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JOURNAL 

OF THE ASSOCIATION OF 

MILITARY 

SURQEON5 

OF THE UNITED STATES. 

EDITED BY 

JAMES EVELYN PILCHER, M.D., L.H.D. 

MAJOR AND BRIGADE SURGEON OF UNITED STATES VOLUNTEERS, 
CAPTAIN, RETIRED, IN THE UNITED STATES ARMV. 



VOLUME XII. 




CARLISLE, PENNSYLVANIA. 
THE ASSOCIATION OF MILITARY SURGEONS. 

1903. 




Contributors. 




Major AZEL AMES, U.8.V. 

Dr. AMERICUS REEVES ALLEN. 

Major DANIEL MITCHEL APPEL, U.S.Army. 

Lieutenant CHARLES NORTON BARNEY, U.S.Army. 

Lieutenant Colonel JOHN SHAW BILLINGS, U.S.Army. 

Major HENRY P. BIRMINGHAM, U.S.Army. 

Major WILLIAM CLINE BORDEN, U.S.Army. 

Major ALBERT HENRY BRIGGS, N.G.N.Y. 

Brigadier General J. FRANCIS CALEF, Conn. N.G. 

Lieutenant JAMES CARROLL, U.S.Army. 

P. A. Surgeon CHARLES ALEXANDER CRAWFORD, U.S. Navy. 

Captain JOSEPH J. CURRY, U.S.V. 

P. A. Surgeon JOHN BENJAMIN DENNIS, U.S. Navy. 

Major RUDOLPH G. EBERT, U.S.Army. 

Surgeon SHELDON GUTHRIE EVANS, U.S. Navy. 

Colonel RICHARD EXHAM, R.A.M.C. 

Captain HENRY CLAY F.ISHER, U.S.Army. 

Lieutenant CLYDE SINCLAIR FORD, U.S.Army. 

Colonel ALFRED C. GIRARD, U.S.Army. 

Contract Surgeon JOHN NELSON GOLTRA, U.S.Army. 

Colonel WILLIAM CRAWFORD GORGAS, U.S.Army. 

Lieutenant Colonel VALERY HAVARD, U.S.Army. 

Captain ARTHUR R. JARRETT, N.G.N.Y. 

Lieutenant Colonel NATHAN S. JARVIS, N.G.N.Y. 

Major JEFFERSON RANDOLPH KEAN, U.S.Army. 

Lieutenant Colonel HENRY SAYLES KILBOURNE, U.S.Army, 

Captain JOHN STEWART KULP, U.S.Army. 

Dr H. H. LANGSDORF.-Dr. C. S. LUDLOW. 

Lieut. Col. ZACARIAS ROJOS de MOLINA, Mexican Army. 

Captain EDWARD LYMAN MUNSON, U.S.Army. 

Major CHARLES BEYLARD NANCREDE, U.S.V. 

Colonel J, L. HUBERT NEILSON, A.M.S. Canada. 

Colonel NIMIER, French Army. 

Major WILLIAM OTWAY OWEN, U.S.Army. 

Major JAMES EVELYN PILCHER, U.S.V. 

Captain FREDERICK P. REYNOLDS, U.S.Army. 

Honorable ELIHU ROOT, Secretary of War. 

Surgeon GEORGE ROIHG ANGER, U.S. Navy. 

Lieutenant Colonel B. SKINNER, R.A.M.C. 

Surgeon JOHANN STEINER, Austko Hungarian Army. 

Medical Inspector FRANKLIN BACHE STEPHENSON, U.S.N. 

Captain JOHN HAMILTON STONE, U.S.Army. 

Captain JAMES PETER WARBASSE, N.G.N.Y. 

Surgeon FREDERICK WILLIAM FERDINAND WIEBER, U.S.N. 

Major FRANCIS ANDERSON WINTER, U.S.Army. 



t^^^o 




JourTnfRf the 
Association of flilitary Surg^eons 

of the United States. 
VOLUME XII, 1903. 



THE MEDICAL DEPARTMENT OF THE UNITED 
STATES ARMY TRANSPORT SERVICE. 

By major henry SAYLES KILBOURNE. 

SURGEON IN THE UNITED STATES ARMY; LATELY MEDICAL SUPER- 
INTENDENT UNITED STATES ARMY TRANSPORT SERVICE. 

THE Army Transport Service is an outgrowth of the war 
with Spain. Prior to that event troop ships were not 
owned or operated by the United States. The require- 
ments of the Array for ocean transportation in former wars have 
been met by the employment of chartered vessels adapted for the 
occasion by such hasty refitting as the nature of the available 
shipping and the time for preparation allowed — the result being a 
series of makeshifts more or less defective. 

