphilis, 
negative Wassermann. After six weeks’ search of blocks from left ventricle wall this colony of 
spirochetes was found at border of fibroid patch. 


are 


SS ies AN _ 


i rae ’ ae, % ~ 
sS00S we . , 's ates op ie tax > ys 


Fig. 16.—Typical syphilitic mesaortitis. All cases of latent syphilis show this lesion in this 
aorta wall; it is a practically constant sign of syphilis. Small plasma-cell infiltrations along the 
vasa vasorum, through the media of the aorta. 


] 
] 


¥ ¢ ‘ 
= “4 , et % F3 
e te, ‘git ig 


BSS 


a - : 

Fig. 17.—Portion of media and adventitia of aorta from case of latent, unsuspected syphilis. 
Characteristic plasma-cell infiltrations around the vasa vasorum, with 
artery. One of the most constant and characteristic lesions of latent 


obliteration of the small 
usually in small numbers and found only in these active foci. 


syphilis. Spirochetes are 


PRT Po TPES ELIT BD &- 
FF: z Pi £4 : 
ia ee ee 
wt 


ee 


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Fig. 18.—Pancreas from case of diabetes, with unsuspected syphilis and negative Wasser- 
mann. Diffuse chronic interstitial pancreatitis. Very small active areas, in which small groups 
of spirochetes were found. 


unsuspected 


syphilis and negative Wassermann reaction. Spirochetes found in heart and pancreas. 


> Ah 


diabetes, 


case of 


areas, from 


active 


syphilitic pancreatitis, with 


Chronic 


19. 


. a foe kz 


From tail of pancreas; same case as preceding. 


syphilitic pancreatitis. 


20.—Chronic 


Fig. 


Fig. 21.—Chronic syphilitic pancreatitis. Higher power. Same case as preceding, plasma-cell 
infiltration ; increase of stroma, and atrophy of acini. 


Fig. 22.—Chronie syphilitic pancreatitis. Same case as in Fig. 18. Small area of active plasma- 
cell infiltration and edema, in which spirochetes were found. 


+ “%, 
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Area of active syphilitic 


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Same case, 
inflammation ; new formation of pancreatic 


3.—Chronic syphilitic pancreatitis. 


2 


Fig. 


acini. 


area of plasma-cell 


active 


view of 


High power 


pancreatitis. 


rhilitic 


SY] 


Chronic 


infiltration seen in preceding. 


Tr 5 ee ee oe a = oP 3 re, ee =, I im F 
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17S ¥% Pe 4 : k mn : a“ r 

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25.—Chronic syphilitic pancreatitis. 
of acini, Healed, inactive area. 


High power, showing fibroid stroma and atrophy 


ek 


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eta ees Pe ee a gt a PTS : BFS 
Fig. 26.—Chronic syphilitic pancreatitis. Area of severe change; fibrosis, destruction of 
pancreatic tissue and atypical regeneration of acini from pancreatic ducts. Such newly formed 
acini are usually mistaken for new islands of Langerhans. 


‘ie 


wate, 


Fig. 27.—Colony of spirochetes in edematous, infiltrated area between lobules. 


Pe alae Toe ae 2 
fg ne ve 4 
att K 


oe eae * et eee 
ee atl oor * ° 1 eae See 
* 


* X ., - wi G 


Fig. 28.—Syphilis of the adrenal.  Plasma-cell infiltrations in inner zone of adrenal cortex 
and in medulla. One of the most constant findings in latent syphilis. These infiltrations are 
usually much less marked than in this ease. 


ty 
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Slight 


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Fig. 29.—Liver 
of this 


lesion 


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Vig. 30.—Active syphilitic 


Fig. 381.—Subacute syphilitic orchitis. Increase of stroma; atrophy of germ cells; hyaline 
thickening of basement membrane of tubules; active syphilitic infiltrations. From case of 
congenital syphilis. Patient, aged 19 years. 


Fig. 82.—Chronie syphilitic orchitis. Complete fibrosis of testis, hypertrophy of interstitial 
cells. From same case as Fig. 6. 


THE NEW PATHOLOGY OF SYPHILIS 81 


the intima and media really represent a slow anemic infarction 
due to the shutting off of the blood supply as the result of the 
obliterative endarteritis in the arteries of the vasa vasorum in 
the adventitia. The obliterated arterioles often appear as con- 
centric formations resembling tubercles, miliary gummata or 
even suggesting epithelial formations. The lymphocytic and 
plasma-cell infiltrations are in the early stages most marked in 
the perivascular lymph-spaces of the arterioles; but later these 
infiltrations often become very marked around the greatly dilated 
veins. A new formation of capillaries is often seen in the adven- 
titia and outer portion of the media. These infiltrations often are 
large enough to be regarded as miliary gummata, but the de- 
velopment of well-defined gummatous nodules with ecaseating 
centres and giant cells is rare. When these do occur they are 
usually multiple. 

The demonstration of spirochetes requires much time and 
patient search. I have found them in the aorta of acquired cases 
of syphilis only in the perivascular infiltrations of the adventitia. 
They occur usually in small colonies. In congenital syphilis, how- 
ever, the intima of the aorta may show localized proliferations and 
infiltrations containing great numbers of spirochetes. In such 
congenital infections the syphilitic lesions of the intima may later 
heal and present the appearances of atherosclerosis. They then 
can not be distinguished from the local lesions of the intima found 
in typhoid fever and other infections. 

Pulmonary Artery—I have studied and reported a case of 
syphilitic aneurism of the pulmonary artery with marked and 
characteristic syphilitic arteritis of this vessel and its branches. 
The presence of the spirochete was demonstrated in the aneuris- 
mal sae, with blood-clot in the wall. The organisms were found 
in very small numbers, possibly owing to the previous salvarsan 
treatment. The microscopic changes in the wall of the pulmonary 
artery were identical with those of syphilitic aortitis. How fre- 
quently such changes have occurred in the pulmonary artery in 
my cases I am unable to say, as no especial attention was paid 
to this vessel. In the microscopic notes on the lungs of these eases, 
there is frequent mention of thickened and hyaline pulmonary 

6 


82 HARVEY SOCIETY 


vessels; these changes were usually referred to the chronic 
passive congestion of the lung present in practically all cases. 
In but two other cases were there changes in the pulmonary artery 
so marked as to attract attention. One of these cases was that 
of a male who had had for some years a well-marked ease of 
chronic cyanosis and polycythemia (Vaquez’s disease). At 
autopsy his pulmonary arteries showed marked dilatation and 
atherosclerotic changes in the main branches with hyaline fibrosis 
and complete obstruction of many capillaries. The microscopic 
examination showed the presence of a typical syphilitic mesarte- 
ritis of the pulmonary arteries; and the polycythemia is explained 
as compensatory to the circulatory changes in the lung. This case 
undoubtedly falls into the group, of which a number have been 
reported from South America and India, of syphilis of the pul- 
monary arteries associated with polyeythemia and cyanosis 
(‘‘Ayerza’s disease’’). The other case of unusual atherosclerosis 
of the pulmonary artery showed microscopic changes of syphilitic 
arteritis without other complications. 

Syphilis of Peripheral Arteries——In several cases syphilitic 
arteritis of the femoral artery and its large branches, the popliteal 
and the tibial arteries was noted. In one ease, a colored woman, 
the entire systemic arterial trunks and their smaller branches 
showed severe syphilitic arteritis with multiple thromboses. The 
abdominal aorta from the level of the diaphragm down and all 
of its branches contained organizing thrombi; globular thrombi 
were present in all four chambers of the heart. This case pre- 
sented a condition not described in the literature—a very active 
generalized syphilis of the entire arterial system and heart. In 
all of these cases of syphilis of the larger arteries, the microscopic 
picture is identical with that seen in syphilis of the aorta and 
pulmonary arteries. There is the same lymphocytic and plasma- 
cell infiltration along the vaso vasorum of the media and adven- 
titia with localized degeneration and fibrosis of the intima and 
inner portion of the media. In the smaller branches the entire 
vessel wall is involved and the process takes on the character 
of a proliferative endarteritis, as in the case of the arterial vasa 
vasorum. The clinical importance of these arterial changes in 


THE NEW PATHOLOGY OF SYPHILIS 83 


this autopsy material has been chiefly that of aneurism, throm- 
bosis, embolism, infarction and gangrene, in about 5 per cent. 
of the total number of autopsies; in the remaining cases no 
definite clinical symptoms could be ascribed to the aortic changes 
beyond the general circulatory disturbances common to all of the 
syphilitic cases, and which have been interpreted as chiefly 
cardiac in origin. 

Pancreas.—The pancreas in all of the old cases of syphilis 
showed a greater or less degree of atrophy and interstitial fibrosis. 
In the majority of cases the changes were irregularly scattered 
throughout the organ, the body and the tail portions showing 
an especial tendency to involvement. Lobules showing marked 
change may be surrounded by those showing no change. In 
other cases the entire pancreas showed a diffuse fibrosis, varying 
from slight to the most marked degree. The connective-tissue 
increase is both inter- and intralobular. In the majority of cases 
it was old, containing few cells; but in two cases of diabetes it 
was more fibroblastic in character and contained many eells of 
lymphocyte and plasma-cell type. Careful search has revealed, 
however, in every case active areas of plasma-cell infiltration. 
These areas often show an cdematous or myxomatous connective 
tissue, the plasma-cells and lymphocytes may be few or many. 
Such inflammatory areas are most often found at the border 
of a lobule, and the latter are invaded by new connective tissue 
from the periphery usually, although occasionally the process 
appears to begin within the lobule. Fibrosis of the islands in 
varying degrees is often associated with the interstitial inflam- 
mation. In all of the cases of diabetes but two, island fibrosis 
was very marked, and presented characteristic features, the chief 
of these being the thick crowding of large hyperchromatic cells 
around the border of the hyaline fibroid islands. These cells were 
interpreted as regenerative or hypertrophic. In several non- 
diabetic cases the chronic pancreatitis and fibrosis of the islands 
was as marked, or even more so, than in the diabetic cases. 

The pancreatic acini show varying degrees of atrophy in the 
affected areas. As the acini disappear fat is deposited in the 
connective-tissue cells; in many cases such fatty infiltration 


84 HARVEY SOCIETY 


following the atrophy of the pancreatic parenchyma is very 
marked. Islands completely surrounded by fat tissue are often 
seen in the tail portion of the organ. Regenerative formations 
may be found in practically every case; they often reach such a 
degree as to appear neoplastic, resembling adenomata or ecyst- 
adenomata. The newly formed acini resemble islands and are 
undoubtedly often mistaken for newly formed ones. They arise 
from the epithelium of the lobular ducts and also from that of 
the larger ducts. Newly formed acini may even be found within 
dilated larger ducts. In every one of the cases of syphilis the 
pancreas showed evidences of progressive destruction and repair. 
No evidence of the new formation of islands, however, was ever 
seen. Sclerosis of the blood-vessels of the organ may or may not 
be associated with the pancreatitis. Some degree of it was often 
found in the lobules showing marked interstitial change ; but only 
in a relatively small number of cases was the inflammatory process 
associated with a general sclerosis of the pancreatic arteries. 
(See Figs. 18 to 26.) 

As to the syphilitic nature of these lesions, they are identical 
with those produced by the spirochete in other tissues and 
organs. The localized plasma-cell infiltrations, slight fibroblastic 
proliferation, cedematous or mucoid stroma, eventually fibrosis, 
are histologically specifie characteristics, I believe ; and in further 
proof of this view, spirochetes were demonstrated in these areas 
in the pancreas of two cases of diabetes. 

So far as the clinical significance of these pancreatic changes is 
concerned the only fact of importance shown is their association 
with diabetes. In eleven out of twelve cases of diabetes coming 
to autopsy, the heart, aorta, pancreas, adrenals (testes, in the 
males), and other tissues showed the characteristic plasma-cell 
infiltrations and fibrosis of latent syphilis. In five cases Spiro- 
chete pallida was demonstrated in the myocardium, and in two 
eases (Fig. 27) in the panereas itself. In the pancreas they 
occurred in small colonies in the areas of cell infiltrations. That 
diabetes is the result of syphilis I do not venture to assert. If it 
is true that a chronic interstitial pancreatitis is the most common 
pathologic finding in the pancreas in diabetes, it seems very likely 


THE NEW PATHOLOGY OF SYPHILIS 85 


that syphilis is the most common cause of interstitial pancreatitis, 
but not necessarily, of course, the only cause. Syphilitie pan- 
creatitis may be a common: cause of diabetes, if it can be shown 
that interstitial pancreatitis is the essential pathology of diabetes. 

Adrenals.—Small infiltrations of plasma cells and lymphocytes 
are of constant occurrence in the adrenals of cases having known 
syphilis and unsuspected latent syphilis. In the great majority 
of eases these infiltrations are slight. They occur usually in the 
medullary portion or in the inner portion of the reticular zone 
of the cortex. (See Fig. 28.) They are usually perivascular. 
Fibroblastic proliferation of the stroma or fibrosis may or may 
not be present; the capsule of the organ is usually thickened, 
and perivascular infiltrations of small size oceur in the sur- 
rounding tissues. The walls of the blood-vessels usually are 
thickened. Very rarely the infiltrations are so marked as to 
assume the characters of miliary gummata. Caseating gummata 
with giant cells have not been seen. In three cases the syphilitic 
infiltrations and fibrosis were so marked as to have caused nearly 
complete atrophy of the greater part of the organ. All three 
of these cases presented the symptom complex of Addison’s dis- 
ease. In one of these cases marked syphilitic infiltrations 
occurred also in the adrenal and semilunar ganglia. With the 
exception of these three cases no symptoms were observed that 
could be directly ascribed to the syphilitic changes in the adrenals. 
Whether in the less severe cases disturbances of adrenal function 
may be responsible for the low blood-pressure seen in some of the 
cases it is, of course, impossible to say. Another striking feature 
of the adrenals in chronic syphilis is the marked lipoidosis of the 
cortex seen in so many cases. This lipoidosis may be patchy 
involving certain circumscribed areas in the cortex, or it may 
involve the entire cortex. The cells are filled with numerous, 
large doubly refracting droplets that stain a brownish red with 
Sudan III and Scharlach R; with osmic acid many of the droplets 
take no stain, while others are grayish brown. The significance 
of this lipoidosis is not apparent, nor is its relation to syphilis. 
It is probably to be interpreted as an expression of a cholesterol- 
emia or cholesterol retention, as a feature of a general disturb- 
ance of metabolism. 


86 HARVEY SOCIETY 


Liver—tThe liver showed chronic passive congestion and 
atrophy (brown atrophy chiefly) in every case. Gummata were 
found in five cases, hepar lobatum in eight, atrophic cirrhosis in 
ten and an intralobular cirrhosis in one, Glissonian cirrhosis in 
three cases, while localized fibrosis was very common. The in- 
flammatory lesions varied from slight plasma-cell infiltrations of 
the periportal tissue to the most marked cirrhotic changes. The 
relationship of these latter changes to syphilis has not been abso- 
lutely determined except in a few cases in which spirochetes 
were found in such infiltrations. It is worthy of note that in a 
ease of secondary syphilis dying of salvarsan poisoning focal 
necroses containing spirochetes were present throughout the 
liver. (See Fig. 29.) 

Tcstis——In all of the male cases the testes showed varying 
degrees of atrophy and fibrosis. In the more active cases plasma- 
cell and lymphocyte infiltration between the tubules, fibroblastic 
proliferation of the stroma, thickening of the basement membrane 
and diminished spermatogenesis are the chief changes. (See 
Fig. 30.) These changes may involve the entire organ, or occur 
im small seattered patches. In the older cases the germinal epi- 
thelium of the tubules may be entirely lost, the tubules collapsed, 
and represented entirely by the hyaline thickened basement 
membrane which still keeps the shape of the tubule. The inter- 
stitial cells remain preserved, and in many cases appear hyper- 
trophic. The stroma between the tubules is thickened and hya- 
line. (See Figs. 31 and 32.) In severe cases the entire testis 
becomes fibroid. Spirochztes can be demonstrated only in the 
active cellular infiltrations. So far as size, shape, and consistency 
are concerned, the gross appearances of the affected organs may 
seem to be normal. The clinical significance of these changes is a 
progressive loss of spermatogenesis and virility. Many of the 
patients had complained of premature loss of sexual desire. 

Other Lesions—Throughout the prevertebral tissues, root of 
mesentery, along the radicles of the portal vein, and in the pelvic 
tissues there constantly occur in the bodies of old syphilities 
minute perivascular infiltrations of lymphocytes and plasma cells, 
associated with fibroblastic and angioblastie proliferations, even- 


THE NEW PATHOLOGY OF SYPHILIS 87 


tually fibrosis, of a more or less marked degree. That the spiro- 
chete is associated with these minute lesions has been definitely 
proved. Therefore, in all cases in which these occur the possibility 
of spirochete localization must be considered. Such minute 
syphilitic inflammations may be widespread; they may be found 
in any tissue or organ. 

Lungs.—The occurrence of syphilitic localization in the lungs 
was positively determined in three cases only, in which there 
were vascularized granulomatous areas, gummatous in character. 
No especial study has been made of this organ. In nearly every 
ease the lungs showed chronic passive congestion and more or less 
marked induration or fibrosis. This has usually been interpreted 
as the result of the chronic passive congestion. As other writers 
have already pointed out, this fibrosis of the lungs may be directly 
the result of syphilis ; but to what extent this has been true in this 
autopsy material I have not had time to determine. The question 
should, however, be taken up by investigators, as our knowledge 
of syphilis of the lung is very fragmentary and vague. 

Spleen.—Chronie passive congestion, atrophy, and sclerosis 
of the splenic arterioles are the almost constant findings in the 
spleens of old syphilitics. Gummata were found in three cases; 
and these were the only positively determined instances of spiro- 
chete localization in this organ. This is also a field requiring 
investigation. I have been unable to extend my studies to 
this organ. 

Kidneys.—Changes in the kidneys—chronic passive conges- 
tion, atrophy, infarctions, local and diffuse inflammations—were 
found in practically all kidneys coming from these cases. The 
proportion of cases of chronic parenchymatous nephritis is very 
striking. Out of the first forty-one cases of this material studied 
there were seventeen cases of acute, subacute and chronic paren- 
chymatous nephritis, and three cases of interstitial nephritis. 
The relation of these conditions to the syphilitic infection is not 
apparent. I have never found spirochetes in the kidney, but they 
have been looked for in only a few cases. This is also a field 
demanding investigation. 

Genital Apparatus.—Outside of the testes spirochetes have 


88 HARVEY SOCIETY 


been found in the sexual apparatus of the cases in this material 
once only, and that in the prostate of a young man with early 
tertiary syphilis clinically latent. Diffuse plasma-cell infiltrations 
oceurred throughout the stroma of the organ, and not around 
the gland spaces as in chronic gonorrhea. The infiltrations were 
perivascular, interstitial, and not periglandular or subepithelial. 
Fibroblastic and angioblastic proliferations were prominent, and 
numerous giant cells occurred in the larger infiltrations, giving 
them the characters of miliary gummata without caseation. 
Groups of spirochetes were found in these. This case was the 
first one in which syphilitic lesions of the prostate were positively 
demonstrated. No spirochete study has been made of other por- 
tions of the internal reproductive tract in either sex. 

Lymph-nodes.—The lymph-nodes of the older cases of syphilis 
(even in young individuals) were atrophic and presented lym- 
phoid atrophy, chronic sinus eatarrh and hyaline formations 
(sears) in the germ centres and lymphoid tissue. In younger cases 
the nodes are frequently hyperplastic, but the germ centres, while 
enlarged, show a marked lymphocyte exhaustion. These appear- 
ances indicate a continuous demand made upon these organs 
against a persistent infection. 

Bone-marrow.—Premature and excessive osteoporosis of the 
bones, and fatty atrophy of the marrow characterized the majority 
of cases. In a small number of cases the lymphoid-marrow was 
found to be increased. 

Hemal-nodes.—These were atrophic, in the great majority of 
eases. In association with marked anemia, and syphilis of the 
portal vein with Banti’s disease complex, a marked hyperplasia 
of these nodes was seen, with great numbers of hemophages block- 
ing the sinuses. 

SUMMARY 

The pathologie lesions, as described above, are common to all 
eases of old syphilis (secondary stage onwards). They were 
found in known active eases of late syphilis (aortic aneurism, 
gumma of brain and liver, tabes, paresis, ete.), in cases with 
history of syphilis treated and regarded as cured, in cases with 
negative and cases with positive Wassermann reaction; and, in 


Fig. 33.—Syphilitic infiltrations in prevertebral tissues. _ Common findings in 
all old latent cases. 


root 
and are found particularly 


of plasma-cells around nerve trunk and vessels in 


Fie. 34.—Small syphilitic infiltrations 
ases of active latent syphilis 


of mesentery. These are common in all old e¢ 
near the abdominal aorta and solar plexus. 


THE NEW PATHOLOGY OF SYPHILIS 89 


the great majority of autopsies, in the bodies of those who gave 
no history of syphilis and no clinical signs or symptoms inter- 
preted by the clinicians as indicating syphilis. It is probable that 
many of these patients never knew that they had syphilis; the 
infection in some eases is probably congenital, in others accidental. 
In other patients the previous infection may have been entirely 
forgotten or supposed to have been entirely cured. As syphilis 
is a ‘‘skin disease’’ to the average mind, both lay and medical, 
the symptoms predominating in this class of patients were not 
likely to arouse any suspicion of any relationship to the old 
infection, unless excited to such suspicions by direct and intensive 
questionings along this line, which they failed to receive. 

It is, therefore, evident that syphilis as a latent infection is 
very much commoner than is generally supposed; and that the 
proportion of syphilitics in our ailing class is very high. It is, 
perhaps, idle to estimate the number of cases of syphilis in our 
population. To my mind the estimates of 5 to 15 per cent. given 
by various writers are all too low; we would place the incidence of 
syphilitic infection in this country as nearer 30 per cent. An 
analysis of our vital statistics will easily show that at a very 
low estimate about one-tenth of all the deaths occurring in the 
United States can be attributed to syphilis. Osler has recently 
made a similar estimate for Great Britain. Syphilis is the 
leading infection and the chief cause of death, even when esti- 
mates are based upon our incomplete and imperfect knowledge 
of the pathology and symptomatology of the disease after the 
ehanere and skin-symptom stages have been passed through. 
Death is rare in the first two years after infection with syphilis; 
the incidence of syphilitic death increases progressively with the 
years after the infection. Syphilis is particularly the cause of 
death in males between forty and sixty years of age; and as its 
symptomatology at this stage is in the great majority of cases 
either myocardial, vascular, renal, hepatic, ete., it is not recog- 
nized clinically as syphilis. 

It is, further, very evident that infection with syphilis means 
spirochete-carrying in many, if not in all cases. The cases in the 
material analyzed in this study represent ‘‘spirochete carriers,’’ 


90 HARVEY SOCIETY 


and the pathology given above is the pathology of a mild latent 
infection in which there is but little antagonism between the 
infecting organism and its host. Syphilis after a preliminary 
invasion and disturbance of the body tends in the great majority 
of cases probably to become an infection not much more active 
or injurious than the streptococci of the mouth cavity. The very 
slight lesions found in so many cases prove this point beyond 
dispute. In women, particularly, does the infection often become 
so mild as to be practically non-existent, except when pregnancy 
occurs and there is born a syphilitic child, or a syphilitic abortion 
or stillbirth oceurs, with spirochetes in placenta, fetus, or child. 
The spirochete carrier is immune to new infection only as long 
as he carries spirochetes. This axiom we accept to-day, but we 
are yet far from understanding the reactions between the host 
body and the parasitic spirochete. The individual tissue immuni- 
ties and susceptibilities that undoubtedly exist, the reawakening 
of virulence on the part of the quiescent organism, its relationship 
to the Wassermann reaction, the question of positive cure, ete., are 
chief among the unsolved problems connected with this most 
important of all infections. 

As to eurability, I have never seen pathologically a cured case 
of syphilis. In all cases examined at autopsy active areas of 
specific inflammation are always seen, and such areas mean always 
the persistence of the spirochete. Perhaps these intra-tissue para- 
sites should in cases without symptoms and negative Wassermann 
reaction be regarded in the same light as that in which we look 
upon the streptococci of the mouth cavity. Does the spirochete 
cease to be a cause of disease, and the body become a earrier of 
relatively or even quite completely harmless organisms? That 
some progressive injury is being caused is demonstrated conelu- 
sively by these studies. Immunity to the Spirochete pallida, and 
probably to all other organisms that enter the body tissues or, 
perhaps, even its passages and cavities, is paid for with a pricee— 
the price of defense. The infiltrations of lymphocytes and plasma 
cells in themselves may cause damage—infinitesimal, perhaps— 
but when persistent over a period of years may finally produce 
functional disturbances. The persistent shght damage and neces- 


THE NEW PATHOLOGY OF SYPHILIS 91 


sary repair by fibroblastic proliferation and the eventual fibrosis 
explains the latent period of syphilis and the final outcome in such 
terminal conditions as aortitis, myocarditis, pancreatitis, etc. The 
majority of cases of syphilitic infection die from the results of 
these slow mild inflammatory processes in the viscera and blood- 
vessels rather than from paresis or tabes. I am convinced that 
the great majority of all cases infected with syphilis die of 
chrome myocarditis. 

The syphilitic is pathologically ‘‘damaged goods;’’ and the 
damage is a progressive one. He wears out sooner, his viscera 
more quickly reach their histogenetice limits, he actually becomes 
prematurely old, and there is a constant strain upon his defensive 
powers. All of these are arguments for the prevention of syphi- 
litie infection rather than for its eure. No man can acquire 
syphilis, become clinically cured, which as far as we know means 
latency of the infection, that is, spirochete carrying, and have 
the same potential body-value and expectancy of life as before 
the infection. 

This pathologie conception of the syphilitic, as probably always 
a spirochete carrier once the infection is acquired, should in- 
fluence the therapeutic management of this chronic infection. 
The syphilitic, even when apparently perfectly well, should have 
his life laid out for him along lines tending to prevent the re- 
awakening of the virulence of the organism or an increased sus- 
ceptibility of the body tissues and organs. This is done for the 
patient who has once had clinical tuberculosis; when properly 
treated his future life is planned to prevent the reawakening of 
his infection, because he, too, is usually, if not always, still a 
carrier of the infective agent. But in the case of the syphilitic 
such hygienic measures are not applied, implicit reliance is 
usually placed upon a certain amount of salvarsan or mercurial 
treatment, while the infected individual is permitted to take up 
his life again as if he were an ordinary individual, and, as a 
rule, he succumbs prematurely to the stress and strains incident 
even to ordinary living. The treatment of syphilis, as it is ordi- 
narily carried out, looks only to the present moment; it should 
look to the whole future life of the infected individual. 


92 HARVEY SOCIETY 


Syphilis in the woman presents peculiar problems. In the 
great majority of women infected with this disease it runs an 
absolutely latent course; the lesions at autopsy in the heart and 
aorta are always, except in rare cases, much milder than in man. 
Such women die of secondary infections or other conditions, 
rather than of myocarditis or aortitis. The pancreas and adrenals 
are, however, affected to the same degree as in man, the adrenals 
perhaps more so. A syphilitic woman may, however, pass her 
entire life without any clinical manifestations of syphilis, except 
the production of syphilitic progeny. I have come into touch with 
numerous examples of this kind, of which a few may be cited here. 


1. Wife of a school teacher gave birth to a dead child. Autopsy of the 
infant revealed syphilis of the liver, and spirochetes. Both father and 
mother were above suspicion, absolutely negative histories, no signs, re- 
peated Wassermanns of both negative. Pathologic diagnosis of syphilis 
not accepted by clinicians. Woman without treatment was allowed to 
become pregnant again and in a little over a year was again delivered of a 
dead and macerated fetus showing syphilis of liver and heart, and spiro- 
chetes. Repeated Wassermanns of both father and mother were negative. 
The only explanation of this case that could be obtained was in the fact 
that the father of the mother had been a chronic drunkard since youth. 

2. Case similar to above. Two syphilitic children from father and 
mother, both apparently healthy, no history and no signs of syphilis, nega- 
tive Wassermann in both. Father of mother a chronic drunkard since 
early manhood. 

3. Father and mother apparently healthy, no signs and no history of 
infection, negative Wassermann in both, repeated abortions, one living child 
dying a few months after birth of congenital syphilis of liver, spleen and 
heart. The history of this case brought out the fact that the mother’s 
father had been a chronic drunkard, “a beast,” and diseased. Mother as a 
very young child had been rescued from the family conditions and brought 
up by a relative. A sister left behind became a keeper of a house of ill fame, 

4. Grandfather on both sides a chronic drunkard. Father and mother 
apparently well, no signs of syphilis, negative Wassermann in both. Three 
apparently healthy children, although minute examination reveals certain 
stigmata in bone development, then a child dying of active syphilis, then 
two more children apparently well, than a dead dropsical fetus showing a 
marked syphilitic placenta. 

5. Father a preacher, no history or signs of syphilis, negative Wasser- 
mann; mother’s father has “blood poisoning,” mother herself apparently 
well, negative Wassermanns repeatedly. Three syphilitic miscarriages. 


THE NEW PATHOLOGY OF SYPHILIS 93 


It is very probable that in each of these cases the mother had 
congenital syphilis from her father. When there is a history of 
chronic alcoholism, syphilis is almost invariably present, too. I 
believe that congenital syphilis in the woman is particularly lhkely 
to run a mild latent course without clinical manifestations, but 
that during the early months of pregnancy the spirochetes gain- 
ing entrance to the fetal circulation may regain their virulency 
and cause abortion, miscarriage, stillbirth, or give rise to active 
clinical syphilis in children born alive. Such children may show 
the infection at birth or later. 

It is very difficult to demonstrate spirochetes in the placentas 
of syphilitic children born at or near full term. In the fibroid 
villi they can not be found. In the young, myxomatous hyper- 
plastic villi of the syphilitic abortion occurring in the early 
months of pregnancy they are demonstrated more easily. I have 
found syphilitic lesions and spirochetes in placenta and tissues of 
a dead macerated fetus coming from a mother thoroughly treated 
with salvarsan according to modern methods, said by an expert 
in syphilology to be cured, and told that she might have healthy 
children. The first child was a syphilitic. It is also of interest 
to note the apparent fact that the tissues of the macerated fetus 
appear to be a good culture medium for the spirochete. 

The constant occurrence of syphilitic lesions in the testes of 
latent syphilities throws light upon the clinical facts, already 
known, that such cases may transmit the disease, and show spiro- 
chetes in their semen. The pathologic findings warrant the asser- 
tion that any individual who has had syphilis is particularly likely 
to pass out spirochetes in the semen and cause a seminal infec- 
tion of woman or child. The localization of the spirochetes in 
the basement membrane of the seminiferous tubules makes this 
form of transmission practically a certainty. It is very probable 
that the great majority of cases of congenital syphilis are seminal 
infections of the mother and placental infections of the fetus. 

So far as the Wassermann reaction is concerned, I believe 
that a well-marked positive reaction indicates syphilis, with very 
few exceptions, such as generalized carcinomatosis, sarcomatosis, 
ete. In these conditions a 4-plus reaction may be found without 


94 | HARVEY SOCIETY 


any autopsy signs of syphilis. A negative reaction can not be 
taken as indicating the absence of syphilitic infection, nor can 
repeated negative reactions. I have repeatedly found active 
lesions of syphilis with spirochetes present when the reaction 
was negative. This is particularly true of gumma of the brain 
and congenital syphilis. As has been frequently noted the blood 
reaction is frequently negative in brain and cord syphilis when 
that of the spinal fluid is positive. I have had an opportunity 
of examining the bodies of eight cases dying from salvarsan 
poisoning ; three of these were children with congenital syphilis, 
and of the five adult cases, three had syphilis of the central ner- 
vous system and had intradural treatments. In the congenital 
cases the treatment apparently had not in the slightest degree 
affected the number of spirochetes. In two of these cases the 
tissues throughout the body were swarming with spirochetes. 
In an adult case with secondary lesions the liver contained multi- 
ple focal necroses with spirochetes present in the necrotic areas. 
It is a question as to whether these focal necroses were due to the 
spirochetes primarily or to the action of the arsenic. In all 
cases death was apparently due to the toxie action upon the 
renal epithelium. 
CONCLUSIONS 


1. The gumma is not the essential typical lesion of old or 
latent syphilis. It is a relatively rare formation; and the great 
majority of cases of syphilis run their course without the forma- 
tion of gummatous granulomata. 

2. The new pathology of syphilis is based upon the demonstra- 
tion that the essential tissue-lesion of either late or latent syphilis 
is an irritative or inflammatory process, usually mild in degree, 
characterized by lymphocytic and plasma-cell infiltrations in the 
stroma particularly about the blood-vessels and lymphaties, slight 
tissue proliferations, eventually fibrosis, and atrophy or degenera- 
tion of the parenchyma. 

3. These mild inflammatory reactions are due to the localiza- 
tions in the tissues of relatively avirulent spirochetes. 

4. Syphilitic inflammations of this type occur in all tissues 
and organs; but are most easily recognized in the nervous system, 


THE NEW PATHOLOGY OF SYPHILIS 95 


heart, aorta, pancreas, adrenals, and testes. They are, however, 
usually widely distributed throughout the entire body, although 
in individual eases showing especial predilection for certain 
organs or tissues. No explanation of these system, organ, or 
tissue predilections is yet evident; neither is there any explana- 
tion of those cases in which all organs and tissues show the most 
severe degree of these lesions. 

5. The syphilitic is a spirochete carrier. In this respect, the 
Spirochete pallida is to be classed with the trypanosome, the 
malarial organisms, lepra and tubercle bacilli, streptococcus, ete. 

6. Syphilis tends to become a mild process; but at any time 
the partnership between the body and the spirochete may become 
disturbed, and tissue susceptibility or virulence of the spirochete 
become increased so that the disease again appears above the 
clinical horizon. 

7. Immunity in syphilis depends upon the carrying of the 
spirochete. A price is paid for this immunity in the form of the 
defensive inflammatory lesions previously described. 

8. The disastrous effects of syphilitic infection usually require 
a period of years for their development. The slowly progressive 
lesions, fibrosis and atrophy, may at last manifest themselves in 
paresis, tabes, myocarditis, aortitis, aneurism, diabetes, hepatitis, 
or in many other forms of tissue damage and functional disturb- 
ance. Lesions of the viscera are much more common and im- 
portant clinically than those of the central nervous system, but 
they are rarely recognized as syphilitic by the clinician. Syphi- 
litie death occurs most frequently in males between the ages of 
forty and sixty. Chronic myocarditis is the most common form 
of death due to syphilis. 

9. The pathologic diagnosis of syphilis is essentially micro- 
scopic. Only in a relatively small number of cases are the gross 
lesions (tabes, gumma, aortitis, ete.) typical enough to be recog- 
nized by the naked eye. A negative diagnosis of syphilis ean not 
be given with any certainty without a routine microscopic exam- 
ination of all organs and tissues, but particularly of the left 
ventricle wall, the aorta, both its arch and abdominal portion, 
the testes, pancreas, and adrenals. 


96 HARVEY SOCIETY 


BIBLIOGRAPHY 
Authors Publications on Syphilis 


Congenital Syphilis of the Heart, Am. Jour. Med. Se., 1911. 

Congenital Syphilis Simulating Leucemia and Splenic Anemia (Banti’s 
Disease). International Clinics, iv, 20. 

Cardiac Syphilis, Ohio State Med. Jour., March, 1912. 

Localization of Spirochete Pallida in the Heart Muscle in Congenital 
Syphilis, Jour. Am. Med. Assn., 1912. 

Focal Fatty Degeneration of the Myocardium Associated with Localized 
Colonies of Spirochete Pallida, Jour. Am. Med. Assn., 1912. 

Primary Tissue Lesions in the Heart Produced by Spirochete Pallida, Am. 
Jour. Med. Se., 1914, exlvii. 

Ibid., Trans. XVII Inter. Cong. of Med., Sect. of Pathology, Part II, p. 299. 

The Coincidence of Latent Syphilis and Diabetes, Am. Jour. Med. Sce., 
1916, clili, p. 157 (with Miss Wilson). 

Myxoma-like Growths in the Heart Due to Localization of Spirochete 
Pallida, Jour. Infect. Dis., 1916, xix, p. 138. 

The Staining of Spirochete Pallida in Tissues, Bull. Inter. Assn. Med. Mus., 
No. 6. 

The Persistence of Active Lesions and Spirochetes in the Tissues of Cases 
of Clinically Inactive or “ Cured” Syphilis, Am. Jour. Med. Sc., 1916, 
eliii, 508. 

Visceral Lesions in Latent Syphilis, Miss. Valley Med. Jour., April, 1917. 

The Role of Syphilis in Internal Medicine, Oration in Medicine before the 
Illinois State Medical Society, 1917, Jour. Illinois State Med. 
Soe., 1917. 

Syphilitic Aneurysm of the Pulmonary Artery, with Demonstration of the 
Spirochete, Am. Jour. Syphilis, 1917. 


FOOD CHEMISTRY IN THE SERVICE OF 
HUMAN NUTRITION* 


DR. HENRY C. SHERMAN 


Columbia University. 


T the suggestion of the President of the Society, I propose 
to speak this evening of the application of food chemistry 
to problems of human nutrition, with special reference to the 
economic aspects of our present food situation. Let us then 
consider how in the light of our present knowledge we can best 
combine adequacy of nutrition with economic use of food, remem- 
bering that economic in this connection and at this time should 
mean not only the wisest expenditure of money for food from 
the standpoint of the individual consumer, but also such con- 
servation of the food resources of the entire country as shall 
enable us to furnish our Allies and our armies abroad with 
the largest possible share of those foods which are adapted to 
their needs and suitable for exportation. 

Briefly and somewhat crudely, the material requisites of an 
adequate diet may be summarized under five heads. It must: 
(1) Provide sufficient amounts of digestible organic nutrients to 
yield the necessary number of calories of energy; (2) furnish 
proteins in ample amount and of suitable sorts; (3) supply ade- 
quate amounts and proper proportions of the ash constituents, 
salts or inorganic foodstuffs; (4) furnish enough of those as yet 
unidentified substances, the food hormones or so-called vita- 
mines; (5) it must include a sufficient amount of material of 
such physical character as to ensure the proper handling of the 
food mass and its residue in the digestive tract. Since we are 
here to deal with the chemical rather than physical aspects, dis- 
cussion may be limited to the first four of these requisites. Logi- 
eally each of these four categories calls for subdivision. 


* Delivered January 12, 1918. 
7 97 


98 HARVEY SOCIETY 


As sources of energy the carbohydrates, fats, and proteins 
function interchangeably to a very large but not to an unlimited 
extent. If our understanding of the relation of the energy value 
of food to the energy requirement of the body is to be complete, 
we must study the intermediary metabolism of each of the organic 
foodstuffs and its relation to the energy exchange, including the 
problem of its specific dynamic action. 

Similarly the problem of protein requirement divides itself 
into a group of problems having to do with the requirements of 
the body for each of 15 or 16 amino acids which constitute 
the building stones of the body tissues, and which are less 
widely interchangeable than are the energy values of the dif- 
ferent foodstuffs. 

The ash or mineral matter comprises at least ten chemical 
elements not contained in simple proteins, fats, and carbohydrates 
and which are not only not interchangeable, but are in some cases 
actually antagonistic in function. Under ordinary conditions 
and with our usual ample use of table salt the only mineral ele- 
ments which now appear to require special consideration, from 
the standpoint of adequacy of nutrition, are phosphorus, calcium 
and iron. 

The vitamine or hormone value of foods is due to at least two 
substances distinguished as fat-soluble and water-soluble vita- 
mines or as Fat-soluble A and Water-soluble B. To these it now 
appears that a third, the antiscorbutie vitamine, Water-soluble C, 
is to be added. 

It cannot be denied that the rapid progress of our knowledge 
of nutrition during the past few years has tended to complicate 
rather than simplify our conceptions of food values and nutritive 
requirements. But while the problem has become more complex, 
it also has become clearer, because we now for the first time have 
reason to believe that all of the substances needed for normal 
nutrition have been apprehended and ean be reckoned with, 
even though the chemical identification is in some eases not 
yet accomplished. 

It is most fortunate that the recent progress of research in 
nutrition, so largely the work of our own countrymen, has 


FOOD CHEMISTRY 99 


brought us to this stage in our knowledge of nutritive require- 
ments in time for us to apply it to the problem (now for the first 
time really urgent in this country) of making a more economical 
use of our national food resources. 

The efficiency with which economy in the use of food and 
conservation of the food supply can be combined with entire 
adequacy of nutrition is chiefly dependent upon the extent to 
which we can state the various essentials of an adequate diet in 
quantitative terms. 

The quantitative study of the energy requirement has been 
so recently summarized and so fully discussed before this Society 
by the very men?;*;* to whom we are chiefly indebted for its 
progress in recent years that to review the subject here would 
involve unnecessary repetition. Suffice it to say that all authori- 
ties are now in substantial agreement as to the principles of the 
energy metabolism and the fundamental facts regarding the 
energy requirement of the body, particularly of the normal adult. 
So well do different investigators agree in their estimates of the 
basal metabolism of normal men, that it seems safe not only to 
accept their average results as expressing the basal energy re- 
quirement with a satisfactory approach to exactness, but also 
to tabulate together the measurements made in different labora- 
tories upon the energy output under various conditions of work 
and rest so as to furnish a table of ‘‘hourly factors’’ from which 
the day’s energy metabolism and therefore the day’s food require- 
ment, so far as it is measured in terms of energy, may be com- 
puted. Reduced to a common basis of 70 kilograms (154 pounds) 
of body weight and averaged in round numbers, the data thus 
compiled are as follows: 


Table I.—Hourly expenditure of energy by an average-sized man (70 
kilograms; 154 pounds without clothing) under different conditions of 
activity. (Approximate averages only.) 


SHIGE DE ee ee oe cae aes haeteronti zc 60- 70 calories 
Pees VAN AGU: 21. lsiceayxs = sichetera itt 70— 85 calories 
Sittimpeateresta tases verter eek 100 calories 
Standing at, rest, 4. 2.50.2 seer. wet oie 115 calories 


LUNN) chives Gh Aab oaoco oe coe. occu UeGoobeUpIC 135 calories 


100 HARVEY SOCIETY 


Typewriting wapidly. |). . 02/7 sje see bee 140 calories 
Iso GylNGilike ss esaghboucbnocbabosce cdc 170 calories 
“Light exercise” (bicycle ergometer).... 170 calories 
Shoemakanomperre rier crore sek teeth te 180 calories 
Walking slowly (about 2%, miles per 

HOUT) Pence ee eee ena iic & che eeeaats Rive 200 calories 
Wan pPencrypaecyerdavsvelel«) sekoits.cicie er tliekenctioret sr 240 calories 
Wie Apard die Hoek oaponboodacuno seo auce 240 calories 
Industrials pamuinove-.s-ve eei ei ire a= 240 calories 
“ Active exercise” (bicycle ergometer) .. 290 calories 
Walking actively (about 334, miles per 

TROUT) yy Rosia ohare tevsleca tohats ie fee etmek era enestens 300 calories 
Stonework ge cn seyoe te ise bl septa eiere 400 calories 
“Severe exercise”’ (bicycle ergometer)... 450 calories 
SP MEACO tk Boia a godo.cegsce anus Bed os 480 calories 
Running (about 544 miles per hour)..... 500 calories 
“Very severe exercise” (bicycle ergo- 

MELED) Acero ales eee ores eselcpereiene 600 calories 


For a healthy man or woman of normal physique the energy 
requirement for twenty-four hours can be calculated from the 
number of hours spent in each degree of muscular activity, using 
the hourly rates of energy expenditure indicated in the table and 
reducing or increasing the total, according as the body weight 
is less or more than 70 kilograms. 

If the degree or intensity of muscular activity is consistently 
interpreted, the results thus calculated will be found to be in 
satisfactory agreement with the generally accepted estimates of 
the food requirements of people of different occupations, as 
illustrated in the charts recently published by Lusk. 

The available data on the energy requirements of growing 
children vary over a somewhat wider range so that average 
figures are more difficult to give and less accurate to use. 
DuBois * has constructed a curve of basal metabolism per square 
metre of body surface at different ages. But the condition predi- 
cated for the measurement of basal metabolism—complete quies- 
cence on an empty stomach—is so remote from the usual status 
of a healthy growing child, that it is necessary to make large 
assumptions in arguing from the rate of the basal metabolism 
to the total requirement for a day of normal activity. Estimates 


FOOD CHEMISTRY 101 


of the energy requirements of healthy children must therefore 
allow for considerable individual variations. 

The published data regarding energy metabolism and total 
food consumption of children have been carefully compiled by 
Miss Gillett * under the auspices of the New York Association 
for Improving the Condition of the Poor. This study led to the 
system of food allowances shown in Table II. 


Tas.e II.—Foop ALLOWANCES FOR HEALTHY CHILDREN (Gillett) 


Calories per Day 


Age—Years 
Boys Girls 
Winders 2 ies ces Ser is ees ee aoe Bae 900-1200 900-1200 
JOR PFS i orehe GEN Ol cher in icin Ee aS On eo rcerOme eeate 1000-1300 980-1280 
CO GFZ SEAR lie er ieee eI aa Ree Lp Unto 1100-1400 1060-1360 
SO, | Cea taas etc) SEEDS A, OEE Baer hu iotors ule ena care 1200-1500 1140-1440 
Oe NGS UR has SSR on a CROUCH EATON IST Creates 1300-1600 1220-1520 
SSE Ch hse RR ats oa Sep Nee eed CAPM ote) pesee yd 1400-1700 1300-1600 
SOME ORE Ros sty SA RASIE L US Ria Ab Stead Bay 1500-1800 1380-1680 
Be eae G 3 AOR EE RN OIG CIMCEIS Sita mie ciclo 1600-1900 1460-1760 
Sie Ol (erate. cferctons air ceo Ae coe 1700-2000 1550-1850 
Se UO SS caots to a Nici bint Gis erd o ooo 1900-2200 1650-1950 
1 Oe OLE Ben eae Sis eaCN Stee ates ate 2100-2400 1750-2050 
me TPB 183 ah Al Tots de eae ape te Me ten hae Bae 2300-2700 1850-2150 
ne 1s ee ve aien casts ase aioe BEAD eRe CRO REE c 2500-2900 1950-2250 
= Lig ta Ses Geico ois Bo oe 2600-3100 2050-2350 
ss TS IO}e ot Sucks erat Bacaden das Abies aides Hearne 2700-3300 2150-2450 
< LGN 7i ae ink foes Maseevts Ci RS nel Dee beac dlig Eales 2700-3400 2250-2550 


These allowances are for average cases. That very active boys 
may utilize larger quantities of food has been pointed out by 
Gephart and emphasized by Lusk; and Miss Roberts has recently 
shown that the same may also be true of younger children of 
either sex. 

Food allowances for children may well be made liberal 
enough to cover any reasonable doubt. In general, if the age 
should seem to indicate a different food requirement from that 
indicated by the size, the more liberal of the two should be 
followed. In the case of a child which is under weight with 
reference either to age or height, or both, the allowance of food, 
as caleulated in calories, should be high enough to support not 
only a normal but an accelerated growth, or to support continued 


102 HARVEY SOCIETY 


growth and at the same time fatten the tissues already formed, 
until a normal size and fatness, as shown by the relation of 
weight to height and age, is attained. 

With adults as well as with children the maintenance of an 
optimum body weight* is usually the best evidence that the 
energy value of the diet is well adjusted to the needs of the 
individual. ‘‘Counting the ealories’’ in the food eaten is not 
necessary as a means of establishing the adequacy of the custo- 
mary food intake if this is already obvious from the condition 
of nutrition of the individual concerned, but if there be any 
question of prescribing the food—of rationing either an individ- 
ual or a community—then adequate energy value of the ration 
is the first thing which should be considered, for only when the 
energy supply is adequate can the ‘‘tissue-building’’ constituents 
of the body and of the food be conserved to the best advantage. 

The protein requirement has not been so accurately and con- 
clusively measured as has the energy requirement. Chittenden’s 
well-known investigation of over a decade ago® remains the 
largest single contribution to this subject and the eriticisms evoked 
at the time by his advocacy of a standard for protein consumption 
only a little higher than the rate of catabolism shown by his 
observations—corresponding to 44 to 53 grams of protein per man 
of 70 kilograms per day—are perhaps as suggestive as any which 
have been offered. Notable among these criticisms were Meltzer’s 
argument © that the usual high rate of protein consumption con- 
stitutes an important factor of safety which it would be a mis- 
take to forego by reducing the protein content of the ration to a 
figure near the minimum requirement, and Benedict’s criticism * 
of the low protein diets as likely to be accompanied by a less 
complete digestive utilization of the non-protein food. In con- 
nection with the latter point it is interesting to note that Mills * 
found a better utilization of subeutaneously injected fat when 
the experimental animals (cats) were fed a high protein diet than 


* For discussion of optimum body weights at different ages, see “ Stand- 
ard Mortality Ratios Incident to Variations in Height and Weight Among 
Men,” a report of the Joint Committee of the Actuarial Society of America 
and the Association of Life Insurance Medical Directors (New York, 1918). 