For the Cuban campaign coastwise steamers, chiefly of lines 
engaged in the West India and Gulf trade, were hastily chartered 
and dispatched to Tampa, their freight decks fitted with crowded 
tiers of wooden bunks and little else for the accommodation of 
the troops. Some vessels of this improvised fleet had state rooms 
and other conveniences and luxuries for cabin passengers avail- 
able for officers, with but small space below suitable for enlisted 
men with their equipage and supplies. Others were deficient in 
cabin room but with large freight space unsuitable for passengers 
of any sort. All were more or less wanting in adequate equip- 
ment for the proper transportation of troops during a protracted 
sea voyage. The lower decks, designed for freight carrying, 

(1) 



2 MAJOR HENRY SA YLES KILBOURNE. 

lacked ventilation, lighting, latrines and fixtures for washing, 
bathing, messing, etc., necessar>' for maintaining the health 
and morale of troops at sea. In the hot and humid air of the 
tropic these deficiencies quickly became intolerable. Overcrowd- 
ing added to the difiiculties of the situation and a voyage pro- 
longed to three or four times the normal period of making the 
passage further complicated the conditions of the movement. 
The hardships of this protracted voyage could not have been a 
good preparation for the necessary fatigues of the impending 
campaign, although, such was the enthusiasm, without immedi- 
ate eflFect on the spirit of the soldiers. They lived as much as 
po.ssibleon the upper decks, the fine weather permitting this, and 
went below into the stifling heat and moisture only when com- 
pelled by necessity. 

These experiences, with some variations, were repeated on 
the reembarkation of the 5th Army Corps after the surrender of 
the city of Santiago de Cuba. The condition of the victorious 
troops on landing at Montauk, at the close of the campaign, is 
too well known to need comment. The necessity for improved 
methods of over sea transport for troops and war material had, 
among other things, become obvious. In the meantime similar 
difficulties had been encountered in the movement of the first 
expedition to the Philippines. On the Pacific coast, as on the 
Atlantic seaboard, it became evident that suitable vessels for the 
transport of an increasing army rendered necessary by the in- 
surrection of the Filipinos, could hardly be obtained. The occu- 
pation of Cuba and Porto Rico also demanded a continuous ocean 
ser\nce which commercial lines were unable to furnish in a satis- 
factory manner. 

To meet these emergencies on both coasts the War Depart- 
ment organized the Army Transport Service as a separate branch 
of the Quartermaster's Department. A board of officers, the 
senior being the late Gen. Ludlow, devised the scheme and 
formulated the regulations for operating the enlarged service. 
Marine experts gave aid to the Army. Steamships of suitable 
design and tonnage were found on both coasts, surveyed, pur- 
chased, and refitted on plans drawn to meet the requirements of 
troops in transit over sea, as well as for the shorter coastwise 






r 



i 




MAJOR HENRY SA YLES KfLBOURNE. 



voyage to the Spanish Main. The organization provided for 
two divisions of the ocean service, one with headquarters in 
New York City, the other in San Francisco, having similar 
ofl&cers and employees at both stations. An officer of the Quarter- 
master's Department had direction and control as Superintendent, 
assisted by a Commissary and a Medical Officer. To each trans- 
port was assigned a quartermaster, with general charge of the 
ship and a transport surgeon from the Army. The ship's officers 
and crew were drawn from the Merchant Marine, excepting a 




Berth Deck of the United States Army Transport, ''Sumner,'* 
detail from the Army Hospital Corps. The transport quarter- 
master performed the duties of a commissar>' in the absence of an 
officer of that Department. Members of the Hospital Corps and 
Commissary Sergeants were detailed to duty on board as their 
services might be required. 

The plans for refitting vessels for troop ships provided for 
berthing on one or two decks below the main deck, according to 
the size and plan of the ship, with an allowance of from 80 



UNITED STATES ARMY 7RANSP0RT SERVICE. 



to 100 cu. ft. of air space per man. Steel berth sections in 3 
tiers had canvas bed bottoms lashed to the side frames, removable 
for washing. All berth deck and dead air spaces below had 
air ducts leading to incast and outcast ventilator fans on the upper 
decks; the state rooms, saloon, and hospital having also electric 
fans. The whole ship was lighted by incandescent lamps from 
dynamos on the main deck. The main deck, excepting engine 
space and crew's quarters forward, was occupied by mess rooms, 
cook's galleys, dining saloon, bakery, etc. 




Main Ward of the Hospital on the United States Army Transport, ""Meade/* 

On the larger transports the ship's hospital occupied the after 
part of the main deck and aflForded accommodation for from 3 to 
5% of their troop capacity. The airspace per man averaged from 
100 to 150 cu. ft. in the main ward. Above the latter an isola- 
tion ward with a separate room for intractable patients gave ac- 
commodation for from 6 to 12 sick. Separate lavatories, baths, 
and closets for this ward secured isolation of infectious cases. 
A lavatory, closets, a dispensary, operating room, linen room, 
special diet kitchen, surgeon's office, and rooms for attendants, 



6 MAJOR HENRY SA YLES KILBOURNE. 

all with requisite fixtures and furniture adjoined the main ward. 
Lockers for clothing were placed along the ship's sides. A gen- 
eral store room for medical supplies on the deck below had access 
through the floor of the main ward. Air ducts overhead having 
lateral discharge into the ward supplied adequate ventilation 
when port lights were closed in heavy weather. Double tier steel 
berth sections with woven wire bed bottoms (later exchanged for 
canvas) were secured to the deck. Surgical instruments and ap- 
paratus and medical supplies for three months for all on board 
completed the medical equipment. 

On the troop decks and spar deck special attention was given 
to the installation of lavatories, shower baths, water closets, 
urinals, and laundry tubs, as well as an accessible supply of drink- 
ing water for the troops. The water supply came from two 
sources, the ships tanks and a distilling apparatus of sufficient 
capacity to supply potable water for all on board in case of failure 
or impurities of the water shipped in tanks at ports of call. A re- 
frigerating plant with an ice machine attachment provided cold 
storage for all perishable food stuffs and produced ice for the hos- 
pital and saloon mess. In hot latitudes the drinking water was 
cooled by refrigerating coils. A steam laundr\' set up on one 
transport not proving satisfactory in operation was substituted 
by fixed tubs on the others, to which the men had access in relays. 
Excepting in a rough sea, when the majority succumbed to sea 
sickness, these various accessories ensured clean, dry, well aired 
and light dormitories. In tropical seas the men sought to be as 
much as possible on deck. 

On the main deck forward of the engines all space excepting 
crew's quarters could be cleared by folding and stowing the mess 
tables and benches, thus providing room for exercise and recre- 
ation in heavy weather. Besides the articles composing the army 
ration issued to troops and crew the transport commissary sup- 
plied special foods for the sick in hospital as well as additional 
articles for the saloon mess. Regular inspections by the ship's 
officers and the commanding officer of troops in accordance with 
transport regulations was gradually evolved as officers and em- 
ployees became familiar with their duties. Various modifications 
of the original plans were adopted to conform to the size and 






I 




8 MAJOR HENR Y SA YLES KILBOURNE. 

model of the ship and the nature of their service. On the West 
India route hammocks proved more practicable for the troop decks 
than the berth fixtures installed on the over sea troop ships, thus 
making these decks available for freight carrying as occasion de- 
manded. The hospital accessories needed on this route were less 
extensive than those on the larger vessels on the longer voyage 
to the Philippines. Of the fleet refitted at various Atlantic ports 
the greater number carried troops from New York City to Manila, 
via the Suez Canal, sailing thence to San Francisco, and there- 
after being transferred to the Pacific division of the Service, as the 
field of military operations shifted from Cuba to the Philippines. 

On account of the liberal provision for the sick and wounded 
made on the transports and the greater frequency of their voyages 
to and from Manila it appeared practicable to dispense with the 
ser\'ice of two of the hospital ships employed during the Spanish 
war and later dispatched to the Philippines. These, although 
having a record of good service on the Atlantic Coast during the 
war with Spain, proved to be not well adapted for the longer voy- 
ages of the Manila service. The ** Relief,'* a model hospital ship 
for coastwise service, was for a time, retained at Manila as a 
floating hospital after a single voyage to San Francisco from the 
former port to which she had been dispatched by the Eastern 
route, and after voyages from Manila to China and Japan, during 
military operations in the former country. The hospital ships 
on their acceptance by the Army Medical Department passed 
from the Transport Service to the direct control of the Surgeon 
General of the Army. Of the three vessels specially fitted for 
.service as hospital ships all have since been surrendered to the 
Quartermaster's Department for other service. 

Since the return of the Volunteer troops from the Philippines 
all chartered transports have been released from service. Of these 
a .small number served as animal tran.sports, the practice being to 
move men and horses separately. Upward of twelve troop and 
freight transports now continue in ser\'ice the greater number 
sailing between San Francisco and Manila, a voyage of about 30 
days each way. The service has been continually improved since 
its inception and is at this time operating to the satisfaction of 



UNITED STATES ARMY TRANSPORT SERVICE. 9 

the supply departments of the army in their labor of maintain- 
ing the efficiency of the Army of occupation in the Philippines. 
The problem of moving large bodies of troops over sea and deliv- 
ering them in good condition for campaigning in the tropics ap- 
pears to have been fairly solved by the methods and appliances of 
the Army Transport Service. The problem of moving them across 
the continent without loss or injury, by adoption of the methods 
of railway tourist service has also been successfully dealt with. 
The further problem of moving large numbers of troop, battery, 
and draught animals on protracted voyages remains for future 
development. 

The Transport Service is operated under a special code of 
regulations defining the duties of its ofl&cers and employees; the 
authority of officers in command of troops in transit, prescribing 
the daily routine at sea and methods of embarking and disem- 
barking troops their equipage and supplies. These regulations 
have been amended as experience demanded with reduction of 
friction and manifest improvement of the service. Details of plan 
of the earlier vessels became modified in the later ones as the 
needs of the troops and the working of the apparatus installed on 
board required. With naval practice as a model it soon became 
obvious that soldiers, and especially' unseasoned troops, require 
different treatment from .sailors. Unaccustomed to the sea and 
to the confinement and monotony of shipboard soldiers quickly 
fall out of condition for ser\'ice unlesss special care be taken to 
maintain their efficiency. A constant tendency toward over- 
crowding the ships, general seasickness, and the* prevalence of 
infectious diseases, to which recruits and new troops are every- 
where subject, rendered effective sanitation difficult. These dis- 
orders, inseparable in some degree from all military operations by 
sea, had been foreseen and consequently mitigated. The indif- 
ference of mariners generally, to matters of sanitation not hal- 
lowed by the practice and traditions of seafaring had to be met, 
overcome, or compromised, in order to maintain a military hy- 
giene on board adapted to marine conditions. The greater obsta- 
cles arose from the necessary economy of space on shipboard. 