FOOD CHEMISTRY 103 


when they were fed on low protein or fasted. Mills suggested 
that this might be because the high protein diet furnished more 
lipase in the body, and Falk and Siguira® found that their 
(castor bean) lipase preparations were composed essentially of 
protein material, as had already been shown in the case of puri- 
fied preparations of pancreatic and malt amylases.*°.** (See 
Table III.) Since the criteria of purity ordinarily used in 
TaBLE IIJ.—Forms or NiITRoGEN IN PROTEIN MATERIALS AND ENZYME 
PREPARATIONS 
(Expressed in Percentage of the Total Nitrogen in the Material) 


Oy o oO 

a ih n na ee A 
Form of Nitrogen s £8 Pes LEB oe ga S 

oO = ra] 3 Qe 
SB \eol a lesa) S8 (683 
AT OINING | Nese aero: CAN QO ede 1 15.301) TON Ae ag 
istiaines Nees noes ae ee 6.2 AS || Le cll 18355 6.0 | 5.4 6.2 
leyvsinewNieeeesncee crickets 10.3 3-9. | 10:9 | 5.4 7.4 | 5.5 4.3 
C@vstinerNeceen tee oe ae 0.2 5 ie 6.6 2.5 4.9 By 
Amino N of filtrate......... 55.8 | 47.5 | 57.0 | 47.5 | 50.4 | 52.4 | 49.4 
Non-Amino N of Filtrate...| 7.1 160/ 2.9 Sal 4.6 AY Salle 
AMmMoniayNiegeee ie senses: 10.3 | 10.0 5.2 | 10.0 8.1 7.9 | 12.1 
1.3 2.0 3.6 7.4 8} 5.6 3.3 


MelanimesNeaeeeeeele eee 


1 Van Slyke (1910). 

2 Sherman and Gettler (1913). 

3 Falk and Siguria (1915), 
chemical research are not applicable to unstable colloidal sub- 
stances like the digestive enzymes, it is easy to say that such 
preparations as were here analyzed may be far from pure. It 
has even been suggested that the protein matter of which these 
enzyme preparations chiefly consist may be only an impurity or 
a ‘‘earrier,’’ while the ‘‘real enzyme’’ is something of wholly 
unknown chemical nature. There is, however, no positive evi- 
dence in support of this latter suggestion. On the other hand, 
there is much evidence which, while not conclusive, is direct and 
positive in character, tending to show that the common hydrolytic 
enzymes, such as those concerned in the utilization of foodstuffs, 
either are proteins or contain protein matter as an essential 
constituent. Probably, therefore, the food protein must furnish 
material for body enzymes as well as for body tissue. 

Both this consideration and the more familiar one that indi- 


104 HARVEY SOCIETY 


vidual amino acids furnished by the food proteins may serve 
as precursors of body hormones,’ ** naturally tend toward cau- 
tion in the acceptance of a low protein standard, especially since 
the proteins have been shown to vary widely in their amino-acid 
make-up and in their nutritive value when fed singly, especially 
in experiments upon growing animals."*, *® 

These differences in nutritive value among proteins, especially 
as correlated with chemical structure by Osborne and Mendel, 
are of the greatest importance, but we should be careful not to 
mistake them as justifying a reactionary attitude or even a need- 
less degree of timidity in accepting and applying the results of ex- 
periments upon the amount of protein required for normal human 
nutrition. Rather they furnish the information necessary to 
enable us to plan economical use of protein wisely and with 
confidence. Probably the best guide to the amount of protein 
actually needed in the food of the human adult is to be found 
in the average daily rate of nitrogen output when the intake is 
restricted to an amount barely sufficient or not quite sufficient 
to maintain nitrogen equilibrium. 

The nitrogen output on a diet markedly deficient in protein 
and involving a large loss of body nitrogen may be less than the 
nitrogen requirement, since a large nitrogen loss from the body 
might not be convertible to equilibrium by the addition of an 
equal amount of food nitrogen to the intake; but where there is 
nitrogen equilibrium on a low protein diet, it seems safe to con- 
elude that such diet is meeting all the demands of the normal 
nutrition so far as protein is concerned. Also, when the nitrogen 
output is only very slightly greater than the intake, it seems 
permissible to regard the output as approximating the actual 
requirement. It might perhaps be argued that even a small 
loss of nitrogen from the body might, if long continued, be 
serious, possibly on the ground that the extra nitrogen of the 
output over that of the intake may conceivably represent the 
catabolism of some particular amino acid which the food does 
not supply in sufficient amount and whose continued loss would 
be detrimental. The experimental evidence, however, does not 
seem to support this latter view. In experiments, for example, 


FOOD CHEMISTRY 105 


in which gelatin is the sole protein, we do not find a merely 
small loss of body nitrogen which might be mistaken for approxi- 
mate equilibrium, but a loss large enough to indicate plainly that 
the food protein in that case is inadequate. Similarly, in the 
well-known experiments of Osborne and Mendel, in which rations 
containing a single protein are fed to experimental animals, the 
feeding of zein rations results in prompt and considerable losses 
of body nitrogen and body weight. 

It is, therefore, very unlikely that a diet which maintains 
approximate nitrogen equilibrium is so deficient, either in the 
kind or amount of protein which it contains, as to make it a 
source of danger, even if long continued. On the contrary, a 
small negative balance usually means simply that the body has 
not yet completed the adjustment of the rate of output to the 
rate of intake. In most such cases it is altogether probable that 
the continuance of the low protein diet would soon lead to nitro- 
gen equilibrium, and that in taking the output as a measure of 
the requirement, we are probably overestimating the real mini- 
mum requirement for protein. 

It has, therefore, been thought worth while to bring together 
the data of all available experiments in which the dietary © 
conditions and the nitrogen balance were such as to indicate that 
the output of nitrogen might be reasonably construed as approxi- 
mating the actual nutritive requirement. In order to minimize 
the personal equation in interpretation, we have uniformly ex- 
eluded all experiments showing a loss of nitrogen greater than 
1 gram per day. There remain 107 experiments upon adults 
showing no abnormality of digestion or health, in which the diet 
was sufficiently well adjusted to the probable requirement and 
the nitrogen balance showed sufficient approach to equilibrium 
to make it appear that the total output of nitrogen might be 
taken as an indication of the protein requirement. These experi- 
ments are taken from 22 independent investigations in which 36 
different individuals (28 men and 8 women) served as subjects. 
For purposes of comparison, the daily output of total nitrogen in 
each experiment was calculated to protein and this to a basis 
of 70 kilograms of body weight. Reckoned in this way, the 


106 HARVEY SOCIETY 


apparent protein requirement as indicated, by the data of individ- 
ual experiments, ranged between the extremes of 21 and 65 grams, 
averaging 45 grams of protein per man of 70 kilograms per day. 
Thus the average falls well within the range of Chittenden’s 
estimate of the amount of protein required for normal nutrition 
when the energy value of the diet is adequate. 

Examination of the data recorded in the original papers 
indicates that the wide differences in amounts of protein catabo- 
lized in the different experiments can not in these eases be 
attributed primarily to the kind of protein consumed nor to the 
use of diets of fuel values widely different from the energy 
requirements. Apparently the most influential factor was the 
extent to which the subject had become accustomed to a low 
protein diet. 

In view of the fact that individual proteins when fed singly, 
especially to growing animals, have shown striking differences in 
nutritive efficiency, it may seem strange that in the experiments 
hitherto made to determine the protein requirement of man, the 
kind of protein fed has not had more influence upon the amount 
required. There is, however, no real discrepancy between the two 
sets of findings. Experiments like those of Osborne and Mendel, 
for example, were for the object of comparing individual pro- 
teins isolated even from the other proteins which always accom- 
pany them in natural or commercial food materials, and were 
conducted largely upon rapidly growing young animals in which 
there is an active synthesis and retention of protein so that a 
deficiency in the supply of any amino acid which is required in 
the construction of body protein is apt to be quickly and plainly 
reflected in a diminution or cessation of growth. On the other 
hand, in experiments, the purpose of which is not to compare 
proteins but to measure the normal protein requirement, the diet 
is naturally made up, not of isolated proteins or even of single 
or unusual foods, but (ordinarily at least) of sueh combinations 
of staple foods as are believed to represent a normal diet, so that 
even a relatively simple ration arranged for the purpose of such 
an experiment would probably contain a number of different 
proteins among which any peculiarities of amino acid make-up 


FOOD CHEMISTRY 107 


would be apt to offset each other, at least to a considerable extent. 
Moreover, the experiments of the group now under discussion 
have been made entirely upon adults whose protein requirement 
was limited to that of maintenance. In such cases there is no 
longer a demand for amino acids to be built into new tissue, but 
only to maintain the equilibrium which already exists between 
amino acids and proteins in the full-grown tissues. Any of the 
amino acids whose radicles are contained in tissue proteins may 
be expected to contribute something to the maintenance of such 
an equilibrium, whereas there can be no growth unless all the 
necessary amino acids are present. In the protein metabolism of 
growing children or nursing mothers the influence of food selec- 
tion would probably be much more pronounced and even in the 
case of adult men protein requirement will probably be found 
to be considerably influenced by food selection when experiments 
suitably planned to test the question are carried out. The inade- 
quacy of gelatin as a sole protein food and its inferiority to 
meat or milk protein when substituted beyond a certain propor- 
tion is well known. A series of experiments, designed to demon- 
strate differences in nutritive efficiency for man of the protein 
supplied by different staple articles of food, was carried out by 
Karl Thomas,!® in Rubner’s laboratory, and the striking results 
reported have been widely quoted, often on Rubner’s authority. 
These results however, have as yet failed of confirmation, and, on 
some important points have been so directly refuted by later 
workers using longer experimental periods, as to make it appear 
that Thomas’s plan of experimenting and mode of interpretation 
were not suited to the solution of the question at issue. 

Thomas reported that meat protein was greatly superior 
to bread or potato protein for the maintenance of body tissues, 
but Hindhede *’ finds no such difference, being able to maintain 
normal nutrition with either bread or potato nitrogen in relatively 
small amounts. 

Rose and Cooper ’® have also demonstrated the high value 
of potato nitrogen in the maintenance of nitrogen equilibrium, 
and experiments in the writer’s laboratory ’® have tended to 
confirm Hindhede’s finding that nitrogen equilibrium may be 


108 HARVEY SOCIETY 


maintained on a relatively low intake of protein in the form of 
bread alone. Of at least equal practical importance are those 
experiments 7° which show the maintenance of nitrogen equi- 
librium on low protein diets in which bread or other cereal 
product is the chief source of protein, but is supplemented by 
small amounts of milk.* 

At a time when compulsory rationing is being seriously dis- 
eussed and when we know that in any case economic conditions 
are forcing the majority of people to an increased use of the less 
expensive foods which may mean that a larger proportion of the 
protein consumed is not of the kinds having highest nutritive 
efficiency, it becomes important to consider somewhat more closely 
the question of the utility of the so-called incomplete proteins in 
nutrition, and the protein-sparing action of the fats and carbo- 
hydrates which may operate to conserve the protein supply by 
diminishing protein catabolism. In order to do this we should, 
I think, recognize that protein metabolism is not an affair of 
two distinet and separate processes—anabolism and catabolism— 
but is rather to be conceived as involving a series of reversible 
reactions or of approximate equilibria in the body. The tissues 
always contain protein and amino acids which in a healthy grown 
man are constantly in approximate equilibrium: 


Amino acids = Protein 


The supply of amino acids in the tissues is constantly being 
augmented by the digestion products brought by the blood, and 
at the same time is constantly being depleted by deaminization. If 
amino acids are brought to the cell more rapidly than they are 
removed or deaminized, the concentration of amino acids is in- 
creased and this must tend to push the above reaction toward the 
right—.e., to check the rate of protein catabolism or to conserve 


* Attention may also be called to the extended experiments of Osborne 
and Mendel, published since the above was written, showing good growth 
of rats on low protein diets in which wheat or wheat flour furnished most 
of the nitrogen but was supplemented by small amounts of milk, eggs or 
meat (in the latter case with butter and suitable mineral salts). Journal 
of Biological Chemistry 37, 557 (Apr. 1919). 


FOOD CHEMISTRY 109 


the protein of body tissue, and vice versa. Similarly, the intake 
of ammonia salts under proper conditions may check the deami- 
nization of amino acids and thus indirectly take part in the 
maintenance of nitrogen equilibrium. But ammonia may also 
contribute to the actual formation of amino acids in the body, 
as Shown by Embden and Knoop and by Dakin, and this probably 
furnishes us the best explanation now available of the protein- 
sparing action of carbohydrates and fats as illustrated in the 
accompanying diagram. 


FAT CARBOHYDRATE PROTEIN 

e.g., Stearin Glucose 
<a | Amino acids 
Stearic acid Glycerol SS | | enna 
Glyceric 

By f-oxidation to aldehyde —> Methyl glyoxal f 
(finally) carbon dioxide | NX 
and water Lactie acid —NH, 


Pyruvie acid 


By oxidation to 
(finally) carbon dioxide 
and water 


Since pyruvie acid appears to be regularly formed in the 
metabolism of carbohydrate and of the glyceryl radicle of fats, 
and ammonia is always being formed in protein catabolism (by 
deaminization of amino acids), and since the ammonium salts 
of a-ketonic acids, such as pyruvic acid, are convertible into 
amino acids which are building materials for body protein, we 
have here a mechanism by which an intermediary product of 
carbohydrate metabolism (pyruvie acid) takes up a ‘‘ waste prod- 
uct’’ of protein metabolism (ammonia) and turns it back into 
amino acid, ‘‘protein material,’’ again. Thus carbohydrate, in 
undergoing metabolism, “‘spares’’ protein, not only by serving as 
fuel so that protein need not be drawn upon for this purpose, but 
also by furnishing material, which in combination with ammonia 


110 HARVEY SOCIETY 


(otherwise a waste product), can actually be converted in the 
body into some of the amino acids of which the body proteins 
are composed and with which they are in equilibrium. This 
explains how an increased intake of carbohydrate, with resulting 
increase of pyruvic acid, naturally leads to increased synthesis 
of amino acids and thus to a tendency toward protein storage, 
or, to express the same thing in somewhat different terms, tends 
to push the reaction, amino acids = protein, toward the right. 

According to present theory, most, if not all, of the energy of 
the carbohydrate becomes available through oxidation processes 
which involve the intermediate production of pyruvic acid, an 
a-ketonie acid whose ammonium salt is capable of conversion 
into amino acid. Of the fat only the glyceryl radicle (about one- 
twentieth of the fuel value) is oxidized through pyruvic acid, 
while the fatty acid radicles, representing about nineteen-twen- 
tieths of the energy of the fat, are metabolized through B-oxida- 
tion processes which yield, so far as we know, no product whose 
ammonium salt is convertible into amino acid in the body. Hence 
complete withdrawal of carbohydrate, even though substituted by 
sufficient fat to yield an equal number of calories, must be 
expected to result in increased excretion of nitrogen. 

Under war conditions, while we may have to economize in the 
use of sugar, there will probably be at least an equal pressure for 
economy in the use of fat so that the energy requirement will 
tend to be met largely by the use of starchy foods. Hence there 
should be at least as high a proportion of carbohydrate in the 
war diet as in that of peace and the full protein-sparing effect 
should be realized. 

Now that we have a chemical explanation of the protein- 
sparing action of carbohydrates and fats which is based on 
reactions which have been definitely demonstrated to take place 
in the organism, we see that only a few of the simplest amino 
acids can be conceived as synthesized by this mechanism, and yet 
we know from the results of many feeding experiments that the 
‘‘sparing action’’ of carbohydrates and fats is a large factor in 
conserving the protein of the body or of the intake. In harmony 
with this we find that ‘‘incomplete’’ proteins, furnishing some, 


FOOD CHEMISTRY Had 


but not all, of the amino acids of which body proteins are com- 
posed, may still play a very important part in the protein metabo- 
lism of maintenance. 

McCollum, in 1911," called attention to the rather surprising 
nutritive efficiency of zein in eases in which only maintenance 
was involved, and offered the suggestion that ‘‘repair’’ processes 
may not involve the disruption and reconstruction of entire pro- 
tein molecules. The same idea may be expressed from a slightly 
different point of view by saying that having in the cell under 
conditions of maintenance an equilibrium, amino acids = pro- 
tein, between protein and a whole group of amino acids the 
catabolism of protein will be diminished by increasing the con- 
centration of any (even though not all) of the amino acids into 
which the protein molecule tends to be resolved. 

Thus food proteins which do not furnish all of the amino acids 
needed for the construction of body tissue and which therefore 
could not properly be made the chief reliance in the feeding of 
growing children, or of women during pregnancy or lactation, 
may still be depended upon to a very large extent for the ordinary 
maintenance of adults. 

Nor does it seem necessary to assume that because of the 
differences in nutritive value among proteins, a very large margin 
for safety must be allowed above the average amount found in 
the 107 experiments cited above. This would be true only if the 
diets in these experiments had been selected from among materials 
whose proteins are of more than average value, which in general 
was not the case. In fact, in the low protein diets used in these 
experiments there was often, if not usually, a more than average 
proportion of bread or other grain protein so that, if anything, 
the experiments tend to overstate the amount of protein which 
an ordinary mixed diet must furnish in order to cover the require- 
ments of normal protein metabolism in the adult. Under these 
conditions it seems abundantly liberal to allow when planning 
for an economical use of food, a protein ‘‘standard’’ 50 per cent. 
higher than the average estimate of the actual requirement (which 
as already shown is probably an overestimate). Such a 50 per 
cent. margin for safety would lead to a tentative standard allow- 


112 HARVEY SOCIETY 


ance of about 70 grams of protein per man, or 1 gram per 
kilogram of body weight, per day. The requirements of children 
for protein, as well as other tissue-building material, will be 
considered as proportional to their energy requirements, and 
therefore much higher per unit of weight than in the case 
of adults. 

The phosphorus and calcium requirements have in the past 
been much less studied than the protein requirement, although 
in principle they are equally well adapted to investigation by the 
method of quantitative comparison of intake and output. Until 
recently the results of such experiments were not sufficiently 
numerous or concordant to give us much confidence in the 
validity of the average; and as a basis for general conclusions 
regarding phosphorus and calcium requirement in human nutri- 
tion, they were open to the further criticism of having been 
made almost exclusively upon male subjects. Experiments 
upon women were therefore plainly needed and since the 
effects of the monthly cycle upon phosphorus and calcium 
metabolism had not been studied, it was especially desirable 
that the determination of intake and output should continue for 
an entire month without intermission. Four young women, grad- 
uate students and research workers in the writer’s laboratory, 
have served as subjects in such experiments, taking diets uni- 
form from day to day for 28 or 30 days consecutively with quanti- 
tative determinations of intake and output of nitrogen, phos- 
phorus and ealcium balanced in experimental periods of three 
or four days each. Three of the four subjects have each made 
two such series of experiments.** From the data of all these 
experiments there does not appear to be any distinct monthly 
eycle in the total quantitative metabolism of either phosphorus 
or calcium; nor was the output of either of these elements in the 
menstrual flow large enough to materially affect the average 
daily metabolism for the entire month. From this standpoint 
the material lost in menstruation is essentially blood, and as such 


FOOD CHEMISTRY 113 


is important to the estimate of the average daily requirement for 
iron, but is of minor consequence in the nitrogen, phosphorus and 
calcium metabolism. 

The determination of phosphorus and calcium balance in 
three- or four-day periods for twenty-eight or thirty days with- 
out intermission gave, therefore, in each case a series of seven 
to ten experiments of unusual value for the purpose of studying 
the normal nutritive requirement, since the diets were so arranged 
as to furnish the desired amounts of energy and protein with 
quantities of phosphorus and ealcium small enough to test the 
ability of the body to establish equilibrium on the amounts fur- 
nished, and to show to how low a level of phosphorus or of calcium 
metabolism the body could adjust itself. 

The minimum requirements thus found, computed, for con- 
venience of comparison and application, to a basis of 70 kilo- 
grams body weight, corresponded respectively to 0.91, 0.72, 0.83, 
0.89 gram phosphorus, and 0.49, 0.38, 0.44 gram calcium ‘“‘per 
man per day.’’ 

Averaging these results with those of several other experi- 
ments made in this laboratory upon both men and women and 
with all comparable data found in the literature, indicates a mean 
requirement per 70 kilograms of body weight of 0.88 gram phos- 
phorus and 0.45 gram calcium per day. 

Considering both the number of experiments contributing 
to the average and the range of results in each ease, it would 
seem that our present knowledge of the quantities required for 
normal nutrition is probably about equally accurate as regards 
protein, phosphorus, and calcium. This being so, we have as 
much reason to set phosphorus and calcium ‘‘standards’’ as to set 
a ‘‘standard’’ for protein, and it seems logical to allow as much 
margin for safety in the one case as the other. The accompany- 
ing table summarizes the data on which these estimates of ‘‘re- 
quirements’’ and ‘‘standards’’ are based and shows also the 
relative frequency of American dietaries which fall below the 
standard or even the bare minimum requirement in each ease. 

8 


114 HARVEY SOCIETY 


TABLE IV.—NUTRITIVE REQUIREMENTS AND ACTUAL INTAKE. 
“Per Man Per Day.” 


Protein Phosphorus Calcium 

Number of experiments. 107 95 63 
“Requirement” grams 

1a) (eles AAO sia oi 21-65 0.52—-1.20 0.27-0.78 

IAVCTACC eer eietet het 45 0.88 0.45 
“Standard” (50% 

above ‘“requirement’”’) 70 grams 1.32 grams 0.68 gram 
Actual amounts in 246 

dietaries (avg.) ... 106 grams 1.60 grams 0.74 gram 
Percentage of cases 

below “Standard” .. 6 % 29 % 52. % 
Percentage of cases 

below “Requirement” none : 4% 16. % 
Percentage of cases 

below “Requirement” 

if dietaries below 

3000 calories per man 

per day were brought 

up to that amount.. none Less than 1% 8. % 


It must be stated with all possible emphasis that the words 
‘‘requirement’’ and ‘‘standard’’ are used here only for lack of 
better terms and that they have not and cannot have the uncon- 
ditional significance which is apt to be attached to them. 
McCollum’s recent work ** emphasizes the fact, which earlier 
work on the metabolism of calcium and iron,?* 25 had illustrated, 
that the amount of any one nutrient required will depend to a 
considerable extent upon the amounts of other nutrients fur- 
nished. In taking the average of supposed minima found in 
various investigations as an estimate of the ‘‘requirement,’’ we 
do not mean that just this amount would be literally required in 
each case. The very experiments from which this average is 
derived are sufficient to show that the actual requirement varies 
with the subject and the diet if not with other conditions. 
Similarly, in taking an amount 50 per cent. above the average 
requirement as a ‘‘standard,’’ it is by no means intended to 
imply that this amount will be always the most desirable. On 
the contrary, a larger amount might easily be advantageous, 


FOOD CHEMISTRY 115 


especially in the case of calcium as a safeguard against failure of 
completely normal absorption in the digestive tract. 

Thus the quantitative statements of what are here called 
‘‘requirement’’ and tentative ‘‘standard’’ must not be literally 
interpreted nor rigidly applied. They are, however, directly 
useful as a concrete basis for classifying the results of dietary 
studies as to whether they contain liberal or scanty amounts of 
the element in question. An intake less than the so-called re- 
quirement does not necessarily mean a continuing deficit leading 
finally to disaster in every individual case, but does mean that 
there is this danger wherever such low intakes are habitual. 

In individual cases in which intake and output are quantita- 
tively determined and the inability of the subject to establish 
equilibrium is demonstrated, there can be no doubt that the intake 
is inadequate for the subject and conditions of the experiment 
and the fact of such a deficiency with reference to any particular 
element (calcium, for instance) may be established with entire 
certainty by the laboratory evidence without awaiting the de- 
velopment of any pathological symptoms. 

Of the 246 dietary studies referred to in Table IV, 144 were 
originally recorded by the United States Department of Agri- 
culture and have recently been subjected to more detailed analysis 
and computation, especially as regards the mineral elements, in 
connection with the investigations upon mineral metabolism at 
Columbia University; 102 were collected and studied in detail 
by Miss Gillett, working under the joint auspices of the Univer- 
sity and the New York Association for Improving the Condition 
of the Poor. Nearly all of the latter were from New York City. 
Of the 144 government studies, 54 were made in New York 
City, 46 in other large cities, 44 in small cities or towns and rural 
regions. In each of these groups calcium is the element most often 
deficient and of which the average intake shows the least margin 
of safety above the bare requirement. It is particularly inter- 
esting to note the agreement of this result with the emphasis laid 
upon calcium by Osborne and Mendel ** in their recent discussion 
of the mineral elements in nutrition and with that of MeCollum 7” 
who has found in his studies of laboratory animals that it is 


116 HARVEY SOCIETY 


largely if not chiefly because of insufficient calcium that such 
animals do not show normal nutrition on rations derived too 
largely from seeds. American dietaries, both urban and rural, 
tend to consist too largely of the products of seeds, meats, sugar 
and fats, all of which are poor in calecium—and too little of milk 
and vegetables which should be used in larger proportion, both 
for their mineral constituents and for the vitamines which 
they furnish. 

As might be expected in view of New York City’s great size 
and the difficulty and expense of bringing in adequate supplies 
of perishable foods—milk, for instance, having to be brought 
from seven states and from distances sometimes as great as 400 
miles or more—the New York City dietaries show a smaller 
average calcium content than those of other cities, while the 
small towns and rural regions show the best average. 

Most of the New York City dietaries, recorded by United 
States Department of Agriculture, were observed in 1895-1896. 
By the time of the investigation by the Association for Improving 
the Condition of the Poor in 1914-1915 the average calcium con- 
tent had improved about 14 per cent. Undoubtedly this is chiefly 
due to the increased per capita consumption of milk which is 
known to have occurred during this twenty-year period, and 
which in turn is no doubt largely attributable to the good in- 
fluence of the public and private agencies which have been 
working in New York City for a better and more adequate milk 
supply, and to the better understanding of the importance of 
milk by the general public largely due to the efforts of the 
dietitians, visiting nurses, and other visitors of the social and 
relief organizations and to the teachers of domestic science in 
the public schools. That the calcium content of the dietary is 
very closely related to the amount of milk used and that the 
latter can be influenced by education are both well illustrated 
by data which have been presented elsewhere.** By analysis of 
the data of the 44 dietaries studied in small towns and rural 
regions it was found that here also the adequacy of calcium intake 
depended chiefly upon the amount of milk consumed, adequate 


FOOD CHEMISTRY 117 


calcium being found, on the average, only in those dietaries which 
contain at least one-third of a quart of milk per man per day. 

The results of the dietary studies indicate very strongly that 
the average American dietary contains a much more liberal mar- 
gin of protein than of calcium, and that while the danger of 
a protein deficiency is rarely serious, the danger of a deficiency 
of calcium is very real. So far as the actual requirements of 
the calcium metabolism are concerned, these (as well as other 
‘‘mineral’’ requirements) could be met by the addition of simple 
mineral salts to the food, but since the foods naturally rich in 
calcium, notably milk, eggs, vegetables and many fruits, are 
so valuable for other properities as well, it seems wiser in deal- 
ing with human nutrition to encourage the more liberal use of 
these naturally calcium-rich foods, rather than the artificial 
addition of calcium salts. 

Phosphorus deficiencies are probably four to five times as 
frequent as are deficiencies of protein, and calcium deficiencies 
are much more frequent still. The old assumption that adequate 
protein may be taken as meaning adequate supplies of all tissue- 
building material is found to be wholly misleading. Adequate 
energy intake is, in practice, more apt to ensure adequacy of min- 
eral elements, but even if all of the 246 dietaries had been 
brought to a basis of 3000 calories per man per day, 8 per cent. 
of them would still have furnished less than the average ‘‘require- 
ment’’ of calcium. 

The iron requirement is much less definitely known than that 
for phosphorus or calcium. From the few experiments which now 
appear trustworthy, it would seem that the actual requirement 
may average about 0.010 gram, and the corresponding standard 
be placed at 0.015 gram, per man per day. On this basis it would 
appear that the danger of a deficient intake of iron on freely 
chosen diet is less than in the case of calcium, but much greater 
than is the danger of a deficiency of protein. 

Standard allowances of protein, phosphorus, calevum and 
iron for children’s dietaries—It will, of course be understood 
that in all these statements regarding adequacy of family die- 
taries or of food allowances for a family or a community, the 


118 HARVEY SOCIETY 


child’s requirement for protein, phosphorus, calcium, or iron is 
reckoned as proportional to his energy requirement and there- 
fore as much more than proportional to his weight. Starting with 
the food allowances for healthy children, tabulated above in 
terms of calories, it may be convenient to reckon the requirements 
of children or of families containing children as follows: 


Protein, (etc) 2.5* grams per 100 calories 
Phosphorus ... 0.045 gram per 100 calories 
Calcwm weno 4. 0.023 gram per 100 calories 
ATOn Ke eee a 0.0005 gram per 100 calories 


The ‘‘vitamine’’ requirements naturally cannot be stated in 


terms of actual weights of the substances involved until these 
are identified chemically, but the percentages of certain foods 
rich in the one or the other of these essentials which suffice to 
make an othewise satisfactory diet adequate for normal growth 
and reproduction have been determined experimentally for 
several food materials by Osborne and Mendel *° and by McCollum 
and his associates,°° so that we now know in a general way the 
relative richness of several of the chief types of food in each 
of these dietary essentials and can take account of this factor of 
food value in considering the prominence which should be given 
to each type of food in planning an adequate and economical diet. 

It is both interesting and important to find how generally 
the types of food rich in calecium—milk, eggs, vegetables—are 
rich in vitamines (particularly the fat soluble vitamine) as well, 
so that in safeguarding against deficiency of the element most 
likely to be deficient, we at the same time secure an ample intake 
of the food hormones or vitamines. 

To apply knowledge of nutritive requirements in the choice 
of food, any one of several plans may be followed. 

1. The actual quantity of each essential element could be 
caleulated for every proposed combination of staple food mate- 
rials, but this method would be too cumbersome for general use. 

2. Since in the past it has been customary to treat protein 


* Which should be mainly in the form of milk protein in the dietaries 
of growing children. 


FOOD CHEMISTRY 119 


as the tissue-building material of the food and since we now 
know that dietaries containing enough protein do not necessarily 
contain enough of other building materials, such as phosphorus 
and calcium, we might seek to remedy the situation with a mini- 
mum revision of past habits of thought by so specifying the 
kind of protein as well as its amount as to ensure that adequate 
protein supply shall really ensure (what we formerly erroneously 
assumed) an adequate supply of all essential elements. Thus, in 
specifying that the protein in the dietaries of growing children 
shall be mainly in the form of milk, we ensure not only a good 
form of protein but an adequate supply of calcium, of phosphorus, 
and of vitamines as well. 

3. Again, since food values are commonly stated in terms of 
ealories and the 100-calorie portion of food is becoming a more 
and more familiar unit, it is possible by building up a dietary 
of such units and specifying the number to be drawn from each 
type of food, to ensure that in covering the energy requirement 
an adequate supply of protein, of each of the inorganic elements, 
and of each type of vitamine shall also be ensured. This is per- 
haps the most satisfactory procedure in those cases in which the 
balancing of the diet is attained by careful planning of each meal 
from day to day, and its application has been greatly facilitated 
by the publication of the excellent series of meal plans for which 
we are indebted to Mrs. Rose.** 

4, Still another method of balancing the dietary and insuring 
an adequate supply of each essential nutrient without undue 
expenditure or extravagant consumption in any one direction, 
is to follow a food budget, or in other words, apportion the money 
expended for food among the different types of food materials. 
This plan, while less logical from a scientific standpoint than 
those previously mentioned, has the merit of simplicity, of requir- 
ing no use of technical terms, and of facilitating comparison with 
food statistics which are as apt to be reported in money value 
as in weights and measures, and in any case are much more 
readily reducible to money than to food value when the latter 
is construed as broadly as we now must construe it to cover all 


120 HARVEY SOCIETY 


the constituents of food which we know to be essential to nor- 
mal nutrition. 

Food supplies of American families—The results of inquir- 
ies by the United States Bureau of Labor Statistics in over two 
thousand families, and of very accurate records obtained by the 
United States Department of Agriculture and the New York 
Association for Improving the Condition of the Poor in over two 
hundred households carefully chosen as representative of differ- 
ent economi¢ groups, are quite consistent in showing that of the 
total expenditure for food about one-third is for meats and fish, 
about one-tenth for milk, one-twentieth for eggs, one-tenth to one- 
sixth for breadstuffs and other cereal products, about one-sixth 
for butter and other fats, sugar and other sweets, about one- 
sixth for fruit and vegetables, and one-twentieth to one-tenth 
for all other foods and food adjuncts. This estimate of the 
relative prominence of different types of food is confirmed by 
the statistical estimates of the values of annual product of the 
different food industries of the United States after allowing for 
imports and exports. 

Are the habits of food consumption which these statistics 
reveal the ones which we must consider the best in the light of 
our present knowledge of nutrition? If they are capable of modi- 
fication for the better, can this be accomplished in a manner 
consistent with our responsibilities in the present world food 
situation? I think there is no doubt whatever that the average 
American dietary can be modified to meet all the wishes of the 
Food Administration and be materially improved at the same time. 

We are asked by the larger use of perishable foods, including 
such grain products as are more perishable than wheat flour to 
‘““save,’’ or reduce our consumption of, wheat, meat, fats and 
sugar. It is in fact precisely because of the free use of meat, 
sugar, fat and white flour in American dietaries that so many 
of them are deficient in one or more of the mineral elements, 
particularly calcium, so that the partial substitution of other 
foods for each or any of these four will tend directly to remedy 
the commonest defect in the nutritive value of our food. 

That the mineral and vitamine contents of the average Ameri- 


FOOD CHEMISTRY 121 


can dietary can and should be improved by the larger use of 
milk and vegetables, even if this means a decreased consumption 
of meat, is now well recognized by students of nutrition. Be- 
cause of the economic limitations under which the food for most 
families must be provided, the use of so much as one-fourth to 
one-third of the food money for meat practically results in too 
great a limitation of the consumption of fruit, vegetables and 
milk. Even if there were no war, we should teach a lessened use 
of meat and sugar in order that more milk, vegetables and fruit 
may be purchased and consumed. Since sugars and fats are 
practically devoid of inorganic foodstuffs or of water-soluble 
vitamine, as well as of protein, a diet in which the use of purified 
sugars and fats is reduced and the same number of calories 
supplied by an increased use of other food material, is almost 
sure to be improved as regards its calcium, iron and phosphorus 
content as well as made richer in protein and vitamine. The 
only exception worthy of note is the richness of butter in fat- 
soluble vitamine. 

The duty placed upon us by the present food emergency, to 
eat less meat and more of such perishables as milk, vegetables and 
fruit, is therefore precisely what the recent advances in our 
knowledge of food and nutrition have shown to be for our best 
interest in any case. 

It seems a good general rule for families of any level of in- 
come or standard of living (1) to spend at least as much for milk 
as for meat; (2) to spend at least as much for vegetables and 
fruit as for meats and fish. 

If it be objected that many people ‘‘simply cannot buy’’ milk 
at present prices, it should be said in reply that while every 
increase in the cost of milk to consumers is greatly to be regretted 
and should be avoided, if possible, yet milk at any price which it 
has yet reached, or is likely to reach, is a better investment than 
meat. lLusk’s admonition to the housewife to ‘‘buy three quarts 
of milk before buying a pound of meat’’ is excellent advice; 
all the more so in view of the general rise in prices. Any family 
that can afford meat at all can better afford milk. 

A liberal use of milk and vegetables in the diet is the best 


122 HARVEY SOCIETY 


safeguard against any deficiency which might arise through 
restricted choice of foods, and the safest and most practical way 
to ensure that the consumption of enough food to maintain a nor- 
mal weight for the height and age shall meet all other require- 
ments of nutrition as well. 


REFERENCES 


*Lusk: Science of Nutrition, Third Edition (1917) and Journal American 
Medical Association, vol. 70, p. 821 (1918). 

? Benedict: Metabolism During Inanition. Harvey Lectures for 1906-1907, 
p. 170, and Publications of the Carnegie Institution of Washington. 

*>DuBois: The Respiration Calorimeter in Clinical Medicine, Harvey Lec- 
tures for 1915-1916, p. 101, and Papers in the Archives of Internal 
Medicine. 

‘Gillett: Food Allowances for Healthy Children. Published by New York 
Association for Improving the Condition of the Poor. 

*Chittenden: Physiological Economy in Nutrition and The Nutrition 
of Man. 

* Meltzer: The Factors of Safety in Animal Structure and Animal Economy. 
Harvey Lectures for 1906-1907, p. 139. 

™ Benedict: The Nutritive Requirements of the Body. American Journal of 
Physiology, vol. 16, p. 409 (1906). 

* Mills: Archives of Internal Medicine, vol. 7, p. 694 (1911). 

*Falk and Siguira: Journal of the American Chemical Society, vol. 37, 
p. 217 (1915). 

Sherman and Schlesinger: Journal of the American Chemical Society, 
vol. 34, p. 1104 (1912); vol. 37, p. 1305 (1915). 

1 Sherman and Gettler: Ibid. vol. 35, p. 179 (1913). 

2 Willcock and Hopkins: Journal of Physiology, vol. 35, p. 88 (1906). 

Osborne and Mendel: Journal of Biological Chemistry, vol. 17, p. 
325 (1914). 

“Osborne and Mendel: Feeding Experiments with Isolated Food Sub- 
stances. Carnegie Institution of Washington, 1911, and subsequent 
papers in the Journal of Biological Chemistry. 

4 Mendel: Nutrition and Growth. Harvey Lectures for 1914-1915, p. 101. 

% Thomas (K.): Archiv. fiir Anatomie und Physiologie, 1909, p. 219. 

% Hindhede: Skand. Archiv. fiir Physiologie, vol. 30, p. 97; vol. 31, p. 
259 (1913-14). 

Rose and Cooper: Journal of Biological Chemistry, vol. 30, p. 201 (1917). 

Sherman: Journal of Biological Chemistry, vol. 41, p. 97 (1920). 


FOOD CHEMISTRY 123 


* Sherman, Wheeler and Yates: Journal of Biological Chemistry, vol. 34, p. 
383; Sherman and Winters, Ibid. vol. 35, p. 301; Sherman, Winters 
and Phillips, Ibid. vol. 39, p. 53 (1919). 

* McCollum: American Journal of Physiology, vol. 29, p, 215 (1908) (1912). 

* Sherman, Gillett and Pope: Journal of Biological Chemistry, vol. 34, p. 373. 
Sherman, Wheeler and Yates: Ibid. vol. 34, p. 383. 

* McCollum and Simmonds: Journal of Biological Chemistry, passim. 

* Von Wendt: Skand. Arch. Physiologie, vol. 17, p. 211 (1905). 

* Sherman: Bulletin 185, Office of Experiment Stations, United States De- 
partment of Agriculture, p. 37. 

* Osborne and Mendel: Journal of Biological Chemistry, passim. 

77 McCollum, Simmonds et al.: Journal of Biological Chemistry, passim. 

*Sherman and Gillett: A Study of the Adequacy and Economy of Some 
City Dietaries. Published by New York Association for Improving 
the Condition of the Poor. 

* Osborne and Mendel: Journal of Biological Chemistry, passim. 

® McCollum: Supplementary Dietary Relationships Among Natural Food 
Materials. Harvey Lectures for 1916-1917. 

** Rose: Feeding the Family (New York, 1917). 


THE RESULTS OF HIGH EXPLOSIVES ON 
THE EAR* 
J. GORDON WILSON, M.A., M.B., C.M. (Edin.). 


HE large number of men incapacitated for military service 
on account of deafness, due to the concussion of high- 
explosive shells, is engaging the attention of military authorities 
in all the armies in this war. The number of men who will 
return to civil life with seriously impaired hearing demands 
the attention of otologists. I have chosen this subject for con- 
sideration, not only because it is urgent, but also because I have 
had considerable opportunity to observe such results in warfare, 
and in addition have studied in a very modified degree corre- 
sponding effects in the laboratory. It shall be my endeavor to 
describe my observations and the results of my investigations 
rather than to attempt to offer any explanation or form 
any hypothesis. 

One word of personal explanation: On my arrival in Eng- 
land, I was assigned to a base hospital specially equipped by 
the Canadian Government for injuries and diseases of the eye 
and ear, and was given as my chief duty the examination of cases 
of injury to the internal ear, including cases designated as shell- 
shock deafness. In December, 1916, I was transferred to France, 
again to observe cases of deafness due to shell concussion, first, 
to a Casualty Clearing Station, situated about four miles from 
the first-line trenches, and later to a stationary hospital situated 
somewhat further behind the lines, to which were sent severe 
head injuries, and eases with little or no trauma suffering from 
a variety of nerve symptoms, due to bursting of shells and gener- 
ally designated as shell-shock. In addition, by courtesy of the 
officers in charge, I was permitted to observe cases at neighbor- 
ing Casualty Clearing Stations and near-by stationary hospitals. 
It has, therefore, been possible to see injuries to the ear from 

* Delivered February 9, 1918. 

124 


RESULTS OF HIGH EXPLOSIVES 125 


shell explosions first a few hours after they were received, see- 
ond within a few days, and third after the lapse of several 
months. This work could not have been carried on without the 
assistance of the commanding officers of the hospitals to which I 
was assigned. To all of these I am indebted, but specially to 
Colonel Courtney, of Ottawa, Canada, whose sympathetic codpera- 
tion was invaluable. 

The otological cases resulting from the bursting of a shell 
are divided into two groups: 

1. Those in which a piece of the shell has struck the ear. 
The trauma may have been limited to the external canal or to the 
mastoid, or may have involved the middle and internal ear. In- 
juries to the external canal or mastoid cause total or partial 
deafness on that side and at the same time some loss of hearing at 
least temporarily in the other ear. In addition we have the 
results of the suppuration and contractures of the external meatus 
s0 apt to follow. Injuries involving the middle and internal ear 
are usually immediately fatal from associated injury to the brain, 
and those who survive are totally deaf in that ear. 

2. Those in which the damage has come from the explosion 
without any fragment of the shell striking the ear or its immediate 
neighborhood. In some there has been no objective signs of 
trauma, in others some fragments may have caused a trauma in 
a part remote from the temporal bone. It is with this second 
division that this paper is concerned. It includes a large number 
of cases in which the diagnosis is frequently very difficult and 
the treatment as yet unsettled and obscure. 


THE EXPLOSIVE FORCE 


The present conflict is preéminently the war of trenches and 
high explosives. Many thousands of shells of high-explosive 
force are in each engagement sent over to blow up trenches and 
prepare the way for the attack. These shells vary in weight 
from a few pounds to about a ton, and each consists of a thick 
iron case with a central cavity containing the charge which may 
be as much as 200 pounds of high explosives. These shells do 
not contain bullets. The injury comes from the explosive force, 


126 HARVEY SOCIETY 


from the fragments of the shell, and from débris from adjoining 
structures which they have shattered. Concussion effects are no 
longer confined to the men who fire the big guns; far greater 
and more numerous are the disastrous effects produced by the 
burst on all classes of combatants. 

The effect of the high explosive is a great compression fol- 
lowed by a great decompression; it is probable that the serious 
damage done to the ear results from the compression. I have 
had men under my care who have been blown considerable dis- 
tances; thus, one man was blown out of the trench and then 
became unconscious, another was blown six yards, became dazed, 
and finally lost consciousness for three days. 

The explosive force varies with the shell used, and its effects 
with the location of the burst—open ground, trench or dugout. 
Mott,! who is a recognized authority on the effects of shell ex- 
plosions on the nervous system, says: ‘‘Lord Sydenham, one of 
the highest authorities on the dynamics of explosives, concludes 
that the forces generated are sufficient to cause instantaneous 
death, and he has informed me that in the American Medico- 
Military report it is stated that ‘an aneroid showed that the 
explosion of one of these shells caused a sudden atmospheric 
depression of about 350 mm. of the mercury tube, corresponding 
to a dynamic pressure of about ten tons to the square yard.’ 

‘“*M. Arnoux, a French civil engineer, has also studied this 
question. A pocket aneroid barometer carried by an officer had 
been exposed to an explosion of the kind referred to, and was put 
out of working order by the force of the concussion. M. Arnoux 
had the aneroid repaired; he then placed it under the reservoir 
of an air-pump and exhausted until he had produced the same 
effect on the aneroid as was observed before it was repaired. 
He caleulated from observations and experiments that the 
dynamic pressure exerted by the surrounding air on bodies within 
a few yards of the exploding shells had amounted to over 10,000 
kilos per square metre. Men standing close to the exploding 
shell would be blown into the air or dashed against the ground 
with great violence, but in the case of men leaning against the 
side of a trench wall only the static depression could affect them.’’ 


RESULTS OF HIGH EXPLOSIVES 127 


These figures, when expressed in terms of atmospheric pres- 
sure (15 pounds to the square inch, or 76 cm. Hg), are roughly 
equivalent to increasing by one atmosphere the pressure on one 
surface of the tympanic membrane. We cannot estimate the 
concussion effects on the ear from the presence or absence of 
rupture of the tympanic membrane. In men the resisting power 
of the healthy membrane to concussion is very great and my 
present opinion derived from frequent observations is that it 
varies greatly in different animals and is greater in man than in 
most animals. But that this pressure is sufficient to cause the 
rupture of even normal membranes is evident from the experi- 
ments of Zalewski on temporal bones obtained at autopsy. He 
found that there is a considerable range of variation in apparently 
normal membranes. With air pressure gradually raised the aver- 
age bursting pressure on apparently normal drums was 120.9 em. 
of mercury, though some (10.8 per cent.) burst at less than one 
atmosphere (76 em. Hg). Membranes with thin spots or scars 
ruptured at much lower pressure than one atmosphere. But the 
effects produced by the instantaneous concussion of a shell will 
be vastly greater than that of a gradually increased pressure, 
so in an average group of men there are many membranes that 
will rupture at pressures produced by shells exploding in the 
neighborhood. As might be supposed concussion effects are very 
prone to occur should the burst occur in trench or dugout. So 
great, however, is the resistance of the tympanic membrane to 
pressure that a number are not ruptured by the shell explosion. 
The concussion effects are probably transmitted through the 
ossicles to the internal ear. Concussion deafness with no rupture 
of the drum have formed a large percentage of the worst cases 
I have seen. 


PREVALENCE OF WAR DEAFNESS 


It has long been known that cases of temporary deafness occur 
during big gunfire. In these cases, tympanic ruptures are rare. 
The artillery men and navy gunners are able to take precautions 
such as standing back of the gun, plugging the ears with the 


128 HARVEY SOCIETY 


fingers or cotton, and opening the mouth when the guns are fired. 

In previous wars concussion deafness was extremely rare. 
Gruber, who was in charge of the otological wards in the military 
hospital in Vienna for several years, including the war-time of 
1864-1866, saw only one case of ruptured tympanic membrane 
and total deafness. According to Friedlander in the Franco- 
Prussian War there were only 12 cases of indirect injury to the 
hearing in the Prussian army; in the Russo-Japanese war only 
101 cases were reported in the Japanese army. 

I know of no available figures that can help us to form even 
an approximate estimate of the numbers injured in hearing, either 
temporarily or permanently, by shell explosions. Whatever 
figures I give in this paper are to be understood as of only rela- 
tive value. When in France, the fronts I was stationed at were 
relatively quiet and cases arising from exposure to heavy bom- 
bardment were rare, so my figures only show what may be ex- 
pected in times of quietness. The base hospital, at which I was 
stationed and which was equipped for eye and ear eases, had sent 
to it either for examination and report or for admission and 
treatment many patients with deafness of long duration, but only 
such as had no need for general surgical or medical care. So 
obviously such figures would be misleading. 

In the early days of the war the large number of cases of 
deafness after shell explosion, the intensity of deafness, and 
sometimes long persistence of this symptom, gave serious ground 
for fearing a serious lesion comparable to that of labyrinthine 
hemorrhage. This is disproved by the subsequent history of cases 
and by the available post-mortem examinations. There have been 
published alarming percentages on the subject, based on con- 
clusions from an insufficient number of cases. While total and 
seemingly incurable deafness is rare, yet according to Jobson * 
a large number who have been exposed to a heavy bombardment 
which caused severe or complete deafness for one or more days 
and who declare they now hear quite well, will be found on 
examination to have some definite signs of deafness. In a series 
of examinations Jobson found a large majority, more than 80 
per cent., were quite unaware of being deaf. 


RESULTS OF HIGH EXPLOSIVES 129 


Dr. Sohier Bryant,* of Boston, has recently published a 
statement in regard to the number of men incapacitated from 
injuries and diseases of the ear in the French armies, based not 
only on personal observations made by himself and his ecol- 
leagues in the French army, but on figures given by the French 
war office: 

‘Tn the zone des Armées at the Front, the total sick contains 
16 per cent. of ear cases in the evacuation hospitals. From the 
evacuation hospitals 414 per cent. of ear cases are evacuated 
to the rear. : 

‘““ In the rear of the zone des Armées, in the zone des Etapes, 
ear cases form 614 per cent. of total sick. These figures rise 
during time of inactivity at the Front and fall during military 
activity. Seven per cent. of these cases are evacuated from the 
zone des Etapes to the Interior. 

‘*TIn the Interior region ear cases form 9 per cent. of total sick. 

‘*T estimate that about 80 per cent. of the ear cases will show 
considerable impairment of function. This impairment will be 
sufficient to permanently interfere with the civil occupa- 
tions of the patients. The above figures are for 1917, some of 
them approximate.’’ 

These figures obviously include all ear troubles, infective and 
traumatic, but even then they are sufficiently alarming. One 
recognizes that an ear damaged even slightly by the bursting of 
a shell is more lable to the invasion of pathogenic organisms 
and to suppurative processes. My experience leads me to believe 
that in the British forces the number permanently incapacitated 
from injuries and diseases of the ear is smaller than those 
above quoted. 