Among improvements in sanitation effected, the following are 
the more notable: The prevalent dampness of lower decks was 



10 MAJOR HENR Y SA YLES KILBOURNE. 

diminished by the incast and extraction fans installed on all over- 
sea troop ships. A free circulation of air below appears to be a 
prime necessity for vessels sailing in tropical waters where com- 
bined heat and humidity are inimical to passengers and destruc- 
tive to cargo. Apparatus for cooling or wanning the air distribu- 
ted added further to the health and comfort of the troops. The 
use of folding mess room furniture (tables and benches) per- 
mitted the clearing of deck space for exercise and recreation of 
the troops during heavy weather when they would otherwise be 
restricted to the berth decks. The refrigerating apparatus besides 
supplying cooled air improved the dietary of the ration by afford- 
ing cold storage preservation of perishable foods, as well as ice for 
the sick. The segregation of the sick with adequate hospital 
appliances facilitated their proper care and the protection of pas- 
sengers and crew. The installation of lavatories, baths, latrines, 
and laundry, on the troop decks prevented disease and preserved 
the morale of the troops. An ample supply of pure water was 
secured by the double system of storage and distillation. These, 
with separate galleys for soldier's mess where a full ration could 
be prepared and served, and strict cleanliness on the berth decks 
met the principal requirements of effective sanitation. 

Quarters for the ship's company were refitted on similar lines 
but with yet greater economy of space. Ample deck room for sol- 
diers is had only at the expense of carrying capacity. In berth decks 
with 9 ft. between deck floors an allowance of 6^x4 ft. deck .space 
for 3 tier double berth sections, including gangways 3 ft. wide, 
yields 6^x4x9:r234 cu. ft. airspace, or 78 cu. ft. per man, fixtures, 
furniture, etc. included. This is clearly insuflScient on theoreti- 
cal grounds for .proper ventilation; practically it is deemed a lib- 
eral allowance for transportation by sea and is increased only by 
outfall of the ship's sides and large hatches in some compartments 
of a troop ship. The evils of such close stowage are mitigated by 
fan ventilation, electric lighting and cleanliness of the person, 
bedding, and deck floors. Vacating the upper berth affords a 
ready remedy but seldom available. Hammocks as used in the 
Navy swung" in two tiers offer more air space when in use and 
more free deck space when stowed. Soldiers prefer the ' 'standees. ' ' 



UNITED STATES ARMY TRANSPORT SERVICE, \\ 

The number of fixtures on troop decks in lavatories, bath rooms, 
water closets and urinals varies with troop capacity. A wash 
basin for each 10, a closet for 20, a shower bath and urinal for 30 
men are sufficient for disciplined troops, but should be had in 
larger proportion for untrained men. 

It is obvious that the berth decks are not suitable for squad 
rooms. In daytime the men must live on the upper decks. These 
on all transports are much encumbered with machinery, life 
boats, and other marine apparatus, yet the larger ships usually 
afford space for the men to move about in when occupied by 
comp>anies, or battalions in turn. The mess service on a full ship 
is necessarily by relays when a seat and place at table is ordered, 
or allowed. From one-third to one-half of the men can be served 
at the same time without delay, 

The equipment of a transport hospital is similar in personnel 
and materiel to that of a post hospital with allowance for the 
limitations of a ship. The medical service, medical supplies, 
records, reports, etc. , are maintained on army methods. Provis- 
ion is made for aseptic surger>', special diets, and isolation of in- 
fectious diseases. On the larger ships, of the ** Thomas*' and 
**Logan" class, carrying a. maximum regiment there is hospital 
accommodation for about 70 sick. This has proved adequate 
excepting when measles has prevailed among unseasoned troops 
on board. For the greater requirements of raw troops it was 
found necessary to add largely for waste and loss of supplies in 
their outfitting. Quarters for female nurses were omitted as in- 
expedient in the plan of the transport hospitals. Carried as pas- 
sengers their services have frequently been utilized and proved 
valuable as in the general hospitals on shore. Further details of 
the service of transports are omitted. Plans and a description of 
the troop ship * 'Thomas' ' may be found in the Reference Handbook 
Medical Sciences (Wood, N.Y., 1901) Vol. I, in an article contribu- 
ted by the author of this sketch. The administration and organi- 
zation of the transport service are set forth in the * 'Regulations of 
the Army Transport Service' * published by the War Department 
and amended in a subsequent revision. 



EXPERIENCES OF THE BRITISH ARMY MEDICAL 
SERVICES IN THE WAR IN SOUTH AFRICA. 

By colonel RICHARD EXHAM, C.M.G., 

ROYAL ARMY MEDICAL CORPS; DELEGATE FROM THE 
BRITISH ARMY MEDICAL SERVICES. 

IN the invitation sent to the British Army to send a delegate 
to your Annual Meeting, a wish was expressed that the del- 
egate nominated might be an officer who had served during 
the war in South Africa: hence I have the pleasure of being pres- 
ent at your meeting. The wish I have alluded to has caused me 
to presume that you are desirous of hearing what improvements 
in our arrangements for the care of the sick and wounded the ex- 
periences of that campaign have shown to be desirable: and act- 
ing on that presumption I propose that the remarks I have the 
honor to address to you shall be of a general nature. 

Although heavy guns, throwing large shells to a long dis- 
tance have, of course, been used in many wars as guns of position 
and in siege trains, I think it is the first campaign in which such 
guns have been brought into the field and virtually used as field 
guns. The Boers made such use of guns throwing shells of 96 
lbs. in weight with an extreme range of about 11,000 yards. Al- 
though these shells were not, as a rule, ver>* destructive, they 
occasionally were so. As instances: in Ladysmith 8 men were 
killed and 9 wounded by a single shell; again 6 men were killed 
by another; and a third wounded 5 officers of one regiment. 
Shell fire of this nature necessitated the troops defending posts 
much exposed to it, having to live in deep and covered trenches, 
and this mode of life for a long period was certainly detrimental 
to health. But it is to the effects on medical arrangements in the 
field that I wish particularly to refer. It is obvaous that, when 
guns of such long range are employed, we must expect the dis- 
tance from front to rear over which casualties occur to be much 
greater than formerly, and thus extra labor must be caused to 

(12> 



MEDICAL EXPERIENCES IN SOUTH AFRICAN WAR. 13 

those collecting the wounded. Further, long range fire will often 
prevent Field Hospitals, or even dressing stations, being estab- 
lished as near to the front as is wished and, as a result, wounded 
men have to be carried' a longer distance to such hospitals or sta- 
tions. The modem long range rifles, in a similar manner, cause 
the wounded in an action to be spread over a large area. 

Another peculiarity in the campaign which occasioned the 
wounded to be spread over a larger area than usual, was that the 
whole of the Boer forces were mounted. They were thus able to 
move rapidly to any point of their position threatened; turning 
movements had consequently to be much wider than is usual and 
when large forces were engaged the flanks of our army were often 
very many miles from the centre of advance and from the lines of 
communication. 

Although it is not to be expected that in any future wars 
the whole of any nation's forces will consist of mounted men, it 
is certain that the employment of such troops, particularly in the 
form of mounted infantry, will be much greater than has hither- 
to been the case and we, as army surgeons, must consider what 
effect this will have on our field medical arrangements. The ex- 
perience of the campaign has shown the British Medical Ofiicers 
that a large increase in the personnel of bearer companies is nec- 
essary. It has also made many of the opinion that in addition to 
the ambulances with these companies, one should form part of 
the regular transport of each mounted unit. 

Although it is evidently necessary that the personnel of our 
bearer companies must be augmented, it is not considered that 
the increase should come from our trained Medical Corps men; on 
the contrary it is considered that the number of trained men 
might be reduced so as to set them free from hospital work and 
that only sufficient trained men need be kept in the bearer com- 
pany to supply one man per stretcher and a few for duties of a 
technical nat-ure. The men to complete the bearer companies 
would be either specially enlisted carriers or, preferably, men of 
Militia or Volunteer Medical Staff Corps or of the St. John Am- 
bulance Brigade. As an instance of what can be done by such 
untrained men I may mention that in Natal a corps of about 1200 



14 COLONEL RICHARD EXHAM, C. M. G, 

was formed by Colonel Gallwey, P.M.O. of the force in that col- 
ony, and these men removed the 800 wounded at the battle of 
Colenso so quickly that the field was cleared before dark. The 
P.M.O. of the force at Spion Kop reported that without their as- 
sistance the wounded could not all have been brought in for days 
as, owing to the diflficult and hilly nature of the ground, the use 
of ambulances in the second line was impossible. As a further 
instance of good work done by these men, I may mention that 
when the force retired from Springfield to Colenso, a distance of 
25 miles, they carried the whole of the seriously wounded men on 
stretchers; 12 men were allotted to each stretcher on this occa- 
sion. The stretchers had two extra handles at each side so that 
6 men could carry it. 

As you are, no doubt, aware, in the British Army there are 
two field medical units, bearer companies and field hospitals. 
Most of our officers are now, however, of opinion that these 
should be combined into one unit, as is the case in the Indian 
Army, and given some such name as ** Field Ambulance," that 
they should be divisible into 4, or at all events, 2 sections, and 
that the equipment should all be marked by sections so as to ad- 
mit of the unit being rapidly divided when necessary. Such di- 
vision has very often been required in South Africa, particularly 
during the latter part of the campaign when the army was split 
up into numerous mobile columns. 

Presuming that our bearer companies and field hospitals as at 
present existing are amalgamated, the duties of the combined 
units would be collecting the wounded and caring for them for 
only such time a.s to permit a hospital to arrive. This hospital 
would be probably something on the lines of our present * 'sta- 
tionary hospital," which would become our real "Field Hospi- 
tal," and would probably be so called. Each hospital would be 
equipped for 200 patients but would be capable of division into 
two sections. One of these hospitals would be regularly allotted 
to a division of 10,000 troops, but in addition, others would be kept 
on the lines of communication ready to be thrown forward to any 
place necessary. The hospitals allotted to divisions should be 
pushed forward rapidly as the troops advance and should be able to 



MEDICAL EXPERIENCES IN SOUTH AFRICAN WAR. 15 

relieve the ** Field Ambulance'* of its wounded in a day or two after 
a battle. These hospitals would in their turn evacuate into gen- 
eral hospitals which should be rapidly established along the lines 
of communication as the army advances. These general hospi- 
tals should be provided in sufficient numbers to accommodate 
sick and wounded at the rate of 10 per cent of the strength of the 
force. It is on these lines that the future medical arrangements 
of the British Army will probably be framed. I cannot too 
strongly represent the necessity of having these general hospitals 
ready to accompany, or if possible precede, an army to its base so 
as to be capable of being established in the rear of the army as 
quickly as possible as the army advances. The nearer to the 
army these hospitals are established the less will be the suffering 
of the ^ick and wounded and the less the difficulties in providing 
for them. 