Lannois and Chevanne * report on 1000 cases whom they had 
seen at Lyons up to June, 1916. These they class as follows: 


1. War-deafness in patients having auricular lesions in process of evolu- 
tion, with a non-healthy auditory mechanism: 


(a) Chronic suppurative otitis media ................ 189 cases 
(b) Sclerosis of the middle ear affecting or not the 
UNCETNA] CAPs a:cis joy siers sleraigiane kent ofe als ctshoohe Aatatiee tices 134 cases 


9 


130 HARVEY SOCIETY 


2. War-deafness in patients with healthy auditory apparatus: 


(a) Simple labyrinthine concussion .................; 262 cases 
(0) Labyrinthine concussion with rupture of the tym- 
RPMI. |. owokngonobobgsiciiegodedosdoonwoopsoSaesac 82 cases 


(c) Labyrinthine concussion with rupture of the tym- 
panum, followed by acute suppurative otitis media... 301 cases 
3. War-deafness or deaf-mutism from traumatic newrosis...... 32 cases 


These figures agree generally with my observations. There 
is one group I wish particularly to eall attention to, (b) and (c) 
of section (2). The amount of acute suppuration following rup- 
ture is probably a fair average, but in the armies of all the 
combatants is in excess of what it ought to be. The fact that only 
82 out of 383 escaped suppuration does not speak well for the 
treatment of early cases. This is no reflection on the distinguished 
Lyons otologists who probably saw many of the cases after sup- 
puration had started. Otologists in the war zone are agreed that 
with early and appropriate treatment such a percentage can be 
reduced. My experience has been that in all cases invalided from 
the effects of shellfire the ears ought to be examined early, and 
the requisite treatment employed. 

My observations on cases of concussion deafness near the Front 
are given on a subsequent page. Here it may be said that a large 
proportion of the men suffering from shell-coneussion deafness 
get better very rapidly, in one ear usually more rapidly than the 
other; those with simple rupture of the tympanum, without 
suppuration, are the first to recover; about 50 per cent. of these 
have serviceable hearing within a month. My experience is that 
even those showing slight improvement at the end of one month 
may still improve. But the longer the delay in improvement, the 
less likely they are to get better. The most obstinate show clini- 
eally only signs of labyrinthine concussion. 


‘“SHELL-SHOCK’’ DEAFNESS DEFINED 


In considering deafness due to high explosives, one should, 
as far as possible, dismiss from the mind preconceived ideas. 
To get a fair conception of what has happened, the subject ought 
to be considered with an open and critical mind, and especially 


RESULTS OF HIGH EXPLOSIVES 131 


when one is concerned with the ear, where the intracranial con- 
nections are so extensive and so little understood. 

The term shell-shock deafness has met with just condemnation 
from otologists. Though the term has still a fascination for the 
lay mind, its vagueness as a medical term must be obvious to an 
audience such as this and but serves to emphasize our ignorance 
of its pathology. Shell-shock deafness means that the patient 
has been made deaf by the concussion of the shell, associated, it 
may be, by little obvious injuries due to its bursting. In many 
the probability of internal injury to the nervous system must be 
considered. By the force of the explosion the soldier may have 
been blown violently against the parapet or wall of the dugout, 
or hurled for some distance through the air, or struck by débris 
from shell destruction of neighboring buildings. One man de- 
scribed it as a soft irresistible force pushing him up against 
the parapet wall, close to which he was standing when the shell 
burst in the trench. As a result of the explosion the men may 
be buried for a varying period, and as Mott pointed out, this 
may have an important bearing on the symptoms which follow. 
It must be noted that though not observable to the casual exam- 
iner a trauma to the ear is frequently present and observable 
to the otologist. In recent cases seen by me, minute ruptures were 
observed which, under ordinary conditions, would close in a week; 
and when no rupture was seen the congested condition of the 
membrane and of the middle ear indicated that the blow had 
been sufficient to cause considerable disturbance. In many of the 
cases seen some time after the concussion in which no trauma 
had been diagnosed at the first examination, the history of aural 
hemorrhage and of rotation vertigo, made it more than likely 
that an injury to the peripheral aural mechanism was present 
at the time of the explosion. But if the term ‘‘shock”’ is to be 
condemned as too indefinite, it is just as important, perhaps 
more so, to avoid as far as possible the terms ‘‘hysteria’’ and 
‘‘neurasthenia.’’ These elastic and indefinable terms are too 
often applied to such cases, probably less now than in the early 
stages of the war, and have resulted not only in an unwarranted 
stigma but often in disastrous effects. The cases here reviewed 


132 HARVEY SOCIETY 


will be discussed in some measure to ascertain how far the 
psychogenic explanation can be accepted. 


THE RELATION OF THE EAR TO PRESSURE 


The ear is the peripheral sense organ which a priori we should 
expect to suffer greatly from concussion effects. Like all periph- 
eral organs, it is a mechanism adapted to transform one form 
of external energy into nerve impulses. There are two separate 
and distinct mechanisms in the internal ear, one concerned with 
hearing, one concerned with equilibrium. Each of these mechan- 
isms is adjusted and made sensitive to register minute pressures 
and transform them into nerve impulses. The nerve impulses are 
carried to the central nervous system there to be interpreted and 
utilized. In hearing, air vibrations (varying, say, from thirty-two 
double vibrations per second up to several thousand double vibra- 
tions per second) in various combinations are transmitted nor- 
mally through the external auditory meatus to the drum mem- 
brane, which is finely swung to catch them. The vibrations are 
then transmitted through the ossicles and the middle ear to the 
cochlea, where they are transformed into nerve impulses. Nerve 
impulses may also be set up in the cochlea by vibrations through 
bone, but these so far as hearing is concerned are of secondary 
importanee. The nerve impulses are conveyed along the cochlear 
nerve and acoustic path to the temporal lobe, where they enter in 
one definite bundle. Here they come into association with various 
parts of the cerebrum. The route from the periphery to the tem- 
poral lobe is not one undivided path. To put it roughly, there 
is not one telephone wire from the ear to the receiving and 
interpreting station in the cortex. The path is broken at various 
synapses or junctions or telephone exchanges. At these synapses 
connection is made with other nerve paths, and communication 
ean be and is established with other physiological systems. What 
the significance of this probable interchange may be we do not 
know. Possibly the directing of the eyes to a source of sound 
and the erection of the ears in animals are among them. 

The other pressure mechanism in the internal ear is a system 
of canals containing fluid, a manometer, designed to register 


RESULTS OF HIGH EXPLOSIVES 133 


and signal to the central nervous system movements of the head. 
This mechanism is adjusted to indicate very small varying pres- 
sures. Here also in the central path we have numerous synapses 
influencing other cranial pathways, somewhat better, though 
still very inadequately, understood. The information so obtained 
from the vestibular peripheral mechanism is codrdinated with in- 
formation received from other sources (the eyes, joints, etc.) and 
enables the muscular mechanism to adapt itself rapidly to varying 
alterations of our centre of gravity to preserve the equilibrium— 
for instance, to maintain the erect posture during movements 
of the head. 

There are certain limits of pressure normal to these two 
mechanisms. Pressure beyond the normal produces disturb- 
ances which are pathological. Disturbances of hearing may cause 
hyperacusis, hypoacusis or total deafness. Disturbances of the 
canalicular system produce disturbances of equilibrium—for 
instance, vertigo and nystagmus. 


PATHOLOGICAL EFFECTS OF EXPLOSIVES 


Injuries to hearing due to shell explosions may be: 

1. Temporary—lasting a few minutes or a few hours, and 
probably due to hyperemia in the middle ear or the internal ear. 

2. Persistent over long periods or permanent, due to a lesion 
in the hearing mechanism—to the drum membrane, or the middle 
ear, or the internal ear, or disturbances in the acoustic path or 
central mechanism from minute hemorrhages. 

Our knowledge of the pathological effects of explosives on the 
ear has come largely from the experimental work of Witmaack,° 
Yoshii,’ and Hoeslii,’ who investigated the results of pistol or 
revolver shots near to the ear of animals, chiefly guinea-pigs. 
Yoshii, whose work is the most complete, experimented in two 
series: (1) Effects of firing a single shot and (2) effects of firing 
repeated shots, daily, over a definite period. Some of the ani- 
mals were killed at once, others were kept alive for a varying num- 
ber of days—up to sixty. His findings in the first series may be 
thus briefly summarized: There were very constantly rupture of 
the tympanic membrane and hemorrhages into the middle ear 


134 HARVEY SOCIETY 


cavity. Pathological changes were present in all the coils of 
the organ of Corti. The hair-cells were swollen, had lost their 
characteristic shape and loosened from their support. Deiter’s 
cells had lost their normal appearance and appeared as a homo- 
geneous mass. The cells of Hensen were flattened out. The pil- 
lars of Corti were bent and the tunnel filled with a homogeneous 
mass probably extravasated cell contents. Nuel’s space could no 
longer be seen. 

The tectorial membrane was raised sharply up and in extreme 
eases its free end reached Reissner’s membrane. In recent cases 
blood-ecorpuscles were seen in the Scala Tympani and in the 
vestibule. Immediately after the firing a change was observable 
in the ganglion cells of the cochlear nerve. Nissl bodies had dis- 
appeared and the chromophile substance was no longer distin- 
guishable. In the nerve fibres changes were seen, especially in 
the myelin sheath. 

These changes were observed immediately after the explosion 
and had reached their maximum in two or three days. Then a 
restorative process slowly set in, especially noted in the basal coil. 
In animals killed after eight days the pillars were straightening 
out, the mass in the tunnel was absorbed though the cells were 
not clearly outlined. Later regeneration proceeded in all the 
cells, but even after sixty days the hair-cells and Deiter’s cells 
were not fully reformed in the basal coil and could not be 
distinguished in the other coils. At this time the ganglion cells 
were again nearly normal. 

As a result of repeated pistol shots Yoshii found that the 
pillars had collapsed and all the cells had lost their characteristic 
shape. This was specially observable in the region at the junc- 
tion of the basal coil to the second coil where a complete atrophy 
of Corti’s organ could be seen. 

Pathological observations in man as the results of high ex- 
plosives are very few and this lends additional interest to the 
recent observations of Mott,’ who has reported two eases of com- 
motio cerebri (‘‘shell-shock’’) without external injury. He 
found the veins congested throughout the brain, both in the 
meninges and in the gray and white matter. There were scat- 


RESULTS OF HIGH EXPLOSIVES 135 


tered subpial hemorrhages of microscopic size almost everywhere, 
due to rupture of the dilated congested veins, but no punctate 
hemorrhages such as he had described in gas poisoning. The 
perivascular and perineuronal spaces are seen dilated. The gen- 
eral appearance is similar to that observed in experimental 
anemia in animals produced by ligature of both carotids and 
vertebrals. He thus sums up the histological changes: ‘‘There 
is a generalized early chromatolytic change in the cells of the 
central nervous system. This change varies in intensity. The 
cells most affected are the small cells in which the basophile sub- 
stance has partly or almost totally disappeared. In the larger 
cells the Nissl granules are smaller and not packed so closely 
together as normal. The small cells of the medulla and pons are 
slightly swollen, and the nucleus is large and clear. This change 
is present in some of the large cells, but it is less evident. This 
change indicates a relative degree of exhaustion of the kineto- 
plasm, assuming that the amount of the basophile substance is an 
index of biochemical neuropotential. The Nissl granules are not 
present in the neurone during life, but they disappear altogether 
in a cell that (prior to death of the whole body) has been so 
injured as to decay and die. Granted this premise, then, it may 
be assumed that the cells of this man are in a state of commencing 
nervous exhaustion, some nuclei of cells show the changes more 
markedly than others—for example, the cells of the vago-acces- 
sorius nucleus. In the white matter of the corpus callosum, 
the internal capsule, the pons and medulla, there are seen con- 
gested veins and hemorrhage into the sheath of these vessels, 
with occasional extravasation of blood-corpuscles into the adja- 
cent tissues.’’ 


HYPOTHESES ADVANCED TO EXPLAIN SHELL-CONCUSSION DEAFNESS 


The pathology of nerve deafness from high explosives in the 
present war is still little known; complete pathological examina- 
tions have been few. The involvement of the middle ear seen 
in a large number of patients, with or without rupture of the 
tympanic membrane, will produce diminution of hearing, but 
will not account for the total deafness to air and to bone conduc- 


136 HARVEY SOCIETY 


tion as well as other symptoms which follow the explosion. We 
have, therefore, to look for some explanation in the inner ear 
or its central connections. 

The following hypotheses have been advanced: 

1. Pathological changes in the organ of Corti and the ganglion 
cells in the internal ear. 

2. Hemorrhages into the inner ear. 

3. Interruption of the central auditory path from small 
hemorrhages, cedema, ete. 

4. Temporary interruption of the central auditory path from 
functional disturbance and not due to any organic lesion. 

Mr. Sydney Scott, of London, has reported a case in which, 
after a bullet fracturing the vertex of the skull, with no paralysis, 
but great bilateral though not total deafness, the post-mortem 
examination showed intact tympanic membrane; no injury to 
the stapes, or annular ligament, or membrana secundaria; no 
hemorrhage into labyrinth; blood-clot in both middle ears, no 
fracture of the base. 

J. S. Fraser and John Fraser,’ of Edinburgh, have recently 
published the results of pathological examinations of four cases 
of concussion deafness. ‘‘Our findings,’’ they say, ‘‘lend little 
support to the view that in ‘explosion’ or ‘shell’ deafness (1) 
large hemorrhages occur in the peri- or endolymphatie spaces of 
the labyrinth, or (2) that rupture of the delicate neuro-epithelial 
sacs and tubes of the membranous labyrinth takes place.’’ The 
only changes of importance found in their four cases of ‘‘explo- 
sion’’ injury of the ear were: (1) Rupture of the drumhead in 
three cases, and hemorrhage into the middle-ear in all four. 
(In one a large plug of wax was present in the external meatus 
and probably for this reason the tympanic membrane was not 
injured. (2) Hemorrhage in the fundus of the internal meatus 
in three of the four cases at the points where the nerves enter the 
bony’ canals. In two eases the neuro-epithelial structures of the 
labyrinth appear to be normal. In one the changes are possibly 
of ‘‘post-mortem’’ origin, but they appear to us to be due rather to 
an early stage of ‘‘degenerative neuritis,’’ while in Case 6 they 


SCALA VESTIBULI 


Reissner’s membrane 


hay Stria 
ny vascularis 


}eh 
9 
Membrana tectoria DUCTUS COCHLEARIS 
Suleus spiralis 
internus > 
Ligamentum 


Limbus Jamin spirale 


spiralis ~ 


Sulcus spiralis 
externus 

Cochlear rista basilaris 
nerve fibres 


Inner hair cell 
Outer hair cells 
Membrana basilaris 


SCALA TYMPANI 


Fig. 1. Section through the ductus cochlearis (Retzius) showing the generally ac- 
cepted structure of the cochlea. C—tunnel of Corti bounded by arch formed by pillars 
of Corti. The four rows of outer hair cells are separated by sustentacular cells (Deiters’) 
and by Nuel space clearly seen between outer pillar and innermost of outer hair cells. 


RESULTS OF HIGH EXPLOSIVES 137 


are caused by a fault in the preparation of the specimen. The 
vestibular apparatus, as was to be expected, showed less change 
than the cochlear. The neuro-epithelium of the saccule and 
utricle and the cells of the vestibular ganglion in the internal 
meatus appear to be better preserved than the corresponding 
parts of the cochlear apparatus. Displacement of the otolith 
membrane of the saccule or utricle and displacement of the cupola 
of one or more of the canals in two cases quite probably are 
artefacts. It seems quite possible that in many cases of ‘‘shell”’ 
or ‘‘explosion’’ deafness we have to deal with a functional affec- 
tion, as suggested by Milligan and Westmacott. On the other 
hand, rupture of the drumhead and hemorrhage into the middle- 
ear spaces must cause a certain loss of hearing, while hemorrhage 
in the fundus of the internal meatus may give rise to deafness, 
tinnitus, giddiness, and other symptoms of an inner ear lesion. 

I was able to secure several petrous bones while in France from 
patients who died shortly after injury from shells. Two have 
been sectioned and studied, one especially I wish to describe in 
detail. Very little information could be got of the case except 
that the man was blown up. He received abdominal injuries 
from which he died two days later. A piece of shrapnel pene- 
trated the right supercilliary ridge and he was totally deaf. 
The right drum membrane had a small rupture in the posterior 
half, but there was little blood in the tympanic cavity. The 
petrous temporal was congested, as were also the meninges. Both 
petrous temporals were removed within six hours of death and 
the superior semicircular canals opened; the bones were placed 
in formalin, which was changed repeatedly. Ten days later they 
were placed in a tin containing formalin, hermetically sealed, and 
brought to Chicago, where the further examination was made. 

These sections showed, the following conditions: 

I. The foot-plate of the stapes was uninjured (Fig. 2). 

II. The ductus cochlearis showed the following important 
changes (Figs. 3 and 4): 

1. The tectorial membrane was thrust sharply up and was 
attached to Reissner’s membrane by serous effusion. 


138 HARVEY SOCIETY 


2. There was a small-celled exudate along Reissner’s mem- 
brane, especially marked in the areas near to the attached tec- 
torial membrane. 

3. The stria vascularis was cedematous and showed hemor- 
rhagic infiltration. 

4. The basilar membrane was edematous and showed small 
eell infiltration. 

5. In the organ of Corti the pillars of the tunnel were un- 
altered. There was serous effusion and numerous small-cell infil- 
tration which filled the tunnel and Nuel spaces. The other cells 
were indistinct. In some of the hair cells the hairs could 
be distinguished. 

III. The scala vestibuli and the scala tympani had no 
hemorrhage. 

IV. (Edema was seen, also infiltration of smalls cells through- 
out the area of the cochlear ganglion; in some of the ganglion 
cells the nuclei were well stained, but as a rule the cell contents 
were very indistinct. (Figs. 7 and 8.) 

V. At the deeper part of the internal auditory meatus where 
the cochlear nerve enters the modiolus, there were dilated small 
veins with small hemorrhages due to rupture (by rhexis) and also 
hemorrhages through the interstices of the capillary walls (by 
diapedesis). (Figs. 7 and 8.) 

VI. The vestibular mechanism was very little affected, except 
that there was a slight dilatation of the veins and some serous 
effusion and edema. No rupture of the membranous labyrinth 
could be seen and there was no hemorrhage into the canals. 
(Figs. 5 and 6.) 

These microscopic findings corroborate those of J. S. and 
J. Fraser, though in addition there was present the upward thrust 
of the tectorial membrane, so characteristic of the experimental 
work on guinea-pigs already referred to. These findings tend to 
substantiate the hypothesis that deafness from the effects of 
high explosives may result in distinct damage to the peripheral 
organ of hearing with little damage to the middle ear or the 
drum membrane. 


& 


Fig. 2.—Foot-plate of Stapes (s) uninjured from case of concussion 
deafness. M.E. = middle ear, y = vestibule of internal ear. 


Wig. 3.--Section through cochlea from case of concussion deaf- 
ness. .S.V scala vestibuli, D.C. = ductus cochlearis, S.T. = seala 


tympani. M.T. = membrana tectoria, R = Reissner’s membrane. 


Fig. 4.—Section through ductus cochlearis, from case of concussion deafness. D.C. = ductus 
cochlearis, M.T. = membrana tectoria, C. = Corti’s organ, St.V.—stria vascularis. 


Fig. 5.—Semi-circular canal and ampulla. From case of con- 
cussion deafness. S.C. = semi-circular canal, A.=ampulla, C.A. = 
erista acustica with cupula. 


Fig. 6.—Macula Acustica (M.A.) of utricle, from case of concussion 
deafness. N.U.—= nerve to utricle, N.V. = nerves and vessels. 


Fig. 7.—Nerves passing through lamina cribrosa at. depth of 
internal auditory meatus. Case of concussion deafness. Small 
hemorrhages by rhexis and by diapedesis. (X90.) 


Fig. 


8. 


Same as Fig. 


it 


(X130.) 


C.N. = cochlear 
ganglion at base of modiolus, H. = hemorrhage. 


nerve, 


G. 


RESULTS OF HIGH EXPLOSIVES 139 


GENERAL SYMPTOMS OF NERVE DEAFNESS FROM SHELL CONCUSSION 

We are here concerned chiefly with the results of one severe 
concussion, followed by total or diminished loss of hearing. In 
some of the cases a previous concussion may have damaged the 
hearing, and the second made it worse, or resulted in total loss. 
Cases of gradual diminution of perception of sound from long 
exposure to gunfire do not come within this paper. 

The otologist is accustomed to differentiate two types of 
deafness : 

1. Conduction or obstructive deafness where the lesion lies in 
the external or middle ear. 

2. Nerve deafness where the lesion lies in the internal ear or 
its central connections. 

There are tests which enable one fairly accurately to deter- 
mine which type one is dealing with. In a mixed type with both 
obstructive and nerve deafness, it is often very difficult to assign 
a relative value. In shell-concussion deafness we are, as a rule, 
dealing with the mixed type. 

In testing cases of deafness following exposure to shell con- 
cussion, it was noted that we were dealing with a type which 
is not usually recognized in civil practice. The chief charac- 
teristics are: 

1. That there is a diminution in the tone perception both for 
bone and air over the whole range of the forks. 

2. When hearing is markedly diminished the diminution for 
the forks is marked at both ends of the scale and is least marked 
at about C? (512 dv.) and C* (1024 dv.). 

3. When hearing is completely obliterated there may still 
remain a remnant to bone conduction in the region correspond- 
ing to C?-C? forks. 

4. With restricted tone perception, the use of a greater inten- 
sity makes it often possible to extend the area of sound perception. 

In considering these findings, it is well to recall that physicists 
place the localization at which a minimum of energy will produce 
audible sounds at about 1000 dv. below rather than above this 
figure. Further, otologists (Bezold and Siebenmann?°) claim 
that from 480 dv. to 768 dv. ‘‘is the most important part of 


140 HARVEY SOCIETY 


the sound scale for hearing and understanding speech.’’ These 
facts throw light on our findings that in concussion cases per- 
ception may linger for the tones C? (512 dv.) and C* (1024 dv.) 
while tones above and below fall below the threshold of audible 
sounds. It brings this area into line with the macula of the 
retina and its relation to vision. It makes of interest our findings 
that associated with concussion deafness there is frequently 
concentric limitation of the field of vision. In addition, since in 
concussion deafness increasing the intensity extends the area 
of sound perception, this would further strengthen the analogy; 
for in indirect vision the more the object is illuminated the 
further it can be seen at the periphery.‘ The elaboration of this 
subject must be left for a future paper. 


NERVE SYMPTOMS ASSOCIATED WITH TOTAL LOSS OR DIMINUTION 
OF HEARING 


The symptoms frequently associated with loss of hearing from 
high explosives are included by neurologists within that group 
of nerve diseases called traumatic neuroses. In some of our cases 
there is a recognizable physical trauma, in the head or elsewhere, 
received during a period of mental excitement. In addition to 
deafness, which was the chief complaint of the men who came 
to the otological wards, there were other symptoms varied and 
complex. There were present, for instance, exaggeration of ten- 
don reflexes, tremors, vasomotor disturbances, sweatings, lethargy, 
sleeplessness and headaches. Vertigo with disturbances of equi- 
librium is commonly present and very much complained of. 
There was frequent concentric narrowing of the fields of vision. 
In many of our eases fields of anesthesia were present. In two 
of our cases of total deafness there was complete anesthesia and 
loss of thermal sense. In one with total loss in one ear and great 
diminution in the other there was anesthesia on one-half of the 
body and hyperssthesia on the other. The ear symptoms cer- 
tainly accord with those which Dejerine classifies under traumatic 
hystero-neurasthenia. Some patients, as in neurasthenia, had 
hyperacusis with subjective sounds; others, as in hysteria, had the 


RESULTS OF HIGH EXPLOSIVES 141 


auditory acuity diminished, sometimes on both sides, sometimes 
on one only. 

While granting that the symptoms accompanying the deaf- 
ness often, but not always, fell within Dejerine’s classification of 
traumatic hystero-neurasthenia, yet one would err if one were 
to insist that the nerve deafness is to be explained as due to a 
functional neurosis. The sudden onset of these labyrinthine 
symptoms and the slowly accumulating, though as yet very 
meagre pathological findings, make one chary of fully accepting 
the neurosis hypothesis in all of these cases. A study of the 
ear cases that have come under my observation has convinced 
me that in a large number the trauma has caused an organic 
lesion in the ear, and that, if functional symptoms be present these, 
so far as the ear is concerned, are secondary and subsequent to it. 
It is altogether possible that these functional symptoms may 
persist after all traces of the lesion has ceased to be capable 
of recognition. 


CASES SEEN SOON AFTER INJURY 


The cases of deafness as they present themselves soon after 
injury show a variety of types. All have been more or less dazed 
—some are admitted as stretcher cases in varying depths of 
stupor, in many the stupor or unconsciousness has passed off 
previous to admission. All have a varying amount of vertigo, 
but nystagmus due to labyrinthine irritation I have never seen. 

I. No trauma from shell fragments and only slight injury 
observable in the ear. 

Lance Corp. 8. was knocked down and partly buried by a 
shell on the evening of the 22d December, 1916. He was brought 
into the Casualty Clearing Station early on the morning of the 
23d, in a dazed condition. There is no demonstrable trauma. 
He lies in bed with muscles relaxed in a stupor from which he 
cannot be roused by pinching the skin or by loud noises. There is 
no nystagmus. Later in the day, while still in a state of stupor, 
his muscles at times are seen to be twitching, the pupils react 
quickly to light, the conjunctive are insensitive to touch. He 
swallows what is placed in the mouth. When disturbed he twists 


142 HARVEY SOCIETY 


himself away and buries his face in the bedclothes. On the 24th 
he is obviously less dazed. He obeys when sharply directed by 
motion to put out his tongue and to turn his eyes to right or to 
left, during the whole time sweating freely. On the 25th he is 
conscious but totally deaf. He answers written questions in a 
whisper, though in a hesitating manner. He remembers the shell 
explosion and then his memory is blank until this morning. He 
complains of a roaring in the head and a severe frontal headache. 
So long as he lies still he is comfortable, but when he attempts 
to sit up he feels as if something were falling on him. He sweats 
freely. Later on in the day he was seen curled up in bed writing 
a letter. At this time he was able to sit up and did so without 
any apparent vertigo. On examination, concentric round both 
ears there was found a patch of anesthesia and absence of thermal 
sensation. He cannot hear forks, whistle or voice. The right 
drum membrane is driven in and congested, is loose and freely 
movable, but there is no perforation and no hemorrhage. The 
left drum membrane is congested, not displaced, but has a 
small perforation near the hammer in lower half. The tubes are 
open. About 10 o’clock that night when he was sleeping quietly, 
speaking loudly to him or pinching him over anesthetic areas did 
not rouse him, but when touched over the centre of forehead he 
awoke suddenly and in fright. He had been shocked at the 
Somme in June and was then totally deaf for ten days. Since 
then his hearing has been defective. Evacuated to base. 

But the muscles are not always relaxed. Private B. admitted 
a few hours after being blown up by high explosive shell was 
in a deep stupor, from which he could not be roused. He was 
lying on his right side with the thighs rigidly flexed on the 
abdomen and the fingers clenched. The deep reflexes were very 
brisk and the plantar reflex was flexor in type. The pupillary 
reflexes were sluggish. Swallowing presented no difficulty and 
the attendants were able to get him to urinate. At this time the 
left drum membrane was normal and the right had the main 
vessels congested and showed through a retracted drum marked 
congestion over the inner wall of middle ear. Later, on recover- 


RESULTS OF HIGH EXPLOSIVES 143 


ing from stupor, he was found to be totally deaf. Evacuated 
to base. 

II. A large number show signs of trauma in the drum mem- 
brane or middle ear. The damage may be slight, heal quickly, and 
pass unnoticed, and even where there is a considerable perfora- 
tion, pain in the ear is rarely complained of and the hemorrhage 
may pass unnoticed. Months after a large number show defective 
hearing which they trace to the explosion. 

H. G., 12 C. C.S.: Examined December 21, 1916. No previous 
ear trouble. On 15th December, 1916, a shell burst and threw 
him six feet. Though dazed, he was not unconscious. There 
was no nausea. He had rotation vertigo for three or four days 
and now feels as if he would pitch forward in walking. He 
denies hemorrhage from ears. Each tympanic membrane has a 
large irregular posterior perforation showing the head of the 
stapes. There is blood-clot in the middle ear but no suppuration 
is present. The left membrane has its anterior part pushed on 
to the internal wall of the middle ear, leaving the hammer 
projecting forward and apparently undisturbed. In both ears 
C (128 dv.) is not heard by air but is heard by bone. C? (512 dv.) 
is heard but diminished—90 seconds by air and 30 seconds by 
bone. C* and C* are not heard. The Galton Edelmann whistle is 
heard if blown loudly. In both ears conversation voice is 
heard at 20 inches. There is no Romberg; equilibrium is good, 
except on bending, and very little tremor. 

Private E. C. B., 207 R. G. H., 2d Canadian C. C. 8. Previous 
illness: In winter of 1915 had double otorrhea following rhinitis 
from which he recovered completely. 

On December 7, 1916, he was knocked over by a shell and 
dazed. He had no aural hemorrhage; no nausea, but was dizzy 
and deaf. The ear was washed out with hydrogen peroxide and 
he had rotation vertigo and fell over. Whenever he blew his 
nose he got dizzy. Seen December 13, in 2d Canadian C. C. S. 
Complains of deafness and hyperesthesia of meatus. There is a 
constant tendency to shake ear with finger in meatus. Has 
severe tinnitus all the time. No nystagmus. When walking 
staggers (to right). If he shuts eyes, gets dizzy and sways, 


144 HARVEY SOCIETY 


but to no particular side; feels as if going from left to right; 
with eyes open, objects appear to go back and forward. Even 
with eyes open cannot stand on either foot; dizzy if he bends to 
tie his boots. Pointing poor. Frontal headache. Right mem- 
brana tympani has small perforation. Left membrana tympani 
normal. Tubes open. Hears voice close to either ear, slightly 
better in right ear. Rinne positive in right—in left is either in- 
different or negative. Weber to left. Bone conduction dimin- 
ished in both ears. Can distinguish loud, sharp whistle. 

Testing with the forks give: 

Right ear—C (64)=O ; C(128)=0. C?(512)—heard, diminu- 
tion 86 seconds by air and 25 seconds by bone; C*=— 0. 

Left ear—C(64)—=0O; C(128)=0O. C?=heard, diminution 
of 80 seconds by air and 15 seconds by bone. C*=—O. 

Sent to base. 


SUMMARY 


Of 22 cases examined soon after the shell explosion with nerve 
deafness, 18 had demonstrable lesions of the drum membrane. 
Four had no demonstrable lesion, and of these four, 3 had history 
and indication of old trouble. Only 1 had no previous ear trouble 
or no demonstrable trauma. 

In one Stationary Hospital, to which cases of shell-shock were 
sent, including cases of shell-shock deafness, I saw 200 cases with 
little or no trauma exhibiting nerve symptoms ascribed to high 
explosives. Of these, 50 complained of deafness of varying 
degree. Of these 50, 17 showed demonstrable signs of injury to 
the internal ear traceable to the explosive. Of the other 33 the 
deafness had been temporary and no objective signs of disturb- 
ance of equilibrium could now be seen. The persisting defect of 
hearing in many of these was due to middle-ear involvement; in 
some of old standing; in others to blockage of the external canal 
from wax or some other cause. Of the 17 cases, 7 had symptoms 
of nerve deafness without perforation of {he membrana tympani; 
10 had deafness with signs of perforation ; 6 had definite middle- 
ear trouble previous to the concussion; of the other 11, with no 
previous history of ear trouble, 6 had recent perforation ; 12 com- 


RESULTS OF HIGH EXPLOSIVES 145 


plained of vertigo and had observable signs due to it; the others 
had, when examined, no symptoms of equilibrium disturbances. 

A large proportion of the men suffering from shell-concus- 
sion deafness get better very rapidly, in one ear usually more 
rapidly than the other. My experience is that even those showing 
slight improvement at the end of a month may still improve. 
According to Lannois and Chavanne those with simple rupture of 
the tympanum without suppuration are the first to recover; 
43 per cent. were cured in one month; 33 per cent. in two months; 
12 per cent. in three months; the others required four, five, seven 
and eight months (2 cases). Simple labyrinthine concussions 
are the most obstinate; their figures give 24 per cent. of cures in 
one month; 22 per cent. in two; 19 per cent. in three; 12 per cent. 
in four; the others vary from five to nine months. 


VERTIGO IN CASES SEEN SOON AFTER EXPLOSION 


Next to deafness vertigo is the chief complaint. It is very 
difficult in many to estimate the amount of vertigo which is 
present. Vertigo is a subjective sensation and subjective sensa- 
tions are difficult to describe; the average individual has a very 
indefinite idea of what medically we mean by dizziness and often 
includes in the term all variations in cerebral consciousness. But 
even moderately severe labyrinthine vertigo is accompanied by 
some objective signs such as nystagmus, pointing error, or other 
signs of unstable equilibrium as may be produced by shutting 
the eyes on standing or walking. Of eighteen men who com- 
plained of severe vertigo with deficient hearing due to recent 
injury from shell explosions and who were carefully examined 
for signs of vertigo, twelve gave a distinct history and showed 
signs of labyrinthine vertigo. In many the objective signs of 
vertigo pass away quickly. The greater number were comfortable 
so long as they remained quiet or moved slowly. Vertigo was 
experienced if the head were placed quickly in an unusual posi- 
tion and was especially apt to occur on bending. There did 
not appear to be any relation between the return of hearing 
and the disappearance of the vertigo. Six had no objective signs 
of vertigo. D. had been knocked out with slight deafness. C. had 

10 


146 HARVEY SOCIETY 


large double perforations and wounds on extremities of both sides 
which kept him absolutely quiet in bed. In G., though the perfor- 
ation was large, the deafness was chiefly of middle-ear type. H., 
whose hearing had been bad before enlisting, had deafness largely 
due to middle-ear conditions. 

My conclusions from observations made in France and for- 
warded, to the Headquarters of the C. A. M. C. were: 

1. Exposure to high explosives may produce rupture of 
the membrana tympani. This rupture may occur at any part 
of the membrane. It varies in size and two perforations are 
occasionally seen. Small perforations are most frequent, but 
there may be a large perforation. The force may be so great 
as to dislocate the malleus and drive it in on the promontory. 

2. The rupture in the membrana tympani tends in most cases 
to spontaneous closure. Its non-closure is usually due to its large 
size, or middle-ear suppuration following the rupture. Appro- 
priate treatment hastens healing and diminishes the risk of sup- 
puration. Resulting adhesion of the malleus to the internal wall 
of the middle ear is not infrequent. 

3. Coneussion of the internal ear with nerve deafness and 
equilibrium disturbances occurs with or without rupture. In 
many the concussion passes off with slight damage to hearing, 
though equilibrium disturbances may persist for a consider- 
able period. 

4. The coneussion may pass off, leaving an injured nerve 
mechanism demonstrable by (a) nerve deafness of a varying 
degree; (b) defects of equilibrium. 

5. The treatment of recent perforated membrane which gives 
most satisfactory results aims at cleaning the external meatus 
and leaving the blood-clot over the perforation intact. The 
following has been found satisfactory: A plug of cotton is placed 
in the meatus and the lobe of the ear is cleaned and dried. The 
plug is removed and then the outer part of the external meatus 
is cleaned by pledgets of cotton dipped in hydrogen peroxide. 
The meatus is then dried and washed with pledgets dipped in 
alcohol and again dried. A piece of sterile cotton is then placed 
in the ear. The ear ought to be kept dry. 


RESULTS OF HIGH EXPLOSIVES 147 


6. All the cases sufficiently severe to be sent to a Casualty 
Clearing Station ought to be kept in bed for at least ten days to 
allow the effects of the concussion to subside, thereby the man’s 
return to his unit may frequently be hastened. 

7. High explosives may cause a definite injury to the internal 
ear and its central connections. The diagnosis requires con- 
siderable experience. Speedy recognition of those injured by 
high explosives with appropriate treatment means more rapid 
recovery of hearing, diminution of subjective symptoms of ver- 
tigo, so apt to persist, and subsequent military usefulness. The 
figures given above show that in a considerable proportion of 
the cases of deafness following exposure to high explosives exam- 
ined within three or four weeks after the exposure, no trauma 
in the internal ear could be demonstrated, and the deafness then 
present was accounted for by some other cause. In view of these 
facts an otologist of experience ought to be available at appro- 
priate centres. 


CASES SEEN SOME TIME AFTER INJURY 


The base hospital to which I was assigned was at Folkestone, 
that old Kentish town where William Harvey was born in 1578. 
The hospital looked out on the square where the townsfolk have 
erected a statue to perpetuate the memory of his birth. The 
monument crowns the Leas, as the elevated seaside promenade is 
called, and overlooks one of the most beautiful stretches of the 
English Channel with the coast of France outlined on the distant 
horizon. The hospital has been especially provided by the Cana- 
dian authorities for eye and ear injuries and diseases. All the 
staff were specialists in the eye or ear, and at that time the 
commanding officer was a well-known eye and ear specialist 
from Ottawa. 


CLASSIFICATION OF CASES 
The cases of deficiency in hearing following exposure to, or 
injury from high explosives, seen by me at the base hospital, 
date their onset back anywhere from two months to eleven 
months. It was not judged sufficient to take the patient’s state- 


148 HARVEY SOCIETY 


ment that he had been exposed to shell-fire. It was necessary 
to have at the time of examination symptoms pointing to such 
or an official record supporting the statement. All have been 
under treatment since the injury, many in the care of competent 
otologists. In a great number the deficiency in hearing was due 
to conduction deafness traceable to injury to the middle ear; for 
instance, injury to the membrana tympani or to middle-ear sup- 
puration following rupture. Consideration of these is not in- 
cluded in this paper. 

The cases of nerve deafness can be divided into three groups: 

1. Those with nerve deafness. 

2. Those who have had nerve deafness of a varying degree, 
and who, with a varying amount of indefinite nerve symptoms, 
have still the fixed idea that they cannot hear. This group in- 
cludes all cases of patients who hear without being conscious 
of doing so. 

3. Malingerers. The majority in this group undoubtedly have 
had shell concussion which affected the hearing for a time. At 
the time of examination many still showed traces of traumatic 
neurosis. But the defective hearing had now been recovered 
from partially or entirely and they were consciously exaggerating 
the defects still remaining or consciously claiming its persistence. 

It is a difficult matter to separate the second group from the 
third. Experience, the general condition of the patient, his 
answers to the test questions, largely aid the examiner. The 
following may be given as an example of Group 2: 

Private De S.: Admitted October Ist because of total deafness 
in right ear. Severely wounded in head by bullet on May 28, 
1916; unconscious for several hours; when recovered conscious- 
ness was deaf in right ear. Has a depression (5.2 em. by 1.5 em.) 
in the right parietal bone near interparietal suture through 
which pulsation of brain can be seen. Right membrana tympani 
slightly retracted, otherwise normal; tubes open; no hearing 
for voice or forks. Left membrana tympani normal; hearing 
for voice and forks normal. No paralyses, no anesthesia, no 
astereognosis, no tremor, no Romberg. Eyes: Movements nor- 


RESULTS OF HIGH EXPLOSIVES 149 


mal; fields normal; fundi normal; vision in both 6/9. To exam- 
ine the vestibular mechanism the calorie test (cold) was applied 
to right ear. The normal vestibular reaction was quickly obtained 
and immediately after the voice of the examining officer was heard 
in right ear at room length (7 yards) and whisper at 20 inches. 
No suggestion was made in this case. 

To this second group belong cases that yield to suggestion 
or recover hearing rapidly, often completely, after excitement 
or intense stimulation. To discuss the third group and how the 
malingerers can be detected is outside the limits of this paper. 


CASES OF NERVE DEAFNESS 


The cases now to be considered have been exposed to and 
damaged in some way by the shell explosion. It was not possible 
in a military hospital on the lines of communication to keep 
patients long—all one could hope to do was to keep as long as 
possible those promising improvement and to outline fur- 
ther treatment. 

As stated above, cases are not now considered in which a 
trauma to the ear has come from the explosion but in which, when 
examined, the deafness was middle ear in type and in which little 
or no evidence of nerve deafness now was present. Further, there 
are eliminated cases of gross damage to the middle ear or the 
external meatus from pieces of shell or shell contents, even 
though accompanied by nerve deafness. My endeavor will be 
to consider cases showing the effects of high-explosive shells on 
the ear without any wounds to the temporal bone other than 
those due to the explosive force. In some there were present 
injuries from pieces of shell in parts of the body more or less 
remote from the ear—but in these the trauma could not have 
damaged the internal ear. The majority of the cases under 
review had vertigo in a varying degree, but this symptom I 
am not here considering. Many were examined in whom the 
nerve deafness had almost, if not entirely, disappeared, but in 
whom disturbance of equilibrium was still complained of and 
in some objectively present. 


150 HARVEY SOCIETY 


The number of cases of persisting deafness after shell ex- 
plosion is still very much in doubt. This is shown by the follow- 
ing quotations from competent otologists: 

‘“War deafness in patients with healthy auditory apparatus: 
The intensity of deafness exhibited by soldiers suffering from 
labyrinthine concussion, and sometimes the long persistence of 
this symptom, gave, at the outbreak of hostilities, serious ground 
for fearing a functional importance comparable to that of laby- 
rinthine hemorrhage. Some authors, prematurely drawing con- 
clusions from an insufficient number of cases, have published 
alarming percentages on the subject. Labyrinthine concussion, 
however, is most frequently a question of simple shock, not a 
definite lesion. Of 262 cases of simple labyrinthine concussion 
we have had only 5 per cent. of almost total and seemingly 
incurable deafness.’’ (Lannois and Chavanne, loc. cit.) 

A large number who have been exposed to a heavy bombard- 
ment which caused severe or complete deafness for one or more 
days, and who have declared they hear quite well, will be found 
on examination to have some diminution of hearing. According 
to Jobson ? a large majority—over 80 per cent.—were quite una- 
ware of being deaf. We have no reliable statistics. But it ean 
be said that even at the best a large number of men are left 
at the end of two or three months with impairment of hearing 
and showing little or no tendency to improve. If left alone, they 
are not likely to improve. The question then arises what can 
be done for them to better the remnant of hearing still present. 
To this I will now direct your attention. 

In my work it was early observed that when certain forks 
eould not be heard by air or bone, by summation of stimuli it 
was possible to get the note perceived through the mastoid. To 
make sure that this was so, the patient was required to hum 
the note. It was further noted that after repeated applications 
of the fork the time required for the perception of the note 
gradually diminished and that at this period he was able to per- 
ceive the note passed into the ears by tubes attached to resonat- 
ing boxes. With these observations as basis, the following 


RESULTS OF HIGH EXPLOSIVES 151 


treatment was adopted—varying in accordance with the degree 
of deafness present: 

1. Tuning-forks are applied: (a) To the bone (the mastoid) ; 
(b) through resonators, attached to the ear by tube; (c) through 
the air. In our worst cases the time given to (a), (0), or (c) 
varied with the amount of deafness. 

2. The voice is used: (a) Through resonators with tube in 
ear; (b) with speaking tubes; (c) without any aid. Each period 
of treatment is short, for fatigue is rapidly produced. If the 
treatment be too long, headaches, vertigo, and occasionally pain 
in the ear is complained of and profuse sweating is very fre- 
quently present. 

3. In those complaining of total deafness, as early as possible 
it is ascertained if the semicircular canals are functioning, be- 
cause when there is reaction to the caloric or rotation tests one 
feels justified in continuing treatment for some time. 

4. As soon as possible carefully graduated physical exercises 
are given. In exercise the two essentials are short duration and 
no bending. The treatment (except the drill) is given twice a 
day in the worst cases; it ought to be given twice in all. 

In the totally deaf to voice it is sometimes difficult to pass 
from bone to resonator; in these we found it convenient to use 
the resonating box of the piano. We find that at each successive 
stage we have to use summation of stimuli; thus, not only must 
the fork on the resonator be kept up for some time, but with the 
voice we have to repeat the word, and even then there is a marked 
delay before the response comes. In the later stages the delay 
is still present. Then it appears to be not so much that he does 
not hear, but that he hesitates to attach the word to the sound, 
for, if asked what he thinks it is he frequently answers cor- 
rectly. In some cases in which an ear was totally deaf with 
a vestibular mechanism reacting normally, we failed to get any 
response. In those who had not total deafness but some percep- 
tion of sound, for instance, through bone, all improved—some 
very considerably. 

The following examples may be given: 


152 HARVEY SOCIETY 


Gunner R. Previous to enlisting, defective hearing in left 
ear sufficient to exclude him from Australian Government tele- 
phone service. On July 30, his battery was struck by a shell, 
and he was blown up. Does not remember anything for three 
days (unconscious?), then rotation vertigo, great nausea, deaf in 
both ears. Hearing came back gradually in left ear after twelve 
days without treatment. No return of hearing in right ear. 

Admitted September 14, 1916. Right ear—membrane nor- 
mal, no hearing for voice or forks. Left ear—membrane normal ; 
hearing for conversation voice two yards; cannot hear whisper. 
C1 and C? heard; C* and C* on increased intensity. Bone condue- 
tion diminished. Severe vertigo at times. 

Treatment began 17th September. September 20—in right 
ear hears voice through resonator. October 3—hears voices at 
12 inches in right ear. October 7—hears voice at two feet in 
right ear. October 12, 1916, sent to the C. C. A. C. with this 
report: Conversation voice, in right ear—20 inches; in left ear— 
5 yards. Sent to convalescent hospital. 

Private H. Age, 22. Iron moulder. Complaint—partial 
deafness in right ear, complete deafness in left; tinnitus and 
headache. Vertigo not complained of. No previous ear trouble. 

June 28, 1916. Blown up by shell explosion; piece of shell 
caused sealp wound over left parietal; unconscious for several 
hours; hemorrhage from left ear and ear discharge for five days. 

Seen September 14, 1916. Right ear—conversation voice, 
2 yards; loud whisper close to ear. Membrane retracted. 64 
dr. and 128 not heard. C1, C?, C* heard. C* not heard. Bone 
conduction diminished ; Rinne positive. 

Left ear—drum congested—no perforation. No hearing for 
voice, forks or whistle. Hears C* on summation of stimuli. Both 
tubes open. 

September 17. Right ear, 7 yards; whisper, 9 inches—all 
forks. Left ear, 4 yards; whisper, 2 inches. Forks, C1 and C*. 

October 15. Right ear, normal; whisper, 24 inches. Left ear, 
7 yards; whisper, 15 inches—all forks. 

Private L. Dublin Fusileers. Complains of deafness and 
tinnitus. No previous ear trouble. 


RESULTS OF HIGH EXPLOSIVES 153 


August 6, 1916. Blown up; not unconscious; no hemorrhage 
from ears, no otorrhea; complete deafness. Later, left ear 
recovered hearing slightly. 

Examined October 9, 1916. Right—drum membrane vessels 
markedly dilated, small area of relaxation. No hearing for 
voice or forks. Caloric in right produced marked nystag- 
mus with four ounces of water at 65° with dissociation of 
eye movements. 

Left ear—drum membrane normal—hears voice at 5 feet and 
all forks. Bone conduction diminished for all the forks. 

Fields concentrically contracted within 10 mm. ring. Nose 
and nasopharynx normal; tubes open. 


October 16. Hears all forks with right ear. Air and bone 
conduction diminished as follows: 


Right Ear Left Ear 
Air Bone Air Bone 
128 dv. — 46 sec. 10 sec. 37 sec. 26 sec. 
256 dv. — 70 sec. 20 sec. 107 see. 20 sec. 
(Oz — 50 sec. 22 sec. 35 sec. 25 sec. 
C — 4 sec. 3 sec. 
Ct — 7 sec. 6 sec. 


October 31. Conversation voice at 5 yards in left ear and 
with noise apparatus in left hears voice in right. 

November 18. Left ear, 7 yards. Right ear, 3 yards. 

Private H. No previous ear trouble. On June 18, 1916, after 
two months in France, ‘‘blown over parapet’’ for 10 feet and 
became unconscious for some hours; totally deaf in both ears. 

Examined September 4, 1916. Right membrane congested; 
left retracted and congested. Totally deaf in both ears to voice, 
forks and all sounds. Can distinguish and differentiate C* and C? 
on right mastoid by summation of stimuli. Mentally clear and 
intelligent; bilateral anwsthesia; no thermal sense for heat and 
cold; deficient sense of position for elbow, wrist and fingers; 
easily fatigued; irritable; if eyes are closed frequently drops off 


154 HARVEY SOCIETY 


to sleep; taste accurate but weak; concentric limitation of fields 
of vision. Vertigo, staggers if eyes are shut. Frequently com- 
plains of tingling and itching in the ears. (N. B.—This is a 
frequent complaint in these eases.) 

September 14, 1916. Gets notes on the piano, note corre- 
sponding to C? (512), down two octaves by right ear, and all 
forks over right mastoid. Galton whistle at right ear not heard, 
but feels like a prick of a needle. (N. B.—Because of the tendency 
to rapid fatigue, treatment very brief and chiefly confined to 
right ear.) 

October 4, 1916. Hears all forks over mastoid in both ears. 
Right ear—hears tuning-fork over resonator connected to his ear 
by a tube at 16 inches. While listening perspires very freely. 
Sings tunefully and rhythmically. 

October 20. Hears in right ear short sentences with the aid 
of a speaking tube, and in left ear words spoken into a resonator 
connected to the ear with a tube. Caloric in left gives reaction 
with 4 ounces of water at 66° F. 

On October 30 the right ear was carefully examined for 
tuning-fork perception, and it was found that he could not hear 
below C! (256), but could hear C? (512) and C* (1024), and on 
increased intensity C* (2048). 