In South Africa we experienced great difficulties in conse- 
quence of these hospitals not having been ready in sufficient 
numbers in the early months of the campaign. Hospitals had to 
be improvised with whatever equipment could be obtained on the 
spot, and this entailed much work to the Medical StaflF and took 
up time which might have been much better employed attending 
to the sick and wounded. I may mention that at the time of the 
relief of Ladysmith there were in Natal 6,500 sick and wounded, 
the majority of which had to be and were well provided for in 
improvised hospitals. At Blcemfontein alone we had at one time 
4,500 sick and woimded and we dealt with 13,000 in one month: 
this could only be done by extending our general hospitals to 
about 1,500 beds each with such equipment and tentage as could 
be collected, but hospitals of this size are too large for thorough effi- 
ciency and, as at Blcemfontein, it is usually impossible to obtain 
suitable equipment on the spot. Provision should also be made 
beforehand for rapidly fitting out hospital trains so that they mav 
be ready for use at the commencement of the campaign. When 
the lines of communication are long as was the case in South 
Africa, many trains will be required if the force is a large one. 
We had there seven, six of which were made up locally by con- 
verting the ordinary rolling stock of the railway into suitable 



16 . COLONEL RICHARD EXHAAf, C M. G, 

wards, etc., and the other was sent out from England. Even 
with this number a very large number of the sick and wounded 
going towards the base had to be carried in ordinary trains com- 
posed of saloon or such other carriages as were available, but 
such carriages are not really suitable for any except trivial cases 
of illness. 

In the train sent from England three tiers of cots were pro- 
vided but this did not prove satisfactory and I recommend only 
two tiers, as was the case in our other trains. In the English 
train the cots could be removed from the supports and this 
enabled patients to be placed on them in one hospital, removed to 
the train and from thence to their beds in another hospital with 
the least possible disturbance, which is certainly an advantage. 

When it is necessary to move seriously wounded men or seri- 
ous cases of sickness a moderate distance by rail, and hospital 
trains are not available, the plan adopted in the instance I am 
about to relate is a good arrangement and was found to incur the 
minimum of discomfort to the suflFerers. When Ladysmith was 
relieved it was necessary to move 400 serious cases from our hos- 
pitals outside the town to one of our hospitals on the line of com- 
munication. Owing to the Boers having blown up the railway 
bridge over the river Tugela a hospital train could not be brought 
up; there was, however, a road bridge over the river and we had 
plenty of trucks in Ladysmith. In these we placed the patients 
on the stretchers on which they were carried from their hospital, 
the trucks were then conveyed to the river, over which the pa- 
tients were carried by hand and then placed on other trucks in 
which they were conveyed to the line of communication hospital. 

As our lines of communication were long and the troops scat- 
tered all along the line defending it, we had, in addition to our 
hospital trains, covered trucks fitted with stretchers either slung 
or resting on fixed uprights (the latter I recommend); these 
trucks were supplied with two orderlies, a stock of medical com- 
forts, a small oil stove, water tank, etc., and, attached to passen- 
ger or supply trains, they travelled frequently between the lines 
of communication hospitals, bringing to the latter the patients 
picked up en route; they proved extremely useful. 



MEDICAL EXPERIENCES IN SOUTH AFRICAN WAR, 17 

When a large anny has to be fed and otherwise supplied by 
a long single line of railway, as was the case in South Africa, hos- 
pital trains can, of course, be sent to the front only to a limited 
extent, but if these trains are utilized for bringing up medical 
supplies for the hospitals they do not actually replace a similar 
number of supply trains which could otherwise be conveyed. In 
South Africa we carried all our medical and surgical stores and 
also a considerable amount of hospital equipment up from the base 
in our ambulance trains. 

It is also advisable that arrangements should exist for rap- 
idly fitting out hospital ships, as these will certainly be required 
early in a campaign across the sea; if they are not ready in good 
time hospitals at the base become filled and a regular system of 
evacuation is not possible. Although a large proportion of men 
found unfit for active service can be sent in transports there are 
always many invalids for whom special accommodation is neces- 
sary. In addition to the ** Maine*' and the ** Princess of Wales" 
and two other hospital ships sent out from England, 6 transports 
were converted at Durban in a very efficient manner into hospital 
ships. When transports were used for invalids they were fitted 
with a certain number of fixed cots and with swinging canvas 
cots and ordinary hammocks. In both classes of ships all the 
catering and usual. ship work was carried out by the ship's staflF 
and crew; consequently the medical service had only to provide 
the actual sick attendants. This proved a very satisfactor>' ar- 
rangement. 

The greatest assistance to our medical units was experienced 
in South Africa by the establishment of convalescent camps on 
healthy sites along the lines of communication, to which patients 
were sent ou discharge from hospital. The convalescents in these 
camps were allowed a special dietary and recovered more rapidly 
in them than they would have done if retained in hospital until 
fit for duty. In them they were re-equipped before rejoining 
their units. 