November 10. With a speaking tube (a glass funnel and 
piece of tubing) hears well and can carry on a conversation. 
Hears without tube if one speaks fairly loud. 

Private K. Age, 23. Ranchman. Previous health good and 
no ear trouble. 

June, 1916, blown up and partly buried; unconscious for 
24 hours; hemorrhage from left ear. Complete deafness in 
both ears. 

Examined August 21. Memory very deficient; difficult to 
get information of past events; has brothers, but does not know 
how many; not quite clear as to what he did previous to enlist- 
ing; cannot remember his movements in France. When tries to 
remember gets worried and irritable; not sure if he dreams, but 
knows that wakens with a start and often with a ery. Com- 


RESULTS OF HIGH EXPLOSIVES 155 


plains of being always dopey and of hot and cold flushes. If 
bends head, staggers as if drunk. 

Right ear—membrana tympani normal; C* only fork heard 
on increased intensity. No hearing for voice. 

Left ear—membrana tympani intact, but with adhesions to 
posterior wall. No perception for voice or forks. 

Tubes open. Naso-pharynx normal. 

August 28. Treatment only to right ear. Hears C? over 
right mastoid on prolonged contact. Hears by air C? and C® 
on increased intensity. 

September 1. On getting up this morning had severe attack 
of rotation vertigo. 

September 2. Range of all forks in right ear and voice at 
1 foot. 

September 10. Ordinary voice at 18 inches. Does not now 
shout but speaks in lower tone. 

September 16. Got excited over quarrel with room-mate and 
sent to psychopathic wards of Moore barracks. Seen several 
weeks after and hearing showed slight improvement. 

Private B. Cook. Deafness in right ear and deficient vision 
in right eye. No previous ear or eye trouble. 

In August, 1916, was in dugout when shell hit it. Unconscious 
for several days, then could not see in either eye. Deaf in right 
ear; dulness of hearing in left and tinnitus. Marked rotation 
vertigo and fell when got up. 

Examined November 14. Right ear—membrane has marked 
depression over anterior half; no hearing for voice or forks. 
Bone conduction diminished. Left ear—membrana tympani and 
hearing normal. Fields of vision: Right eye—perimeter chart 
shows visual field much restricted below. He is blind in lower 
nasal quadrant and lower temporal quadrant is markedly con- 
tracted. Left eye, normal. 

November 24. All forks in right ear—voice at 4 yards. Right 
eye—field unaltered. 

Gunner B. June, 1916. Shell exploded in pit where he was; 
blew up ammunition and killed 5 out of 7. Unconscious for four 
hours. No hemorrhage from ears but vertigo. Completely deaf. 


156 HARVEY SOCIETY 


In left ear hearing began to return in about three weeks. Right 
came back slower. 

Examined September 17. Right drum membrane slightly 
retracted; hearing for voice 3/20. Left normal in appearance, 
but adherent to the posterior wall. Hearing 5/20. 

Right ear—C, and C not heard; C' and C* heard; C* and C* 
not heard. Left ear—C, not heard; C and C' and C? heard; C* 
and C* not heard. 

Duration of forks for air conduction diminished greatly in 
both ears; e.g., in left ear C'—30 to 40 seconds ; C?—25 seconds. 
Tubes open. Bone conduction diminished. Rinne unsatisfactory. 

Fields of vision contracted. Fundi normal. Deficient sensa- 
tion over body for touch and thermal sense. Marked vertigo; 
very slow rotation produced nausea. 

October 6. Voices heard in right and left ears at 4 yards. 
C® in both ears; C* in left; C, not heard in either ear. 

October 18. Voice heard at 6 yards in both ears. 

Private H. Deafness and discharge from left ear. No pre- 
vious ear trouble. 

March 26, 1916. Blown up, buried, unconscious for one 
hour. Hemorrhage from nose, none from ear, deafness from 
which never completely recovered. Could not be trusted to get 
or deliver messages because of deafness. Returned to lines. 

June 3, 1916. Blown up and buried. Hemorrhage from 
left ear, and since then otorrhea and deafness. 

Examined September 14. Right ear—membrana tympani 
thickened and retracted. Tubes open. Voice at 2 yards. Left 
ear—large perforation, mucopurulent secretion. Conversation 
voice—2 feet and whisper close to ear. Bone conduction dimin- 
ished. In left ear forks show: 64 and 128 not heard; C* and C? 
heard; C* and C* not heard; whistle not heard. (Zone of tone 
perception in left ear clearly marked, but because of otorrhea no 
stimulation of hearing with forks.) 

Thirty-four cases of concussion injury, showing nerve deaf- 
ness of over three months’ duration without perforation of the 
tympanic membrane, were examined in October and November. 


RESULTS OF HIGH EXPLOSIVES 157 


1. Of these seventeen were given the treatment above men- 
tioned, and improved. 

2. Three showed evidence of improving hearing when they 
first came under observation, received no treatment, and con- 
tinued to improve. 

3. Two had slight deafness but marked tinnitus and vertigo. 

4. The other twelve showing no improvement may be thus 
classified : 

Three had section of the VII nerve from bullet wound outside 
the skull. Deafness with injury to the facial nerve have shown 
no tendency to improve. 

Two had total deafness in one ear (good hearing in the other) 
and gave no vestibular reaction to caloric test. 

One had Méniére syndrome associated with old radical mastoid. 

Two had had severe cranial concussion—S. had been struck 
also by bullet over frontal; L., a dispatch rider, was blown up 
by a shell bursting under his machine. 

In four no explanation could be offered. Of these four—two 
totally deaf, left ear; one markedly deaf, left ear; one markedly 
deaf in both ears. 

During that time among the men sent down for concussion 
deafness, eight had had concussion deafness and now were 
classed as malingerers or suffering from the fixed idea that they 
could not hear. 

Many of the cases seen had perforation of the tympanic 
membrane and in these suppuration of middle ear was frequently 
present. In these the deafness was a combination of conduction 
and nerve deafness. It was impossible to assign the relative 
amount of deafness due to each. In these, treatment was first 
directed to check the otorrhcea, and acoustic stimulation was not 
given till the suppuration had stopped. Our records of results 
date from this time, and in thirty-four cases—19 showed improve- 
ment, in some markedly so. It might be urged that improved 
hearing may have followed cessation of the ear discharge, but 
the records for the forks and the bone conduction changes show that 
something else was at work than the middle-ear improvement. 


158 HARVEY SOCIETY 


GENERAL RESULTS 


Examination of the tuning-fork records of shell-concussion 
cases of deafness give the following interesting results: 

1. There is a lack of perception of the forks at both ends of 
the scale, and the perception for all forks is diminished for air 
conduction and for bone conduction so far as these could be tested. 

2. There never were found gaps in the hearing of tones as 
figured by Bezold? in deaf mutes. It would appear that the 
remnant of hearing left for tone perception is best considered as 
the apex of the normal curve of tone perception which curve has 
as a result of the injury fallen as a whole below the threshold 
of perception. This is strengthened by the fact that in some 
increase of intensity will increase the limits of perception. 

3. The last note to disappear is somewhere near the frequency 
of C?-C*; and the first to be perceived by air is also near this 
frequency. It is interesting to associate this with physiological 
findings that it is near this frequency that the minimum intensity 
gives perception. 

SUMMARY 

1. In deafness resulting from concussion due to high ex- 
plosives, there is frequently a trauma demonstrable in the ear. 
The perception of sound is diminished over the whole normal 
range both for bone and air conduction. This diminution may be 
so great as to totally abolish perception of sound. 

2. In the totally deaf who improve, bone conduction is per- 
ceived before air conduction. In these cases summation of stimuli 
plays an important part in the perception of sound. It is essen- 
tial to differentiate vibrations from musical notes. 

3. There is a marked diminution of the duration of hearing 
along the whole series of forks, both through bone and air. 

4. The normal stimulus (musical notes or voice) is an ade 
quate stimulus for the nerve and is the best stimulus. Elee- 
tricity is contraindicated and likely to do harm since it so 
easily produces vertigo. 

5. If the conducting mechanism is damaged or destroyed, it 
not only takes longer to get improvement, but complete recovery 
cannot be expected. 


RESULTS OF HIGH EXPLOSIVES 159 


6. As the deafness diminishes there may persist for a long 
time an inability to grasp intelligently what is said or to retain 
the memory of it. Thus a word may have to be repeated two 
or three times before the patient gets it; or, if he be asked to 
repeat two or three numbers given consecutively, he will repeat 
the last one; he knows that there were others but ‘‘did not 
get them.’’ 

7. Pathological examinations show that the auditory mechan- 
ism may be seriously damaged while the vestibular shows little 
or no change. Therefore the vestibular mechanism may react 
to stimulation in cases where the cochlea is seriously damaged. 

&. Prognosis is good, as a rule, especially in cases where there 
is no trauma demonstrable in the peripheral organ, no marked 
history of aural vertigo, and a normal calorie reaction. The 
most noteworthy exception met with so far is damage to the 
seventh nerve. In these cases, if hearing returns, it returns but 
slowly, and so far as we have observed very imperfectly even with 
a normal drum membrane, little if any signs of middle-ear 
inflammation, and a caloric reaction present. 

9. The frequency of labyrinthine symptoms immediately fol- 
lowing the atmospheric compression and decompression from the 
shell burst speaks against an exclusive view of the psychogenic 
explanation of the deafness. The percentage of early recovery 
speaks against any very serious damage to the peripheral organ 
of Corti. My early investigations, based on clinical observa- 
tions, led me to believe that in many of the cases we were deal- 
ing with some ultra microscopic change probably at the synapses. 
But my recent pathological observations have led me to believe 
that while this is so in some, yet organic changes in the periph- 
eral organ and its nerve offer a more satisfactory explanation for 
the deafness and vertigo. 

The progressive recovery of hearing, so constantly observed, 
suggested in the light of our pathological and experimental knowl- 
edge, that we are dealing with injuries of the nature of contu- 
sions with edema, capillary hemorrhages, changes in the myelin 
sheaths and molecular changes in the nerve-cells. That in the 
majority of concussion cases we have a marked destruction of 


160 HARVEY SOCIETY 


the organ of Corti or a definite lesion of the auditory cortex 
appears to me doubtful, for in both of these regions we are dealing 
with a highly specialized structure in which regeneration would 
be unlikely. 


REFERENCES 


*Mott: Lettsonian Lectures. Transactions of the Medical Society of 
London, xxxix, 160 and 172. 

* Jobson, T. B.: Lancet, 1917, 566. 

* Bryant, W. S.: Journal of Laryngology, Rhinology, and Otology, 1917, 
Nov., 338. 

*Lannois and Chavanne: Lyon Médical, 1916, exxv, 35-40. 

’Wittmaack, K.: Uber Schiidigung des Gehérs durch Schalleinwirkung, 
Ztschr. f. Ohrenh., 1907, liv, 37. 

® Yoshii, U.: Experimentelle Untersuchungen iiber die Schiidigung des 
Gehérsorgan durch Schalleinwirkung, Ztschr. f. Ohrenh., 1909, Iviii, 201. 

THoessli, H.: Weitere experimentelle Studien iiber die akustische Schiidi- 
gung des Saugetierlabyrinths, Ztschr. f. Ohrenh., 1912, lxiv, 101, and 
1913, Ixix, 224. 

*Mott: Brit. Med. Jour., 1917, Nov., 10. 

® Fraser, J. S., and Fraser, John: Journal of Laryngology, Rhinology, and 
Otology, 1917, Nov., 340 and 369. 

” Bezold and Siebemann: Textbook of Otology, Chicago, 1917, p. 71. 

"Luciani: Human Physiology, London, 1917, 4, p. 339. 

2 Bezold and Siebemann: Otology, p. 53. 


CERTAIN ASPECTS OF THE APPLICATION OF 
ANTISEPTICS IN MILITARY PRACTICE * 
Dr. E. K. DUNHAM. 


T will be my endeavor in this lecture to bring together, in some 

sort of consecutive form, the essential facts concerning the 

chlorine group of antiseptics, their action and the principles 
underlying their successful application in surgical practice. 

We may distinguish chlorine in three conditions: First, as 
free chlorine in the gaseous condition or compressed to liquid 
form; second, compounds in which the chlorine is ‘‘available’’ 
or ‘‘active;’’ and, third, fixed chlorine, so firmly in stable’ com- 
bination that it is no longer ‘‘available’’ or ‘‘active,’’ and is also 
devoid of antiseptic potency. Of these three states, the free 
chlorine is, in general, the most reactive; 2.e., the most prone to 
seek combination with other elements. It may have either a direct 
ehlorinating or an indirect oxidizing action upon substances 
with which it comes into contact, depending upon the nature of 
the substance, the absence or presence of water and various 
physical conditions, such as temperature, exposure to light, ete. 
The reactivity of free chlorine is of such a high order that its 
use in surgical and medical practice is extremely limited. Even 
in very dilute solution it is highly irritating and the mass of 
chlorine that can be applied is consequently very limited, too 
small, in fact, to be of material value for disinfection in the 
presence of any considerable organic matter. Its chief use is 
for the disinfection of potable waters, for which purpose it is 
admirably adapted because no objectionable end products remain 
in the water. 

For surgical purposes, the so-called ‘‘active’’ chlorine com- 
pounds are the ones that have come into wise use and acquired 
a high reputation for efficiency. In those particular compounds 
that have proved most valuable, the chlorine is linked to either 
oxygen, as in hypochlorous acid and its salts, the hypochlorites, 


* Delivered October 19, 1918. 
11 161 


162 HARVEY SOCIETY 


or to nitrogen in the chloramines. These linkages mitigate the 
reactivity of the chlorine but do not preclude its entering into 
those reactions which result in still more stable compounds and 
which are also intimately related to the process of disinfection, 
including the killing of bacteria. 

In the third or fixed state, the chlorine is displaced from the 
existing combination with such difficulty that no spontaneous 
antiseptic action is possible. 

Before taking up the various members of the active chlorine 
group of antiseptics in detail, it seems important to point out the 
differences between these as a class and antiseptic substances not 
dependent upon chlorine for their action. Most of these, such as 
phenol, the inorganic metallic salts and probably other substances, 
such as alcohol and formaldehyde, appear to act as coagulants. 
The speed of the coagulation they effect, the firmness of the 
coagulum and the depth (penetration) to which it extends varies 
with the concentration of the agent and other conditions and also 
depends upon the particular agent employed. Many of these 
substanees are used as fixative agents in histological technic to 
bring about a coagulation of living tissues with a minimum of 
undesirable distortion of structure, and this use exemplifies their 
mode of action. The active chlorine compounds do not occasion 
such fixation. They are not to be classed as coagulants, and in 
fact one of these compounds, sodium hypochlorite, the active 
ingredient of Dakin’s solution, exerts a marked solvent action 
upon solid protein substances, a unique property of the greatest 
value in many infections, as will be presently emphasized. 

Most compounds containing active chlorine are capable of 
liberating free iodine from inorganic iodides, such as potassium 
or sodium iodide, in the presence of water. This reaction may be 
regarded as an oxidation, as exemplified in the equation, HOCI + 
2HI = HCl + H,0 + L,, in which the hydrogen of hydriodie acid 
is oxidized to water by hydrochlorous acid. It will be noted that 
an atom of active chlorine is equivalent to two of iodine, a faet to 
be borne in mind when this reaction serves as the basis for the 
indirect determination of hypochlorite by titration with a stand- 
ard solution of thiosulphate. 


APPLICATION OF ANTISEPTICS 163 


It is not surprising that these compounds should be in greater 
or less degree unstable, for their utility as antiseptics depends 
upon their reactivity at ordinary temperatures. The most im- 
portant physical deteriorating influences are light and heat. Con- 
tact with acids and readily oxidized or chlorinated organic or 
inorganic substances also rapidly consumes the active chlorine, 
reducing or abolishing the antiseptic potency. 

Sodium hypochlorite cannot be preserved in solid form and, 
in practice, must be prepared by chemical means in the solution 
destined for use. There are several methods for so preparing it, 
and under various conditions one or another will prove of greater 
convenience. The original method consisted in preparing a solu- 
tion of calcium hypochlorite from bleaching powder (chlorinated 
lime). This was then mixed without previous filtration with a 
solution of sodium carbonate and well shaken to render the cal- 
cium carbonate which was formed granular and then, after 
standing, the supernatant fluid was siphoned off and filtered. 
The resulting solution, containing sodium hypochlorite, was more 
or less strongly alkaline, because a variable amount of calcium 
hydrate is always present in chlorinated lime. While this alka- 
linity rendered the hypochlorite solution more stable, it was 
objectionable because it augmented the irritation of the tissues 
with which the solution came in contact. To avoid the use of 
strong acids to obtain neutrality and provide ‘‘buffer’’ salts 
capable of adjusting the reaction of the solution to varying con- 
ditions of slight fortuitous acidity or alkalinity when in use, borie 
acid was employed to neutralize the hypochlorite solution, and 
sufficient boric acid was added to abolish the development of a 
pink color on the addition of solid phenolphthalein to a sample. 
The resulting solution, diluted to a hypochlorite concentration 
of 0.5 per cent. NaOcl, was the original Dakin’s solution, which 
proved so efficacious in the treatment of septic wounds in France, 
when used with a proper regard to its chemical and _ bacterio- 
cidal properties. 

There have been several modifications of minor essential im- 
portance devised to facilitate the preparation of sodium 
hypochlorite solutions, but none of these can be entrusted to 


164 HARVEY SOCIETY 


the inexperienced with the same confidence as can the origi- 
nal procedure. 

One of these methods, devised by Daufresne to do away with 
the neutralization with boric acid, consists in the use of a mixture 
of sodium carbonate and bicarbonate in the preparation of the 
hypochlorite from chlorinated lime. The purpose of the bicar- 
bonate was to care for the calcium hydrate in the bleach, sodium 
carbonate being formed in place of sodium hydrate. It is obvious 
that the proportion of bicarbonate used must be adjusted to the 
amount of calcium hydrate in the actual sample of bleach em- 
ployed. This being done, the method has proved convenient and 
is very commonly used. A third frequently employed mode of 
preparation is based on the reaction between chlorine gas and 
sodium earbonate with the production of sodium chloride and 
carbonic acid as by-products. The resulting solution is rather less 
stable than the foregoing, owing to the absence of buffer salts, 
but can be to some extent stabilized, as can all the others, by the 
addition of small quantities of potassium permangate. A solution 
of sodium hypochlorite can also be prepared by electrolysis of a 
salt solution, and is characterized by the same sort of instability 
as the preceding solution prepared with chlorine. 

Whatever may be the mode of preparation, it is important 
that the hypochlorite strength of the solution be checked before 
use of titration with a standard solution of sodium thiosulphate 
and that the presence of free alkali be avoided. The maximum 
permissible concentration, as shown by clinical experience, is 
approximately 0.5 per cent. of NaOCl. If the strength is less 
than 0.4 per cent., the germicidal efficiency of the solution is 
materially reduced. 

It cannot be asserted that the complete modus operandi of the 
germicidal action of Dakin’s solution is fully understood. A 
complete understanding is in fact, lacking with respect to all 
antiseptics. But the nature of the interactions of hypochlorites 
with protein substances in general strongly suggests that similar 
processes are involved in the process of disinfection. When 
proteins are acted upon by sodium hypochlorite, among the reac- 
tions which may take place is an interchange of chlorine and 


APPLICATION OF ANTISEPTICS 165 


the hydrogen of the amino radicals, chloramine groups being 
formed on the one hand and sodium hydrate on the other. 
(=N —-H +- NaOCI==N-Cl+ NaOH.) This change in the 
amino groups of the protein molecule induces an instability re- 
sulting in a more ready cleavage into complexes containing chlo- 
ramino acids. In the free state, these are generally insoluble 
in aqueous media, but the sodium salts are more or less readily 
soluble. Since essentially equimolecular quantities of sodium 
hydrate are formed at the same time, an opportunity for the for- 
mation of such soluble salts is furnished by the sodium hypo- 
chlorite coincidently with the chlorination of the amino groups. 
The occurrence of this chain of events offers a reasonable explana- 
tion of the solvent action of sodium hypochlorite upon protein 
substanees, such as fibrin and necrosed tissue, as well as its lethal 
action upon bacteria. That free alkali can be formed by reac- 
tions upon Dakin’s solution is shown by the pink color which 
promptly develops when an alcoholic solution of phenol-phthalein 
is added to a solution not reacting alkaline to the solid indicator. 
This color soon vanishes. The difference is evidently due to the 
presence of the aleohol, which occasions the loss of chlorine on the 
part of the hypochlorite, thus liberating free alkali. This evanes- 
cent reaction in the presence of alcohol receives practical applica- 
tion to detect such an acidity in a hypochlorite solution as would 
neutralize the alkali as formed and the presence of which would 
cause not only an abnormally rapid deterioration in hypochlorite 
strength but also impair its solvent action upon proteins. 
Dakin’s solution occupies a high position among chlorine 
antiseptics because of its very great reactivity associated with a 
solvent action upon dead tissues and the solid portions of 
inflammatory exudates. It is, because of these properties, pre- 
eminent as an agent for the cleansing of septic wounds or cavities 
(e.g., empyemata). Tissues with an abundant blood supply and 
active circulation are so largely protected by substances con- 
tained in the transuded serum which react with the hypochlorite 
that relatively little damage is done under such conditions to 
the fixed and living tissue elements. Where this circulation 
is absent or inadequate, an excess of Dakin’s solution will exert 


166 HARVEY SOCIETY 


a damaging and solvent action upon the living tissues. This is 
exemplified by the destruction and removal of the epidermis 
when the skin is bathed with quantities of the hypochlorite. 
‘‘Burns’’ occasioned in this way frequently occur in the neigh- 
borhood of wounds when the skin is not protected from contact 
with full-strength Dakin’s solution. The skin defect in such 
cases is confined to the epidermis; the underlying corium being 
protected from serious injury by transudation of fluid from the 
tissues, and ulcerations of appreciable depth do not occur. The 
process is a simple denudation of the corium by a dissolution of 
the epithelial covering. This can be obviated by a coating of 
vaseline which prevents the wetting of the skin by the Dakin’s 
solution. It has been noted that people with oily skins, par- 
ticularly negroes, are less prone to these burns than others, unless 
the natural sebum be previously removed by ether, gasoline or 
some other fat solvent. 

When applied to septic wounds or purulent cavitiesy Dakin’s 
solution comes in contact with many substances contained in the 
secretions with which the hypochlorite reacts. These reactions 
take place with great but not all with equal rapidity. Those 
substances which oceasion foul odors are usually the first to be 
destroyed by the action of the hypochlorite, resulting in a 
sweetening of the secretions. Complete sterilization does not 
usually occur until the quantity of pus has become trivial and 
very little secretion is produced. 

The hypochlorite has no specific germicidal properties. Steri- 
lization is one of the incidents of the wide range of chemical 
reactions which take place and probably one of the more tardy. 
It is certain that where infections are overcome by applications 
of Dakin’s solution, certain species of bacteria disappear more 
rapidly than others. As a rule, the putrefactive varieties are 
first eliminated, such forms as the bacillus pyocyaneus next, and 
last of all the hxemolytie streptococcus. Whether this be due to 
entanglement of the pathogenic microdrganisms in the meshes of 
fibrin and bits of necrotic tissue, or to a greater resistance to 
the chlorinating action of the hypochlorites, must be left unde- 
termined. The fact that after apparently satisfactory cleansing 


APPLICATION OF ANTISEPTICS 167 


certain dangerous pathogenic organisms for a while may linger 
in the wound, suffices to indicate that the antiseptic treatment 
must be continued for a period beyond that at which obvious pus 
has disappeared. A bacterial control on considerable quantities 
of secretion can alone ensure confidence that sterilization has 
been completed. The character of this control will receive fur- 
ther consideration. 

Since the active chlorine constituting the essential antiseptic 
agent of this group of substances, passes into other combinations 
during the process of disinfection and is finally locked up in 
combinations rendering it inert, the antiseptic substance is 
itself necessarily destroyed in that process. The process is, 
therefore, a summation of reactions in which all the reagents 
undergo changes that destroy their powers for good on the one 
hand, for evil on the other. To secure progress in a favorable 
direction, it is therefore important that the mass of antiseptic 
used should more than keep pace, not only with the multiplication 
of the bacteria present, but also with the production of other 
chemical substances appropriating to themselves the active chlo- 
rine which may be present. The mass of antiseptic which should 
be employed in a given case will depend upon the pathological 
processes and their extent. No rigid rule can be formulated. 
But it is possible to form an estimate of the rate at which the 
active chlorine is consumed by testing the secretions for chlorine 
in that condition at intervals after a given amount has been 
applied. This can be done with paper previously impregnated 
with a mixture of potassium iodide dissolved in a thin starch 
paste and then dried. If a drop of the wound secretion be used 
to moisten this paper, a distinet blue spot will at once be formed 
if available chlorine be present. An absence of this reaction 
demonstrates the absence of chlorine in this state. If viable 
bacteria still exist in the exudate, they then have opportunity 
to multiply. 

The most direct and conclusive way of following the progress 
of disinfection is, at intervals, to estimate the number of bacteria 
present in the exudate. This ean be done in either of two ways, 
each of which has certain advantages over the other, and not 
infrequently it will be desirable to employ both. 


168 HARVEY SOCIETY 


The most ready method for estimating the abundance of bac- 
teria in secretions is to prepare films and count the organisms 
per field of an immersion objective. If the film be stained by 
Gram’s method, any abundant infection with anaérobie gas 
bacilli will be revealed; for these retain the gentian violet. A 
rapid survey is also afforded of the variety of bacterial forms 
and their approximate number. It is generally assumed that if 
the total number does not greatly exceed one bacterium in ten 
fields, the wound is, for practical purposes, substantially sterile. 
But this rule does not hold if streptococci be present; for these 
are not readily eared for by the secretions or phagocytosis. 

A less rapid method than the foregoing is the preparation 
of poured culture plates after mixing a considerable and definite 
amount of the secretion with a suitable culture medium. This 
procedure does not yield results as promptly as the stained film, 
but in many respects the information gained is more accurate 
and useful. A larger sample of the secretion can be taken without 
increasing the labor and time required for its examination. The 
personal equation in enumerating the number of colonies on a 
plate culture is somewhat less marked than in counting individual 
microorganisms with an immersion lens. But the most important 
advantage of the plate culture over the film is the insight it 
gives concerning the bacterial species and their relative numbers. 
For example, if the culture medium selected be plain agar, with 
an addition of from 5 per cent. to 10 per cent. of defibrinated 
blood, the colonies of hemolytie streptococci will be easily distin- 
guished from those of other species and ean be enumerated. 
These streptococci usually appear on films as small diplococei not 
distinguishable from other less objectionable species. 

We possess, then, convenient means both chemical and bio- 
logical for obtaining information of essential value in guiding 
our treatment of septic conditions when active chlorine antisepties 
are employed. 

The specal technic which has been devised for applying 
Dakin’s solution had its origin in the necessity that the antiseptic 
must be carried as directly as possible to all parts requiring its 
action, since its high reactivity would lead to decomposition of 


APPLICATION OF ANTISEPTICS 169 


the hypochlorite, did one trust to diffusion for the dissemination 
to parts distant from the point of immediate application. This 
same instability necessitates frequent renewals of the applications. 
All of these requirements are met by the system of small tubes 
with fine perforations so ingeniously elaborated by Carrel and so 
widely known in association with Dakin’s solution. 

The importance of securing free drainage of a wound or 
eavity when Dakin’s solution is used is not so generally appreci- 
ated as should be the case. Too much reliance is often placed 
upon the ability to disinfect the secretion, no matter how abund- 
ant this may be. Attention has, however, already been called 
to the reactions by which substances in the exudate rob hypo- 
chlorites of active chlorine. Free drainage reduces the mass of 
these substances, which in some eases is so great that difficulty 
is encountered in adding a countervailing amount of Dakin’s 
solution. To drain away these inhibiting substances is often the 
first requisite to inaugurating successful treatment and is always 
a contributing factor of great importance. 

When, through the use of Dakin’s solution, a wound or cavity 
has been cleansed, 2.e., freed of fibrin and necrosed tissue, the 
question will arise whether the use of this form of chlorine anti- 
septic should be continued or another antiseptic of the same or 
some other group should be substituted. There appears to be no 
doubt that the hypochlorite solution exerts a solvent action upon 
dense fibrous tissue, including poorly vascularized cicitricial tis- 
sue. If it be desired to effect such solution in a particular case, 
the continued use of Dakin’s solution is, in cases presenting no 
contraindication, advisable. If, on the other hand, such con- 
tinued solvent action be inadvisable, there is good evidence that 
the continued use of this antiseptic beyond a certain dosage 
determined by the nature of the case very materially retards the 
development of granulations and healing. Experiments upon 
animals have shown the injury done to normal serous surfaces, 
such as the peritoneum, by the direct application of chlorine 
antiseptics, especially by Dakin’s solution. The damage described 
exemplifies the rapidity with which these antiseptics react with 
proteins. It takes place before any outpouring of fluid can serve 


170 HARVEY SOCIETY 


as a protection. Where an inflammatory exudate has been pre- 
viously formed, the reactive substances within this fluid come into 
immediate contact with the antiseptic solution, and while them- 
selves acted upon, shield the underlying tissues. Experiments 
of this character do not militate against the use of these anti- 
septics for purposes of disinfection. 

It is possible to continue chlorine antisepsis without occasion- 
ing any marked solvent action by employing either chloramine-T 
or dichloramine-T. As already pointed out, these substances are 
a degree less reactive than the sodium hypochlorite and appear 
to be entirely devoid of a solvent action upon solid proteins. 

Chloramine-T is a solid aromatic substance erystallizing with 
three molecules of water. These crystals contain something over 
12 per cent. of active chlorine. Weight for weight it has about 
the same antiseptic potency as sodium hypochlorite, a 0.5 per 
cent. solution might therefore be substituted for Dakin’s solution 
without sacrificing germicidal action upon microdrganisms with 
which the solution came into immediate contact. Since a solution 
of this concentration is hypotonie, it is advisable to use physiologi- 
cal salt solution rather than pure water as a solvent. The 
chloramine-T is extraordinarily stable considering the high active 
chlorine contact, and solutions may be boiled without marked 
deterioration, and exposed to light with immaterial loss of 
strength. It is freely soluble in water, saturation not being 
reached at ordinary temperatures below 16 per cent. It may 
be applied in solution with the same technic as Dakin’s solution, 
or in the form of a paste prepared with sodium stearate and 
water. Gauze may be impregnated with the salt and used dry 
for packing a wound. It does not cause appreciable irritation of 
the skin. These various properties fit it admirably to take the 
place of Dakin’s solution as well as for employment in ways for 
which the hypochlorite is unsuited. For example, solutions con- 
taining from 0.1 per cent. to 0.2 per cent. can be used in the eye 
and the bladder may be irrigated with still weaker solutions 
with benefit. The exact strength advisable for such irrigations 
eannot be stated, since the susceptibility of different cases varies 
greatly. It is wisest to begin with very weak solutions, 1: 10,000 


APPLICATION OF ANTISEPTICS 171 


in physiological salt solution, and to gradually increase the con- 
centration until the strength comfortably tolerated is determined. 
It is possible that reactions taking place in residual quantities 
of urine may have an influence, for the bladder appears to be 
more susceptible than other mucous membranes. In ordinary 
wounds, a 2 per cent. solution is well borne and 4 per cent. is in 
most cases no more irritating. 

In dichloramine-T we possess a very potent antiseptic con- 
taining nearly 30 per cent. of active chlorine. It is but slightly 
soluble in pure water. Its distinctive property is a marked solu- 
bility in certain oily substances and its practical use is based 
upon this property and originally had special reference to its 
employment in sprays and atomizers for application to the naso- 
pharynx. It has, however, come to be used for other purposes. 
When pure, it is relatively non-irritating and oil solutions may 
be applied to the nasal mucosa without notable irritation. But 
as compared with the closely related chloramine-T, it is prone to 
undergo a rather rapid decomposition on exposure to light, par- 
ticularly in the presence of moisture. It is also much more 
subject to deterioration by heat. Unfortunately, highly irritating 
substances, including hydrochloric acid and free chlorine, are 
among the products formed on decomposition of dichloramine-T, 
and it is, therefore, essential that solutions should be prepared 
from undeteriorated samples and be protected from decomposition 
until used. Among the solvents proposed for dichloramine-T, the 
most satisfactory is chlorcosane, a rather heavy oil prepared from 
paraffin wax. A 5 per cent. solution in this medium is well 
tolerated when applied to wounds, and a 2 per cent. solution 
can be freely used in the nasopharynx. In the absence of water, 
dichloramine-T is apparently inert. Metals immersed over long 
periods in a dry oil-solution are not corroded, but the presence 
of even a trace of moisture suffices to occasion a marked action. 
When used as an antiseptic, the active chlorine passes from the 
oil to the aqueous medium, with which it is in contact, and it is 
here that the antiseptic action is manifested. The oil serves as a 
medium for storing the antiseptic, which by diffusion replenishes 
the supply in the wound secretions, thus maintaining action until 


172 HARVEY SOCIETY 


the whole amount has been consumed. Where a mild, but pro- 
longed, chlorine antisepsis is desired, this is a very convenient 
and suitable means of meeting the requirements. It is important 
to note, however, that it is often difficult to attain perfect contact 
with all parts to be treated, since the oil does not mix readily 
with secretions and must be actually carried to all parts requiring 
treatment. It is best applied to relatively dry surfaces that can 
be reached by sprays, swabs, or dressings soaked in the oil-solution. 
Where wounds secrete very freely, a sufficiently prolonged con- 
tact of the oil and wound surfaces is sometimes unattainable, 
but the wound secretion is very frequently markedly diminished 
in quantity under the influence of dichloramine-T in chloreosane 
solution. In contrast to this diminution of serous exudate from 
the surfaces of wounds is the stimulating effect which similar 
applications exert on the secretion of mucus by mucous mem- 
branes. This is often so marked, that applications of the anti- 
septic are thereby contraindicated, particularly when the 
secretion cannot readily escape. This, and the difficulty of 
securing intimate contact between a heavy oil and all parts of 
a moist membrane containing infected glands, are reasonable 
explanations of failure to successfully treat acute urethritis with 
this preparation. The particular field of greatest usefulness, 
aside from nasopharyngeal antisepsis, for oil-solution of dichlo- 
ramine-T is the maintenance of sterility on granulating surfaces ; 
for it appears to have but little restraining influence upon grow- 
ing epidermis and can here be readily applied without injury 
and dressings can be removed with minimal trauma from the 
oiled surfaces. 

Before closing these preliminary remarks and proceeding to 
a practical illustration, I should like, by way of summary, to call 
attention once more to certain considerations that apply to all 
antiseptic procedures. 

1. In the choice of an antiseptic, attention should be paid to 
the relative speed of disinfection manifested by different germi- 
cidal substances. Iodine and the chlorine antiseptiecs are among 
the most rapidly acting agents at our disposal, but iodine is by 
far more coagulant than the members of the chlorine group. 


APPLICATION OF ANTISEPTICS 173 


2. The antiseptic used must be brought in contact with the 
microorganisms to be destroyed. This is a problem in application. 

3. The antiseptic must be present in adequate mass to 
enter into all the collateral reactions which may be associated 
with disinfection. 

4. It must be present in adequate concentration for a sufficient 
period of tame to complete the desired reactions; for it must 
be constantly borne in mind that disinfection is not an instan- 
taneous reaction, however short the requisite period may be. 

The particular example which I have chosen in illustration 
of the practical application of chlorine antisepsis, is the 
disinfection of an empyemic cavity that has been opened 
by thoracotomy. 

Let us assume that the operation was done three months ago 
and a litre of pus evacuated at that time. The bacteriological 
examination at that time revealed the presence of innumerable 
hemolytic streptococci. A tube to provide drainage was inserted 
and dressings renewed daily, or oftener, as required. At the 
present time the opening into the empyemie cavity will admit a 
drainage tube %% inch in external diameter. The discharge is a 
creamy pus containing curdy masses of fibrin and does not readily 
escape through the tube, so that about 400 ¢.c. are habitually 
retained. The discharges have a foul odor and the dressings a 
greenish tinge. Poured blood-agar plates, prepared with a loop- 
ful of the discharge, show about 400,000 colonies after incubation 
over night and the blood has undergone complete lysis. Such is 
a not infrequent picture. 

The first indication in such a ease is to secure free drainage. 
While there is a large retention of pus, efforts to disinfect the 
cavity are so hampered by destruction of antiseptic that they are 
likely to prove futile. The opening should be enlarged. This 
ean often be accomplished by inserting progressively larger rub- 
ber tubes. Should this fail, or be too slow, operation may be 
advisable. The opening should be large enough to accommodate 
a fair-sized drainage tube and one or more Carrel tubes. When 
this has been accomplished, the daily procedure towards steriliza- 
tion may begin. 


174 HARVEY SOCIETY 


At the morning dressing, the skin about the wound is carefully 
wiped clean. The surfaces of the wound, the skin and the cavity 
are then gently irrigated with Dakin’s solution applied through 
a soft rubber catheter. The only contraindication to such irri- 
gation of the empyemic cavity is the presence of a pleuro- 
bronchial communication through which the solution enters the 
lung. This possibility imposes caution until it is certain that no 
such communication exists. Postponing for the moment the 
modifications in treatment necessitated by this complication, the 
cavity is irrigated until the return is clear, the patient being 
directed to change his position so as to completely fill and then 
empty the cavity. This affords an opportunity to gauge the 
capacity of the cavity, and if the patient be induced to cough 
to estimate also the resulting expansion of the lung, by the force 
with which fluid is ejected from the opening. 

After this irrigation and cleansing and drying the surround- 
ing skin, the latter is protected from the action of hypochlorite 
by close applications of gauze impregnated with vaseline and 
sterilized in the autoclave. A fenestrated drainage tube, just 
long enough to pass through the thoracie wall and guarded by 
a safety-pin, is then introduced, and also one or more Carrel 
tubes. If only a single Carrel tube can be admitted through the 
opening, this should extend to the remotest part of the cavity 
and be abundantly provided with minute perforations for the 
distribution of the hypochlorite to all surfaces. If more than 
one tube can be accommodated by the opening, they may well vary 
in length and, as far as feasible, in distribution within the 
eavity. The free ends of these tubes are carried upwards and 
fastened with a strip of adhesive plaster in the region of the 
shoulder beyond the edges of the future binder. Pieces of loose 
gauze moistened in Dakin’s solution, or, perhaps preferably, in 
a stronger solution (2 per cent.) of chloramine-T, are packed 
around the tubes. A gauze dressing, split to accommodate the 
tubes is placed over this packing and beneath the safety-pin 
transfixing the drainage tube and the whole covered with numer- 
ous fluffs of sterile gauze. Large absorbent pads and a tight- 
fitting binder to hold dressings and drainage tube in place com- 


APPLICATION OF ANTISEPTICS 175 


plete the dressing, which is not renewed until the following day. 

The Carrel tubes projecting beyond the margin of the binder 
serve for the periodic instillation of Dakin’s solution. An im- 
portant question for decision is the frequency and amount of 
solution to be injected into the cavity. Let us consider for a 
moment the objects sought. The amount of pus produced in a 
cavity such as that under consideration, may be 250 c.c. per day, 
or even more. This secretion militates against the antiseptic 
action of the hypochlorite which must be introduced in amounts 
adequate to cope with the constant discharge into the cavity of 
this reactive exudate. In practice, it has been found that at 
least 100 e.c. of Dakin’s solution should be instilled at hourly 
intervals during the day and not less frequently than every two 
hours at night. If there be more than one Carrel tube, the total 
amount injected is equally divided among them. The return 
through the drainage tube is caught in the dressings, which may 
become wet through, but do not as a rule have to be renewed. 
It is important to push the application of hypochlorite at the 
very beginning of antiseptic treatment, because it is at this time 
that the secretions destroying its activity are most abundant. 
Trivial amounts of hypochlorite accomplish little if anything 
towards an improvement in conditions. Irritation of the skin 
need not be feared, particularly if the instillation of hypochlorite 
is made slowly, for the overflow into the dressings will contain 
little or no active chlorine. 

For ascertaining the progress of disinfection, bacteriological 
examinations are of great importance; for a complete under- 
standing is essential. Poured plates made with plain agar, to 
which about 7 per cent. of defibrinated blood has been added, 
give the most satisfactory information, as has been already 
pointed out. Where there are a number of cases under treat- 
ment, the most convenient method is the following: 

The requisite number of Petri dishes to correspond with the 
number of cases, each receives 5 or 6 drops of a sterile 2 per cent. 
solution of sodium thiosulphate. A loopful of secretion taken 
directly from the cavity is washed off in this antidotal solution 
within the dishes, which immediately stops further antiseptic 


176 HARVEY SOCIETY 


action. The plates are then taken to the laboratory, and the 
melted blood-agar, at a temperature not exceeding 45° C., is 
poured into each dish and the whole well mixed by agitating 
and inclining the plate from side to side with a rotary motion 
before the medium solidifies. The plates are then incubated in 
the inverted position until the next day. The wire loop used 
to collect samples of secretion should always be the same and 
the loop can conveniently have a diameter of about 2 millimetres. 
This loop should be completely filled with the secretion each time 
a sample is taken. By this means, a fair degree of uniformity in 
the amount taken for each examination is secured. The following 
day, the total number of colonies, the number of colonies of the 
hemolytic streptococcus, and those of any other species it is 
desired to record, are counted. When the hemolytic strepto- 
coceus is very abundant, the number of colonies on the plate will 
be so great that the crowding brings about an inhibition of 
growth. The individual colonies are very minute, often invisible 
to the naked eye, but all the blood will be hemolyzed. Such 
plates often lead to an erroneous impression that they are sterile. 
Examination under the microscope with a low power reveals 
a multitude of tiny colonies, not infrequently a hundred or more 
to the microscopic field. These may be counted under the micro- 
scope, the numbers per field being noted on different parts of 
the plate and the average taken. This number is then multiplied 
by a factor representing the ratio between the area of the field 
and that of the plate and the resulting figure is an approximation 
of the total number on the plate sufficiently accurate for prac- 
tical purposes.* 

These bacteriological examinations should be made twice 
weekly, until a sterile plate is obtained, then at more frequent 
intervals, as will be presently made clear, until no evidence of 


1The ratio mentioned may be calculated with the aid of a hemocyto- 
meter slide, the smaller squares having a side of .05 mm, The number of 
such squares included in the diameter of the microscopic field is multi- 
plied by .05. Half of this squared and multiplied by 3.1416 (a) gives 
the area of the field in square millimetres. The area of the plate (about 
6400 square mm. for a dish 9 cm. in diameter) divided by the area of the 
field gives the factor sought. 


APPLICATION OF ANTISEPTICS 177 


infection has been detected for a week, when the chances of 
recurrence are so small that the risk of closure may be reason- 
ably incurred. 

The first clinical sign of progress in disinfection is the aboli- 
tion of foul odors. The quantity of pus then becomes progres- 
sively less, until little, if any, appears either in the return flow 
on irrigation or upon the dressings. 

It is usual at autopsies to find the empyemie cavities in un- 
treated cases lined with a fibrino-purulent deposit of consider- 
able thickness overlying a thickened pleura. In the early stages 
of disinfection, this deposit appears to be but little affected, the 
action of the hypochlorite being expended upon the fluids with 
which it comes into more immediate contact. But when the 
secretions have become markedly reduced in amount, some pro- 
portion of the hypochlorite introduced into the cavity reacts 
with the fibrin and the process of dissolution begins. The charac- 
ter of the secretion collecting on the dressings then changes. In 
place of the purulent stain, a glairy material resulting from the 
action of hypochlorite on proteins collects on the dressings, and 
this may continue for forty-eight hours. With the appearance of 
this form of secreton, but usually more pronounced shortly after 
it has ceased, the lung shows greater freedom of expansion, the 
irrigating fluid is clear from the beginning, and, on coughing, 
may show slight streaks of discoloration due to blood pigment 
modified in color by action of the hypochlorite. At this period, 
plate cultures usually remain sterile or show less than 100 
colonies, usually of hemolytic streptococci, which are generally 
the last to disappear. These successive phenomena appear to indi- 
cate the chemical removal of the fibrinous deposit and thinning 
of the dense cicatricial tissue forming the outer part of the 
thickened pleura and to mark the completion of the cleansing 
action of the Dakin’s solution. There is now much less secretion 
to react with the hypochlorite and the amounts instilled may 
be reduced. 

The assumption that the fibrinous coat and thickened pleura 
are uniform throughout the cavity and equally acted upon by 
the Dakin’s solution in all parts is not warranted, and it is 

12 


178 HARVEY, SOCIETY 


advisable to continue this treatment with reduced quantities 
for a short time. But there is good reason to believe that over- 
prolonged treatment with sodium hypochlorite delays convales- 
cence by retarding the development of healthy granulations, 2.e., 
the productive processes by which adhesions between the vis- 
ceral and parietal pleural surfaces finally bring about oblitera- 
tion of the cavity. 

When the hypochlorite has wrought this cleansing of the 
cavity, it is well, therefore, to cease its use and to continue anti- 
sepsis with a solution of chloramine-T, which has a much less 
injurious action upon the animal cells. For this purpose a 0.5 
per cent. solution in physiological saline is appropriate, the same 
procedures of irrigation and periodical instillation through 
Carrel tubes being employed. 

In eases infected with the hemolytic streptococcus, this is 
usually the last species of bacterium to disappear under antiseptic 
treatment. It appears, also, more important to eradicate this 
species than any other commonly met with; for the immunity 
acquired by the tissues and fluids of the body to cope with 
minimal infections of this character, appears to be very slight. 

Before closing the wound by operation or allowing it to close 
spontaneously, it is wise to intermit treatments for a day or two, 
applying only sterile dressings, and then to test the contents of 
the cavity by plate culture to insure the absence of hemolytic 
streptococci. In the interval, there is a chance for any strepto- 
cocci still lingering where they have access to the cavity to multi- 
ply and thus reveal their presence. 

The foregoing mode of treatment cannot be earried out with 
this thoroughness in the presence of a pleuro-bronchial com- 
munication. In such eases it is of great importance not to dis- 
tend the empyemie cavity, as this tends to make the pulmonary 
opening more patent. The importance of free drainage is more 
emphatic than in other cases, since effective irrigation is pre- 
eluded. It is usually found, however, that in some position 
taken by the patient, usually the sitting posture, small quantities 
of Dakin’s solution can be introduced into the cavity without 
bronchial irritation exciting coughing. In this position small 


APPLICATION OF ANTISEPTICS 179 


quantities (perhaps only 5 e.c.) should be instilled at hourly 
intervals, to be gradually increased in amount from day to day. 
It is often surprising to note a gradual development of tolerance 
which finally permits full treatment as with other cases. It 
would appear that in many eases a cleansing of the parts adja- 
cent to the pulmonary opening takes place, with a healing which 
abolishes this complication. In one ease treated with dichlora- 
mine-T, 5 per cent. dissolved in chloreosane, a communication 
with a bronchus was accidentally discovered. Severe coughing 
followed the introduction of the oil and the patient spat chlorco- 
sane at intervals for a period of about four hours. Treatment 
was suspended for a couple of days and then cautiously resumed. 
No further trouble ensued. The communication had closed after 
this single unintentionally vigorous antiseptic application. 

As already pointed out, caution must be exercised, not to allow 
the thoracic wound to close until reasonably convineed that the 
cavity is sterile. It frequently happens that the bacterial count 
falls below a hundred within ten days or a fortnight, but persists 
at a low level for many days without material change. Such an 
occurrence gives warning that for some reason the antiseptic 
applications are ineffective and the presumption will be, in every 
case, that there is some focus of infection not readily accessible to 
the antiseptic applications. It may be a small side pocket with a 
narrow opening into the main cavity, through which small quanti- 
ties of infected secretions are discharged but the instilled hypo- 
chlorite fails to gain entrance. Occasionally this opening will 
suddenly enlarge and a purulent discharge take place from the 
thoracic opening, after which disinfection to complete sterility 
assumes a normal course. In other cases the source of the 
contaminating organisms will prove to be a necrosed and infected 
rib or a foreign body in the crevices or meshes of which the 
organisms find protection and a chance to multiply. Where the 
antiseptic procedure fails to follow a progressive course to actual 
sterility, the adventitious cause must be sought and removed. 

After a time the thoracic wound is prone to close down upon 
the inserted tubes, forming a sinus in which these fit so closely 
that they prevent access of antiseptic solutions to the walls of 


180 HARVEY SOCIETY 


the opening. Often after the secretions within the cavity are 
sterile, the walls of the sinus harbor large numbers of bacteria. 
These may be reached by applications of dichloramine-T in 
chlorcosane applied before the introduction of the tubes, or with 
gauze impregnated with chloramine-T. Very frequently the 
organisms present in this situation are harmless saprophytes. 
In all cases, cultures from the sinus should be made as soon as 
this question becomes of clinical importance. Where a rib 
resection has been practiced, hemolytic streptococci may be pres- 
ent in the secretions from an osteomyelitis. Unless removed, 
these are liable to reinfect the pleural cavity. 

It must be obvious from all of the foregoing that earnest 
antiseptic treatment once begun must be unremittingly carried 
on until sterility is attained. The cases must receive individual 
study, and any remission in the procedures is liable to open the 
way for a reversion to the original condition. On the other hand, 
intensive and persistent devotion to necessary details offer the 
reward of a relatively brief convalescence, with a minimal subse- 
quent disability. 


THE PSYCHOLOGICAL EXAMINATION OF 
THE SOLDIER* 


By MAJOR ROBERT M. YERKES 


ENTLEMEN: Asa representative of a science which is still 
in its infaney, I am highly honored by this opportunity to 
address the Harvey Society. For your invitation to speak on 
‘‘The Psychological Examination of the Soldier,’’ I am deeply 
grateful because it enables me to bring to you a message con- 
cerning the practical relations of psychology to medicine. 
Although I know little concerning your art, I am at home with 
you in the medical sciences. It is my earnest hope that what 
I shall say to-night, on the basis of academic, clinical, and mili- 
tary experience, may help to forge a durable and mutually 
profitable bond between psychology and medicine. 

I invite your attention, Members of the Harvey Society, Ladies 
and Gentlemen, to a discourse whose plan comprehends the follow- 
ing related topics: (a) Enumeration of the several lines of psycho- | 
logical military service; (6) an historical sketch of psychological 
examining in the army; (c) a description of army methods of 
mental testing; (d) a summary of results of army psychological 
examining; (e) the exhibition of some of the chief applications 
and practical values of these results; (f) suggestions for the 
utilization of similar methods in education and industry; and (g) 
finally, as the conclusion to which all has tended, a discussion of 
the desirable relations of psychology to medicine. 

The human factors in most practical situations have been 
largely neglected because of our consciousness of ignorance and 


* Delivered January 25, 1919. Published with the approval of the 
Surgeon General of the Army, from the Section of Psychology of the Medi- 
cal Department. For the factual materials, as contrasted with the opin- 
ions, of this lecture, I am indebted to the efficient, loyal and enthusiastic 
psychological personnel which carried army mental testing to success. 


181 


182 HARVEY SOCIETY 


inability to control them. Whereas engineers deal constantly 
with physical problems of quality, capacity, stress and strain, they 
have tended to think of problems of human conduct and experi- 
ence either as unsolved or as insoluble. At the same time there has 
existed a growing consciousness of the practical significance of 
these human factors and of the importance of such systematic 
research as shall extend our knowledge of them and increase 
our directive power. 

The great war from which we are now emerging into a civiliza- 
tion which is in many respects new has already worked marvelous 
changes in our points of view, our expectations and practical de- 
mands. Relatively early in this supreme struggle it became clear 
to certain individuals that the proper utilization of man power, 
and more particularly of mind or brain power, would assure ulti- 
mate victory. The war demanded of us the speedy mobilization 
of our military machine and in addition the organization and 
training of an immense new and supplementary armed force, 
the manufacture of ordnance and munitions of war in well-nigh 
unimaginable quantities, the construction of ships, motor trans- 
ports, and of varieties of rolling stock in vast numbers. All this 
had to be done in the least possible time. Never before in the 
history of civilization was brain, as contrasted with brawn, so 
important; never before, the proper placement and utilization of 
brain power so essential to success. 

Our War Department, nerved to exceptional risks by the stern 
necessity for early victory, saw and immediately seized its oppor- 
tunity to develop various new lines of personnel work. Among 
these is numbered the psychological service. Great will be our 
good fortune if the lesson in human engineering which the war 
has taught is carried over directly and effectively into our eivil 
institutions and activities. 

Searcely had war been declared by our country before the 
psychologists were brought together in a plan to make their 
professional knowledge, technic, and experience useful in the 
emergency. In April, 1917, the American Psychological Asso- 
ciation appointed numerous committees to study the situation 
and prepare for action. At the same time a Psychology Com- 


PSYCHOLOGICAL EXAMINATION 183 


mittee was organized by the National Research Council. Thus 
it happened that from the outset American psychologists acted 
unitedly, whereas their professional colleagues in France and 
Great Britain served individually wherever they could discover 
opportunity. The Psychology Committee of the National Re- 
search Council has continued active over a period of nearly two 
years. Almost all of the psychological contributions which the 
United States has made to the war are either directly or indirectly 
due to the efforts or the support of this body, the work of which 
has been carried on through conferences, subcommittees, or mili- 
tary appointees in the army and the navy. 

In order that the psychological examining of the soldier may 
be seen in its proper setting, the various chiefly significant 
lines of psychological service will be enumerated and 
briefly characterized. 

Under the Adjutant General, the Committee on Classification 
of Personnel in the Army, which was originally organized by a 
group of psychologists who were at the time serving as members 
of the Psychology Committee of the National Research Council 
or of committees of the American Psychological Association for 
the furtherance of the military service, developed and introduced 
throughout the army methods of classifying and assigning en- 
listed men in accordance with occupational and educational 
qualifications and also methods of rating officers for appointment 
and promotion. The services of this committee, to the work of 
which the War Department dedicated nearly a million dollars, 
ultimately touched, and more or less profoundly modified, almost 
every important aspect of military personnel work. 

To the Signal Corps, and subsequently to the Division of 
Military Aeronautics, psychological service was rendered in 
connection with measurement of the effects of high altitude and 
also in the selection and placement of men. Numerous important 
methods, new or adapted, were introduced in this service by 
groups of psychologists whose primary concern was improved 
placement and the proper utilization and protection of the flyer. 

The Psychology Committee promoted effectively interest in 
measures for the control and improvement of both military and 


184 HARVEY SOCIETY 


civilian morale. The interest and persistent activity of its mem- 
bers ultimately resulted in the organization of a Morale Branch 
within the General Staff of the Army. At various times as many 
as twenty-five officers and enlisted men trained in military 
psychology have been engaged in the conduct of practical 
morale work. 

For the Division of Military Intelligence psychological 
methods have been devised or adapted to assist in the selection, 
placement, and effective training of scouts and observers, and 
in addition service of minor importance has been rendered in 
numerous training camps. 

In response to requests from the Chemical Warfare Service, 
psychological problems presented by the gas mask have been 
studied and the major recommendations resulting from these 
psychological investigations have been embodied in the latest 
improved form of mask. 

The psychological problems either partially or completely 
solved for the navy are comprehended in the proper selection, 
placement, and training of gunners, listeners, and lookouts. 
Numerous situations were carefully analyzed for the navy, and 
methods and mechanical devices which have achieved extensive 
application and appreciation were developed. 

Within the Medical Department of the Army a Division of 
Psychology was organized for the administration of mental 
tests to enlisted men and commissioned officers in accordance with 
plans perfected during the summer of 1917. The history of this 
work will be briefly told as an introduction to the account of 
methods and results which is to constitute the body of this lecture. 

The chief purpose of the psychological assistance, originally 
offered to the Medical Department, was the prompt elimination 
of recruits whose grade of intelligence is too low for satisfactory 
service. It was believed by psychologists assembled in confer- 
ence that their profession is better prepared technically and 
by practical experience to measure intelligence than are members 
of the medical profession and that psychologists therefore should 
be able in the military emergency to render invaluable assistance 
to army medical officers by supplying reliable measures of intelli- 


PSYCHOLOGICAL EXAMINATION 185 


gence which might be used as basis for rejection or discharge. 
It was thought that thus the efficiency of the service might be 
considerably increased and the costs materially diminished. As 
it happens, the purposes of this service as actually developed 
differ radically from that originally proposed; moreover, they 
serve to identify this work even more closely with the personnel 
work of the Adjutant General’s Office and of the General Staff 
than with anything in the Medical Department of the Army 
aside from neuro-psychiatrie work. 

To meet the prospective need of psychological assistance a 
committee of seven experts in practical mental measurement was 
organized in the summer of 1917 and called together for the 
preparation or selection of suitable methods. This group of men 
worked almost continuously for a month, devising, selecting, and 
adapting methods. Another month was spent in thoroughly 
testing the methods in military stations in order that their 
value might be definitely established before they should be 
recommended to the Medical Department of the Army. The 
results were gratifying and the methods were therefore recom- 
mended to the Surgeon General of the Army in August, 1917, and 
promptly accepted for official trial. During October and Novem- 
ber they were applied in four cantonments under conditions 
which could scarcely have been more unfavorable but with results 
which led the official medical inspector to formulate the following 
statements and recommendations: 

‘‘The purposes of psychological testing are (a) to aid in 
segregating the mentally incompetent; (b) to classify men accord- 
ing to their mental capacity; (c) to assist in selecting competent 
men for responsible positions. 

‘‘In the opinion of this office these reports (accompanying 
recommendation) indicate very definitely that the desired results 
have been achieved. 

‘‘ The success of this work in a large series of observations, 
some five thousand officers and eighty thousand men, makes it 
reasonably certain that similar results may be expected if the 
system be extended to include the entire enlisted and drafted 

personnel and all newly appointed officers. 


186 HARVEY SOCIETY 


‘‘In view of these considerations, I recomend that all com- 
pany officers, all candidates for officers’ training camps, and all 
drafted and enlisted men be required to take the prescribed 
psychological tests.’’ 

In January, 1918, this new work of the Medical Department 
was extended in accordance with the above recommendation. 
Subsequently, adverse criticisms and misunderstandings caused 
delays and obstruction of the work which virtually destroyed its 
value during weeks which should have been filled with the most 
fruitful labor. It cannot be forgotten that these weeks were 
wasted in the most trying of struggles for the existence and 
continuation of this service. 

The methods originally prepared for army use were subjected 
to repeated revisions, in the light of results, for increase in relia- 
bility and military value. The procedure finally adopted and 
used throughout the army consists of two chief types of exam- 
ination, the group examination and the individual examination. 
The former was necessitated by the demand for speed of exam- 
ination and reporting, the latter by the desire for reliability and 
fairness to the individual. 

Of group examinations there are two varieties used in the 
army; the one for men who ean read and write English fairly 
well (literates), known as Alpha; the other for men who are 
unable to read and write English well (illiterates), known as 
Beta. The individual examination includes three varieties devel- 
oped as were the group examinations to suit different types of 
subjects. They are: (1) The Point Seale examination; (2) the 
Stanford-Binet examination; and (3) the Performance Scale 
examination. Both the Point Seale and the Stanford-Binet are 
used in the army in three forms: (a) As complete seales, for 
literate subjects; (b) as abbreviated scales, for literate subjects ; 
(c) as specially adapted scales, for relatively illiterate subjects. 
These two types of examination, the Point Seale and Stanford- 
Binet, are used as alternates, the examiner selecting in accordance 
with his preference. 

For the examination of foreign and illiterate men who ean 
neither read nor write English and of whom many speak and 


PSYCHOLOGICAL EXAMINATION 187 


understand it very imperfectly, the special form of examination 
known as the Performance Scale, has been developed and is 
effectively used. 

Examination Alpha consists of eight tests, describable by title 
as follows: Test 1, Directions or commands test; Test 2, Arithmeti- 
cal problems; Test 3, Practical judgment; Test 4, Synonym- 
antonym; Test 5, Disarranged sentences; Test 6, Number series 
completion; Test 7, Analogies; Test 8, General information. 

With this method men are examined in groups as large as five 
hundred. Every man is supplied with a pencil and an examina- 
tion blank. He then, under military discipline, follows direc- 
tions to the best of his ability. The examination requires approxi- 
mately fifty minutes. It demands almost no writing, since 
responses are indicated by underscoring, crossing out, or check- 
ing. The examination papers are quickly scored by means of 
stencils, and mental ratings recorded for prompt report. To 
avoid, within reasonable limits, the risk of coaching, several 
duplicate forms of this examination have been made available. 

Each test of Examination Alpha consists of a number of parts 
arranged in order of difficulty from low to high. It is therefore 
possible for low-grade subjects to make a start on each test, and, 
at the same time, practically impossible for highly intelligent 
subjects to complete the tests within the time allowed. The tests 
are varied in character and undoubtedly sample the most import- 
ant types of intellectual process. 

Examination Beta consists of seven tests, listed thus by title: 
Test 1, the Maze test; Test 2, Cube analysis; Test 3, the X—O 
series; Test 4, Digit-symbol; Test 5, Number checking; Test 6, 
Pictorial completion; Test 7, Geometrical construction. This 
examination which was devised, after Alpha had been put into 
use, to meet an unexpected demand for the examination of sub- 
jects of low literacy and extreme unfamiliarity with English, is 
in effect, although not in strictness test for test, Alpha trans- 
lated into pictorial form so that pantomime and demonstration 
may be substituted for written and oral directions. Beta may 
be given successfully to men who neither speak nor under- 
stand English. 


188 HARVEY SOCIETY 


Examinations Alpha and Beta are so constructed and ad- 
ministered as to minimize the handicap of men who, because of 
foreign birth or lack of education, are little skilled in the use 
of English. These group examinations were originally intended 
and are now definitely known to measure native intellectual abil- 
ity. They are to some extent influenced by educational acquire- 
ment, but in the main the soldier’s inborn intelligence and not 
the accidents of environment determines his mental rating or 
grade in the army. 

Like Alpha, Examination Beta requires about fifty minutes 
and the papers are scored by the use of stencils. 

Both Alpha and Beta yield numerical scores or intelligence 
ratings which for practical military purposes are translated into 
letter grades. The several letter grades used in the army, with 
their score equivalents, and appropriate definitions are presented 
in the following table: 


Intelligence Definition Score (Alpha) Score (Beta) 
Grade 

A Very Superior 135-212 100-118 
B Superior 105-134 90-— 99 
C+ High Average 75-104 80- 89 
C Average 45- 74 65- 79 
C— Low Average 25- 44 45- 34 
D Inferior 15- 24 20- 44 
D— Very Inferior 0- 14 o- 19 


E grade was reserved for men who were recommended for 
rejection, discharge, development battalion, or service organiza- 
tion. All men deemed satisfactory for regular military duty 
were graded D- or higher. 

Neither the Point Seale’ nor the Stanford-Binet Scale * 
need be described in detail, since both are widely known and 
adequate descriptions are available. The military adaptations 
of the scales may prove useful in various civil situations, but it 
is not feasible within the limits of this lecture to describe these 

1See “Point Scale for Measuring Mental Ability,” by Yerkes, Bridges 
and Hardwick; Warwick & York, Baltimore. 


2 See “The Measurement of Intelligence,” by L. M. Terman; Houghton, 
Mifflin Company, Boston. 


PSYCHOLOGICAL EXAMINATION 189 


modifications of the methods or to present standards of judgment 
which have been secured and used to increase military efficiency. 
It is true, however, that the several procedures of individual 
examining have played a most important role in the military 
service and that the examiner who lacks familiarity with them 
and reasonable skill in their application and the interpretation 
of their results is ill-prepared for psychological military service. 

The army Performance Scale cannot be adequately described 
by reference, since it is in the main a product of military experi- 
ence and effort. It consists of ten tests, the titles of which 
fairly well suggest their nature: Test 1, the Ship test; Test 2, 
Manikin and feature profile; Test 3, Cube imitation; Test 4, 
Cube construction; Test 5, Formboard; Test 6, Designs; Test 7, 
Digit-symbol ; Test 8, Maze; Test 9, Picture arrangement; Test 10, 
Picture completion. 

As in the case of group examinations Alpha and Beta, so also 
in that of the several forms of individual examination, numerical 
ratings for subjects were secured which could be translated into 
letter grades. 

The general procedure of examining which was developed to 
meet military requirements is briefly describable as follows: 
A group of draftees, the size of which is determined by the seating 
capacity of examining rooms (it varies from one hundred to 
five hundred men), is reported to the psychological examining 
building for mental test. The first essential step is the segre- 
gation of the illiterates. This is accomplished by having all 
men who cannot read and write their own letters and those who 
have not proceeded beyond the fifth grade in school step out of the 
original group. The remaining men are sent to the Alpha room. 
Naturally, among them there are likely to be several who will 
subsequently have to go to the Beta examination. The illiterates 
are sent direct to the Beta room. 

Men who fail in Alpha are sent to Beta in order that injustice 
by reason of relative unfamiliarity with English may be avoided. 
Men who fail in Beta are referred for individual examination by 
means of what appears to be the most suitable and altogether 
appropriate procedure among the varied methods available. This 


190 HARVEY SOCIETY 


reference for careful individual examination is yet another 
attempt to avoid injustice either by reason of linguistic handicap 
or accidents incident to group examining. 

It is to be emphasized that the interests of the individual who 
is elther in the army or in the process of being accepted for 
military service are safeguarded by a system of three types of 
examination which serve as sieves. Every soldier is required 
to take at least one examination. Men who are of low mentality, 
those who are of foreign birth, or for other reasons illiterate, and 
those who exhibit marked peculiarities of behavior, may be 
required to take either two or three examinations before psycho- 
logical report can be completed. 

Despite the necessity for haste, which in some instances com- 
pelled small examining staffs to grade and report on as many as 
two thousand soldiers per day, the army mental test work has 
been done with an average thoroughness and degree of relia- 
bility which would do credit to any school system or other 
civil institution. 

When psychological examining was originally accepted by the 
Medical Department for official trial, there was extreme and 
widely prevalent skepticism even among psychologists themselves 
concerning the reliability of the measurements of intelligence 
which could be secured and still more concerning their practical 
value to the army. The measures of reliability or validity of 
army methods of mental measurement which have been obtained 
during the past eighteen months are therefore quite as important 
as partial basis for safe opinion concerning the significance of 
this service as are the evidences of practical value which have 
accumulated. Effort will be made to present, as adequately as 
is possible within brief compass in this lecture, samples of both 
kinds of measure. First, let us consider reliability. 

For examination Alpha the probable error of the score is 
approximately 5 points. This is one-eighth of the standard 
deviation of the seore distribution for unselected soldiers. The 
reliability coefficient is approximately .95. Alpha yields ecorre- 
lations with other measures of intelligence as follows: (1) With 
officers’ ratings of their men, .50 to .70; (2) with Stanford-Binet 


PSYCHOLOGICAL EXAMINATION 191 


measurements, .80 to .90; (3) with Trabue B and C completion 
tests combined, .72; (4) with Examination Beta, .80; (5) with 
composite of Alpha; Beta, and Stanford-Binet, .94; (6) in the 
ease of school children Alpha measurements correlate with (a) 
teachers’ ratings .67 to .82, (b) school marks .50 to .60, (c) school 
erade location of thirteen- and fourteen-year-old pupils .75 to .91, 
(d) age of pupils .83." 

Results for Examination Beta correlate with Alpha, .80; 
with Stanford-Binet, .73; with composite of Alpha, Beta, and 
Stanford-Binet, .915. 

Results of repetition of the Stanford-Binet examination in 
ease of school children correlate .94 to .97. The abbreviated form 
of the Stanford-Binet scale consisting of only two tests per year, 
extensively used in the army, correlates .92 with results for 
the entire scale. 

Reliability coefficients for results of Point Scale examination 
closely approximate those for the Stanford-Binet scale. 

The several tests of the Performance Scale correlate with 
Stanford-Binet measurements, .48 to .78. Five of the ten tests of 
the Performance Scale yield a total score which correlates .84 
with Stanford-Binet results. 

It is definitely established that Examination Alpha measures 
literate men very satisfactorily, considering the time required, 
for mental ages above eleven years. Examination Beta is some- 
what less accurate than Alpha for the higher ranges of intelli- 
gence. There are convincing evidences that some men are not 
fairly measured by either Alpha or Beta and that the provision 
of careful individual examination for men who fail in Beta is 
therefore of extreme importance. 

A brief statistical summary of psychological examining in the 
army with be presented at this point as an introduction to the 
discussion of military applications and evidences of practi- 
eal value. 

After preliminary trial in four cantonments psychological 
examining was extended by the War Department to the entire 


‘Chiefly because of the relatively narrow age range, the correlation of 
Alpha score with age of recruits is practically zero. 


192 HARVEY SOCIETY 


army, excepting only field and general officers. To supply the 
requisite personnel, a school for training in military psychology 
was established in the Medical Officers’ Training Camp, Fort 
Oglethorpe, Georgia. Approximately one hundred officers and 
more than three hundred enlisted men received training at 
this school. 

The work of mental examining was organized finally in 
thirty-five army training camps. A grand total of 1,726,000 men 
had been given psychological examination prior to January 1, 
1919. Of this number, about 41,000 were commissioned officers. 
More than 83,000 of %*he enlisted men included in the total had 
been given individual examination in addition to the group 
examination for literates, for illiterates, or both. 

Between April 27 and November 30, 1918, 7749 men (0.5 per 
cent.) were reported for discharge by psychological examiners 
beeause of mental inferiority. The recommendations for assign- 
ment to labor battalions, because of low-grade intelligence, num- 
ber 9871 (0.6+ per cent.). For assignment to development 
battalions, in order that they might be more carefully observed 
and given preliminary training to discover, if possible, ways 
of using them in the army, 9432 men (0.6+ per cent.) 
were recommended. 

During this same six-month interval there were reported 
4744 men with mental age below seven years; 7762 between seven 
and eight years; 14,566 between eight and nine years; 18,581 
between nine and ten years. This gives a total of 45,653 men 
under ten years mental age. It is extremely improbable that 
many of these individuals were worth what it cost the govern- 
ment to maintain, equip, and train them for military service. 

The psychological rating of a man was reported promptly 
to the personnel adjutant and to the company commander. In 
addition, all low-grade cases and men exhibiting peculiarities 
of behavior were reported also to the medical officer. The mental 
rating was thus made available for use in connection with rejec- 
tion or discharge, the assignment of men to organizations, and 
their selection for special tasks. The mental ratings were used 
in various ways by commanding officers to inerease the effi- 


PSYCHOLOGICAL EXAMINATION 193 


ciency of training and to strengthen organizations by im- 
proved placement. 

It was repeatedly stated and emphasized by psychological 
examiners that a man’s value to the service should not be judged 
by his intelligence alone, but that instead temperamental charac- 
teristics, reliability, ability to lead and to ‘‘earry on’’ under 
varied conditions should be taken into account. Even after the 
feasibility of securing a fairly reliable measure of every soldier’s 
intelligence or mental alertness had been demonstrated, it re- 


weeeem Enmistes Men (19792) —Recaticey Miterare 
qammmee Fuisrio Men (82936)=Lircrare 
nrsenserees Consoracs (4023) 

weme= Seaceants (3393) 

eeccccccecce OSTG: (9240) 

(8819) 


Bo ee ee Bn 


Fig. 1.—The distribution of intelligence ratings for typical army groups. The 
illiterate enlisted men were given group examination Beta. All others were given group 
examination Alpha, 


mained uncertain whether these measurements would correlate 
positively with military value to a sufficient degree to render 
them useful. Data which have become available during the past 
year settle this question definitely by indicating a relatively 
high correlation between officers’ Judgments of military value 
and the intelligence rating. 

The various figures which follow are presented not as a sum- 
mary of the results of psychological examining in the army, but 
as samples of these results, the chief value of which is to indicate 
their principal relationships and practical values. 

The sample distribution curves of Fig. 1 indicate the value of 

13 


194 HARVEY SOCIETY 


mental ratings for the identification and segregation of different 
kinds of military material. The illiterate group of this figure 
was examined by means of Beta, all other groups by means 
of Alpha. 

Comparison of various military groups, distinguished from one 
another by actual attainment in the service, shows that the psy- 
chological tests discriminate between these groups with definite- 
ness. This point may be illustrated by reference to the per- 
centages of men of different groups making A and B grades 
in Examination Alpha: Officers, 83.0 per cent. ; officers’ training 


A BC+C C- D 
Percent 
Success O.T-C. 
1375 
Men 
Percent 
Failure 


Fig. 2.—Relation of intelligence ratings to the success of students in officers’ 
training schools. 
school candidates, 73.2 per cent.; sergeants, 53.4 per cent.; cor- 
porals, 39.7 per cent.; literate privates, 18.8 per cent. The com- 
parison of measures of central tendency reveals equally striking 
differences. Moreover, within the officer group itself significant 
differences appear for different branches of the service. 

The relation of success or failure in officers’ training schools 
to intelligence ratings is exhibited by Fig. 2, in which it is to 
be noted that elimination through failure in the school increases 
rapidly for ratings below C+. Of men rating above C+, 8.65 
per cent. were eliminated; of those below C+, 52.27 per cent. 
The data for this figure were obtained from three schools with 
a total enrollment of 1375 men. 

Similarly, Fig. 3 shows the relation between success or failure 


PSYCHOLOGICAL EXAMINATION 195 


in non-commissioned officers’ training schools and intelligence 
ratings. The elimination increases rapidly for grades below C++. 
Of men rating above C, only 18.49 per cent. were eliminated ; 
of men rating below C, 62.41 per cent. The results presented 
in this figure were obtained from four schools with a total enroll- 
ment of 1458 men. 

Increasingly extensive and effective use has been made of the 
psychological rating as an aid in the selection of men for officers’ 
training schools, non-commissioned officers’ training schools, and 
other lines of training or service which require special ability. It 


A BC+C C-D D- 


N.C.O. 


1458 
Men 


Fig. 3.—Relation of intelligence ratings to success of students in non-commissioned 
officers’ training schools. 
has been convincingly demonstrated that the data of psychologi- 
cal examinations can readily be used to diminish necessary elimi- 
nation during training and thus to increase the efficiency of 
the schools. 

The extreme differences in the intellectual status of army 
groups are fairly indicated by Fig. 4, which presents the data 
for groups whose military importance cannot readily be over- 
emphasized. Roughly, the groups in the upper half of the figure 
are important because of their relatively high intelligence and 
the mental initiative demanded for success, whereas those in 
the lower half of the figure are important because of poor intelli- 
gence and relative inefficiency or uselessness. 

These results suggest that if military efficiency alone were to 


196 HARVEY SOCIETY 


be considered, the army would undoubtedly gain largely by 
rejecting all D- and E men. This procedure would greatly 
lessen the group of disciplinary cases so troublesome and costly 
in the military organization and also the group which in the 
figure is distributed among ‘‘ten poorest privates,’’ ‘‘men of 
low military value’’ and ‘‘unteachable men.’’ 


D,D--E C*,C,C- AaB 
COMMISSIONED OFFICERS 
> saa 


0. TS, STUDE NTS 
cS | 


“TER BEST’ PRIVATES 
2 (eee as] 


WHITE RECRUITS 


7299 


EC 
DISCIPLINARY CASES 

Pos te a] | 
“TEN POOREST” PRIVATES 
Le 


“MEN OF LOW MILITARY VALUE” 
— iO) Ct 


“UNTEACHABLE MEN” 
f mes Hancet 


Fig. 4.—Proportions of low, average, and high-grade men in various important 

army groups. 

Numerous varieties of evidence indicate the extreme military 
importance of the prompt recognition of low-grade men. The 
percentages of men ranking below the average in psychological 
examinations are notably large for the disciplinary group, men 
having difficulties in drill, men reported as ‘‘unteachable’’ and 
men designated by their officers as ‘‘poorest’’ from the stand- 
point of military usefulness. 


PSYCHOLOGICAL EXAMINATION 197 


The comparison of negro with white recruits reveals mark- 
edly lower mental ratings for the former. <A further significant 
difference based on geographic classification has been noted in 
that the Northern negroes are mentally much superior to 
the Southern. 

The relation between officers’ judgments of the value of their 
men and intelligence ratings is exhibited in somewhat different 
ways by Figs. 5 to 7. Thus the median scores for five groups of 


Officers’ 
Rating Median Score 


Very 
Poor 28 


Poor 
51 


Fair 
70 


Good 
vis) 


Best 
99 
Fig. 5.—Median intelligence scores for groups of soldiers designated as “ best,”’ 


“ good,’ ‘* fair,’ ‘‘ poor,’? and ‘‘ very poor,’’ with respect to military usefulness. The 
numbers in the figure represent median scores. 


? 


privates, arranged in order of military value from ‘‘very poor 
to ‘‘best,’’ are presented in Fig. 5. The total number of indi- 
viduals in the group is 374. The men were selected from twelve 
different companies, approximately thirty men in each company 
being ranked by an officer in serial order from ‘‘best’’ to 
‘poorest.’ The rank order for each company was then corre- 
lated by the psychological examiner with the rank order supplied 
by psychological examination. In seven of the twelve companies 
the correlations ranged from .64 to .75. The average correlation 
was .536. These correlations are high, considering the large 


198 HARVEY SOCIETY 


number of factors which may influence a man’s value to 
the service. 

The median score for the ‘‘very poor’’ group of Fig. 5 is 
28 points in an examination whose maximal score is 212 points. 
By contrast with this, the median score of the ‘‘best’’ group 
of privates is 99 points. 

The commanding officers of ten different organizations, repre- 
senting various arms of the service, in a certain camp were asked 
to designate (1) the most efficient men in their organizations, (2) 
the men of average ability, and (3) men so inferior that they are 
‘barely able’’ to perform their duties. 

The officers of these organizations had been with their men 
from six to twelve months and knew them exceptionally well. 
The total number of men rated was 965, about equally divided 
among ‘‘best,’’ ‘‘average,’’ and ‘‘poorest.’’ After the officers’ 
ratings had been made, the men were given the usual psychological 
test. Comparison of test results with officers’ ratings showed : 

(a) That the average score of the ‘“‘best’’ group was approxi- 
mately twice as high as the average score of the 
‘*noorest’’ group. 

(b) That of men testing below C-, 70 per cent. were classed 
as ‘‘poorest ’’ and only 4.4 per cent. as ‘‘best.”’ 

(c) That of men testing above C+, 15 per cent. were classed 
as ‘‘poorest’’ and 55.5 per cent. as ‘‘best.’’ 

(d) That the man who tests above C+ is about fourteen 
times as likely to be classed “‘best’’ as the man who tests 
below C-. 

(e) That the per cent. classed as ‘‘best’’ in the various groups 
increased steadily from 0 per cent. in D- to 57.7 per 
cent. in A, while the per cent. classed as ‘‘poorest’’ 
decreased steadily from 80 per cent. in D- to 11.5 
per cent. in A. 

In an infantry regiment of another camp were 765 men (regu- 
lars) who had been with their officers for several months. The 
company commanders were asked to rate these men as 1, 2, 3, 4, 
or 5 according to ‘‘practieal soldier value,’’ 1 being highest and 
5 lowest. The men were then tested, with the following results: 


PSYCHOLOGICAL EXAMINATION 199 


(a) Of 76 men who earned the grade A or B, none was rated 
‘¢5’? and only 9 were rated ‘‘3’’ or ‘‘4.’’ 

(b) Of 238 ‘‘D”’ and ‘‘D—”’ men, only one received the 
rating ‘‘1,’’ and only 7 received a rating of ‘‘2.’’ 

(c) Psychological ratings and ratings of company com- 
manders were identical in 49.5 per cent. of all cases. 
There was agreement within one step in 88.4 per cent. 
of cases, and disagreement of more than two steps in 
only .7 per cent. of cases. 

Fig. 6 exhibits a striking contrast in the intelligence status 

and distribution of ‘‘best’’ and ‘‘poorest’”’ privates. The per- 


40 
Ten Best Privates umes 


vs. 


Ten Poorest Privates.xcc 


Per Cent 
N 
° 


Gating OS DiC a Cl Ga vaInTAG 

Fig. 6.—Distribution of intelligence ratings of ‘‘ best’? (———————) and “ poorest’”’ 
CERAE sFheves ance ) privates. The ‘‘ best ’’ numbered 606; the “ poorest,’”’ 582. 
sonal judgment data for this figure were obtained from sixty 
company commanders who were requested to designate their ten 
“‘best’’ and their ten ‘‘poorest’’ privates. Of the ‘‘poorest,”’ 
57.5 per cent. graded D or D-; less than 3 per cent. graded 
A or B. The results suggest that intelligence is likely to prove 
the most important single factor in determining a man’s value to 
the military service. 

In one training camp excellent opportunity was offered to 
compare a group of soldiers selected on the basis of low military 
value with a complete draft quota. In the ‘‘low value’’ group 
there were 147 men, in the complete draft quota 12,341 men. 


200 HARVEY SOCIETY 


The distribution of intelligence ratings for these two military 
groups appears as Fig. 7, from which it is clear that if all men 
with intelligence ratings below C— had been eliminated, the ‘‘low- 
value’’ group would have been reduced by at least half. 

In a certain training camp 221 inapt soldiers, belonging to a 


Rating D- D C- Cc C* B A 


lig. 7.—Distribution of intelligence ratings for men of low military value (.......... ), 
as compared with that of a complete draft quota (——————_). 


negro regiment of Pioneer Infantry, were referred by their 
commanding officer for special psychological examination. Nearly 
one-half (109) of these men were found to have mental ages of 
seven years or less. The army nevertheless had been attempting 
to train these men for military service. In justice to the Psycho- 


PSYCHOLOGICAL EXAMINATION 201 


logical Service, it should be stated that these negroes had been 
transferred from camps where there were no psychological exam- 
iners. For this reason they had not been examined before being 
assigned to an organization for regular training. 

In another instance some 306 soldiers from organizations 
about to be sent overseas were designated by their commanding 
officers as unfit for foreign service. They were referred for 
psychological examination with the result that 90 per cent. were 


ComanyABCDEF CHI K L MMCieto 


o/o 


15 
ILLITERATE 
OR 


FOREIGN 


Fig. 8.—Inequality of companies in an infantry regiment with respect to intellectual 
strength. The upper line of figures indicates the percentage of men in the respective 
companies who attained grades of A or B. The lower line similarly indicates the per- 
centage of illiterate or foreign individuals in the several companies. 


discovered to be ten years or less in mental age, and 80 per cent. 
nine years or less. 

It has been discovered that when soldiers are assigned to 
training units without regard to intelligence, extreme inequalities 
in the mental strength of companies and regiments appear. This 
fact is strikingly exhibited by Figs. 8 and 9, of which the former 
shows the proportions of high grade and of illiterate or foreign 
soldiers in the various companies of an infantry regiment. Com- 
pare, for example, the intelligence status of C and E companies. 


202 HARVEY SOCIETY 


The former happens to have received only 3 per cent. of A and B 
men along with 38 per cent. of illiterates and foreigners; the 
latter received by contrast 29 per cent. of high-grade men 
with only 9 per cent. of men who are, as a rule, difficult to train. 
It is needless to attempt to emphasize the military importance 
of this condition. The tasks of the officers of these two com- 
panies are wholly incomparable, but more serious even than the 
inequalities in response to training are the risks of weak points 
in the army chain as a result of such random or unintelli- 
gent assignment. 

Naturally enough the officers of the army were quick to 


37 36 39 RO 4 = 
Inf Ine Inf INF A FA F. 


Fig. 9.—Inequality of regiments with respect to mental strength. The upper line 
of agar indicates the percentage of men rated as A or B. The lower line of figures 
similarly indicates the percentage of illiterate or foreign individuals in each regiment. 


appreciate the disadvantages of a method of assigning recruits 
which permits such extreme inequalities in mental strength to 
appear and persist. They promptly demanded the reorganiza- 
tion of improperly constituted units and assignment in accord- 
ance with intelligence specifications so that the danger of weak 
links in the chain and of extreme difference in rapidity of train- 
ing should be minimized. 

That serious inequalities existed in regiments as well as in 
smaller units prior to assignment on the basis of intelligence is 
proved by the data of Fig. 9, which pictures the differences 


PSYCHOLOGICAL EXAMINATION 203 


found in four infantry regiments and three regiments of 
field artillery. 

Following the demonstration of the value of psychological 
ratings in connection with assignment, the experiment was tried 
in various training camps of classifying men in accordance with 
intelligence for facilitation of training. To this end A and B 
grade men were placed in one training group, C++, C, and C- 
men in another, and D and D- men in a third. The three groups 
were then instructed and drilled in accordance with their ability 
to learn. Thus delay in the progress of high-grade men was 
avoided and the low-grade soldiers were given special instruction 
in accordance with their needs and capacity. 

The marked differences in the mental strength of groups in 
different officers’ training schools are shown by Fig. 10. For 
the eighteen schools of this figure, the proportion of A grades 
varies from 16.6 per cent. to 62.4 per cent.; the proportion of 
A and B grades combined, from 48.9 per cent. to 93.6 per cent., 
and the proportion of grades below C-+-, from 0 to 17.9 per cent. 
Since it is unusual for a man with an intelligence rating below 
C-- to make a satisfactory record in an officers’ training school, 
it is clear that the pedagogic treatment of these several student 
groups should differ more or less radically and that elimination 
must vary through a wide range if the several schools are to 
graduate equally satisfactory groups of officers. 

Far more important than the contrast in student officers’ 
training groups noted above are the differences in the intelli- 
gence status of officers in different arms of the service as re- 
vealed by psychological examining. Fig. 11 exhibits the data 
obtained for several groups. The variations are extreme and 
seemingly unrelated to the requirements of the service. Medical 
officers, for example, show a relatively large percentage of men 
rating C+ or below,’ whereas engineering officers head the list 
with relatively few men whose intelligence is rated below B. 


+The facts indicate the desirability of more careful scientific selection 
of applicants for admission to medical schools. 


904 
Lewis 


Sheridan 
Devens 
Funston 
Taylor 
Sherman 
Dodge 
Kearny 
Meade 
Grant 
Custer 
Cody 
Travis 
Bowie 
Pike 
Jackson 
Shelby 
Wheeler 


Below C+ =m C+ 


HARVEY SOCIETY 


ERI PA VES Bs a 


—i‘(as eT Pr 


(“Gs FF 


se ee 


_—i‘(a“‘(aé‘éiWA TO ee 


ka — 4 


IS) iii 
OM ccc 
| rT Ts 


2 WA 


HME a rr 


oo HT 


ANUS A 


Aa4B 


Fig. 10.—Difference appearing in the distribution of intelligence ratings in eighteen 


officers’ training schools, fourth series. 


(Total enrollment, 9240.) 


PSYCHOLOGICAL EXAMINATION 205 


There is no obvious reason for assuming that the military duties 
of the engineer demand higher intelligence or more mental alert- 
ness than do those of the medical officer. Since it is improbable 
that any arm of the service possesses more intelligence than can 
be used to advantage, the necessary inference is that certain arms 


OFFICERS’ GRADES 


BNOQneel.  Wostin we ey 
Preid (Art) )( Ge ee 
Field Signal 
Machine Gun 
Infantry 
Medical 

Q. M. C. 
Dental 


Veterinary ae 


Below C+ C+ AangB CO 


Fig. 11.—The distribution of intelligence ratings for officers of different arms of the service. 


__—sC./ 2S 


__.i(#$E HFSS PE eae 
| | 7777 ST Tes 
Mi a as a a a 
Ly C(‘i‘i‘ir 


Oi TR 


would benefit by the elimination of low-grade men and the substi- 
tution of officers with better intellectual ability. 

The principal results of psychological examining in the army 
have been sampled and the more important of their applications 
to the military situation have been indicated. It remains for us 
summarily to appraise this work and to inquire concerning its 
principal relations to prospective scientific, educational, and 
industrial developments. 


206 HARVEY SOCIETY 


By way of appraisal of values, it may safely be said that the 
development of successful procedures for group examining and 
the convincing demonstration of the practicability of mental 
measurement in connection with placement are the conspicuously 
important contributions of psychological service to the army. 
It is generally admitted by those who have taken the trouble to 
consider the matter, that the methods prepared to meet military 
needs have wide applicability and possibility of indefinitely 
increasing value. Within the army, experienced officers as well 
as men new to the service, recognize that the utilization of mental 
ratings has increased efficiency by improving placement and 
facilitating elimination. Psychological service has suddenly 
created a large demand for technological work. This demand 
is most insistent from education and industry, although the 
sciences also are making their needs known. Before the war 
mental engineering was a dream; to-day it exists, and its effec- 
tive development is amply assured. From leaders in our school 
systems, from administrative officers and teachers in colleges and 
professional schools, and from specialists in educational psychol- 
ogy come requests for permission to use the army mental tests. 
It is the hope of many of these men that mental ratings, as soon 
as it is made possible to secure them conveniently and reliably, 
may be used in our public schools as partial basis for grading, 
promotion, and vocational advice and that they may prove valu- 
able also in institutions of higher learning as partial basis for 
admission, classification, grading, promotion, assignment to special 
work, and vocational guidanee. Such applications of mental 
measurement would, it is true, radically change our educational 
system, for at present mental achievement, the extent of infor- 
mation or the lack of it, is virtually the sole basis for admission, 
classification, and promotion. Mental measurement of school 
pupils, college and professional students indicates extreme dif- 
ferences in mental ability throughout the educational range as 
well as important differences in mental constitution. These 
facts must be taken into account if educational procedure is to 


PSYCHOLOGICAL EXAMINATION 207 


benefit the individual in highest degree. It therefore is pro- 
posed that children should be classified in accordance with men- 
tal ability either as they enter school or shortly thereafter, and 
that mental ability should subsequently be taken into account in 
connection with their educational treatment. 

The following plan is offered as a means of utilizing 
mental ratings in the interests alike of education and of voca- 
tional placement. 

On the basis of reliable mental ratings, children should be 


Common Courses Diverse Courses 


(A) High 


(B) Med. Industrial 


(C) Low 


| Montal Classification and Educational Plan 


Fig. 12.—Diagram of a scheme of mental classification in relation to differentiation of 
educational treatment. 


classified in one of three intellectual groups, which may be 
designated by the letters A, B, and C. Group A would consist 
of children of superior intelligence; group C, of children possess- 
ing relatively inferior intelligence; and group B, of those of 
intermediate grade. The three groups would not necessarily be 
of equal size. 

Mental classification having been effected, educational treat- 
ment should be adapted to the needs and possibilities of the indi- 
vidual. To this end the following facts must be recognized: (1) 
That both rate of educational progress and limit of educability 
are conditioned chiefly by degree of native or inborn mental 
ability; (2) that range of vocational choice varies directly with 


208 HARVEY SOCIETY 


mental ability. The diagram which is presented as Fig. 12 indi- 
cates a seemingly feasible way of adapting educational procedure 
to these facts. It assumes that the children of a given grade 
will be classified in three sections, which shall be taught either in 
the same classroom or in different rooms. Each section shall be 
permitted and required to progress in accordance with its mental 
ability ; thus Section A might readily pass through the grades at 
twice the speed of Section C. 

Up ‘to a certain point in their educational development these 
three sections can profitably follow the same course of instruc- 
tion. This point, as indicated in the diagram, is the completion 
of the fifth grade of elementary school. By the time this stage 
of educational development has been achieved, many individuals 
of the C section will exhibit difficulties in learning and diminu- 
tion of interest, both of which, as a rule, indicate approach to 
the limit of one particular sort of educability. In recognition 
of the fact that there is a limit to the educability of every living 
being, the diagram indicates after the fifth grade divergence of 
the courses followed by the three sections. The A grade pupils 
may profitably continue, if they have the will, their primarily 
intellectual course of training toward those vocations or pro- 
fessions which require high-grade intelligence and excellent edu- 
cational training. The middle-grade individuals may more profit- 
ably follow a course in preparation for highly skilled industrial 
vocations or those lines of professional work which make less 
exacting educational and intellectual requirements than do the 
learned professions, so called. Pupils of grade C should, by 
contrast, follow a manual training course as a means of continuing 
their intellectual development to its limit and simultaneously 
fitting themselves for the most appropriate type of voca- 
tional activity. 

Mental classification and educational treatment in accordance 
with this plan, although seemingly undemocratic, is quite the 
reverse. While boasting of equality of opportunity in our 
national life and particularly in our educational system, we are, 
as a matter of fact, seriously discriminating against individuals 
because of our failure to take their characteristics and needs into 


PSYCHOLOGICAL EXAMINATION 209 


account. Equality of opportunity in our schools necessitates 
classification in accordance with ability, individualized treatment, 
recognition of limitations and of practical limits of educability, 


OCCUPATION S NO.CASES #BETA 


ENG OFFS Tae A GTO, 0 675 

MED OFFS 
37 ACCOUNTANTSE: 
38b BOOKKEEPERS E 

ARMY NURSES Bia =e 
38g CLERKS E 
1Qg, ELECTRICIANS HEE 
Sit TELEGRAPHERSE 2 
18s STOCKKEEPERS REx 412 3.4 
24¢ AUTO REPAIRMENGEEE a 1249 86 
6g MACHINISTS ii i251 14.9 


14p PLUMBERS 270170 
23t TRUCK DRIVERS 1019 13.0 
7%, BLACKSMITHS SSU 26 
8s CARPENTERS @ 792170 
40: COOKS 435 285 
45 BARBERS SA7en 

27h HORSE HOSLRS LOZ e282 
12¢ MINERS S 652502 
3. LABORERS El Rese M7 1453 324 

D- 2 BA 


Fig. 13.—Relation of intelligence ratings to occupation in the United States Army. 
The last column of figures (right) indicates the percentage of individuals in each cecupa- 


tion who were given the examination for illiterates. 


differentiation of courses, and vocational direction and training 
which shall enable the individual to avoid failure by reason of 
undertaking the impossible or waste because of the choice of 


an occupation which makes slight demand upon his ability. 
14 


210 HARVEY SOCIETY 


The relation of intelligence to occupation, as studied in the 
army, is of very obvious importance for education and for indus- 
try. Fig. 13 presents the proportions of the three chief groups 
of intelligence ratings for a number of army occupations. The 
data are not comparable with those which would be obtained 
from civilian groups because of various selectional factors which 
appear in the army. 

In order of diminishing intelligence the occupational groups 
represented may be classified thus: Professions, clerical, occu- 
pations, trades, partially skilled labor, and unskilled labor. 
The greatest differences in intelligence required or exhib- 
ited by different occupations appear at the ends of the scale, 
whereas differences in the trained group are relatively slight. 
These differences in range of intelligence for the various occu- 
pations are considerable and probably significant. The range in 
general diminishes from unskilled labor to the intellectually 
difficult professions for the obvious reason that whereas any 
individual may attempt tasks which require relatively little 
intelligence or education, only able individuals can succeed in the 
learned professions. It is well worthy of remark that, whereas 
the group of army laborers contains few individuals of high-grade 
intelligence (A or B ratings), the group of engineering officers 
contains very few except high-grade individuals. 

Fig. 14 presents the relation of intelligence to occupation for 
a similar group of army occupations, but in quite different man- 
ner. The median intelligence grade for each occupation is indi- 
cated by a vertical cross-bar. 

The data sampled by Figs. 13 and 14 suggest both the possi- 
bility and desirability of securing intelligence specifications for 
use in education and industry. Such specifications, if satisfae- 
torily prepared, should greatly assist teachers in advising and 
directing pupils in accordance, for example, with some such 
plan of educational organization as has been suggested in this 
lecture. They should also prove of value in connection with 
industrial placement. 

Within the industrial sphere, as contrasted with the educa- 
tional, intelligent employment management requires abundant 


PSYCHOLOGICAL EXAMINATION 211 


= Cane C+ 


Laborer . - -« ee 
Ga Gen. miner - - —— 

Teamster 2 6 6 6 

BArDOT 6 eee 5 ete 


C+ 


HOT SOSHOCT oo cee 
Bricklayer 6 6 

COOK ow ee 
BakOT oo 6 6 6 0. + ete 
PQANtOr 6 5 oe 6 ee 
Gen. blacksmith ._ ————_+—_____—— 
Gen. carpenter . - ————— 
Butcher . 6 2 2 6 5 ns 
Gen. machinist SEE EE ERE 
Hand riveter 5. 0c See EENIEEEnENT 
Tel.& tel.lineman. .« ————“—- 
Gen. pipefitter ... Se Ee 
Plumber . 6 6 0 6 5 ee 
Tool and gauge maker. ————|+-—__— 
Gunsmith 2 6 eo 6 6 eo mf 
Gen. Me@Chanic oo 5 cm} 
Gen. auto repALrMan oo 
Auto engine mechanic » 6 ———}———____— 
Autc assembler . 6 6 6 6 ———— 
Ship carpenter 2. 6 6 6 fe 
Telephone Operator 2 so 6 6 mpm 


Concrete const.foreman ————— 
Stock-keeper ». - + 6 « + —— 
Photographer © 2 6 6 + mentees 
Telegrapher - +. ++ +s s ea 

Re Re CLOT 6 ee ooo ow + ett 
Piling clerk «6 6 0 6 6 © 6 © een} 
Gen. clerk. . - 
Army nurse . + -+++se-ee+-e+e es wee 
Bookkeeper ss ee 6 + 6 6 6 6 + nf 


Dental officer 2 2 6 6 ee ee ee 
Mechanical draftsman . + « «+ ——$—— 
Acoountant . 6 6 6 6 6 6 6 6 8 ooo 
Civil engineer . . a 
Medical officer se 6 5 6 6 ee 8 8 =o meen 


A { Engineer officer Page ere TE gy eC 
D-= D C= C Clee A 


Fig. 14.—Relation of intelligence ratings to occupations in the United States Army. 
The heavy bar for each occupation indicates the range of intelligence ratings for the 
middle 50 per cent. of individuals rated. The vertical cross-bar marks the position of the 
median rating. The typical occupations exhibited by this figure constitute five groups 
which are designated A, B, C+, C, and C-, in accordance with the position of the median. 


212 HARVEY SOCIETY 


information and the development and use of scientific methods. 
Individuals, if hired and placed at random, seldom hold their 
jobs for more than a few weeks. The enormous labor turn-over 
of many industrial concerns is due chiefly to three causes: (a) 
The relative unfitness (by nature or training) of the individual 
for the work assigned; (b) unsatisfactory conditions of labor, and 
(c) the mechanization and the resulting dehumanizing of indus- 
trial process. 

For wise and effective industrial placement and occupational 
guidance, two things at least are absolutely essential: First, 
definite knowledge of the physical and mental requirements 
(specification) of the job, and second, equally definite knowledge 
of the physical and mental characteristics and capacities of the 
individual to be placed. 

If these requirements are to be met satisfactorily, occupations 
will have to be carefully analyzed in their relations to the indi- 
vidual and for each specifications will have to be prepared. In 
addition, individuals will have to be classified in accordance with 
intelligence, temperament, education, and occupational taste or 
preference. It is now possible to prepare specifications and to 
classify individuals suitably with reference to intelligence, edu- 
cation, and occupational taste. 

For the present at least it is probable that if three grades of 
intellect were distinguished in industry, as has been suggested 
for the school, a very great gain would be made in degree of 
fitness of the individual for his task, his resulting content 
and efficiency. 