Having now referred in general terms to the various medi- 
cal units, I propose, without going into such detail as the items 
of medical and surgical supplies requiring reconsideration, to al- 



18 COLONEL RICHARD EXHAAf, C M. G. 

lude to a few important articles of our equipment which the ex- 
perience of the campaign has shown to require revision. In South 
Africa there are virtually no roads and such tracks as do exist are 
extremely rough. For such a country our army ambulances were 
quite unsuitable; indeed it is considered by many that the ordi- 
nary, long, springless wagon of the country, if it had plenty of 
hay or straw in it, was more suitable for the carriage of wounded 
men. Consequently prizes have now been offered by the British 
Government for the best two ambulances presented for competi- 
tion. It is intended that the ambulance shall be capable of car- 
rying 4 lying down or 12 sitting patients, with one orderly and a 
driver. The extreme breadth of the track may be 6 feet so as to 
admit of a passage way of at least 10 inches beingj provided down 
the centre of the wagon and thus permit of an attendant passing 
between the stretchers. It is intended that the stretcher attach- 
ments shall be provided with springs or insulators, as shall also 
the seats. India rubber tires are to be provided and the ambu- 
lance must travel without excessive vibration both with a light 
and full load, and to secure this check springs may be used. It 
is not proposed to much reduce the weight below that of our 
present ambulance as the experience of the campaign was that 
light ambulances did not stand the rough usage they were neces- 
sarily subjected to. But in addition to the ambulances for bearer 
companies and for general work, it is the opinion of most officers 
that we should have a light two-wheeled ambulance to accompany 
units of mounted troops. In South Africa we had a number of 
Indian Tongas and they were found very useful for this purpose, 
but, doubtless, a much more suitable two-wheeled ambulance can 
be devised. While referring to ambulances, I may mention that 
the Red Cross originally on our ambulances was much too small 
to be seen at such long distances as modern warfare requires. 
These crosses cannot be too large. 

The bell tents used in our field hospitals, although they af- 
ford in proportion to their weight a large amount of accommoda- 
tion for healthy men, or perhaps for trivial cases of sickness, cer- 
tainly do not do so for serious cases and severely wounded men 
who have to be replaced on stretchers and it is not possible in 



MEDICAL EXPERIENCES IN SOUTH AFRICAN WA R. 19 

these tents for medical officers or attendants to properly get at the 
patients. It is considered that a rectangular tent can be devised 
which, weight for weight, will give better accommodation than 
bell tents. Although in South Africa a double fly tent for field 
hospital work is not an absolute necessity in consequence of heat, 
the extra fly adds much to the comfort of patients as a protection 
from the sun's rays and also during the very heavy rain storms 
experienced in that country. I consider that the advantage of a 
double fly tent is so great that such tents should be used. 

Our hospital marquee, which is the tent of our general hos- 
pitals also proved to be a most unsatisfactory tent. It is supposed 
to accommodate 8 patients but will not even provide comfortably 
for six. A new tent, rectangular in shape, is now being devised 
which will accommodate comfortably 20 patients and the weight 
of the tent per patient will be far below that of the present mar- 
quee. The main object in increasing the size of the tent as well 
as its shape, is that it means great economy in nursing staff. 
When the sick are scattered over a large number of tents a far 
larger nursing staff is required than when they are collected more 
together. 

Large cooking ranges proved to be an absolute necessity in 
general hospitals and should always be provided. 

"Threshes" disinfectors were supplied to all our general and 
stationary hospitals: they proved very satisfactory for disinfect- 
ing clothing, bedding, etc., and will, I think, form a regular item 
of the equipment of such hospitals in future. 

Some sort of an incinerator is required in every fixed hospi- 
tal for the destruction of excreta of enteric fever patients. In 
many of our hospitals in South Africa various methods of boiling 
were adopted, but in the majority incinerators were subsequently 
erected and proved much more satisfactor>^ I regret that I have 
not with me drawings of the incinerator mpstly used, but will en- 
deavor to explain its formation and working to any member who 
wishes it. 

Wheeled stretchers were much used, particularly in Natal, 
along the lines of communication for the purpose of conveying 
patients from trains to hospitals. A very good form of stretcher 



20 



COLONEL RICHARD EXHAM, C.Af,G, 




carriage to take the regulation stretcher (See cuts) was devised b>' 
two of our oflScers. In our Indian hospitals we proxnde mattress and 
pillow cases which can be filled with straw, hay, etc. whenever 
available; they add much to the comfort of the wounded and 

are, therefore, 
worth carry- 
ing. In Lady- 
smith there 
fort u n a t e 1 y 
was a large 
stock of these 
articles for 
the use of the 
troops in 
peace time. 
We were thus 
able by filling 
them with 
hay as long 
as this was 
available, and 
af t e r w a r d s 
with coir and 
cotton found 
packed in 
bales for ex- 
portation, to 
provide every 
one of our 
2,500 patients 
with an im- 
provised mattress. Hitherto no hospital clothing has been 
provided in our field hospitals hut the experience of 
South Africa has shown that the provision of pyjama suits is ex- 
tremely desirable. There is always a proportion of wounded 
whose clothing is so dirty, etc., as to make a change an absolute 
necessity. 



Stretcher Carriage, Side View. 