Concerning temperamental measurement and classification, 
there is little to say, for methods at once simple and reliable are 
not yet available. It is nevertheless obvious that temperament 
is as important as intelligence for industrial placement and voeca- 
tional guidance. Despite the seemingly infinite variety of tem- 
perament, there are probably just a few classes which have great 
occupational importance. It is possible, indeed, that even three 
classes, as in the ease of intelligence, might suffice for immediate 
practical requirements, could we but devise methods of measuring 


PSYCHOLOGICAL EXAMINATION 213 


temperamental characteristics as satisfactorily as those now used 
for measuring intelligence. 

The relations of psychology to medicine could nowhere be 
more appropriately considered than in a lecture before the Harvey 
Society. The subject is not threadbare, and it has the additional 
advantage of timeliness in view of the association of the 
psychological with the neuro-psychiatrie service in the United 
States Army. 

Without further preamble it may be stated that a thesis is 
to be defended, namely, that psychology, like physiology, should 
be made a basic medical science. It is not such at present. Only 
a few medical men, and among them, fortunately, some of the 
ablest of the profession, accept the thesis as it has been stated. 

We may proceed to our consideration of the subject by way 
of preliminary definitions of our major terms. Psychology shall 
mean for us the science of behavior and experience, whose varied 
applications in mental engineering constitute the art of con- 
trolling human behavior. The science, as we conceive it, differs 
as markedly from what is popularly known as psychology as does 
modern chemistry from alehemy. Medicine we may define as the 
art of preventing or curing diseases and the corresponding com- 
posite science of health and disease. 

If the above definitions be accepted, it is necessarily true, first, 
that psychology is intimately and importantly related to medi- 
cine because it deals with a body of facts which are of fundamental 
importance to medical students and practitioners, and further, 
because it develops and uses methods and scientific instruments 
which should be invaluable to the medical profession; and sec- 
ond, that it has equally important relations to education, indus- 
try, the various other professions, and to both the physical and 
the biological sciences. 

Assuming the acceptance of these facts of relationship and 
dependence, it is suggested that the following pedagogical or 
instructional situation should be created: (1) A _ thorough- 
going experimental training course in general psychology or 
preferably the science of human action should be required of 
pre-medical students. The course should be informational, 


214 HARVEY SOCIETY 


although planned primarily for training in scientific method and 
to appreciation of the facts and principles of the science of 
human nature. 

It is freely admitted that psychologists who are wholly com- 
petent to give such a course are difficult to find. It is also true 
that an entirely satisfactory course in psychology for pre-medical 
students has not been developed. Given the demand, however, on 
the part of our medical schools, psychology will develop both 
personnel and courses. 

In the medical school, psychology should be taught either as 
a branch of physiology or as an allied subject. The laboratory 
methods should be used and every medical student should be 
acquainted with and drilled in the principal methods of mental 
measurement while acquiring those psychological facts which are 
of greatest importance for his profession. 

Special courses in psychology or lectures in allied subjects 
should meet the needs for instruction and practical experience 
in connection with psychopathology or abnormal psychology, 
clinical psychology, and psycho-therapy. 

The ideal situation would be one in which psychology would 
bear the same relation to the other medical sciences and to medi- 
eal practice that physiology, bacteriology, and anatomy now bear. 
There is, on the one hand, no obvious reason for attempting to 
dissociate psychological aspects of medicine from the whole or, 
on the other, to attempt to identify psychology with medicine and 
to claim for the latter science all of its methods and practical 
results. It would seem entirely reasonable to maintain that 
experts in psychopathology, clinical psychology, and psycho- 
therapy should be thoroughly trained in medicine as well as in 
psychology, but this is far enough from assuming that all psychol- 
ogists who make mental measurements for practical purposes 
should be doctors of medicine or have been trained even in a 
preliminary way in the medical sciences. Instead, we desire to 
emphasize the fact that quite independent of medical relations 
or requirements, the expert in psychological measurement or the 
consulting psychologist is about to take his place beside the 
medical consultant in our schools and our factories. The pres- 


PSYCHOLOGICAL EXAMINATION 215 


tige of the medical profession, even more insistently than the 
suecess of this new type of service, demands that the physician 
should recognize the distinctive province and the services of the 
consulting psychologist in accordance with their scientific and 
practical significance. The fact is that, along with mental engi- 
neering, the consulting psychologist has necessarily arrived. It 
is for the medical profession to decide whether it shall systemati- 
cally develop the medical aspects of mental engineering or whether 
by neglecting them it shall practically compel psychologists to 
give them attention. 

This lecture is in effect as well as intent a plea for the imme- 
diate recognition and use of modern psychology as a basic 
medical science. 


THE HUMAN MACHINE IN THE FACTORY * 


DR. FREDERIC S. LEE 
Columbia University and the U. 8. Public Health Service 


O every student of current events it must be obvious that 

labor presents to-day one of the most serious and difficult 
of all social problems. It is a problem that has long existed 
and has many aspects. From any one of these aspects its con- 
sideration may be approached profitably, and from almost every 
one of them its solution has been attempted; yet the problem 
remains. Human knowledge may become more abundant, human 
intelligence may become more keen, science may become more 
universally applied to human affairs, wars may come and wars 
may go, monarchies may give place to democracies ; but the prob- 
lem of labor we have ever with us and, as time goes on, it appears 
only to increase in intricacy and difficulty of solution. If we try 
to analyze it we see at once that two fundamental questions are 
involved: How much work ought the individual to do, and how 
much wage ought he to be paid? These two questions arise anew 
in almost every labor dispute. While I am not prepared to 
grant that it may not yet be necessary to call in the aid of the 
science of physiology before the question of wages is correctly 
answered, it is rather to a consideration of the extent to which 
it is legitimate to call upon the laborer to work, that I wish to 
call attention here. 

The views of employers and of workers as to the correct answer 
to this question are likely to be diametrically opposed—em- 
ployers demand more, workers less, work—and this difference 
has often led the two into sharp conflict, a conflict that has 
increased in intensity and led to inereased bitterness of feeling 
as time has passed. 

The first attempt, and indeed most of the attempts to put 
an end to the conflict and allay the feeling, proceeded from the 
; * Delivered March 1, 1919. | 

216 


HUMAN MACHINE IN THE FACTORY 217 


humanitarian standpoint. It was in 1784 that investigations by 
Dr. Thomas Percival, and others, of Manchester, drew attention to 
the monstrous over-work to which children were subjected in the 
British factories, investigations that led to definite action by 
the Manchester magistrates toward limiting the hours of chil- 
dren’s labor and later doubtless influenced Parliament to pass 
in 1802 the Health and Morals of Apprentices Act, which had 
been introduced by Sir Robert Peel. Thus was begun a long 
series of legislative measures to bring within reasonable limits the 
work of the working class. Economists have also pointed out 
the evils of over-work, and occasionally enlightened employers 
have on their own initiative introduced mitigations of working 
conditions. But all would-be reformers, whether employers, 
workers, philanthropists, economists or legislators, have builded 
on a basis of ignorance, and, while their combined efforts have 
accomplished much, the fundamental questions remain unan- 
swered and the conflict still continues. And it must ever con- 
tinue until we know more than we know now concerning the 
conditions under which work can best be performed. 

During the quarter century that ended with the beginning 
of the war there appeared here and there isolated, though 
exact, studies that prepared the way for what was to come— 
laboratory studies by Mosso and others on the physiology of 
fatigue, measurements by Mather, Abbe and Fromont of the 
effects of reducing the length of the working day, the analysis 
by Imbert of industrial operations through the application of 
physiological methods, and endeavors by Miinsterberg to deter- 
mine through the aid of psychological tests the fitness of workers 
for specific occupations. All these were signs of a growing 
recognition by men of science that there was need of the em- 
ployment of the methods of exact scientific inquiry in the field of 
industrial occupation, a need that was made still more evident 
by Josephine Goldmark’s sagacious summary of the situation in 
her ‘‘Fatigue and Efficieney,’’ published in 1912. 

Then came the war, with its intensive demands upon industry 
to make more, and still more, munitions, demands which indus- 
try patriotically endeavored to meet by frantic efforts. Discern- 


218 HARVEY SOCIETY 


ing men and women perceived that these efforts, however praise- 
worthy in intention, were often ill-judged and often tended to 
defeat their own ends and that science must lend her aid in 
supplying the information by which industry might be properly 
directed. In England a preliminary inquiry into some of the 
physiological conditions of factory work from the economic 
standpoint, conducted by the British Association for the Ad- 
vancement of Science, gave place to a more extensive investi- 
gation by the Health of Munition Workers Committee. In 
I’rance a similar project, contemplated by the Marey Institute, 
was laid aside for the time. In America the U. S. Public Health 
Service, aided by the Committees on Industrial Fatigue of the 
Council of National Defense and the National Research Council, 
inaugurated a project similar in general to that of England. 
The American and the English investigations were directed by 
intelligent, broad-minded men of science and government officials, 
and have achieved positive and valuable results. In America the 
work of the Publie Health Service is still continuing; in Eng- 
land the Health of Munition Workers Committee has been 
replaced by the Industrial Fatigue Research Board under 
Professor Sherrington, and an ambitious plan for further investi- 
gation is under consideration. Toward the end of the war the 
universities perceived the trend of events and began to make 
preparations for contributing to the general advance. Victoria 
University, Manchester, established a new Department of Indus- 
trial Administration and called to its chair Professor Stanley 
Kent, one of the tried investigators of the physiological aspects 
of occupational work. At Johns Hopkins University the new 
School of Industrial Hygiene contemplates under Professor 
Howell the study of physiological topics in industry. At Har- 
vard these topies will be made prominent in the newly established 
courses for the training of industrial physicians. Other univer- 
sities are not inactive. 

In all this we perceive the birth and rapid growth of a science 
of industrial physiology, whose sphere is the industrial oceupa- 
tions of the human machine, and which by supplying exact infor- 
mation in place of opinion, sentiment, passion and prejudice is 


HUMAN MACHINE IN THE FACTORY 219 


destined, I believe, to contribute valuable aid to the ultimate 
solution of the vexing problem of labor. 

It is pertinent for the Harvey Society to give a place on its 
program to this new topic, and I welcome the opportunity to 
lay before you some of the newly acquired knowledge. I shall 
speak first of the methods that have been used in acquiring 
the data and then of the two topics: How the human 
machine actually works in the factory, and how it may be made 
more efficient. 


I. METHODS OF STUDYING THE HUMAN MACHINE 


In studying the human industrial machine endeavor has been 
made to employ, so far as possible, the methods of all exact 
science and to secure quantitatively measured data. The impor- 
tance of this cannot be too strongly emphasized. Psychological 
tests have been used comparatively little, but there is doubtless 
a large field for them here. Of the various technical physiologi- 
eal tests I will mention only two, since they have been found 
the most valuable of all the objective tests that have so far been 
introduced. These are the spring balance strength test of 
Martin, and the vascular skin reaction test of Ryan. 

The spring balance strength test, which was devised originally 
for determining the return of power in muscles paralyzed in 
poliomyelitis, consists in measuring in pounds the force that is 
required to overcome the contraction of certain selected groups of 
the subject’s muscles and computing from the figures thus 
obtained the total strength of the individual. It is found that 
the strength of most men factory operatives varies roughly from 
3000 to 5000 pounds, while the strength of women averages much 
less, say from 1500 to 3000 pounds. A diminution in strength, 
indicative of fatigue, is often found at the end of a day’s work. 

The vascular skin reaction test consists in making by a blunt 
instrument a stroke on the skin of the forearm, thus driving 
the blood from the capillaries, and then measuring in seconds 
the time that is required for the resulting dermographie streak 
to reach its maximum of whiteness. This time is shorter 
in fatigue. 


220 HARVEY SOCIETY 


One of the most common and most fruitful methods consists 
in measuring the output of the individual worker for a given 
period, such as each successive hour of the day. This is com- 
paratively simple in so-called repetitive operations, where the 
individual’s task consists of the constant repetition of a simple act. 

A fairly correct estimate of the output of the whole factory 
or one of its divisions may often be made from the measurement, 
not of the output of individual workers, but of the electrical or 
other power that is used by the machinery. 

In specific cases it has been found profitable to analyze the 
worker’s movements into their component elements. This has 
been done by means of tambours by Imbert and Amar, by the 
cinematographic method by Amar, Gilbreth and the Marey Insti- 
tute, and by electric connection between the work bench and 
signals recording on a drum by Ryan and Florence under the 
U. S. Public Health Service. 

In specific cases the medical examination of workers has 
been resorted to in order to determine their physical condition 
and the presence or absence of chronic fatigue. The results of 
factory tests and measurements are at times elucidated, too, by 
inquiries into the worker’s occupations outside the factory. 

While these are the chief methods that have been used so far, 
there is need for others, and suggestions of methods are always 
to be welcomed that will satisfy the requirements of exactness 
and ready applicability to factory workers, without arousing 
their suspicions of unfairness. As an instance of a method that 
is inexact and therefore not to be commended, I might mention 
the studies that are now being made on the results of reducing 
working hours in several industries ‘by the National Industrial 
Conference Board, an association of American manufacturers. 
Instead of making exact measurements of output before and after 
the reduction in time the Board bases its conclusions on the 
opinions of the employers, opinions that were obtained by the 
inexact method of the questionnaire with all its pitfalls. Con- 
clusions based on data obtained by such means are always to be 
viewed with suspicion. I speak of the need of the ready applica- 
bility of any test to workers because of their disinclination to 


HUMAN MACHINE IN THE FACTORY 221 


submit to tests that require long absence from their daily wage- 
earning occupation. An instance of the danger of arousing the 
suspicions of workers is afforded by the rumor that was cireu- 
lated among the operatives of a certain factory that was being 
investigated by the Public Health Service to the effect that the 
introduction of the spring balance test was for the purpose of 
determining the fitness of the workers for military service. 


Il. HOW THE HUMAN MACHINE WORKS 


1. The Diurnal Course of Work 


The diurnal course of work, as determined by output, varies 
with individuals, with the nature of the work, with the length 
of the working period, and with the part of the twenty-four 
hours, whether day or night, in which the work is performed. 
The investigators of the Public Health Service have been making 
a considerable study of this subject, measuring output for each 
successive hour of the working period, and their data may best 
be presented in the form of graphic curves, which, while alike in 
certain main qualitative features, present quantitative differ- 
ences varying with the conditions of the work. Where the indi- 
vidual works honestly and naturally, without artificial limitation 
of his output, the main features of the diurnal course for each 
spell are the following: Following the output of the first hour 
there is usually an increase in production, which may reach a 
maximum in the second, third, or sometimes even as late as the 
fourth, hour, and is followed by a decrease. The corresponding 
graphic curve thus shows at first a rise and then a fall. The 
rise is usually ascribed to the effect of practice, the fall in part 
to the effect of fatigue, although it is probable that each of these 
features will be ultimately capable of further analysis. Be- 
tween the two spells occurs the luncheon period, which is charac- 
terized physiologically by two antagonistic features: On the 
one hand there come to the worker rest and food, both acting 
to restore working power and thus to establish the proper con- 
ditions for subsequent increase in production; and, on the other 
hand, practice ceases during the luncheon period, a condition 


222 HARVEY SOCIETY 


of decrease in production. According to the dominance of the 
one or the other of these antagonistic influences there may be 
either a temporary improvement or a temporary impairment of 
the productive power, indicated graphically by a heightened or 
a lowered curve at the beginning of the second spell. During 
the second spell the practice rise is usually less pronounced than 
during the first spell, and there is a greater fall, indicating in 
part at least the cumulative fatigue of the day. Our investigators 
have made a tentative classification of the factory operations that 
have been studied, into four groups, namely, the dexterous, 
muscular, lathe-machine, and miscellaneous machine type of work, 
the names of which are self-explanatory, and each type presents 
an output curve that is characterized by certain distinctive 
features. The dexterous type is marked by a, moderate practice 
effect, a late appearance of the maximum, a lack of recovery after 
the luncheon period, and a late postponement of the effect of 
fatigue. The muscular type is characterized by a less pronounced 
practice effect, an early maximum followed by fatigue, recovery 
after luncheon, and a very marked fatigue effect during the 
second spell; the two falls in the curve are sometimes broken 
each by a slight rise, indicating a spurt on the part of the 
worker. The lathe machine work is characterized by an un- 
usually low early production, and a pronounced practice effect 
during the first, and a general maintenance of production during 
the second, spell. The output curves of the miscellaneous 
machine types of work appear to be less distinctive than the others. 

Sharply contrasted with the course of production during the 
day is that of the night. This has been studied in one prominent 
and reputable munition factory which maintains, as is not un- 
common, a ten-hour day, and a twelve-hour night, shift. Here 
the striking features of the curve are the unevenness of produc- 
tion, as compared with that of the same operation in the day 
shift, and especially an extraordinary fall during the last two 
hours, which in some eases reaches zero forty minutes before 
the end of the final hour. The time required for a certain specific 
operation for the four suecesive three-hour periods of the night 
was found to be 12, 13.3, 16.5, and 17.4 seconds, a slowing of 


HUMAN MACHINE IN THE FACTORY —§ 223 


nearly 50 per cent., while a count made during the final three 
hours showed 43 per cent. of a gang of seventy-four men asleep 
at some period. Night workers at the same plant were found 
to be muscularly weaker, by 500 pounds, than day workers, but 
whether this was a result of their work is not determined. All 
these facts, brought to light by the American observers, testify 
to the less efficiency of night, as contrasted with day, work, and 
this is confirmed by observations made under the British Com- 
mittee, which reveal that with approximately equal working 
times night workers produce from 6 to 17 per cent. less than 
day workers. 

I have spoken of the fall in the diurnal curve of output as 
indicative of fatigue, but the American observers have felt that 
more objective evidence than that of output was needed before a 
correct conclusion as to the existence of fatigue was possible. 
In an endeavor to secure such evidence they have used the 
strength and the vascular skin reaction tests, and have found 
both valuable in revealing a parallelism between their respective 
showings and output. The strength test shows, first, that on days 
when strength is high, output tends to be high; and secondly, 
that there is frequently a definite measurable falling-off in 
strength coincident with the day’s work, an effect that is more 
pronounced with the hard jobs and the weaker workers, than with 
the easy jobs and the strong workers. The skin reaction also 
reveals fatigue for both the forenoon and the afternoon work, 
the cumulative fatigue of the day, and a greater fatigue with a 
greater output. 


2. The Self-linitation of Work 


All investigators of the work of the human machine observe 
one baneful feature of it, which unfortunately is very common 
in the factories. It would hardly seem necessary to emphasize 
that one of the fundamental conditions of industrial efficiency 
is that workers should do their best; in other words, that the 
human machine when working should approximate its capacity 
for work; and yet deliberate limitation of output, ‘‘soldiering,’’ 
or as the American investigators have called it, ‘‘stereotyping’’ 


224 HARVEY SOCIETY 


of output, is extremely common and is indeed one of the tra- 
ditional ways of labor. The American observers found it preva- 
lent in more than half of the departments of one of our pro- 
gressive factories. For example, in one of the many operations 
on shell fuses one man finished exactly 1000 pieces on each of 44 
out of 45 nights observed; in another operation each of sixteen 
different workers, night after night, for one week, turned out 
3600 pieces, no more and no less. If the operator’s machine were 
stopped for a brief period and the working time were thus 
shortened, the operator speeded up for the remaining time and 
finished the day’s work with the usual production to his credit. 
I cannot here go into a detailed discussion of the causation of 
stereotyping, which is probably complex, but I may merely say 
that the main factor appears to be found, not in the human 
machine itself, but in the far too common and unwise custom 
of employers, who reduce the piece rate when in their opinion 
the worker is earning too large wages. The worker therefore 
protects himself by restricting his output. It is a lamentable 
condition of labor. ‘‘Soldiering’’ not only complicates the work 
of the investigator enormously, but its existence in antagonistic 
to the organization of industry on the proper physiological basis. 
Physiological capacity should be the guide for achievement for 
both employers and workers. By physiological capacity I do not 
mean physiological exhaustion. One of the most important tasks 
of the industrial investigator is to determine the physiological 
capacities of individuals and the amount of work which each ean 
do and still maintain unimpaired his working power. 


3. Industrial Accidents 

The human machine, like other machines, experiences acci- 
dents, and this is another detriment to efficiency. By far the 
most of industrial accidents have a physiological origin, that is, 
they are due to something within the body of the worker, rather 
than occurrences outside his body. Industrial accidents have 
received considerable study from various investigators and both 
the Americans and the English have recently contributed to 
the subject. The American observers of the Public Health Service 


HUMAN MACHINE IN THE FACTORY = 225 


have secured the records covering some 40,000 accidents in two 
factories and are now engaged in making an analysis of the data. 
Accidents usually increase in number during the working spell 
and reach their maximum shortly before the close of work, 
the peak of the curve being followed by a sharp decline. The 
American observers emphasize the importance of tabulating the 
accident risk, by which is meant the ratio of accidents to output— 
while during much of the day the curve of accident risk runs 
fairly parallel to the curve of accidents, at times the two are 
far apart. Thus, in the final hours of the day’s work at the ten- 
hour plant, while there is a marked decline in both accidents and 
output, the accident risk shows an enormous increase. 

There exists considerable difference of opinion as to the rela- 
tive importance of various factors concerned in the causation of 
accidents. Fatigue appears to be one of the leading factors, 
and as one of its manifestations, probably less exact neuro- 
muscular codrdination. Speed of production also enters into 
causation. But a more exhaustive analysis of the physiological 
state of the worker at different stages of his work must be made 
before the subject of accidents is fully elucidated. An especially 
interesting fact has been discovered by the American observers. 
This is a very close parallelism in the monthly curves of accidents 
and the number of new hands employed—an indication of the 
part played by inexperience in accident causation. 


4. Labor Turnover 


This brings us to the consideration of another cause of ineffi- 
ciency, namely, the constant change in the personnel of the 
workers. It is obvious that no factory could be conducted 
economically if its machinery, once installed, were worked for a 
few days or weeks and then scrapped or replaced by other 
machinery. This applies with equal force to the human machines, 
and yet ‘‘labor turnover,’’ as it is called, is one of the prominent 
features of modern industry. It, too, has received much atten- 
tion from recent investigators. It has been estimated that the 
introduction of each new worker costs the employing company 
the sum of $52.92, and probably the most considerable item in 


15 


226 HARVEY SOCIETY 


this expense is the low output of the new hand. When, as is 
not uncommon, more than 50 per cent. of the working force of 
an establishment has to be replaced during the year, the total 
cost of the labor turnover surpasses all conceptions. 


Ill. HOW THE HUMAN MACHINE MAY BE MADE MORE EFFICIENT 


I have spoken so far of some of the ways in which the human 
machine in the factory works. Now let us consider how it may 
be made more efficient. 


1. Selection of Workers 


In the first place, the present empirical method of selecting 
workers and assigning them to their tasks, at best a costly pro- 
cedure, ought to be replaced by more scientific methods, in 
which the qualifications and capacities of the individuals may be 
learned before they are actually put to work. Here there is 
great need of investigation: First, a variety of typical operations 
should be studied and the human qualifications which they 
require for their proper performance should be determined ; 
and then proper tests should be devised for determining whether 
prospective workers possess the required qualifications. Here, 
Martin, under the Public Health Service, has made one important 
contribution. He has found that the workers in each specific 
factory operation approximate a certain standard of strength 
and that the standards differ with the different operations. 
If the spring balance method were introduced into the factories 
as a routine procedure in hiring new hands the economic disad- 
vantage of assigning the worker to the task to which his strength 
is not adapted, would be avoided. I am very hopeful that the 
psychologists will contribute important tests in the near future. 
notwithstanding the enthusiasm and the dreams of Miinsterberg 
as to the possibilities of vocational psychology, comparatively lit- 
tle has been achieved. Perhaps the advance, which is inevitable, 
will come along the lines that have been so successfully followed 
by Major Yerkes and his co-workers in the army. 

The problem of qualification is immediately acute in the 


HUMAN MACHINE IN THE FACTORY 227 


matter of women’s work. One of the most striking of all the 
industrial features of the war has been the increase in the em- 
ployment of women and the incursion of women into types of 
work heretofore limited to men. In France, England and Amer- 
ica the technical processes in the manufacture of munitions, 
largely a new industry, were performed to a large extent by 
women, and in the non-munition industries women replaced men 
in an amazing degree. A British report enumerates some 2000 
processes in which women were substituted for men, and these 
include such diverse procedures as turning and gauging shells, 
lathe working, correcting type, driving horse-vans and motor 
trucks, wheeling heavy barrows, stoking, butchering, clerking 
in shops and offices, carpentering, acting as railway porters, re- 
pairing railway carriages, tanning, digging and shoveling, earry- 
ing heavy steel bars in ship yards, ete. Women’s industrial possi- 
bilities have thus been shown, and yet to mention these occupations 
is not necessarily to commend them—what is permissible in an 
emergency may not be wise as a permanency. That women have 
overworked during the war seems to be demonstrated by an 
intelligent medical examination of some 2500 workers that has 
been conducted by Dr. Janet Campbell and her staff. They came 
to the conclusion that 42 per cent. of the workers examined were 
suffering from fatigue or ill-health. This means probably that 
many women undertook tasks for which they were not physi- 
eally fitted. 

We must accept the fact, I believe, that, just as men and 
women differ anatomically, so they differ physiologically and 
psychologically. The problem, therefore, is to discover, not the 
relative efficiencies of the two in industry in general, but the 
kinds of work for which each is best adapted. There are two 
ways by which this might be done: The empirical way, of trying 
women out and learning by experience, bitter if need be, what 
they are capable of doing efficiently ; and the more scientific way 
of determining their qualifications before assignment. Here 
physiology and psychology have already accomplished some- 
thing, but there is a vast field for further work. The matter is 
urgent, especially in England. Before I left London in Decem- 


228 HARVEY SOCIETY 


ber bands of women workers from the factories were marching 
up Whitehall to the government offices, fearing for their indus- 
trial future and demanding to be taken care of. 


2. Shortening Hours 


One way of increasing efficiency is to shorten working hours. 
Yet here we ought not to judge without careful quantitative data. 
While there is a considerable fund of evidence showing increased 
output with diminished working time, the nature of the operation 
is probably of considerable moment. The British observers report 
that reduction of the weekly working time in a ‘‘heavy’’ operation 
from 58.2 to 51.2 hours resulted in an increase of total output 
of 22 per cent.; reduction in a ‘‘moderately heavy’’ operation 
from 66.2 to 45.6 hours resulted in a 9 per cent. increase in total 
output; and reduction in a light machine operation from 64.9 
to 48.1 hours diminished total output by only 1 per cent. The 
financial loss from such a slight diminution as the last mentioned 
may easily be more than counterbalanced by a saving in over- 
head charges for the lessened time required to keep the factory 
in operation, while the workers may gain physiologically. <A 
recent and yet unpublished study by Vernon of the very exhaust- 
ing work of millmen in the manufacture of tinplate shows that 
their total output was 8.3 per cent. greater on 6-hour than on 
8-hour shifts. 

Such figures as these, and they are now being contributed 
from many directions, indicate that the greatest increase in 
output by shortening hours occurs in those operations in which 
the physiological factor, as distinguished from the machine fac- 
tor, is most pronounced. In other words, the output of a lifeless 
machine is directly proportional to the time during which it 
works—the longer the day the larger the output; with the living 
machine, within limits, the longer the day the smaller the output. 
With what duration of work the maximum output can be ob- 
tained, while at the same time the health and working power 
of the worker are maintained, probably varies greatly with the 
kind of work and the eapacity of the worker. The general 
tendency of accurate research is toward the 8-hour day and the 


—— 


HUMAN MACHINE IN THE FACTORY — 229 


44- to 48-hour week as the optimum for most operations and 
most workers. 

In this connection the comparative study of an 8-hour and a 
10-hour plant by the Public Health Service is interesting. The 
8-hour factory was engaged in the manufacture of automobiles; 
the 10-hour factory produced brass goods, and especially fuses for 
explosive shells. Because of the difference in the kind of work 
and the different personnel no conclusions as to comparative total 
outputs of the two plants were attempted. One of the most 
significant features of the comparison is the relatively steady 
maintenance of output during the day in the 8-hour plant, and in 
the 10-hour plant the variation from the maximum and especially 
the marked fall in the second spell. At the 8-hour plant there was 
a minimum of lost time; at the 10-hour lost time was abundant. 
At the 8-hour plant output seemed to vary with physiological 
capacity ; at the 10-hour plant stereotyping of output was widely 
prevalent. The accident risk was greater at the 10-hour than at 
the 8-hour plant, and this was associated with greater fatigue. 
Whether these findings are peculiar to the factories studied or are 
applicable to the 8-hour and 10-hour systems in general cannot 
now be said, but they are most suggestive. 

The Industrial Fatigue Research Board is now beginning a 
comprehensive comparative investigation of an 8-hour and a 
12-hour plant in the steel industry of Wales. Such studies must 
be multiplied and extended before the question of the length 
of the working day can be decided rationally. It appears prob- 
able that they will show that the 8-hour day is too long for cer- 
tain kinds of work and certain individuals, and too short for 
other kinds of work and other individuals, and hence that there 
is no rational universal working day. The universal institution 
of an 8-hour day would not end the discussion. A prominent 
labor leader announced in my hearing in a public meeting in this 
city a few years ago that as soon as this was achieved labor would 
proceed at once to attempt to secure a day of six hours. In Eng- 
land, Lord Leverhulme is already seriously advocating, on the 
grounds of lessened fatigue and increased total production, the 
introduction of the 6-hour day for the individual, with two 


230 HARVEY SOCIETY 


separate shifts for a total,day of twelve hours or, if still greater 
production is required, four shifts for twenty-four hours. 

Much of the current discussion of the subject is confused by 
the lack of a clear distinction between eight hours as a work 
day and eight hours as a pay day. Many workers who are clamor- 
ing for the shorter time are comparatively indifferent to the 
duration of the labor; they are willing to work more than eight 
hours provided they are paid relatively higher wages for the over- 
time. The extension of the 8-hour system to the railways merely 
establishes a basic day for payment and has practically nothing 
to do with the question of the duration of work. This is primarily 
a question for physiology to decide, and physiology ought to 
recognize here its opportunities and its obligations. 


3. Introducing Resting Periods 


The chief resting period in the day’s work is the luncheon 
period, and its desirability as affording an opportunity to recu- 
perate is supported by statistical data. The luncheon period 
eliminates fatigue, as is shown by the Ryan test, and arrests the 
downward course of production. British investigators unani- 
mously condemn, however, the common custom in their country of 
requiring work before breakfast and then a breakfast interrup- 
tion; and it is encouraging to see that, as the war progressed, 
more and more factories abolished this pernicious custom. En- 
deavors to determine with scientific exactness the influence of 
resting periods have related so far chiefly to their effect upon 
output. Here it is necessary to distinguish between the average 
output of the hour and the total output of the whole day. What- 
ever the effect of the introduction of a resting period may be on 
hourly output, if it does not diminish, or even increases, the total 
output it may be regarded as probably advantageous to both the 
employer and the worker; if it diminishes total output it may 
or may not be advantageous, and further investigation would 
then be needed. 

There exist many isolated instances of a striking improve- 
ment in production accompanying recess periods, and both the 
American and the English investigators have tried to study the 


HUMAN MACHINE IN THE FACTORY — 231 


problem carefully. These studies are not completed, and indeed 
the whole subject deserves much more extensive investigation ; 
but certain indications of the final results are interesting. In 
the majority of cases the break of a spell by a ten- or fifteen- 
minute recess appears to increase the average hourly output. 
Thus, Vernon under the British Health of Munition Workers 
Committee reports that the introduction of a quarter-hour break 
in the forenoon spell, together with the abolition of the interval 
for breakfast, increased the hourly output 5 per cent. The 
American observers have made a considerable number of obser- 
vations on the experimental introduction of a 10-minute resting 
period into each of the two spells of both an 8-hour and a 10-hour 
factory. The data secured at the 8-hour plant were fragmentary 
and indeterminate. At the 10-hour plant the hourly production 
was frequently increased. Moreover, while there was considerable 
variation among individuals, in all but one of the twelve opera- 
tions studied there was an increase in the average daily output 
of the worker, and this augmented with each successive period of 
observation. <A striking instance of this appeared in a certain 
soldering operation in which for three successive periods of two or 
three weeks each after the introduction of the two 10-minute rests 
there was an average increase in production of 3, 17 and 26 per 
cent. respectively. 

Thus, present evidence is strongly in favor of the allowance 
of brief resting periods for the human machine during the 
working spell as an aid to efficiency. 

Holidays, too, are beneficial. It will be recalled that the 
U. S. Fuel Administrator closed the factories in January, 1918, 
for a period of five days. The American observers found 
the average output of the men on a certain automobile operation, 
as measured for three days before and after the closure, to 
inerease 8 per cent. Since the men were on time, instead of 
piece, payment, the result did not signify a spurt to make up 
lost wages. The Fourth of July increased the average production 
of each of seven men at one of our factories by 2 per cent., the 
week of the fourth being compared with the previous week. 


232 HARVEY SOCIETY 


4. Improving the Physical Conditions of Work 


That the human machine is affected by its physical environment 
is a truism. I will speak here only of atmospheric conditions. It 
has now been abundantly shown that the human body works best 
when the surrounding air is at a reasonably low temperature, is 
only moderately humid, and is in motion. These general prin- 
ciples have now received striking confirmation from the unpub- 
lished observations by Vernon in the work of millmen in the tin- 
plate industry. The totals of five factories that were studied 
show the least output during the summer and the greatest during 
the winter months, with a striking contrast in the curves of output 
and temperature. Output was 10 per cent. less in August than in 
January. High humidities, e.g., from 85 per cent. upward, 
decreased production. The influence of these baneful conditions 
was counteracted to a considerable degree in some of the factories 
by artificial ventilation—seasonal variation of output was least 
in well-ventilated factories—and Vernon estimates that thor- 
oughly efficient ventilation may increase the average output of a 
previously unventilated factory by 14 per cent. 


IV. CONCLUSION 


In the brief course of a single lecture I have been able to 
present only selected instances of research, and mainly those in 
which there has already been definite achievement. Others are 
in progress or in contemplation. The American investigators 
have well under way a promising study of rhythm in factory 
operations; the beginnings of a determination of the amounts 
of energy that are transformed by the worker in different opera- 
tions are being made in England; Hastings, of the Public Health 
Service, has been studying in my laboratory for more than a 
year some of the chemical changes that occur in the body in 
fatigue, such as relate to the sulphurs and phenols, the hydrogen- 
ion content of the urine, and the alkaline reserve of the blood; 
and plans for still other investigations are contemplated in the 
United States, Canada, England and France. There are alluring 
opportunities for work of this nature in almost any direction. 


| 


eet ets al acta 


HUMAN MACHINE IN THE FACTORY — 233 


What we are observing in all this is, as I have already intimated, 
the making of what is virtually a new science, a science of indus- 
trial physiology. While sufficiently distinctive to deserve the 
name of a new science, it really represents the extension of the 
physiological point of view—and within the physiological I 
would include much of the psychological as well—to the peculiar 
problems that are presented to the human body in industrial 
occupation. Industrial physiology needs investigators, organ- 
izers, advocates. Offering, as it does, a new line of thought, 
and being, as it now is, largely in the hands of university men, 
whom as a class it is customary to stigmatize as idealistic and 
unpractical men, industrial physiology incurs the risk of being 
classed as academic. The term ‘‘academic,’’ I might be per- 
mitted to say, is in these present days losing much of its custo- 
mary opprobium. Industrial physiology is capable, I believe, of 
showing itself to be preéminently practical. It affords, I think, 
the most promising line of progress of all endeavors to solve 
the vexing problem of labor. It is not partisan, as between em- 
ployer and worker; it is in the interests of both. It sees clearly 
that the work of the human machines in industrial establish- 
ments, if they are to be organized properly, must be organized 
on a scientific basis. Empiricism and tradition, long the obstacles 
to medical advance, are potent to-day in the factory; and, just 
as science has been the savior of medicine, so it must, sooner 
or later, come to the rescue of industry. Here America has, I 
believe, a wonderful opportunity for leadership. 


THE PHYSIOLOGY AND EXPERIMENTAL 
TREATMENT OF POISONING WITH 
THE LETHAL WAR GASES* 


DR. FRANK P. UNDERHILL 
Yale University 
Recently Lieutenant-Colonel, Chemical Warfare Service, United States Army 


HE gases employed in the recent war may be divided into 
four great groups, as follows: 

1. Asphyxiant or suffocating gases. For example, chlorine, 
phosgene (COCI1,), diphosgene and chlorpicrin (CCL,NO,). 

2. Tear gases or lachrymators. For example, xylyl and 
benzyl bromide. 

3. Sneezing gases or sternutators. For example, diphenyl- 
chlorarsine. 

4. Blistering gases or vesicants. For example, yperite mus- 
tard gas (C,H,Cl).S. 

This division of gases is, however, only a rough elassification 
inasmuch as a gas may fall into more than one of the groups 
quoted. Thus a gas may have at least two different warfare uses, 
it may be both a lachrymator and an asphyxiant, or again possess 
suffocating properties in addition to a blistering action. 

The elassification given then carries with it the conception 
that the placing of a gas in one or another group is on the basis 
of the most important effect elicited by a given gas. 

From the viewpoint of the military purpose for which gases 
are employed they may be divided into two large groups: (a) 
the Lethal Gases, and (b) the Neutralizing Gases. Under the 
term of lethal gases are included all those gases used in warfare 
which are employed for the object of killing the enemy. The 
principle substances comprising this group are chlorine, phosgene 
(earbonyl chloride) and chlorpicrin (nitrochloroform). On the 
other hand, extensive use was made of a large variety of gases 


* Delivered March 15, 1919. 
234 


WAR GASES 235 


the main purpose being not to kill the enemy but to make him 
work under difficulties; in other words, to neutralize his military 
efficiency. Hence this group of substances received the name of 
neutralizing gases and included the lachrymators, the sneezing 
gases and the vesicants. 

In general, the neutralizing gases produce effects upon the 
human organism of a nature which cause discomfort rather than 
serious injury. On the other hand, many of these substances, 
if in sufficient concentration, are quite capable of inducing grave 
effects or may even be the direct cause of death. For example, 
mustard gas was used primarily for its vesicant action, produc- 
ing blisters which in certain cases might involve the entire skin 
and eause death in this manner; or again, a sufficient quantity 
of gas could be inspired so as to seriously injure the respiratory 
tract in such a way that the whole mucous membrane of the upper 
respiratory passages would peel off as a cast. Portions of this 
cast might get into the bronchi or bronchioles, acting as a 
mechanical plug and so interfere with respiration as to cause 
death by asphyxia. 

In general, the sneezing gases and the lachrymators induced 
effects, such as relatively slight irritation and congestion, which 
called for no special investigation to alleviate or combat the detri- 
mental influence. The treatment involved in such cases was 
obvious. In a large measure the same may be said of the vesicant 
gases where the primary effect to be treated was the blister or 
the burn. Here a serious sequel to the gassing is dependent 
almost entirely upon the evil effects of secondary infection. In 
the treatment of mustard gas the prevention of infection was the 
object aimed at and it was attained by a variety of means, all of 
which were designed to keep the wound as aseptic as possible. 

While these statements are true in general for these three 
groups of gases, the sneezing gases, the lachrymators and the 
vesicants, they are capable of producing additional effects if 
inspired in sufficient quantities. On the other hand, such effects 
were not especially prominent in producing casualties in the field 
and hence the exact character of these additional influences has 
not been extensively investigated. 


236 HARVEY SOCIETY 


THE LETHAL GASES é 

Of especial importance in warfare have been the lethal gases. 
This group contains such substances as chlorine, phosgene and 
ehlorpicrin. Other substances are also included in this group, 
but from a practical standpoint the gases cited are the most 
important. Chlorine was the first gas employed, phosgene fol- 
lowed, and then chlorpicrin appeared. These three substances are 
unlike in that chlorine and phosgene are gases, whereas chlor- 
picrin is a liquid. Chlorine and phosgene, especially when 
mixed, allow their use in the form of a cloud, the first method 
of gas warfare. The perfection of the gas shell, however, in- 
ereased the number of substances that could be employed and 
greatly augmented the efficiency of gas as a means of warfare, 
inasmuch as the substance could be distributed in the area desired 
without dependence upon the conditions of the wind or the dan- 
gers of the gas being blown back. 

These three gases are alike in that each contains chlorine as 
an essential part of the molecule, and one might assume at first 
glance that the physiological effects produced by phosgene and 
ehlorpicrin are due to the action of the free chlorine or the 
hydrochlorie acid formed as a result of the hydrolysis or other 
decomposition of the gases. This is an interesting hypothesis, 
but from the pathologists’ findings can hardly be true, inas- 
much as the lesions produced in the three cases are quite distinet 
and specific. 

The three gases are lachrymators as well as respiratory irri- 
tants. Chlorine is preéminently a respiratory irritant and is 
characterized by the extreme rapidity with which it produces 
its typical effects, namely, pulmonary cedema and congestion. 
On the other hand, phosgene is less likely to cause immediate 
cedema, but it is regarded as a more effective fighting weapon 
as its use leads to a large number of casualties and deaths. The 
toxie action of phosgene is slower than that of chlorine, probably 
because to produce its effects it must undergo chemical change. 
This latent period in the action of phosgene has earned for it 
the name of having a delayed action. Chlorpicrin is not as 
rapid in its action as chlorine, but produces its typical effects 


WAR GASES 237 


much sooner than phosgene. This gas is regarded as especially 
valuable from a military standpoint, since it penetrates masks 
more readily than either of the other two gases. 


THE SYMPTOMS OF GAS POISONING 


The exposure of the dog to the gases elicits reactions which 
are quite characteristic for each gas. The general clinical symp- 
toms induced by gassing with chlorine are, at first, general excite- 
ment as indicated by restlessness, barking, urination and defe- 
eation. Irritation is distinctly evident as seen by the blinking 
of the eyes, sneezing, copious salivation, retching and vomiting. 
Later, the animal shows labored respiration with frothing at 
the mouth. Food is refused, although a large quantity of water 
may be drunk. The respiratory distress increases until eventually 
death may occur from apparent asphyxiation. On the other 
hand, if the concentration of the gas is not lethal the animal may 
present an emaciated appearance and be greatly distressed for 
several days, followed by ultimate recovery and return to 
apparently normal conditions. 

Phosgene acts chiefly as a respiratory irritant, but is also a 
lachrymator. Very small doses, scattered in the air, cause cough- 
ing, watering of the eyes, and intense dyspnea. It differs from 
chlorine in that in these small concentrations its influence is 
limited mainly to the terminal air cells of the lungs. This effect 
leads to edema of the lungs and consequent cyanosis, which 
may terminate in death. The first symptoms are dizziness and 
cyanosis on exertion. It usually takes several hours for the 
serious symptoms to develop and in the interval there is no 
sign of danger. 

At high concentrations there is slight lachrymation and un- 
easiness. The pupil becomes clouded but the animal exhibits 
no violent symptoms. Subsequently there may develop a hard 
cough, respiration becomes more and more difficult, usually there 
is a rattling in the throat and death follows within the first 
twenty-four hours after exposure. The heart action grows weaker 
as death approaches but persists after all attempts at breathing 
have ceased. 


238 HARVEY SOCIETY 


Exposure to chlorpicrin produces coughing, nausea and vomit- 
ing, and in large quantity may cause unconsciousness. Secondary 
effects are bronchitis, shortness of breath, a weak irregular heart, 
and gastritis. It may also cause acute nephritis. Liquid chlor- 
picrin has a corrosive action on the skin, and scratches and 
abrasions, if exposed to chlorpicrin fumes invariably become 
septic and abscess formation may result. 

A comparison of the three gases shows quite plainly that chlo- 
rine has a very strong irritating action, the animal becoming 
excited and in evident distress. With chlorpicrin the character 
of the reactions produced is very similar to those of chlorine 
poisoning, except that the symptoms are less pronounced. Phos- 
gene, on the other hand, appears to cause the animal no immediate 
distress. Instead of becoming unduly excited the dog lies quietly 
in the chamber and even when the symptoms appear hyperex- 
citability is not present. It would seem that a certain degree of 
peripheral anesthesia is present, handling the animal failing to 
act as a stimulus to muscular activity, struggling, so charac- 
teristic with chlorine and chlorpicrin dogs. 


PATHOLOGY OF GAS POISONING * 


From the pathological aspect chlorine produces injury to the 
organism by causing immediate death of the epithelium lining 
the upper respiratory tract. Areas of focal necrosis in the 
lung itself are attributed to the direct action of chlorine on parts 
of the lung not protected by bronchiolar spasm. The destruction 
of the epithelium of the trachea and bronchi removes the normal 
protective mechanism of the upper respiratory tract and allows 
pathogenic bacteria from the mouth to find their way into the 
injured bronchioles within a very short period after the epi- 
thelium has been destroyed. This bacterial infection results in 
a pneumonia, lobar, lobular or necrotizing, the type depending 
upon the organism concerned. The pneumonia is associated in 
all eases with an infection lesion of the bronchi. The infection 
tends to persist in animals surviving the acute period, resulting 
in a chronic bronchitis, organizing or obliterative bronchiolitis 


* Taken from the reports of Dr. M. C, Winternitz. 


; 


WAR GASES 239 


with scarring of the lung. Such lesions are demonstrable in 
dogs dying or killed as late as six months after gassing. The 
irritating action of chlorine results in a bronchiolar spasm, 
which, interrupting the normal inflow and outflow of air, causes 
an acute emphysema or atalectasis, most marked in animals 
dying in the acute stage. 

(Hdema of the lungs, trachea and bronchi is the most striking 
feature of acute death from chlorine gassing. It is probably 
brought about by the direct action of the gas which so damages 
the bronchi and alveoli as to render permeable the adjacent capil- 
lary wall. The coagulation of the plasma as it passes out through 
the alveolar wall leads to the deposition of fibrin in this situation 
which must seriously interfere with the inflow of blood through 
the lung, thus putting a strain upon the right side of the heart. 

With phosgene gassing the lesions seen at autopsy vary 
according to the length of time the animal survives after ex- 
posure to the gas. At first there is a severe pulmonary edema 
associated with extreme congestion, which reaches a maximum 
after the first 24 to 36 hours and disappears gradually in animals 
surviving ten days or longer. The cedema is associated with an 
inflammatory exudation of fibrin and leucocytes, which is most 
marked in and around the finer bronchioles and which spreads to 
a variable extent through the lung tissue. A typical lobular or 
pseudo-lobar pneumonia is the result. The pneumonia is fre- 
quently complicated by a necrotization of the wall of the bronchus, 
which may involve the adjacent alveoli to form abscesses. On the 
other hand, the inflammatory process may be combated success- 
fully but in an attempt at healing, foci of organizing pneumonia 
and obliterative bronchiolitis result. They constitute chronie foci 
of infection, as shown by bacteriological studies. 

The character of the phosgene lesion is explained by the local- 
ization of the action of the gas upon the air tubes. The epithelium 
of the trachea and larger bronchi is not damaged, while that of 
the smaller bronchi and bronchioles is seriously injured, the 
more distal portion suffering most. In addition to the changes 
in the mucosa the bronchi also show pathological contractions 
and distortions which result in the more or less complete oblitera- 


240 HARVEY SOCIETY 


tion of their lumina. These in turn lead to mechanical dis- 
turbanees in the air sacs, resulting in a chronic condition of 
atalectasis or emphysema. 

Chlorpicrin injures the epithelium of the entire respiratory 
tract, but all portions of the tract are not equally affected. The 
trachea and largest bronchi, though irritated, suffer only transient 
injury. The medium-sized and small bronchi are the most affected. 
There is a uniform and widespread damage of the alveolar walls 
which, however, is not severe enough to lead to necrosis. The 
alveoli are apparently nowhere protected by constriction of 
the bronchi. 

The overwhelming cedema of the lungs rapidly follows expos- 
ure to the lethal concentration of the gas. In extreme cases 
practically every alveolus is filled with fluid. In addition to the 
fluid in the lung itself there is also marked cedema of the medias- 
tinal tissues and pleura which is even more striking than in 
phosgene and chlorine gassing. The edema fluid contains fibrin 
and a great deal of fibrin is found in the alveolar walls. Partial 
or complete occlusion of the smaller bronchi by inflammatory 
exudate or masses of necrotic cells leads to foeal emphysema 
or atalectasis, but this is not such a striking feature at autopsy, 
as in the case of death from some of the other respiratory irritant 
gases, for example, phosgene. Infection of the lungs with the 
development of a widespread bronchitis and broncho-pneumonia 
is seen in a large percentage of those animals which do not die 
in the first few hours after gassing. Abscess formation, pleurisy, 
fibrinous or purulent, and organizing pneumonia are common 
complications. In recovered animals there is a regeneration of 
the epithelium of the bronchi and alveoli, and organization of the 
necrotic bronchiolar wall with sear formation. Focal atalectatie 
emphysematous patches remain as prominent gross evidence of 
the gas injury. 

A comparative study of the pathology of chlorpicrin, chlorine 
and phosgene shows that chlorpicrin in its action on the respira- 
tory tract occupies a position somewhere between chlorine and 
phosgene. It damages the trachea and larger bronchi less than 
chlorine but more than phosgene. In its action on the bronchioles 


Sl 


: 
: 


WAR GASES 241 


and alveoli it resembles phosgene very closely, but in several 
other respects the lesions are more like those of chlorine. The 
gross and microscopic differences in the effects of the three gases 
on dogs are sufficiently clear cut to enable an experienced observer 
to determine by autopsy which gas has been used. 


AN INTERPRETATION OF GAS POISONING 


In the time allotted it would be impossible to describe in detail 
the character of the various types of work carried through in our 
investigation on the war gases. It will suffice to say that under 
carefully controlled conditions the influence of the lethal gases 
upon the organism of the dog has been studied both intensively 
and extensively. In this investigation several thousand animals 
were employed. As a result of this work it may be stated that 
pulmonary edema is the prominent feature of the effects induced 
by these gases. In addition to pulmonary cedema, gassing has 
a definite influence upon the respiration, heart-beat, temperature, 
the concentration of the blood, the water content of the lungs and 
other tissues, the chloride content of the blood and tissues with 
resulting changes in chloride excretion by way of the kidney, 
the number of the red and white cells of the blood, and the respira- 
tory function of the blood leading to dyspnea and partial 
asphyxia. Acidosis is present at times and there is a distinct 
influence upon protein metabolism. Some of these effects are of 
course dependent upon the development of pulmonary cedema, 
but others are not so readily explained in this way. It should 
be stated that so far as can be determined by experimental 
methods, the lethal gases act specifically upon the respiratory 
tract, which action results in edema. Little or none of the gases 
is absorbed. Hence, whatever influence is exerted upon the 
organism by these gases must be explained by an interpretation of 
the effects induced in the respiratory tract. 

The effects of gassing as enumerated above are so various that 
an attempt at correlation or the assignment of cause and effect 
seems at first glance well-nigh impossible. Further study of the 
problem, however, brings to light one significant feature which 
stands out clear and distinct from all the other effects induced 

16 


242 HARVEY SOCIETY 


by exposure to gas. This is the well defined curve of changes in 
blood concentration. Upon the basis of alterations in blood con- 
centration quite definite stages in gas poisoning may be outlined. 
These stages stand out most clearly with phosgene and therefore 
the picture presented by this gas will be considered first. 


STAGES IN PHOSGENE POISONING 
First Stage: 


In the first few hours (5-8) after phosgene poisoning there is a 
notable decrease in the concentration of the blood. The de- 
crease occurs rapidly and then the blood gradually tends to 
assume the normal concentration. In this period there may 
be significant dilatation of the heart (observed by Eyster). <Ac- 
companying the decreased concentration of the blood, there is a 
sharp drop in, the chlorides of the blood and a marked increase 
in the chlorides and water content of the lungs. The chlorides 
of the urine increase immediately after gassing, reaching a maxi- 
mum between the third and seventh hours, then decreasing. The 
heart-beat is distinctly slowed at first, with a tendency to regain 
the normal, or be somewhat above the normal before this period is 
over. The immediate effect upon the respiration is a distinct 
increase in the rate. During this period the temperature shows 
a marked increase, attaining a maximum coincident with the 
termination of this period. Oxygen capacity of the blood, the 
number of erythrocytes and hemoglobin follow a curve parallel 
with that of the changes in the blood throughout all stages of 
phosgene poisoning. The oxygen content of both arterial and 
venous blood decreases significantly. The saturation of hemo- 
globin with oxygen decreases somewhat. In general the decrease 
is more marked in the venous than in the arterial blood. In the 
first period of phosgene poisoning an influence upon protein 
metabolism is not noticeable. 


Second Stage: 


The period of blood dilution is followed by an interval during 
which the blood rapidly becomes concentrated to a point far above 
the normal value and remains near this level for several hours. 


WAR GASES 243 


In this stage the heart may be markedly decreased in size 
(Eyster). During the period of increased blood concentration 
the chlorides of the blood show a tendency to regain the normal. 
The water and chloride content of the lungs reach a maximum 
and then gradually fall. The heart-beat and respiration are both 
markedly accelerated. In animals that are in a serious condition, 
although the rate of respiration is markedly increasing, there 
is a decrease in depth so that rapid, shallow breathing exists. 
The temperature steadily decreases to a degree or more below 
normal. If the animal dies in this stage, the temperature may 
fall steadily up to the time of death. Most of the fatalities occur 
in this stage. The oxygen content of arterial blood remains 
fairly stationary at a nearly normal value, whereas that of venous 
blood falls rapidly to a very low level. The saturation of 
hemoglobin with oxygen decreases rapidly in both arterial and 
venous blood, but the fall is greater in venous blood. There is no 
evidence of an influence upon protein metabolism. 


Third Stage: 


After the period of increased concentration the blood grad- 
ually becomes more dilute until it is slightly under the normal 
value, which is eventually gained, and the animal recovers. The 
chlorides of the blood gradually tend to regain the normal level. 
The chloride and water contents of the lungs follow a similar 
course. In animals reaching this stage, the heart-beat and res- 
piration rise to a maximum and then gradually attain the normal. 
The temperature rises to normal or above in those animals that 
eventually recover. In those animals that die during this period 
the heart-beat and respiration rise but the temperature steadily 
falls. The oxygen content of arterial and venous blood tends to 
regain the normal. Chloride excretion by the kidney is markedly 
decreased but later is much augmented. Coincident with the 
increased chloride excretion is a noticeable increase in the pro- 
tein metabolism. 

The interpretation which may be placed upon the different 
stages of phosgene poisoning is as follows: In the first stage there 
is marked dilution of the blood. There are at least two ways 


244 HARVEY SOCIETY 


in which this dilution may be explained. In the first place it may 
mean an increased blood volume, the excess fluid finding its way 
into the blood from the tissues in response to the strong irritation 
stimulus exerted by the gas upon the respiratory tract. Or sec- 
ondly, a diluted blood would result if the red cells were removed 
in part and deposited in some organ or tissue. In the present 
investigation no studies have been made to determine actual 
changes in blood volume. Reports by Eyster and Meek, however, 
who have made such estimations, tend to the conelusion that in the 
stage of phosgene poisoning under discussion blood volume is not 
increased, and they account for the dilution of the blood on the 
hypothesis that red cells are stored in the lungs, at least tem- 
porarily. Whichever explanation is correct, it is certain that 
during this first stage two features may be quite prominent, 
namely, cedema of the lungs and dilatation of the heart. Gidema 
can be explained very readily on the hypothesis of increased blood 
volume and it is also possible that such a condition might lead to 
a dilated heart. On the other hand, the deposition of corpuscles 
in the lungs, by causing an obstruction in the circulation, would 
lead to a dilated heart. The relatively large transport of fluid 
to the lungs during this period is, however, not so easily explained 
by this hypothesis. Whichever hypothesis is accepted, edema of 
the lungs prevails and there may be a dilated right heart. 

In the second period cedema has reached its maximum develop- 
ment and here also blood concentration is at its height. The 
latter state is undoubtedly induced by the withdrawal of fiuid 
which finds its way into the lungs. During the interval of blood 
concentration the blood volume is definitely decreased and the 
heart may be noticeably diminished in size (Eyster). This 
would presumably result in a decreased efficiency of this organ 
and lead to an inadequate circulation. Later, when the blood 
resumes its normal degree of circulation, normal heart action 
is reestablished. 

The development of cedema induces a mobilization of chlorides 
in the lungs at the expense of the chlorides of the blood, the 
lowered chloride content of which may be explained in part by 
loss of chlorides through the kidneys, since at this period the 


WAR GASES 245 


output of chlorides in the urine is appreciably augmented. Later, 
during the second stage, the chlorides of the lungs reach a maxi- 
mum, the blood content is not called upon and therefore an 
approximately normal blood chloride content may be found which 
is maintained thereafter. This chloride retention by the lungs 
coincides with the fact that on the second day of phosgene 
poisoning the urinary excretion of chlorides is usually below 
normal. The period of readjustment now follows, during which 
cedema subsides in the lungs, and presumably both fluid and chlo- 
rides are demobilized by the lungs and find their way into the 
blood. The excess of chlorides over the normal in the blood 
is eliminated through the kidneys, which would account for the 
large output on the third day after gassing. 

The changes in oxygen capacity, erythrocytes and hemoglobin 
follow the curve of alterations in blood concentration throughout 
the entire course of phosgene poisoning which might well be antici- 
pated. Oxygen content of arterial blood in general shows rela- 
tively unimportant changes, whereas that of venous blood 
progressively diminishes throughout the first. and second periods 
of phosgene poisoning. This may be explained in the first period 
by the fact of diluted blood and in the second period is undoubt- 
edly caused by the longer contact of the blood with the tissues 
induced by an inefficient circulation. 

The respiratory changes are correlated with the impaired 
respiratory functions of the blood, such as lowered oxygen content 
and incomplete saturation of the hemoglobin with oxygen. 

In the first stage decreased heart-rate may be explained best 
perhaps on the hypothesis of nervous inhibition. The later rapid 
pulse is directly induced by the viscous character of the blood 
which causes oxygen want. Although specific data are lacking, 
it appears quite evident that there is a distinct fall of blood 
pressure. One may assume a direct relationship between the 
heart’s efficiency and temperature. Thus, in the first part of the 
first stage the heart action is slow, there is inefficient circulation, 
and the temperature falls. Later the greatly accelerated pulse 
is accompanied by a rise in temperature far above the normal. 
From this it would appear possible that the heart has temporarily 


246 HARVEY SOCIETY 


overcompensated, resulting in an efficiency of the circulation 
above the normal. 

Now follows the stage of concentration of the blood. This 
concentrated blood is, without doubt, more difficult to circulate 
through the body, and if the heart is only doing its normal work 
there will be, as a result of the thickened blood, a circulation of 
less than normal efficiency and such a condition apparently results 
in a falling temperature. In ease the heart responds with a 
much higher rate during the period of concentration, so that even 
with the thickened blood it appears that a circulation of close 
to normal efficiency is being maintained, it will be found that 
the temperature is also well maintained. 

In the animals which are less seriously affected and in which 
only a slight edema of the lungs develops, with a consequent 
slight loss of fluid from the blood, it will be found that the tem- 
perature is well maintained, provided the heart-rate is normal. 
However, even in such eases, the continuous, even though slight, 
loss of fluid from the blood, will eventually result in a concentra- 
tion of the blood which will bring the circulation below normal 
efficiency, even with a high pulse-rate, and the temperature will 
slowly drop until at about the twenty-fourth hour it is about 
one degree centigrade below the normal. On the other hand, 
in the animals which are seriously affected, the blood concentrates 
very rapidly. The heart, even though the rate is maintained far 
above normal, is nevertheless not able apparently to maintain 
a circulation of normal efficiency, the temperature drops very 
rapidly and the animal dies within less than twenty-four hours 
after gassing. 

In brief, then, it seems plausible that the temperature is 
directly related to the efficiency of the circulation and this in turn 
is determined, in part at least, by the concentration of the blood 
and the pulse-rate. | 

This view seems to be further strengthened by the results 
obtained from a study of animals gassed with chlorine and chlor- 
picrin. In both of these cases there is, in general, a state of 
concentration of the blood beginning immediately after gassing. 
Only in rare instances does dilution of the blood oeeur and then 


eee 


WAR GASES 247 


it is only for a short time. From the first, then, in animals 
poisoned with these last-named gases, there obtains a condition 
in which the blood is above normal in concentration and in corre- 
spondence with this the temperature remains below normal 
and the more seriously the animal is affected and the greater 
the concentration of the blood, the greater will be the fall 
in temperature. 

Phosgene poisoning has been considered in detail since it is 
unique in showing among its effects the initial stage of dilution 
of the blood. At times chlorpicrin presents a similar stage, butt 
this interval is never so pronounced either in degree or length 
as obtains in phosgene poisoning. Usually a preliminary dilution 
period is lacking. It is this period that undoubtedly gives to phos- 
gene the distinction of possessing a so-called ‘‘ delayed action.’ 
Chlorine gas rarely if ever causes a period of blood dilution. In 
general, if one should consider the changes in blood concentration 
outlined for phosgene, minus the initial dilution period, the 
remaining curve would represent fairly accurately the alterations 
occurring in the blood in both chlorine and chlorpicrin poisoning. 
This would, of course, entail differences in time relationships, 
but under the conditions noted the changes in blood concentration 
of chlorine and chlorpicrin would be accompanied by the same 
general type of effects which is obtained with phosgene. Under 
these circumstances it appears superfluous to recite further the 
correlation of the effects of chlorine and chlorpicrin poisoning. 


THE CAUSE OF DEATH IN GAS POISONING 


It is generally assumed that the cause of death in gas poisoning 
is due directly to edema of the lungs aided, of course, by the 
accompanying congestion. It has been said that death is caused 
by an individual literally drowning in the water of his lungs. 
The quantity of water may reach as high as a liter or more, and 
such a conception as the cause of death seems quite obvious. 
On the other hand, one may well ponder whether death is usually 
induced in this way or whether there may be some other cause 
to which one may point with more certainty. The most obvious 
condition, other than edema, which could lead to death is the 


248 HARVEY SOCIETY 


concentration of the blood. Of course, it is evident that edema 
and blood concentration are closely associated. (#dema is 
assuredly the cause for blood concentration and thus indirectly 
at least brings about death, but it would appear that blood con- 
centration is much more likely to produce death than is the 
presence of fluid in the lungs. There are therefore two possi- 
bilities open. 

Death by cedema could be caused by the prevention of an 
adequate oxygen supply in the pulmonary blood. On the other 
hand, through extensive experiments of Winternitz,* it is quite 
possible to introduce large quantities of fluid directly into the 
lungs of normal dogs without causing death, the fluid being 
absorbed with surprising rapidity. It must be conceded, how- 
ever, that the conditions obtaining in the lungs of a normal dog 
and in those of a gassed animal are quite different, for in the 
experiments cited simple salt solution was introduced, whereas in 
the edematous lung the fluid more nearly represents blood plasma. 
Such a fluid would have a much greater tendency to inhibit 
adequate oxygen exchange than would a simple salt solution. 
The adherents of the idea that cedema is the cause of death must 
ascribe death to asphyxiation. There is little doubt that well- 
developed cedema does interfere with oxygen exchange of the pul- 
monary blood, but usually, the efficiency of the arterial blood 
as an oxygen carrier is surprisingly high. It would seem a simple 
matter to put the question to the test experimentally. Thus, 
it might be assumed that if ceedema is the cause of death, this 
operating by producing asphyxia, administration of oxygen 
should save the animal provided the oxygen could be absorbed. 
Such experiments have been carried through in this investigation 
and the results have demonstrated that though the oxygen in the 
arterial blood may be raised and maintained within the higher 
normal limits, death intervenes an usual. Then again some ani- 
mals seem to die with much less ceedema than others and the 
different gases also possess different degrees of ability in provok- 
ing edema. If edema is the cause of death it is difficult to 
explain why some animals with an apparent excessive quantity 


* Unpublished. 


a tt 


Sp — 


WAR GASES 249 


of fluid in the lungs should survive. Death is caused by some- 
thing more than simple inability of the blood to absorb oxygen, 
by something more than a physical obstacle in the lungs. 

It seems quite logical to assume that blood concentration is 
immediately responsible for death. Blood concentration means 
a failing circulation, an inefficient oxygen carrier, oxygen star- 
vation of the tissues, fall of temperature, and finally, suspension 
of vital activities. The whole aim of treatment in gas poisoning 
has been to prevent blood concentration or else restore it to a level 
more nearly normal. When this is accomplished the animal sur- 
vives in spite of the fact that the lungs may be very cedematous. 
It may be stated, then, that in the presence of cedema and a 
concentrated blood entrance of oxygen into the circulation does 
not prevent death. On the other hand, restoration of blood to a 
more normal concentration enables an animal to survive 
even though an extensive cdema exists. Administration of 
oxygen under the last named conditions undoubtedly makes 
recovery easier. 

Therefore, while it is accepted that indirectly the cedema 
of gas poisoning results in death, the immediate cause of death 
must be assigned to blood concentration. 


THE TREATMENT OF PHOSGENE POISONING 


From the foregoing considerations it is quite apparent that 
changes in blood concentration constitute the most important and 
significant action of phosgene upon the animal organism. It is, 
therefore, quite logical that in any endeavor toward alleviation 
of the effects of phosgene poisoning efforts should be directed 
toward the restoration of the blood to a concentration more 
nearly approximating the normal. 

It must also be evident that for the successful accomplishment 
of such a purpose there should be some criterion, or criteria, which 
shall indicate time of treatment and if possible type of treatment. 
Such eriteria are to be found in changes in temperature and in 
hemoglobin estimations. Both are very simple procedures and 
best results are obtained when they are employed in conjunction. 
There are conditions, however, especially in the field where 


250 HARVEY SOCIETY 


hemoglobin estimations may be impracticable. Under these cir- 
cumstances treatment may be successfully applied in accordance 
with the temperature changes alone. It should be stated that 
hemoglobin determination is selected inasmuch as it may be 
substituted for the more arduous total solid estimation. Changes 
in hemoglobin and total solids in gassed dogs follow similar if 
not exactly parallel courses and hemoglobin estimation is a 
much more sensitive test for changes in blood concentration than 
is total solid determination. 

In accord with these principles an outline of the treatment 
evolved in this investigation is as follows: 


Treatment of First Stage: 


Approximately one hour after gassing, blood is drawn from 
a vein to the extent of one per cent. of the body weight. Bleeding 
at any time up to four hours after gassing is beneficial, but the 
best results are obtained when the withdrawal of blood is practiced 
about an hour after gassing. 


Treatment of Second Stage: 


In the first stage blood concentration may exhibit one of two 
features after bleeding. (a) The blood becomes markedly dilute 
and slowly returns to normal concentration. (b) There is no 
significant dilution of the blood. The latter is an exceptional 
condition. The time of further treatment will therefore depend 
upon which of these two conditions obtains. When the blood 
becomes markedly dilute and then slowly returns to the normal, 
infusion of 0.97 per cent. sodium chloride solution equal in 
amount to the blood withdrawn should be practiced when the 
blood concentration regains the normal level. This usually takes 
from 8 to 10 hours. On the other hand, when even after bleeding 
the concentration of the blood is not definitely decreased, infusion 
of salt solution should be delayed until there is a clear indication 
that the blood is becoming concentrated. This usually occurs 
from 6 to 8 hours after gassing. In any ease the infusion should 
not be delayed beyond the point where the blood has reached a 
concentration of more than 25 per cent. above normal. 


WAR GASES 251 


After the infusion of the salt solution the concentration of the 
blood is followed at one-hour intervals by determination of 
hemoglobin in order to ascertain whether subsequent salt in- 
fusion is indicated. In general, after the first infusion the blood 
may begin to concentrate again within one hour and when this 
concentration continues it may be desirable to infuse subsequently, 
but judgment must be exercised in order to strike a proper mean 
between insufficient and excessive infusion. Insufficient infusion 
leaves the blood concentrated. Excessive infusion augments 
edema. So long as the concentration of the blood remains con- 
stant, infusion is unnecessary, and when the concentration dimin- 
ishes the individual is on the road to recovery. 


Treatment of Third Stage: 


Usually rest and warmth are all that are necessary in this 
stage but if the blood should become greatly diluted again and 
remain so a further bleeding may be necessary. This condition, 
however, rarely occurs. 

The principles of treatment are therefore very simple—vene- 
section when the blood is diluting and infusion of salt solution 
during the initial period of blood concentration. Venesection 
tends to diminish the degree and extent of dilution. Infusion of 
salt solution tends to keep the blood concentration at a level 
where it is possible to maintain an approximately efficient circu- 
lation ; in other words, blood concentration is kept at a level where 
an animal may survive. Infusion actually accomplishes this and 
when properly practiced does not augment pulmonary edema. 

The treatment as given must be considered as a mere outline 
of the principles followed rather than as a recital of the detailed 
procedure. Experience with the method soon showed that inten- 
swe treatment in the first stage of phosgene poisoning, that is, in 
the period of dilution, will, in the majority of cases, prevent ex- 
treme concentration of the blood characteristic of the second 
stage. In other words, the second stage is very greatly modified 
by proper treatment of the first stage. During the first stage 
water should not be given. 

Proper treatment of the first stage consists in venesection to 


252 HARVEY SOCIETY 


the extent of 0.5 per cent. body weight as soon after gassing as 
practicable. The temperature and hemoglobin are then followed 
at one-half hour intervals. So long as the temperature remains 
normal and blood concentration does not diminish, further treat- 
ment is not indicated. When, however, the temperature rises 
rapidly and a fall in blood concentration occurs (the two changes 
take place simultaneously) a second venesection of 0.5 per cent. 
body weight is practiced. This procedure may be repeated a 
second time, that is, until blood to the extent of 1.5 per cent. 
of the body weight has been withdrawn. The large major- 
ity of cases need no further treatment and practically every 
animal survives. 

If in spite of intensive treatment in the first stage the blood 
becomes markedly concentrated and a marked fall in temperature 
takes place, the condition of the animal must be considered as 
very serious, and if left untreated will surely die. At this point, 
of course, infusion of salt solution is indicated. 

The essential feature in the stage of blood concentration is to 
diminish if possible the degree of concentration and we have 
found by experience that it matters little how this is attained. 
Thus this purpose may be accomplished by infusion of salt solu- 
tion, by oral administration of water or even by intraperitoneal 
injection of salt solution. Probably one-half the animals in a 
serious condition in this stage of blood concentration may be 
saved by following either procedure. The fact that fluid by 
mouth or peritoneal cavity acts with about the same efficiency 
as direct infusion into the circulation, increases the practical- 
ity of the method when applhed to man under field conditions 
where in many instances infusion into a vein would be out of 
the question. 

The efficiency of the method of treatment may be realized 
from the following figures. When dogs are gassed at a concen- 
tration of 80 to 90 parts phosgene per million of air for one-half 
hour and given no treatment 21 per cent. recover. Under the 
same conditions treatment as outlined enables 63 per cent. of 
animals to recover. Presenting it differently, treatment increases 
the recoveries three-fold. 


WAR GASES 253 


With respect to the treatment of chlorine and chlorpicrin 
poisoning the principles enunciated for phosgene hold true. 
While the principles are the same there is a difference in the 
time of application, for in general in chlorine and chlorpicrin 
poisoning the initial stage of dilution is lacking. With phosgene 
carly bleeding and delayed infusion are advocated ; with chlorine 
and chlorpicrin early bleeding and early infusion are imperative. 
Moreover, in chlorine poisoning there is evidence of a significant 
acidosis, hence, administration of sodium bicarbonate by mouth 
is advocated, in addition to the treatment outlined for phosgene. 

When dogs are gassed with chlorine at a concentration of 800 
to 900 parts per million of air for one-half hour and given no 
treatment 9 per cent. of animals recover. Under the same condi- 
tions with treatment as outlined 30 per cent. of dogs recover. 

When dogs are gassed with chlorpicrin at a concentration 
of 110 to 130 parts per million of air for one-half hour and 
given no treatment, 48 per cent. of animals recover. With 
treatment 80 per cent. recover. 

Various other types of infusion fluids, such as other salt 
solutions, dextrose solutions, acacia solutions, ete., have been 
tested in an endeavor to obtain a blood diluent which would 
remain in the circulation for a considerable period. An extended 
experience has shown that none of these solutions answered our 
purpose so well as simple isotonic sodium chloride solution. 

The results of the treatment as given justify the conclusion 
that the factor in gas poisoning exerting the greatest detrimental 
influence is the alterations in blood concentration, and further, 
that if blood concentration can be controlled a gassed individual 
has very fair chances of recovery from the effects of the gas. 


OXYGEN IN THE TREATMENT OF GAS POISONING 


Lack of oxygen in certain stages of gas poisoning plays a 
significant role. There is little or no evidence of an inadequate 
supply of oxygen in the arterial blood during the first part, 
if not the whole of the first period. When, however, blood con- 
centration becomes marked insufficient oxygen in the arterial 
blood is quite apparent. In this investigation changes in blood 


254 HARVEY SOCIETY 


concentration have been assumed as the responsible factors lead- 
ing to the condition of anoxemia. According to this view the 
viscosity of the concentrated blood leads to impaired circulation 
in the tissue capillaries, thus accounting for the extremely low 
oxygen content of the venous blood, which is so characteristic of 
gas poisoning. 

The question naturally arises, ‘‘ Will administration of oxygen 
eliminate anoxemia?’’ Again, if anoxemia is alleviated will this 
allow the individual to survive the effects of phosgene poisoning? 
From clinical experience there seems to be conflicting evidence 
as to the value of oxygen in the treatment of gas poisoning. On 
the whole, however, it would appear that the consensus of opinion 
indicates that oxygen administration is decidedly beneficial in 
the circumstances under discussion. On the other hand, from 
an experimental viewpoint, oxygen as the only treatment of 
gas poisoning appears to have very little value, inasmuch as just 
as many gassed animals die when continuously kept in an atmos- 
phere of 50 per cent. oxygen as without oxygen treatment. 
Though this conclusion is inevitable from the data, it must be 
conceded that oxygen administration seems to relieve the animal. 
It rests more quietly, respiration is less difficult, and obvious 
cyanosis disappears or is absent. 

An analysis of the situation reveals the reason for the failure 
of oxygen to change the death-rate in phosgene poisoning. Oxy- 
gen administration to lethally gassed dogs may improve markedly 
or even restore to normal the oxygen content of arterial blood, 
without, however, significantly increasing the content of the 
venous blood. In those instances where venous oxygen content is 
maintained within approximately normal limits recovery fol- 
lows. The same thing may occur, and to the ‘same extent, without 
oxygen treatment. It is therefore quite evident that though 
arterial blood contains sufficient oxygen the tissues are under- 
going oxygen starvation. Oxygen treatment alone does not strike 
at the fundamental difficulty namely, oxygen starvation induced 
by an inadequate circulation. The concentrated blood is respon- 
sible for the inefficient circulation, and if the gassed individual’s 
condition is to be improved, measures must be taken to restore 


; 
‘ 
‘. 


——s 


WAR GASES 255 


the blood to a concentration at which life is possible. It has been 
found that when the blood is treated in this way by the method . 
outlined earlier, sufficient oxygen may be provided for tissue 
respiration without oxygen administration. It is a significant 
fact, however, that bleeding and infusion followed by oxygen 
administration results in the restoration of both arterial and 
venous blood to approximately normal conditions with respect 
to oxygen content. It would appear from these facts that bleeding 
plus infusion so changes the physical character of the blood as to 
render possible a more complete oxygenation of the tissues. 

From another viewpoint the value of oxygen in treatment is 
indicated. Exposure to phosgene diminishes appreciably the 
oxygen consumption. Breathing oxygen under these circum- 
stances increases oxygen consumption. Bleeding slightly in- 
creases oxygen consumption, although it is still below normal. 
It is thus apparent that venesection increases somewhat the ability 
of the animal to obtain oxygen. Breathing oxygen after venesec- 
tion still further raises oxygen consumption. Infusion raises 
the oxygen consumption to a still higher level. Oxygen adminis- 
tration after infusion brings the oxygen consumption back to the 
normal level and may indeed carry it above. This should be 
considered in connection with the percentage saturation of arterial 
and venous blood. As has been pointed out above, the venous 
blood carries more oxygen after infusion than before. The 
administration of oxygen after infusion, results practically in 
complete saturation of the arterial blood as well. The oxygen 
consumption is equal to or greater than normal; while the arterial 
blood is almost completely saturated and the venous percentage 
saturation indicates that the tissues are getting an ample supply 
of oxygen. 

The conclusion is therefore warranted that the method of 
treatment involving venesection, infusion and oxygen administra- 
tion is definitely indicated for the reéstablishment of normal 
conditions in the respiratory functions of the blood in an 
animal gassed with phosgene. Under these circumstances re- 
covery is made possible. 


THE PHYSIOLOGY OF THE AVIATOR* 
DR. YANDELL HENDERSON 
Yale University 


OUBTLESS you have all read the delightful historical 
accounts by the late Admiral Mahan of the great naval 
battles of the eighteenth century, when France and England 
struggled for the mastery of the sea. You will recall the stress 
laid on the weather gauge, or windward position. If the wind 
blew from the eastward, as does the ‘‘northeast trade’’ among the 
Caribbean Islands where a great part of the struggle occurred, 
whichever admiral was able so to manceuvre as to be to the east 
of his enemy obtained a great, and often a decisive, advantage. 
He could choose the time and mode of attack, while his antagonist 
was compelled to remain on the defensive, unable either to force 
the fighting or to escape it. 

In modern naval warfare the position of the sun in relation 
to the enemy's fleet affects the accuracy of aim. The speed of 
the ships is of importance equalling that of their gunfire. But 
there is no element of position which quite corresponds to that of 
the weather gauge for a fleet under sail. 

In the battles of the ships of the air, however, there is again 
a condition which corresponds quite closely to the tactical advan- 
tage of mancuvring between the wind and the enemy. In this 
case it is not a direction in the plane of the horizon, except so 
far as light is important; but it is the direction at right angles, 
vertical to this plane. It is the upper position—the advantage 
obtained by him who can climb above his enemy, and, choosing 
the moment of attack, can swoop down upon him from above. 

With this as one of the fundamental conditions of aerial 
warfare, it was inevitable that in the development of the battle 
plane there should be the utmost effort to produce machines of 
continually greater speed and, its correlative, climbing power. 


* Delivered March 22, 1919. 
256 


PHYSIOLOGY OF THE AVIATOR 257 


Likewise in the air, the greatest practicable altitude has meant 
for the flying man at once an advantage over his enemy and a 
reduction of his own chance of being hit by anti-aircraft fire from 
the enemy’s guns on the ground. 

Accordingly, from the comparatively low altitude at which 
the aerial fighting of the first year of the war usually occurred, 
the struggle rose, as more and more powerful airplanes were con- 
structed by both sides, until at the end of the war it was quite 
common for battle planes to ascend to altitudes of 15,000 to 
18,000 feet—three miles up, higher than the summits of the 
Rocky Mountains or the Alps. 

Along with this development there occurred with increasing 
frequency among the aviators a condition of so-called ‘‘air-stale- 
ness.’’ It is a condition closely similar to, perhaps identical with, 
the ‘‘overtraining’’ or staleness, the physical and nervous impair- 
ment of athletes in a football team or college crew. In the last 
year of the war this condition had become so common that, as 
reported to us by some observers, the majority of the more experi- 
enced aviators in the British service were incapacitated to ascend 
to the necessary altitude, and many could no longer fly at all. It 
was to make good this most serious military deficiency that the 
enlistment and training of aviators was undertaken by the 
American Air Service on the enormous scale that it was. It 
was for the purpose of testing our airmen initially, and of 
keeping tab on their physical condition thereafter, that the work 
at the Mineola laboratory, of which probably you have heard, 
was undertaken. 

It is work which lies in a field of physiology in which before 
the war not half a dozen men in America, and not many more 
in Europe, were interested, and for them it was a field of what 
is called ‘‘pure’’ science. To-day it promises contributions of 
practical value not only to aviation, but to problems in medicine, 
climatology, athletics and hygiene. 

We will turn then to the problem of the aviator and the 
methods of human engineering which have been developed for its 
solution. But first, it will be advisable to review briefly what is 
known concerning the immediate effects of low barometric pres- 

17 


258 HARVEY SOCIETY 


sure and the functional readjustments involved in acclimatization 
to elevated regions; that is, life at great altitudes. 

Paul Bert,’ the brilliant French physiologist, was the first 
to demonstrate, in 1878, that the effecis of lowered barometric 
pressure or altitude are wholly dependent on the decreased 
pressure of oxygen. He carried out experiments upon men and 
animals both with artificial gas mixtures and reduced barometric 
pressure in a steel chamber. 

He showed that in pure oxygen at 21 per cent. of atmospheric 
pressure life goes on in practically the same manner as in air, 
which contains 21 per cent. of oxygen, at the ordinary pressure. 
So also the breathing of an artificial gas mixture containing only 
10.5 per cent. of oxygen has the same untoward effects at sea level 
that breathing pure air has at an altitude of about 20,000 feet, 
where the barometer is reduced by one-half. 

These considerations are fundamental for the differentiation 
of the disorders induced by rarefied air—so-called mountain sick- 
ness—from the conditions resulting from work in compressed air 
—so-called caisson disease. It is clear that it is from the former, 
and not at all from the latter, that aviators suffer; but, as the two 
disorders are sometimes confused, a few words regarding the 
latter are in place here. 

Caisson disease—known also as the ‘‘bends,’’ ‘‘diver’s palsy,’”’ 
and by other names—depends upon the fact that, under the high 
pressure necessary for diving, tunneling, and other work below 
water, the nitrogen of the air dissolves in the blood and in the 
other fluids and tissues of the body in amounts proportional to the 
pressure. This in itself does no harm, and has in fact no effect 
upon the body, until the subject comes out of the pressure lock 
or caisson, or rises from the depth of the sea where he has been 
working. Then the nitrogen which has been dissolved begins to 
diffuse out of the body. This also does no harm and has no effect 
unless the pressure under which the man has been working is so 
high, and the lowering of the external pressure is so rapid, that 
the dissolved nitrogen separates in the form of bubbles. Such 
bubbles may form in the blood, in the synovial fluid of the joints, 
and even in the brain. They induce intense pain, and even 


PHYSIOLOGY OF THE AVIATOR 259 


paralysis and death. In order that bubbles may be formed it is 
essential, however, that the pressure with which the tissues are in 
equilibrium should have been lowered considerably more than half 
its absolute amount in a few minutes. 

In the present state of the art of flying it is scarcely possible 
for an aviator to rise to a height of more than 20,000 feet, where 
the barometer would be less than half of that at sea level, in a 
period sufficiently short to allow bubbles of nitrogen to form 
in this way. The disorders from which aviators suffer are, there- 
fore, of a different class from those to which workers in com- 
pressed air are exposed. 

When the study of the effects of lowered barometric pressure 
was begun, it was supposed that the circulation might be primarily 
disturbed. The blood in the arteries of a healthy man is under 
such a pressure that, if a glass tube were inserted vertically into 
one of the arteries of his neck, and the blood were allowed to 
flow up the tube, the column of blood would come to rest at a 
height of 4 or 5 feet above his heart, corresponding to pressures 
of 120 to 150 mm. mereury. Knowing that the air pressure is 
reduced at great altitudes, some of the earlier writers made the 
mistake of supposing that such a column of blood would rise 
higher, and the blood-vessels would be under a greater strain, and 
more likely to burst therefore, at a great altitude than at sea 
level. That which they looked for they found. One writer has 
left a lurid description of how, while crossing a pass in the Andes, 
he got off his mule and walked for a time to rest the animal. On 
the least exertion his breathing became oppressed, ‘‘his eyes 
bulged and his lips burst.’’ The odd part of this is that in reality 
the blood-vessels are under no greater strain at a high altitude 
than at sea level. When the air pressure upon the exterior of 
the body and in the lungs is reduced, a part of the gas—at least 
the nitrogen dissolved in the blood—rapidly diffuses out through 
the lungs, so that the gas pressures within and without the blood- 
vessels are again equal just as at sea level. The idea is still 
prevalent that hemorrhages occur under low barometric pressures. 
However, among thousands of people whom I had an opportunity 
to observe on Pike’s Peak during a five weeks’ stay at the summit, 


260 HARVEY SOCIETY 


I saw not a single nose bleed, except one which was caused by the 
forcible application of a hard, object to the organ in question. 

The only direct effects of changes of pressure are those which 
are felt in the ears, and occasionally in the sinuses connected with 
the nose. The ear-drums are connected with the throat and con- 
tain air at the prevailing pressure. If the pressure is lowered 
this air expands, and forces its way out through the Eustachian 
tubes into the throat. If the outside pressure is increased, it 
sometimes happens, particularly when the subject has a cold and 
the Eustachian tubes are inflamed, that air does not pass readily 
into the middle ear. Accordingly the tympanic membranes are 
forced inward by the pressure; and this may cause acute pain. 
Workers in compressed air are accustomed, while going ‘‘into the 
air,’’ 2.e€., into pressure, to hold their noses and blow at frequent 
intervals as a means for expanding the ear-drums. Aviators, 
even during very rapid descents, are generally relieved by 
merely swallowing. 

To sum up all that has been said thus far, the influence of 
low barometric pressure is not mechanical but chemical. Life 
is often compared to a flame; but there are marked differences, 
depending upon the peculiar affinity of the blood for oxygen. 
A man may breathe quite comfortably in an atmosphere in which 
a candle is extinguished. The candle will burn with only slightly 
diminished brightness at an altitude at which a man collapses. 
The candle is affected by the proportions of oxygen and nitrogen. 
The living organism depends solely upon the absolute amount of 
oxygen—its so-called partial pressure. 

Unlike the flame, a man may become acclimatized to a change 
of atmosphere in the course of a few days or weeks. He is thus 
adjusted to the mean barometric pressure under which he lives. 
Every healthy person is so adjusted, New Yorkers to a mean 
barometric pressure of 760 mm. no less than the inhabitants of 
Denver or Cripple Creek to their altitudes. Even your tall build- 
ings could probably be shown to exert a slight climatic effect upon 
the tenants of the upper stories. The study of the processes in- 
volved in such acclimatization affords us one of the most promising 
means of analyzing some of the fundamental problems of life. 


PHYSIOLOGY OF THE AVIATOR 261 


In fact, is not the gaseous interchange of protoplasm, the 
earbon and oxygen metabolism of the cell, the central fact of 
life? Is not the mode of regulation of the interior environment 
of the body—the constants of the ‘‘humours’’—the prime prob- 
lem of the ‘‘vegetative’’ side of physiology. 

Among the ill effects of lack of oxygen we may distinguish 
three more or less distinct conditions. They are comparable, in 
terms of more common disorders, to acute disease in contrast with 
chronic conditions of various degrees. Thus any one suddenly 
exposed to acute deprivation of oxygen, as is the balloonist or 
the aviator in very lofty ascents, shows one set of symptoms. 
If the exposure is less acute, as in the case of one taking up resi- 
dence on a high mountain, the effects develop gradually ; he passes 
through the stages of mountain sickness, a condition much like 
sea sickness, to a state of acclimatization and renewed health. 
If, however, the ascent or the flight is for only two or three 
hours, a period too short for any degree of acclimatization to 
develop, and this strain on the oxygen-needing organs is repeated 
daily, as is the case with the aviator of the upper air, the condition 
of ‘‘air staleness’’ is likely sooner or later to result. It is the 
effect of repeated slight oxygen deficiency on an individual who 
does not become acclimatized. It is, I believe, closely related 
to those effects of repeated overexertion and oxygen shortage which 
appear in the overtrained athlete. 

The classic description of collapse from oxygen deficiency is 
that written by Tissandier,? the sole survivor of a fatal balloon 
ascent in 1875. 


I now come to the fateful moments when we were overcome by the ter- 
rible action of reduced pressure. At 7000 metres (Bar. 320 mm.) we were 
all below in the car. . . . Torpor had seized me. My hands were cold 
and I wished to put on my fur gloves; but without my being aware of it, 
the action of taking them from my pocket required an effort which I was 
unable to make. At this height I wrote, nevertheless, in my notebook 
almost mechanically, and I reproduce literally the following words, though 
I have no very clear recollection of writing them. They are written very 
illegibly by a hand rendered very shaky by the cold. My hands are frozen. 
I am well. We are well. Haze on the horizon, with small rounded cirrus. 
We are raising. Crocé is panting. We breathe oxygen. Sivel shuts his 


262 HARVEY SOCIETY 


eyes. Crocé also shuts his eyes. I empty aspirator. 1.20 P.m.,-11°, Bar. 
320. Sivel is dozing. 1.25-11°, Bar.—=300. Sivel throws ballast. Sivel 
throws ballast. (The last words are scarcely legible.) . . . I had taken 
care to keep absolutely still, without suspecting that I had already perhaps 
lost the use of my limbs. At about 7500 metres (Bar. 300 mm.) the con- 
dition of torpor which comes over one is extraordinary. Body and mind 
become feebler little by little, gradually and insensibly. There is no suf- 
fering. On the contrary one feels an inward joy. There is no thought of 
the dangerous position; one rises and is glad to be rising. The vertigo of 
high altitudes is not an empty word; but so far as I can judge from my 
own impressions this vertigo appears at the last moment, and immediately 
precedes extinction, sudden, unexpected and irresistible. . . . I soon felt 
myself so weak that I could not even turn my head to look at my com- 
panions. I wished to take hold of the oxygen tube, but found that I could 
not move my arms. My mind was still clear, however, and I watched the 
aneroid with my eyes fixed on the needle, which soon pointed to 290 mm. 
and then to 280. I wished to call out that we were now at 8000 metres; but 
my tongue was paralyzed. All at once I shut my eyes and fell down power- 
less, and lost all further memory. It was about 1.30. 


In this ascent the balloon continued to rise until a minimum 
pressure, registered automatically, of 263 mm. was reached. 
When Tissandier recovered consciousness Sivel and Crocé-Spinelli 
were dead. They were all provided with oxygen, ready to breathe; 
but all were paralyzed before they could raise the tubes to their 
lips. Tissandier’s notes are characteristic of the mental condition 
when oxygen-want is becoming dangerous. 

In marked contrast to this condition is that of men who, 
gradually ascending into the mountains, day by day become accli- 
matized without realizing that any change has occurred. The 
record for the greatest altitude attained by mountaineers is held 
by the Duke of Abruzzi and his party in the Himalayas. They 
reached an altitude of 24,000 feet, where the atmospheric pressure 
is only two-fifths of that at sea level, or practically the same as that 
at which Tissandier’s companions lost consciousness. At this 
tremendous altitude the Duke and his Swiss guides were not only 
free from discomfort, but were able to perform the exertion of 
cutting steps in ice and climbing. Doctor Filippi, the physician 
who accompanied them, in discussing this matter, says that the 
fact of their immunity admits of but one interpretation : 


PHYSIOLOGY OF THE AVIATOR 263 


Rarefaction of the air under ordinary conditions of the high mountains 
to the limits reached by man at the present day (307 mm.) does not pro- 
duce mountain sickness.’ 


In this statement, however, he is certainly mistaken, for the 
observations of others show conclusively that the sudden exposure 
of unacclimatized men to an altitude considerably less than that 
reached by this party would either produce collapse like that of 
Tissandier’s companions, or if long continued would result in 
mountain sickness. The latter effect especially is one which was 
the subject of careful study by an expedition of which I was a 
member, and which during the summer of 1911 spent five weeks 
at the summit of Pike’s Peak, Colorado, altitude, 14,100 feet, Bar. 
450 mm. We were there enabled to make observations upon 
hundreds of tourists who ascended the Peak, and who were accli- 
matized at most to the altitude of Colorado Springs or Manitou 
at the foot of the mountain. We saw a number of cases of collapse 
—fainting—from oxygen deficiency, as shown by the strik- 
ing cyanosis. 

In the majority of cases, however, tourists who spent no more 
than the regulation half hour at the summit of the Peak, and 
then descended, experienced no acute ill effects. Headache and 
some degree of nausea were common even among these persons, 
however—often developing slowly for some hours after their 
descent. On the other hand, among persons who remained over 
night, and were thus exposed for several hours to deficiency of 
oxygen, the classic symptoms of mountain sickness occurred ; and 
few escaped. Their second day at the summit was marked usually 
by extreme discomfort—headache, nausea, vomiting, dizziness 
and extraordinary instability of temper—symptoms which were 
strikingly exacerbated by even the smallest use of alcohol. 

Our immediate party passed through these conditions and 
after two or three days, or in one case nearly a week, re-attained 
practically normal health. A definite functional readjustment 
had oceurred. To illustrate and emphasize the nature of this 
readjustment I will quote a recent experiment * of my friend the 
leader of the Pike’s Peak expedition, Dr. J. S. Haldane. 


* Personal Communication. 


264 HARVEY SOCIETY 


He has equipped his laboratory at Oxford with a small lead- 
lined chamber in which a man can be hermetically closed. The 
carbonic acid which he exhales is continually absorbed by alkali, 
so that no accumulation occurs, while the oxygen is progressively 
decreased by the breathing of the man himself. Doctor Haldane 
found that after a day or two in this chamber he had reduced 
the oxygen to an extent comparable to Pike’s Peak. At the same 
time there had evidently occurred in himself a gradual process 
of adjustment, for he felt quite well. At this stage he invited 
another person to come into the chamber with him, and he had 
the satisfaction of observing the immediate development of blue- 
ness and the other symptoms of oxygen collapse in his companion. 

Evidently acclimatization is a very real phenomenon and of 
the utmost importance to any one exposed to a lowered tension 
of oxygen. 

As we observed it in ourselves during our stay on Pike’s 
Peak acclimatization consists in three chief alterations: (1) in- 
ereased number of red corpuscles in the blood; (2) some change 
in the lungs or blood (Haldane considers it the secretion of 
oxygen inward by the pulmonary tissue) which aids the absorp- 
tion of oxygen, and (3) a lowering of the CO, in the alveolar 
air of the lungs. This lowering of the CO, in the lungs is bound 
up with increased volume of breathing. It is the concomitant of a 
decreased alkaline reserve in the blood just as in nephritis and 
diabetes. Acclimatization in this respect consists therefore in 
the development of a condition which would nowadays be 
ealled acidosis. 

All of these changes are of a quantitative character. Miss 
FitzGerald * has supplemented the results obtained on Pike’s 
Peak by an extensive series of careful observations on the inhabit- 
ants of towns of closely graded altitude from sea level up to that 
of the highest inhabited place in our western country. She has 
thus shown that the mean hemoglobin and the mean alveolar CO, 
of the inhabitants of any town are functions of the mean baro- 
metric pressure of the place. 

I shall not discuss pulmonary oxygen secretion now, because 
the problem is still extremely obscure; nor the increased produc- 


OO 


OOO =— 


a 


ee ee Lee ee 


A taf 


i a 


| 


PHYSIOLOGY OF THE AVIATOR 265 


tion of red blood-corpuscles, which is a slow process requiring 
weeks for completion, and playing no considerable part in the 
matter particularly before us. 

We will fix our attention upon the fact that both the alveolar 
CO. of the pulmonary air and the alkaline reserve of the blood 
are reduced in accurate adjustment to any altitude, or oxygen 
tension, to which a man is subjected for a few days or even a few 
hours. This functional readjustment is, I believe, of great signifi- 
eance in relation to aviation, since it involves a larger volume 
of breathing per unit mass CO, eliminated: it thus compensates in 
part for the rarefaction of the air. 

But how is it brought about? And why are the changes of 
breathing gradual, when the changes of altitude and oxygen 
tension are abrupt? The answer lies in part at least in the mode 
of development, and the nature of that acidosis of altitude to 
which I have referred. It is scarcely necessary to remind you 
that, as L. J. Henderson has shown, the balance of acids and bases 
in the blood, its Cu, depends upon the maintenance of a certain 
ratio between the dissolved carbonic acid, H,CO, and sodium 
bicarbonate, NaHCO,, or, as Van Slyke terms it, the alkaline 
reserve. On the basis of this conception the prevalent view of 
acidosis is that, when acids other than carbonic are produced in 
the body, the bicarbonate is in part neutralized. The alkaline 
reserve is thus lowered, and the carbonic acid of the blood being 
now in relative excess, an increased volume of breathing is caused 
as an effort at compensation. 

Recent investigations® by Dr. H. W. Haggard and myself 
show that an exactly opposite process is likewise possible. We 
find that whenever respiration is excited to more than ordinary 
activity, and the earbonie acid of the blood is thus reduced 
below the normal amount, a compensatory fall of the alkaline 
reserve occurs. The body is evidently endowed with the ability 
to keep the ratio of H,CO, to NaHCO, normal, not only by 
eliminating CO, when the alkali is neutralized, but also by the 
passage of sodium out of the blood into the tissue fluid (or by 
some equivalent process) to reduce the alkaline reserve. A loss 
of CO, during over-active breathing is thus balanced. If it were 


266 HARVEY SOCIETY 


not balanced a state of alkalosis would oceur, which would inhibit 
respiration and induce a fatal apnea. 

It is really in this way I believe that some of those conditions 
arise which nowadays are called ‘‘acidosis.’’ If so they are not 
truly acidosis, or rather the process producing them is not acidosis, 
although the resultant condition gives some of the most character- 
istic tests of this condition. It is on the contrary a state, or rather 
a process, which Mosso was the first to recognize, although ob- 
scurely, and which he termed ‘‘acapnia’’ an excessive elimination 
of CO,. Recent papers ° from my laboratory have shown that a 
sudden and acute acapnia induces profound functional disturb- 
ances, including circulatory failure. 

It is one of the well-known facts in physiology that deficiency 
of oxygen, or anoxemia, causes an ‘‘acidosis.’’ Recent and as 
yet unpublished work of Doctor Haggard and myself indicates 
that the process involved is almost diametrically the opposite of 
that which has heretofore been supposed to occur, and that the 
result is not a true acidosis. Under low oxygen, instead of the 
blood becoming at first} more acid with a compensatory blowing 
off of CO,, what actually occurs is that, as the first step, the 
anoxeemia induces excessive breathing. This lowers the CO, of 
the blood, rendering it abnormally alkaline; and alkali passes 
out of the blood to compensate what would otherwise be a con- 
dition of alkalosis. 

We regard the current explanation, based on the production 
of lactic acid, as needing reversal. 

The application of this idea to the changes of breathing and 
of the blood alkali in acclimatization clears up some of the points 
which heretofore have been obscure. Thus on Pike’s Peak we 
saw that persons whose breathing under the stimulant of oxygen 
deficiency increased quickly to the amount normal for the altitude 
suffered correspondingly little, while those whose respiratory 
centre was relatively insensitive to this influence suffered severely. 
The one type readily developed the acapnia and in consequence 
the pseudo-acidosis which the altitude requires. The other did not, 

Here let me pause a moment to bring these conceptions into 
some degree of harmony with fundamental doctrines regarding 


PHYSIOLOGY OF THE AVIATOR 267 


respiration. For more than a century, in fact ever since the days 
of Lavoisier, the argument has been active whether our breathing 
is controlled by oxygen need or by the output of CO,. For the 
past thirty years, and especially during the last ten or twelve, 
the theory of regulation by CO,, or in its later form by Cu, has 
held the field. Indeed it is established now—almost beyond the 
possibility of contradiction, it would seem—that during any brief 
period of time, and under conditions to which the individual 
is accustomed, the amount of CO, produced in the tissues of the 
body, through its influence on the Cy of the blood, is the factor 
controlling the volume of air breathed. Its effects are immediate. 

But when we view the matter more broadly it is clear that this 
is by no means the whole story. The oxygen tension of the air 
is the influence which determines just how sensitive the respira- 
tory centre is to excitement by CO,. But the effects of any 
change of oxygen tension are slow in developing, requiring in 
some persons, as we saw on Pike’s Peak, hours to begin and several 
days to become complete. In fact, there are many perfectly 
healthy persons who, if caused to breathe progressively lowered 
tensions of oxygen down to 6 or 7 per cent. in the course of half 
an hour, feel nothing. Their breathing shows no considerable 
augmentation. They simply lose consciousness, and if left alone 
they would die, without any apparent effort on the part of 
respiration to compensate for the deficiency of oxygen. In such 
persons the stimulant of oxygen deficiency exerts only a slowly 
developing influence upon the sensitiveness of the respiratory 
centre to the stimulus of CO,. They can become acclimatized 
to great altitude only at the cost of prolonged mountain sickness. 
Evidently they are not suited to be aviators. 

In very sensitive subjects, on the contrary, the period of read- 
justment is much shorter. It is a matter not of days but of hours, 
and the functional alterations begin to develop almost immediattely 
even under slight oxygen deficiency. ‘The upper air is for those 
men whose organization readily responds with vigorous compen- 
satory reactions. 

With this inadequate sketch of present scientific knowledge 
regarding life at great altitudes as a background, we may turn to 


268 HARVEY SOCIETY 


the application of this knowledge to the problems of human 
engineering in the aviation service of our army during the war. 
In September, 1917, I was appointed chairman of the Medical 
Research Board of the Air Service and was asked to lay out a 
plan for the development of a method of testing the ability of 
aviators to withstand altitude. 

You will readily guess the line along which one would attack 
such a problem. It consisted in the development of an apparatus 
from which the man under test breathes air of a progressively 
falling tension of oxygen. The particular form which we use 
is called a rebreathing apparatus. It consists of a steel tank 
holding about 100 litres of air, connected with a small spirometer 
to record the breathing, and a cartridge containing alkali to absorb 
the CO, which the subject exhales. Breathing the air in this 
apparatus through a mouthpiece and rubber tubing the subject 
consumes the oxygen which it contains, and thus produces for 
himself the progressively lower and lower tensions of oxygen 
which are the physiological equivalent of altitude. To control 
and test the accuracy of the results with the rebreathing apparatus 
we installed in our laboratory at Mineola a steel chamber, in which 
six or eight men together can sit comfortably, and from which 
the air can be exhausted by a power-driven pump down to any 
desired barometric pressure. 

Such apparatus was, however, only the beginning. The prac- 
tical problem was to determine the functional changes—pulse- 
rate, arterial pressure, heart sounds, muscular coordination and 
psychie condition occurring in the good, the average and the poor 
candidates for the air service, and then to systematize and intro- 
duce these standards on a very large scale at the flying fields 
in this country and in France. 

That this program was successfully carried through, and was 
approaching completion when the armistice was signed, was due 
chiefly on the scientific side to the brilliant work of my colleagues 
Majors E. C. Schneider, J. L. Whitney, Knight Dunlap and Cap- 
tain H. F. Pierce, and on the administrative side to the splendid 
cooperation of Colonel W. H. Wilmer and Lieutenant Colonel 
KE. G. Seibert. 


PHYSIOLOGY OF THE AVIATOR 269 


We have recently published a group of papers,’ brief but 
fairly comprehensive in their technical details, and I shall not 
now repeat what has there been said, but shall confine myself 
to a few salient points. One of these is a final and striking 
demonstration of our main thesis. Schneider and Whitney went 
into the steel chamber and the air was pumped out of it until the 
barometer stood at only 180 mm., 23 per cent. of the pressure 
outside: the equivalent of an altitude of 35,000 feet. Through- 
out the test they were supplied with oxygen from a cylinder 
through tubes and mouthpieces. They experienced no discomfort 
except from flatus : the gases of the stomach and intestine of course 
expanded nearly fivefold. 

In comparison with this observation is to be placed the recent 
record ascent by Captain Lang and Lieutenant Blowes in England 
to a height of 30,500 feet. They were supplied with oxygen 
apparatus ; but a defect developed in the tube supplying Lieuten- 
ant Blowes and he lost consciousness. Captain Lang seems to have 
suffered only from cold. 

From this it might appear that the simplest way to solve the 
problem of lofty ascents would be by means of oxygen apparatus. 
The Germans evidently made use of such apparatus, for it was 
found in the wreck of one of the German planes shot down over 
London. The British also had such apparatus, but it was difficult 
to manufacture, wasteful in operation, and in other respects left 
much to be desired. In fact, the devising of such apparatus and 
its adaptation to the peculiar requirements of the human wearer 
are problems which can be solved only by the close codperation of 
a physiologist and a mechanical engineer. Mr. W. E. Gibbs, of the 
Bureau of Mines, with whom I had codperated in developing mine 
rescue oxygen apparatus, took up this problem and produced a 
device which should prove valuable. Unfortunately the common 
tendency to favor ideas and apparatus coming to us from Europe 
operated against the adoption of the better American device. 

It is doubtful, however, whether any apparatus of this sort 
will ever quite take the place of physical vigor and capacity to 
resist oxygen deficiency on the part of the aviator himself. 
Imagine him, when fighting for his life above the clouds, handi- 


270 HARVEY SOCIETY 


capped by goggles over his eyes, wireless telephone receivers on 
his ears, a combined telephone transmitter and oxygen inhaler 
over his mouth, and a padded helmet on his head! 

The importance of determining the aviator’s inherent power 
of resistance to oxygen deficiency, if he is to be even for a few 
moments without an oxygen inhaler, is demonstrated by the 
results of the routine examinations made with the rebreathing 
apparatus in the laboratory. These results show that 15 to 20 
per cent. of all the men who pass an ordinary medical examination 
are unfit to ascend to the altitudes now required of every military 
aviator. On the other hand, these tests pick out a small group of 
5 to 10 per cent. who, without apparent immediate physical de- 
terioration, withstand oxygen deficiency corresponding to alti- 
tudes of 20,000 feet or more. 

It is particularly interesting to note that when the rebreathing 
test is pushed beyond the limit that the man can endure, be it the 
equivalent of only 10,000 or 25,000, two different physiological 
types with all gradations between them are revealed. The fainting 
type collapses from circulatory failure and requires an hour or 
two to recover. Often the heart appears distinctly dilated. The 
other and better type, on the contrary, goes to the equivalent of a 
tremendous altitude on the rebreathing apparatus and loses con- 
sciousness, becoming glassy-eyed and more or less rigid, but with- 
out fainting. When normal air is administered such men 
quickly recover. 

Perhaps I ought to say at least a few words regarding the 
other aspects of the work at Mineola: for example, the valuable 
psychological investigations and the controversy over the rotation 
tests, which has figured so largely in our medical journals of late. 
It seemed best, however, to confine myself this evening to my own 
special field. Nevertheless, I can not suppress a public expression 
here of my sympathy for the brave and able scientific men in the 
psychological group at Mineola, who insisted on investigating the 
validity of the rotation tests. I am sure that you will feel as I do, 
when I tell you that they were threatened with punishment for 
insubordination when they refused to recognize that a regulation 


SS 


PHYSIOLOGY OF THE AVIATOR 271 


of the army, which prescribes the duration of nystagmus after 
the rotation test, necessarily makes this a physiological fact. 

I would gladly devote a few minutes also to pointing out 
some of the lessons to be drawn from the rather unusually good 
opportunities which fell to my lot to observe the mingling of 
science and militarism. The chief lesson can be put in a single- 
phrase: They do not mix. The War Gas Investigations, which 
formed the nucleus on which the Chemical Warfare Service 
finally developed, and the Medical Aviation Investigations, of 
which I have spoken this evening, were both successful largely 
because at first they were developed under civilian control, under 
that splendid scientific arm of the government, the Bureau of 
Mines and its able director. It is a wise provision of our govern- 
ment by which the Secretary and Assistant Secretaries of War are 
always civilians. It would also be wise for the general staff in 
any future war to keep scientific men on a scientific status instead 
of practically forcing them into uniform. 

We all hope that we are done with war, and with soldiers— 
at least for a generation. We can, however, derive certain broad 
lessons applicable to the conditions of peace from the experiences 
and intense activities of war, when almost unlimited funds were 
obtainable for research and the experiences ordinarily scattered 
over years were crowded into a few months. One of these lessons 
is that scientific men need to develop the capacity to become 
the heads of large enterprises without ceasing to be scientific, 
without degenerating, as is too often the case, into the super- 
clerk, who seems to be the American ideal of the high executive 
official. It is not enough for the scientific man to become the 
expert adviser to the unscientific administrator. If the latter has 
the responsibility he will use his power as he, and not as the 
scientific man, sees fit. To this rule I have known only one 
splendid exception. 

For the most part among us the great prizes go to the man 
who works up through clerical rather than through expert lines. 
We must find some way to change this. The path of science must 
lead to the top, and at the top must still be science. To achieve 
this ideal, the scientist must show generosity toward colleagues 


272 HARVEY SOCIETY 


and. subordinates, an enthusiastic recognition of their merit and 
an abnegation of self-aggrandizement, no less than skill in plan 
and energy in execution. It is essential also that he should 
develop methods for conserving time and strength by assigning 
clerical work to clerks instead of becoming a clerk himself, in 
order that he may keep mind and desk clear for the really 
important things. 

The Chemical Warfare Service was a success largely because 
the chief of the Research Division followed these principles as the 
spontaneous promptings of science and patriotism.s Medical 
research in aviation was productive just so long as it pursued a 
similar course. 

He who charts this course, so that others may follow it through 
the pathless seas of the future, will make a great contribution 
to science, education, government, and indeed to nearly every 
phase of trained activity in America. 


*Paul Bert, “La Pression Barometrique,” Paris, 1878. 

Quoted from Paul Bert, op. cit., p. 1061. 

?Quoted from Douglas, Haldane, Henderson and Schneider, “Physio- 
logical Observations on Pike’s Peak,” Phil. Trans., 1913, B. 203, p. 310. 

* FitzGerald, M. P., Phil. Trans., 1913, B. 203, p. 351, and Proc. Royal 
Soc., 1914, B. 88, 248. 

®‘ Henderson and Haggard, Jour. Biol. Chem., 1918, 33, pp. 333, 345, 
355, 365. Further investigations will be published in the same Journal 
for August 1920. 

®* Henderson and Harvey, Amer. Jour. Physiol., 1918, 46, p. 533, and 
Henderson, Prince and Haggard, Jour. Pharmac. Expr. Therap., 1918, 11, 
p- 189. 

7Y. Henderson, E. G. Seibert, E. C. Schneider, J. L. Whitney, K. Dun- 
lap, W. H. Wilmer, C. Berens, E. R. Lewis and S. Paton, Journal American 
Medical Association, 1918, vol. 71, pp. 1382-1400. 

8G. A. Burrell, Journal of Industrial and Engineering Chemistry, 1918, 
2, p. 93. 


pg ge 


HUMAN BEHAVIOR IN WAR AND PEACE* 


DR. STEWART PATON 


I 


N August, 1914, we were suddenly and tragically reminded of 
our ignorance of what constitutes the foundations of tem- 
perament and character. A demonstration on a scale of excep- 
tional magnitude alarmed us by showing that it was possible 
for civilized man to revert within a few hours to primitive man. 
Evidences of the advance of a people to the period of national 
development were then replaced by signs indicating the return 
to tribalism. The change at first startled and then depressed us; 
and the depression deepened as the consciousness of our ignorance 
of human nature and consequent inability to forecast behavior 
was impressed upon us. Indeed there have been times during the 
past four years when those who did not have some rational 
philosophy to sustain them were almost ready to blame Prome- 
theus ‘‘for fashioning such animals as men.’’ 

One striking evidence that already we are becoming indiffer- 
ent to the study of the emotional and mental forces that resulted in 
Germany’s aggressions, is reflected in our failure to realize, 
with the historian Lecky, that a ‘‘study of predispositions is 
much more important than the study of arguments.’’ At the 
present time when the world has been turned topsy-turvy and dis- 
organizing influences are operating in society, it is very desirous 
that we should make every effort to find out the causes that pre- 
dispose men to be peaceful or warlike, to be impulsive or deliber- 
ate, to be quick to resent a supposed injury or to be cautious 
in forming an opinion and slow to anger; and, finally, what 
peculiar combination of circumstances has resulted in the over- 
valuation of ideas expressed in such beliefs as are entertained 


* Delivered April 12, 1919. 
18 273 


274 HARVEY SOCIETY 


by persons who are obsessed with ‘he notion of having found the 
only road to ethical, cultural or political salvation. If we are 
intelligent in making preparations for peace, then we should 
be fully alive to the danger threatening civilization whenever 
and wherever egotism, belief in the infallibility of any system, 
and efficiency of organization are combined. We should not 
judge Prussianism, Bolshevism or Pacifism by the arguments pre- 
sented, but should go deeper to study the predispositions of those 
professing these doctrines, which will be found to be the product 
of minds having many traits in common. Predispositions and not 
the arguments of those who plead, either the cause of Democracy 
or Autocracy, are the potent influences in the development of 
our civilization. 

Already there are signs that there is a return of the old spirit 
of indifference to finding solutions for the problems of human 
behavior and to the state of unpreparedness for either peace 
or war; and if it renders us insensitive to our present responsi- 
bility and opportunity, we shall drift along as we did before the 
war, until some catastrophe brings us once again to our senses. 


II 


The greatest foe of civilization to-day is nervousness. We 
do not now refer to the great number of well-recognized types of 
nervous and mental diseases, but to the nervousness of many 
persons of unstable emotional equilibrium possessing unusual 
intellectual capacity. No adequate provision is being made to 
study these super-idealists, fanatics, and visionaries. The menace 
of these wishful thinkers is far greater than that caused by tuber- 
culosis or any of the contagious or infectious diseases; and yet 
our medical schools, the Army Medical Corps and the Red Cross 
do not seem to appreciate the urgent need of attempting to in- 
erease the supply of psychiatrists able to cope successfully with 
the dangerous malady rapidly spreading by suggestion, and even 
now threatening the foundations of society. 

The civilized world is asking for peace, and the adoption 
of every reasonable precaution that will diminish the possibility 


' 


i 
| 
‘ 


BEHAVIOR IN WAR AND PEACE 275 


of another war. At the Peace Conference many ‘‘arguments’’ 
have been presented but we have heard very little of any inquiry 
into those ‘‘ predispositions’’ which incline people either to make 
peace or drive them into war. Under the influence of wish- 
directed thoughts, and without any deep and comprehensive 
knowledge of the forces shaping character, we have begun to 
build up a social structure on the shifting sands of conjectural 
opinion as to what we imagine man to be. Only when we are sur- 
rounded by instances of man’s inability to control his passions 
do we understand that ‘‘Le génie n’est probablement pas le 
resultat de la connaissance de la matiére, mais de la connaissance 
de l’homme.”’ 

Nevertheless, in spite of the storm clouds there is more reason 
to be optimistic in regard to the future of civilization than there 
was four years ago. Society has not only survived a capital oper- 
ation but it has been driven literally at the point of the bayonet 
to take a more rational interest in human behavior. Of course 
there are dark spots on the horizon, but to-day, in contrast to the 
condition four years ago, the problem we have to solve is taking 
definite shape. Although organized fury no longer menaces civi- 
lization, throughout the world morbid instability, quarrelsome- 
ness, extravagances of all kinds, and the neurotic tendency of 
blaming everybody except ourselves for our misfortunes make 
difficult sometimes the realization that man is a rational being. 
We are like children crying aloud for peace, promising ourselves 
only good things, dreaming of Utopias, formulating schemes for 
the reorganization of society, planning new republics, and adver- 
tising our faith in the efficacy of ‘‘isms’’ to take the place of that 
accurate knowledge we should be interested in securing about the 
genesis and nature of the impulses, motives, sentiments and 
trains of thought which either drive people into war or inspire 
them to make and preserve peace. We draw up schemes for re- 
deeming society much faster than we take steps to add to our 
knowledge of man. So many successive plans having as their 
object the redemption of Society are proposed that one is tempted 
to ask, ‘‘Which way go the physiognomists, metoscopists and 
chiromantists to work?’”’ 


276 HARVEY SOCIETY 
ITI 


The members of the medical profession have a magnificent 
opportunity to assist in developing the mental prepardedness 
essential either for maintaining peace or for prompt prosecution 
of war, if this is again necessary to overthrow unjust aggressors. 

The physician should be well qualified to undertake the study 
of human character. Unlike the psychologist, the physician does 
not have to be reminded of the very close interaction of mind 
and body. Even before the days of Aristotle he had approached 
the study of the mind from the side of the body. Long ago he 
recognized the necessity of understanding something about the 
structure and the relation of the various organs as preliminary 
to the study of the machine in action. The medical man while 
only vaguely appreciating the value of functions like feeling and 
thinking as processes assisting in the adjustment of life, recog- 
nized that although there was a close connection between mental 
phenomena and those related to the circulation, respiration 
and secretion of the internal glands, analysis was so difficult 
that little attention was given to exploring emotional and mental 
adjustments. Even if he has not been able to explain the con- 
nection, intimate as it is between body and mind, his line of 
approach to the ancient problem has at least made it easier for 
him than for other investigators since he should see the body- 
mind problem in its proper biologic setting. The physician should 
be ready by reason of his medical training to grasp the significance 
of the recent rediscovery of a very old truth, namely, the doctrine 
of biologic unity. This doctrine when stated in practical terms 
stresses the impossibility of dissociating mind and body and em- 
phasizes the importance of considering as a whole that which for 
so many centuries by some observers have been considered as two 
entirely separate systems working independently of each other. 

The body-mind problem as it was once formulated appealed 
only to the speculative philosopher, but as recast in the world’s 
laboratory of life it has acquired an immediate and tragic interest 
for every thinking person ‘‘Life’’ and ‘‘living’’ have foreed 
these questions into the centre of the field of interest. Doubtless 
we shall soon visualize correctly the present opportunity, see the 


BEHAVIOR IN WAR AND PEACE ar 


problems in their right perspective and make provision for teach- 
ing mental hygiene in connection with departments of hygiene. 
As a matter of fact many physicians do not yet recognize the 
importance of considering these two departments, Physical and 


DiacramMatic REPRESENTATION oF Factors CoNCERNED 
ix ApsustMENTS OF HumAN MacHINE 


Organs governing intake (I), assimilation (A), storing (S), and elimination 
(E), of energy, and processes of reproduction and growth (R & G), controlling 
mechanism, brain and nervous system, (B, N. 8). 

Motor apparatus, (M). 

Environmental contacts, sense organs, (S). 

In health the human organism is capable of shifting gears from reflex to 
automatic, emotional or intellectual levels to effect the adjustment of internal 
eonditions to external conditions essential for efficiency and the maintenance 
of a well-balanced personality. 


Mental Hygiene, as inseparable and as representing two phases 
of one great problem. 

Will it be necessary for an intelligent lay public to lead the 
medical profession to appreciate its present opportunity and 
responsibility in this particular field ? 

The war has served to remind medical men of the fact that 
there was one side of the great human problem to which they 


278 HARVEY SOCIETY 


have unfortunately given comparatively little attention. They 
have been occupied in getting the human machine in order to 
run, but have given little or no attention to the amount of strain 
it would stand, the distance it would go without repairs, and 
took little notice of the kind of work it is best fitted to perform. 
Every day the physician has been accustomed to ask his patients 
‘‘how they felt,’’ ‘‘ whether they were worrying about anything,’’ 
or ‘‘whether it was not possible for them to take a more rational 
view of living,’’ but little time and attention have been devoted 
to investigating emotional disorders, the causes of worry, and the 
reasons for the psycho-neurotic’s general feeling of dissatisfac- 
tion with life, all of which have such an important bearing upon 
the present complex of symptoms of social unrest. To some per- 
sons the analysis of ‘‘sensations,’’ ‘‘sentiments,’’ ‘‘instincts,”’ 
‘“feelings’’ and ‘‘ideas,’’ seems to be outside the ordinary field of 
exploration reserved for the physician. But on the contrary, 
the rapid growth of functional nervous and mental diseases, 
more general belief in the efficiency of ‘‘isms,’’ and the spread 
of the Christian Science—Pacifistic—and Bolshevist—psychoses 
are decidedly within the field of the medical investigator. 


IV 


At every turn there are signs that many people have strayed 
into a special field of investigation representing the study of 
mind, in which they should be guided by medical men trained in 
the art of studying the human personality. A visit to almost 
any book shop in order to count the number of books in which such 
subjects as ‘‘ Thought Transference,’’ ‘‘Speaking with the Dead,’”’ 
‘‘Theosophy,’’ ‘‘Christian Science,’’ ‘‘The Search for the Phi- 
losopher’s Stone,’’ and various other forms of mysticism are 
discussed, is sufficient to indicate the vagaries of wish-directed 
thinking which represent unsuccessful attempts to satisfy deep- 
seated needs. It is very unfortunate that the members of the 
medical profession have not been more active in directing these 
currents of thought into proper channels. They have waited 
until the public has begun to be impatient at its failure to secure 


BEHAVIOR IN WAR AND PEACE 279 


reliable information in regard to the problems of human behavior. 
Already many intelligent people are showing signs of uneasiness 
because they cannot receive intelligent assistance from members of 
the medical profession in securing satisfactory adjustments in 
their emotional and intellectual life. 

The assumption is often made by a group of investigators who, 
it may be said, have never had time or opportunity to study the 
problems of human behavior, that a great deal is known about 
this subject. This belief is current among scientific men engaged 
in studying the behavior of the lower organisms, as well as among 
persons who have approached this special field from the academic 
point of view. A few hours in a psychiatric clinic where one is 
compelled to explore the personality of patients should be suffi- 
cient to convince any rational person that we have only just 
begun the study of human activities. Possibly it is advisable 
to remind those critics who affirm that very little more informa- 
tion is to be obtained in regard to the behavior of the 
human animal that a distinguished surgeon in the sixteenth 
century declared little remained to be done in advancing sur- 
gical knowledge! 

Before the outbreak of the war there were evidences of in- 
creasing popular interest being taken in the causes and methods 
of preventing nervous and mental diseases. The war directed 
the attention of the intelligent public to special phases of the 
problem; to the war psychoses or to the search for some rational 
explanation for the Prussian psychosis, Bolshevist mania and 
the emotional instability which results in criminal acts and 
general unrest. It is indeed unfortunate that the physician has 
waited until he is compelled by force of circumstances to take 
cognizance of his present opportunity for directing so much of 
the energy now dissipated to strengthen the constructive forces 
in civilization. It is not creditable to the medical profession that 
largely as the result of its indifference to a very important sub- 
ject it has now become much easier to secure large endowments for 
Christian Science temples than it is to find the funds for institu- 
tions for the study of human behavior. 

The physician has interested himself in examining different 


280 HARVEY SOCIETY 


parts of the human machine, and has imitated the example of 
the mechanician who remains in the workshop cleaning out cylin- 
ders and grinding valves but taking little interest in finding out 
how the motor runs while climbing hills or crossing rough roads. 

If the average physician were asked why he has neglected to 
analyze the soul life of his patients, he would doubtless reply that 
he had been so preoccupied in ministering to their physical needs 
that practically no time remained for the study of mental proc- 
esses. This reply is only partially true. In the minds of a great 
many doctors there exists a prejudice as old as the Lucretian 
philosophy that makes it extremely difficult for them to consider 
the study of psychological phenomena as a legitimate field for 
scientific exploration. Physicians have been among the most 
consistent and persistent opponents of mysticism, and yet 
curiously enough they have tacitly accepted the naive mysticism 
with which the radical materialist covers up some of the defects 
in his logic. Science is pictured as having a certain set of sym- 
bols, microscope, balance, and test tube, and it is assumed that 
mental phenomena which ean be neither seen, weighed nor dis- 
solved should be immediately rejected as unworthy of scientific 
investigation. Asa rule the average medical man takes cognizance 
only of those facts in individual experience which fit into his rough 
and ready philosophy of life, and discards those which cannot 
be quickly analyzed and arbitrarily adapted to suit conven- 
tionalized lines of thought. 

There is another factor which has had a very decided influence 
in preventing the physician from developing an intelligent inter- 
est in the study of mental processes. There is nothing particu- 
larly dramatic in exploring the personality of the average patient 
and only the occurrence of some tragic event seems to arouse his 
interest in the drama of life. The character of the methods used 
and the nature of the instruments employed in making a physical 
examination are always suggestive of the possibility of the intro- 
duction of some unexpected element to stimulate the interest of 
the examiner. On the other hand, in analyzing emotional reac- 
tions or intellectual adjustments the examiner is thrown back 
upon his own intellectual resources and there is little opportunity 


BEHAVIOR IN WAR AND PEACE 281 


to manipulate apparatus and stimulate the flagging imagination 
by the suggestion of reality associated with purely objective signs. 

While physicians appreciate that the circulatory and respira- 
tory functions represent mechanisms essential for the successful 
adjustment of life, they seldom stop to consider that feeling and 
thinking are also equally important in securing the adaptation of 
human beings to the environment in which they live. 


V 


Having reviewed some of the sins of omission of the medical 
man we shall probably not be considered prejudiced if reference is 
made to the sins of commission of psychologists. If the physician 
stopped short of the goal he might have reached had he extended 
his field of exploration to include the study of the personality, 
the psychologist has been guilty of trying to build a house without 
paying very much attention to the foundations. The latter in 
practice has followed the lead of Descartes and has discussed 
the ‘‘res cogitans’’ as separate and distinct from the ‘‘res ex- 
tensa.’’ Emotions and mental processes are described as if they 
were not directly modified by physiological processes. The phe- 
nomena of intelligence have often been referred to without any 
suggestion of the relation of these very complicated adjustments 
to mouth-breathing, visual, or lung capacity, or to the supply of 
hemoglobin and other physiological functions. 

It is unfortunate that more psychologists do not take time to 
equip themselves to carry on work in fields into which they have 
been drawn by their enthusiasm. Although excellent work has 
been done by the psychologists in determining the mental fitness 
of individuals for their task, there is no doubt that many of 
the results should be accepted only after they have been carefully 
criticized by members of the medical profession who possess a 
practical knowledge of the different parts of the human machine 
and their reciprocal activities. 

Once the decision has been made by the physician to explore 
a personality, he should not allow himself to be coerced by any 
fear of being thought unscientific into submissively abandoning 


282 HARVEY SOCIETY 


terms which are of value in recording the data collected. The 
mystics of a certain school of materialists object to the use of the 
word ‘‘consciousness,’’ and state that the word behavior is suffi- 
ciently comprehensive to describe the highest as well as the 
lowest forms of adjustment. There has been, as Kempf* has 
pointed out, ‘‘a sleight-of-hand movement in psychology to drop 
the term consciousness.’’ If I slip on an orange peel, bump my 
head on the sidewalk, and remain unaware of what has happened, 
common sense will confirm the diagnosis that self-consciousness 
and not behavior was lost. 

A reference is permissible to the use of the word behavior 
in this paper to include conduct. The word behavior is often 
used to describe those higher forms of response conduct in which 
some guiding motive is present. The retention of the word con- 
duct in our vocabulary is desirable. There can be no doubt that 
we convey a better idea of the functions of the conductor of an 
orchestra by the use of this word than we should do if he were 
described as the leading behaviorist. 

It seems to be the general consensus of opinion that during 
the period of the war many new facts of fundamental importance 
for the study of human behavior were not discovered. We have, 
however, acquired considerable skill in spreading out in a very 
thin layer the small stock of knowledge we possess. The neurol- 
ogists who have had active service in the army know to what 
good use this information has been put in improving treatment as 
well as in preventing the occurrence of the symptoms of mental 
disorders. Progress has also been made in securing increased 
industrial efficiency, and last but not least, in assisting us to 
acquire a new and broader outlook upon life in general. After 
reading the clinical histories of persons suffering from nervous 
or mental diseases, the scientist with a reflective turn of mind is 
ready to sympathize with the French philosopher’s lament that 
there are not more intelligent doubters in the world. ‘‘Sensa- 
tions,’’ ‘‘instinets,’’ ‘‘conflicts,’’ and ‘‘compensatory mental reac- 
tions’’ are discussed in many of these records with a degree of 


*Kempf, E. J.: The Autonomic Functions and the Personality, Nerv. 
and Ment. Dis., Monogr., Series No. 28, 1918, p. 11. 


BEHAVIOR IN WAR AND PEACE 283 


assurance which suggests a great deal of attention has been 
given to analyzing these phenomena; an inference, however, 
which is not justified. 


Wer 


One example may be cited of the desirability of extending 
our knowledge beyond the present stage in which vague concep- 
tions and approximate definitions form the basis from which 
most of our investigations start. We often hear it said that in 
soldiers under fire for the first time, the old instinet to preserve 
life gets the better of the recently acquired central reactions 
associated with a special sense of duty and an understanding of 
the desirability of facing the enemy, with the result that an 
unfortunate conflict is precipitated At once the question is sug- 
gested what phenomena should be included under the term 
instinct and what is the nature of the conflict. 

At present we have only the vaguest sort of notions in regard 
to the synthesis of reactions described collectively as an instinctive 
response and we are also very much in the dark as to just what 
mechanisms are involved in the conflict. In a very general way 
we are correct in saying that the instinct activities may be re- 
ferred to mechanisms in the cord, medulla, and mid-brain. Onto- 
genetically as well as phylogenetically these nerve tracts are 
known to be much older than those concerned in voluntary 
responses. Here within a very small area we see the connections 
between the circulation, respiration, internal secretion, move- 
ment and the general sensibility, which all play a part in the 
instinctive reactions. The majority of physicians adhere con- 
servatively to their determination to study only the objective 
reactions connected with the activities of the lower brain centres. 
A glance at any diagram illustrating the relation of parts in the 
mid-brain and medulla is sufficient to refresh our minds in regard 
to the proximity of all the great nerve tracts radiating from 
these centres to higher ones and suggests the need of more active 
cooperation in research between psychiatrist and internist who 
have arbitrarily separated functions which nature has united. 

Think of what valuable information could be obtained by 


284 HARVEY SOCIETY 


intelligent codperation between the psychiatrist and internist in- 
tent upon studying together the physical and mental symptoms 
associated with the vagaries of feeling, thinking and acting 
occurring in every patient admitted to the wards of a general 
hospital. This entente would be of assistance, not only in laying 
the foundations of an exact knowledge of the psycho-neuroses, 
but as an aid in understanding human nature. A pooling of 
clinical interests is needed in order to conduct a successful attack 
upon the problem of the psycho-neuroses which are probably a 
greater menace to civilization than are all the hostile military 
forces in the world. 

In the vertebrate embryo there is an excellent opportunity of 
tracing the development of the different nervous tracts in relation 
to the rapid elaboration taking place in responses as higher cen- 
tres modify and inhibit more primitive impulse; an important 
relation to understand in its bearing on the psycho-neuroses. 
We are accustomed to talk quite glibly without possessing any 
definite knowledge of the subject about the rebellion of these 
lower centres in ‘‘shell-shock’’ against the control imposed by 
the autocracy assumed by the new brain. 

Professor H. H. Lane, at my suggestion, studied some of the 
earliest reactions in the embryos of guinea-pigs with a view 
to correlating as far as possible the progressive changes taking 
place in the nervous system during growth with the increasing 
complexity of reaction and the assumption of control by the new 
brain. He demonstrated that ‘‘avoiding reactions’’ took place 
in response to olfactory stimulation before the olfactory lobe was 
connected by differentiated nerve tracts with the cerebral cortex. 
The fact that an ‘‘avoiding reaction’’ does occur without the 
intervention of the cerebral cortex suggests the interesting ques- 
tion as to what extent in fear the subsequent responses take place 
without the participation of the higher centres. An interesting 
study could be made to determine in what manner these primitive 
responses are modified as the cortex gradually assumes control. 
A number of years ago I suggested that light would be thrown 
upon this problem by correlating the earliest reactions of the 
human embryo and the progressive structural changes taking 


BEHAVIOR IN WAR AND PEACE 285 


place in the nervous system ; and pointed out the excellent oppor- 
tunity there is in the obstetrical wards of a hospital for extending 
these observations to the human subject. Studies of this character 
are needed to assist in determining what factors are introduced 
as the higher begin to dominate the lower centres, and when 
this is known then the way is open to analyze the conditions 
responsible for ‘‘a conflict.’’ 

Hughlings Jackson,* in a remarkable series of lectures, called 
attention to the control exercised by the ‘‘higher nervous arrange- 
ment’’ over the lower forms from which they had been evolved, 
and compared it to the action of a government directing the nation 
from which the government had been evolved. When any dis- 
turbance in the coordination of function in the higher and lower 
centres take place we have to consider not only the effect of ‘‘the 
taking off’’ of the control, but also the ‘‘letting go’’ of the lower 
functions. The sudden removal of the governing body of any 
country gives reason for lamenting, ‘‘(1) the loss of service of 
eminent men, and (2) the anarchy of uncontrolled people.’’ This 
distinguished representative of the medical profession recognized 
the value of that fundamental knowledge of man which it is not 
inconceivable that some day we shall require our statesmen 
to possess. 

When we come to consider the question of how instincts are 
inherited, we begin to be confronted with serious difficulties. The 
physician is too much inclined to assume that biological inheri- 
tances are transmitted in the same way that psychological 
inheritances are passed on from one generation to another. There 
are two forms of heredity, says Professor Ward; ‘‘the one with 
which the biologist deals and this which he leaves to the psycho- 
logist—who usually leaves it alone.’’ 


VII 


Reference to the methods used in the Air Service for studying 
the personality of the aviator + indicates the possibility of utiliz- 


* Croonian Lectures, 1884. 
+ Manual of Medical Research Laboratory, U. S. War Department, 
Air Service, 1918, pp. 200-212. 


286 HARVEY SOCIETY 


ing even our very limited store of knowledge for conserving both 
energy and life. These examinations are conducted with a view 
to determining the emotional and mental fitness of an aviator 
to fly. It is also interesting to note that far more attention 
is paid to-day in analyzing the predisposition of an aviator and 
determining his fitness for his task than in selecting a President. 
Is it unreasonable to believe that some day we shall judge our 
rulers by their ‘‘predispositions,’’ and not by their arguments? 
The efforts made to safeguard the mental hygiene of the aviator 
unquestionably prevented many accidents. 


MEDICAL RESEARCH LABORATORY 
Hazelhurst Field, Mineola, L. I., N. Y. 


INaMe Tey Hetacie Wi cntnyeie ue eas sPae roi Ranks ees Organization...... 


I. Aviation: 
Enlistment—date, place, sworn in, Assigned to (branch of 
service)—Active Service—Entrance or Transfer to Air Service. 
—Aviation School work—Repeats.—Aviation—active service— 
date of commission, dates and places of training—Hours of 
flying—Maximum Altitude. Duration.—Accidents.—Reasons for 
selecting aviation. 


II. Personal History:—Age—S. M. W. 
Diseases (children’s and adult). 
Injuries, operations. 

Education, School and College. 
Athletic training. 

Occupation of Civil Life—Success. 
Tobacco—Alcohol—Sleep—Family. 


Ill. Physical Examination :— 
Ht. Wt.—— Gain or Loss. 
Pupils—Reaction to light and accommodation, 
Secondary dilatation. 
Knee Jerks. 
Psycho-motor Tension.— 


BEHAVIOR IN WAR AND PEACE 287 


Tic—Tremor. 
Extension in fingers and hands. 


Tongue. 

Drawing parallel lines. 

Writing slowly. 
Dermagraphia before and after rebreathing. 
Appearance—Tired. 

Evidence of anxiety or of stress. 


IV. Personality study :— 

Observation, good or bad—Resourcefulness—Forcefulness. 

Frankness (Does he seem to be genuine’). 

Spontaneity—Emotivity. 

Temperament (mood), even, lively, dull, unsteady, tendency to 
unburden, stable. 

Contentment. 

Alertness. 

Aggressiveness. 

Mental Reactions, quick, slow, deliberate, degree of mental energy, 
dull, well balanced, high tension. 

Coéperation—S portsmanship—Self-possession. 

Remarks : 

Rating : 


This study of the aviator’s personality judged from the medi- 
eal standpoint alone is not sufficiently comprehensive for all 
purposes, but the lines of inquiry followed were suggested by 
the experience gained from examinations made on the field. 
The initial mental symptoms of fatigue have a special interest. 


MENTAL SIGNS OF STALENESS 


1. Lack of pleasure in the work. 

2. Lack of confidence. : 

3. Disgust at the whole business. 

4, Nervousness in attacking the task ; technique goes to pieces ; 

he analyzes every part of it and sees his task too minutely. 

When these are present the aviator should not be allowed 
to fly. 

Personality studies properly made could be used to great 
advantage in laying the foundations for a rational education. 


288 HARVEY SOCIETY 


The Qualification Card for use in schools and colleges was sug- 
gested to me as the result of examining students, and trying to 
assist them in some of their difficulties in adjusting life. The 
need for this kind of work both in schools and universities is 
far greater than had been imagined. The information asked for 
ean be obtained by any intelligent teacher, and it is of such 
a character that special technical knowledge on the part of the 
examiner is not necessary in gathering the data. Important 
results have followed the introduction of even such brief per- 
sonality studies and already have led to more frequent and 
sympathetic codperation between parents, teachers and physi- 
cians. A number of years ago we suggested that a training in 
pedagogics should aim to give teachers some practical insight 
into the methods of exploring a personality; in order that they 
might appreciate the beginning of the pathological tendencies 
which are responsible for so many failures in life.* The pres- 
ent alarming incidence of nervous and mental diseases calls for 
more active efforts on our part to secure reliable information in 
regard to the genesis of these disorders and the methods of 
preventing their development. 


VIII 


The problem of human behavior cannot be discussed without 
some reference being made to the emotional and mental symp- 
toms indicative of the unrest which is appearing in all parts of 
the world. These disorders are part of the price man is paying 
to-day for his neglect in making adequate provision for the study 
of human nature. Various epidemics of bodily disease during 
the middle ages seriously menaced the progress of civilization. 
Since that time the progress in medical science has lessened this 
danger; but unfortunately relatively little attention has been 
given to limiting the spread of mental disorders. As the result 
of the greatest war in history and the present unsettled social 
conditions, our attention is now being forcibly directed to the 


* Paton, S. Psychiatry, 1905. J. B. Lippincott Company, p. 197. 


BEHAVIOR IN WAR AND PEACE 289 


urgent need to remedy this defect. While we are waiting as 
patiently as possible for additional information in regard to the 
fundamental qualities of human nature, we should let our states- 
men realize that the data already in our possession could be used 
to advantage in assisting to restore the emotional and mental 
balance essential to the establishment of peace and order. 

The emotional disorders sweeping over the world to-day seem 
to have a common basis; although the symptoms are modified 
by the local conditions existing in the different countries. There 
is no more room for believing that the emotional instability 
appearing in Russia, France, or the United States is traceable in 
each country to independent causes than there was for believing 
that the extraordinary action of the flagellants, the dancing 
manias, and various forms of psychotie disturbances appearing 
in the middle ages were the result of diseases differing specifi- 
eally from each other. 

Doctor Johnson in defining the word insanity anticipated 
some of our modern psychiatric conceptions when he stated that 
‘* all power of fancy over reason is a degree of insanity.’’ Just 
as soon as fancy begins to supply the data upon which we base 
our plan for the conduct of life, the condition we call insanity is 
present. This is the biologic conception of insanity and not the 
one generally given in the court room. The sane man faces 
squarely the plain facts connected with living and does so under 
all ordinary circumstances without developing a feeling of inse- 
curity or inadequacy. He reviews calmly the fact that life is 
a struggle for existence and the progress of civilization is neces- 
sarily very slow. Having faced these facts, reason, not fancy, 
then prepares and elaborates his program for living. The psycho- 
neurotic, driven by a sense of inadequacy and insecurity, dodges 
the main issues. To him the idea of struggle and the slowness 
of progress are harrowing thoughts. Concrete, well-defined situa- 
tions are extremely harassing as the possibility always exists of 
being forced to meet an unwelcome intruder in the guise of some 
unsolved personal question. General theories and abstractions 
take the place of facts, and if the truth cannot be avoided, to 
quote from Huxley, ‘‘its fair face is varnished with the pestilent 

19 


290 HARVEY SOCIETY 


’ 


cosmetic rhetoric.’’ Just as soon as confidence in self is shaken 
various ruses are adopted to restore the emotional equilibrium. 
Different degrees of egotism may represent the compensatory 
efforts to effect a satisfactory readjustment. The aggressive forms 
of egotism are protective reactions useful in keeping intruders 
off the premises ; thus reducing the danger of the sudden exposure 
of the real personality. In preparing these defenses the power 
of fancy over reason is often clearly in evidence. 

Society has unconsciously made it increasingly difficult for the 
psycho-neurotic to face his own problems. We have been social- 
ized in thought to the extent of avoiding a great many personal 
questions, and the word individual has almost been dropped 
from our vocabulary. 

Feelings and thoughts as well as our living quarters are shared 
with our friends and acquaintances. Such a very keen interest 
has been developed in what other people are doing there is seldom 
time to put our own house in order. It is a great comfort to the 
psycho-neurotie intellectual to forget temporarily the difficulties 
of the individual citizen and to discuss class privileges, class 
distinctions, class rivalries and class judgments. He is also 
enthusiastic in discussing general social conditions, a method of 
diverting attention from the galling recollections of personal 
defeat and personal disappointment. A form of competitive 
notoriety in championing the cause of the people serves to divert 
attention from personal failure. Any suggestion in regard to 
making the facts derived from the study of individual cases of 
human behavior the basis for a science of character is received 
with scant consideration. The psycho-neurotie dreads to be left 
alone with himself but loves to pose in public as a martyr. He 
runs away from unsolved personal problems and develops fanati- 
eal enthusiasms in studying general social questions; and tries 
to put democracy on the patent-medicine shelf as a universal 
remedy hoping thereby to avoid the irritation and mortification 
associated with the recollection of personal insufficiency. 

Numerous illustrations selected from actual life could be 
cited as evidence of the skill acquired in camouflaging the 


BEHAVIOR IN WAR AND PEACE 291 


bitterness of personal defeat and disappointment by resorting 
to semi-rationalization. 

There is the familiar case of the neurotic mother exhibiting 
such an abnormal degree of solicitude in reforming the entire 
educational system, while subjecting her own children to such 
distracting influences in the home that the natural difficulties 
of acquiring good mental habits are immeasurably increased. 
Then there are the men and women who are continually declaring 
their interest in the ‘‘brotherhood of man”’ or in the ‘‘cause 
of the common people’’ who in the inner circle of the home 
exhibit peculiarly exasperating qualities of both temperament 
and character. 

- An interesting illustration of the substitution of general 
terms to describe a concrete situation is exemplified by the person 
who is afraid to apply the tests suggested by reason to determine 
whether his own life has been a success, and suddenly surprises 
his friends by announcing his conviction that there is a great deal 
of good in the present Bolshevist movement. This statement, 
which at first may be as much of a surprise to the person making 
it as to his friends, exposes a side of the personality which was 
carefully hidden from the public view until the cat jumped 
out of the bag. Such a person does not think pertinently nor 
through any of the real issues in his own life. Extreme solicitude 
in concealing personal defects generally results in the exposure 
of the real personality. 

The present widespread emotional instability gives rise to 
many and strange repugnances. In one class of persons where 
there is little intellectual capacity to effect a partial compensation, 
the symptoms of ennui and boredom express the general dissatis- 
faction with self. If there is sufficient mentality to effect a 
compensation of even temporary value there is apt to be a rapid 
multiplication of wish-directed thoughts diverting attention away 
from the skeleton in the closet. The ineffectual character of the 
compensation may be indicated by attacks of mental depression 
and these are followed by a period in which great zeal is shown 
in elaborating plans for the general improvement, not of the 
individual, but of society. The various plans proposed run the 


292 HARVEY. SOCIETY 


gamut from parlor socialism to Bolshevism. We need to be 
reminded constantly of the fact, and reminded by a psychiatrist, 
too, that we can remain sane only if we begin by setting our own 
house in order before starting out to reform the world. And the 
first step in this direction is to learn to face life as it is, and not 
as we should prefer or wish to have it. ‘‘Better the sight of the 
eyes than the wandering of desire’’ is an old Hebrew maxim 
based on the recognition of a very sound principle of mental 
hygiene which was formulated a great many centuries before 
Freud redirected attention to the danger of uncontrolled wishing. 


IX 


It is fortunate for Society that the physician is still interested 
in individual cases, and has not yet shown any indication of 
studying disease or treating his patients as the average social 
reformer attempts to do, en masse. His work compels him to 
attempt to make a diagnosis of each person’s malady, and his 
generalizations as a rule summarize the definite findings of spe- 
cific eases. His practice is based on at least the tacit recognition 
of the principle that human beings are independent autonomous 
organisms, each requiring special study and no two are ex- 
actly alike. 

The average American could profit a great deal by taking 
lessons in the art of balancing his personal accounts, emotional 
as well as mental, and adopting a rational plan for finding out 
whether the debit and credit columns tally. There is sufficient 
evidence to show that as a nation we are untrained in this art. 
Our personal feeling of insecurity, our fear of finding superiors is 
revealed in the emphasis placed on the word ‘‘equality’’ while 
relatively little is said about justice. We are driven to take this 
position by promptings from the subconscious field reminding 
us continually of our inadequacy and unfulfilled ambitions. It 
would be a great comfort to many to feel that there were no physi- 
cal or mental or social inequalities. Marked solicitation charac- 
terizes our plans for developing some form of government in 


BEHAVIOR IN WAR AND PEACE 293 


which the biological inequalities of individual citizens will be 
carefully concealed. As a people we are always afraid of finding 
superiors, and this unfortunate national characteristic is one 
result of the failure to cultivate an intelligent critical spirit. If 
we were satisfied that Democracy had accomplished all we claim 
for it, there would be less inclination to parade its virtues upon 
every occasion. The man who is honest at heart seldom makes 
any personal reference to his own particular virtues, and adver- 
tised virtues are rarely to be considered as pledges of good conduct. 

We have just begun to realize the danger of wishful thinking. 
Most of our wishes are artfully concealed, not only from public 
inspection, but as a result of skilful self-deception even from our 
own recognition. As a wish from the biological standpoint is 
nothing more or less than an indication of the ‘‘motor set’’ de- 
termining the direction of all our activities, the elements com- 
posing it are found largely in our subconscious life. This is a fact 
of which we need to be constantly reminded as the wish when 
translated into overt action may be so easily reinforced by emo- 
tion that its genesis is soon hidden beneath a very complex series 
of compensatory responses. 

Let us hope that the physician to-day will make the best use 
of the opportunity which the war has brought to him to acquire 
for himself and to assist others to acquire the art of intelligent 
self-criticism which is so essential in protecting individuals 
against the incidence of nervous and mental disorders as well 
as in compensating for a pronounced defect in our national life. 
Intelligent self-criticism is needed in this country in order to 
assist in repelling those disorganizing forces which now dissipate 
individual as well as national energy. 

The physician, as has been indicated, should be better qualified 
than the member of any other profession to undertake the study 
of body-mind problems, and immediate action should be taken 
to provide adequate opportunities in our medical schools for 
studying the problems of human behavior. The future of our 
civilization depends first upon the realization of the need for 
training investigators competent to explore these special problems. 


HARVEY SOCIETY 


Mental Social 
Hygiene Service 


Pediatric Surgical 
Clinic Clinic 


CLINICAL RELATIONS 


Study of Human Behavior 


NEURO-PSYCHIATRIC INSTITUTE 
Hospital and Laboratories 


LABORATORY RELATIONS 


Physical & Chemical Physiological Anatomical 
Laboratories Laboratory Laboratory 


Anthropological Psychological 
Laboratory Laboratory 


Institute for Study 


of Geneties 


A neuro-psychiatrie institute is the logical centre for this 


work. The institute should be in close and sympathetie con- 
nection with other clinics and laboratories, and also with other 
scientific departments in a university in order that there may be 
collaboration between investigators in related fields of study. 
When once these centres have been established then we may 
know that an intelligent effort is being made to go to the root of 
many of our social troubles. At the present time money and 


BEHAVIOR IN WAR AND PEACE 295 


energy are wasted in the treatment of the last stage of disorders of 
adjustment found in workhouses, asylums, prisons, reformator- 
ies and various other institutions. The ‘‘down and outs’’ bear 
witness to our unpreparedness to attack directly the real enemies 
of our civilization. It is singularly unfortunate that in a republic 
it has never been possible, until very recently, to organize a 
centre well equipped for carrying on explorations in the field 
of human behavior. 

In Newark, N. J., under the direction of Dr. C. C. Beling,* 
a Bureau of Mental Hygiene is now being organized as one of 
the divisions of the Department of Public Affairs. 

The physician realizes probably to a greater degree than the 
members of any other profession that present social disorders as 
well as other diseases can be most effectively studied by begin- 
ning with the consideration of the facts in individual cases. His 
training as well as his practical philosophy of life should make 
it easy for him to appreciate the value of Socrates’ advice, 
*“Know thyself.’’ Upon the success attained in assisting people 
to practice the precept which for so many centuries has been 
repeated automatically with academic precision, depends the sta- 
bility and development of human institutions. 


* Health Bulletin, May, 1919. Issued monthly by the Department of 
Health, Newark, New Jersey. 


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