'I'bo atK)Vf stretoher carria^^c oonsiNtD ofan unden-nrriuK^ but It 
nportwollgbt whe«*l8 with Kt4>el spokCHand rimn with rublxT 
lyrcB and ball boarlngM. n the a.Kle art' two light olllptir 
HprlnfCH to which Ih attached a traiisvereo neat for the Htretchor 
<«n1er proper. This Is wnmrely bolted on to the sent, and eon- 
HlstA of two pieces of bard wood suitably worked and rornilng an 
angle frame. On the lM>ttoni side the Ktretcher pol<»*« fe»<t, and 
the sIdeH of the L formed by the i-arrler prevent mo«t efflH'tually 
any lerking or turning of the ntretcher when onee It hai* been 
laid In the carrier. The carrier Ik iibout .SO Inches long but can 
be Increased to any length desired. It ha« been foundthat thU 
length Is admirably suited fo • all purposes. To pn'veni the 
stn^tcher (torn any lateral or upward movement two buttons 
with tightening screws are atUicluHl to the top of the t-arrler on 
«iach side. When the stretcher Is laid on the carrier, the wrt^ws 
are tightened, and the stretcher \% held flast. 

Two Iron supports are provided, one at each end and on t»pp<>- 
Hlte sides of the carrier. These are lowenni when It Is dtvlred 
either to place the stretcher on the carriage or n» move It there- 
ftom, which can be effected In aset'ond; the carriage meanwhile 
remains perfectly still. When the carriage Is In motion, the Iron 
support* are turned up, and He along the respe<'tlve sides of the 
carriage, where each restw on a small clip. Tne great object <»f 
this stretcher carriage has been to obtain mobility, strength, and 
lightness, combined with efficiency and a ready and easy means 
of transport for sick and wounded, no matter where a' pn I lent 
has to be transported from. The Uiade<l stretcher and wheeled 
carriage can be readily bandied by one man on good roads and 
by two men In rough country. Thesprlngs and rubber tyres pn*- 
vent any Jerking being felt by the patient. 



MEDICAL EXPERIENCES IN SOUTH AFRICAN WAR. 21 




Stretdier Carrlafifet Praat Vkw. 



As no doubt you are aware, our army in South Africa suf- 
fered mnch from enteric fever and this showed the importance of 
making every endeavor to supply a safe drinking water to the 
troops. A regular system of boil- 
ing and storing the drinking water 
was, after a time, adopts at all 
standing camps and with much suc- 
cess: this is a matter of easy ar- 
rangement, but, as you all know, 
to supply safe water at all times 
to troops actively engaged in the 
field is a very different question and 
presents such diflSculties that they 
have never yet been surmounted. It 
was intended to supply portable Berkefeld filters to all units and 
they were supplied to a certain extent, but were found to be practi- 
cally useless in a countr>' like South Africa where the river water is 
nearly always so muddy that the candles get choked after a few 
strokes of the pump. Clearing the water with alum is too slow a 
process for troops on the march and requires larger vessels than 
can easily be carried. For standing camps a very eflScient 
method for clearing water is that which we adopted at Lady- 
smith, where the water was ex- 
tremely njuddy. Rough wooden 
frames were made about 3 feet 
high and 3 feet square, several 
squares in a row: over these 
squares ordinary sheets were 
loosely spread so that there would 
be a shallow bag over each square. 
Underneath the rows of squares 
were shallow gutters of galva- 
nized iron which conveyed the 
water, as it dripped from the bags, into small receptacles 
(ordinary buckets) which were then emptied into storage 
tanks. Before pouring water into the bags wood ashes were 
sprinkled over the sheets. The result of this method was that 




Stretdier Carriage wtthotit Stretcher. 



22 COLONEL RICHARD EXHAM, CM,G. 

we obtained water so clear that the Berkefeld filters could be 
worked for hours without the xrandles getting choked. 

Experience having shown that it is not possible to supply 
safe water to the troops in the field by filtration or by the ordi- 
nary means of boiling, a trial is now about to be made by the 
British Army of the French water cart, when filling which the 
water is pumped through a chamber containing potassium per- 
manganate enclosed in asbestos. This is looked upon as merely 
a way of obtaining clear water which is subsequently to be steril- 
ized by a Waterhouse- Forbes sterilizer. It is hoped by these 
means to arrange a system of supplying a safe water to the troops. 

In conclusion I will briefly allude to two questions concern- 
ing the Geneva Convention; namely, what should be the rules 
governing the retention of field hospitals, etc., captured by the 
enemy and what should be the practice about (Tarrying the arms 
of the wounded in ambulances and thus bringing them under the 
protection of the Red Cross. These questions will be brought be- 
fore the meeting of the Convention in September next and, there- 
fore, require previous consideration by the delegates who will at- 
tend that meeting. 

At the conclusion of his paper. Col. Exham added: One lit- 
tle point I have not noted in this paper, but upon which, owing 
to the discussion which took place last night, I might make a few 
remarks. It is in regard to the employment of civil surgeons who 
have never received any military training. A great number of 
you expressed the idea that they are not capable of administer- 
ing a hospital. That has been our experience in South Africa. 
However useful they may be in doing their professional duties 
along the lines of communication, they cannot fall immediately 
into military ways and understand how to improvise or start hos- 
pitals and keep them running. But I will give you the opinion 
of a very able, leading London (civil) surgeon. He was out with 
one of the civil hospitals that went to the war. He had excep- 
tional opportunities of seeing the work of the hospitals and was 
given very large powers and privileges in going around to all the 
hospitals. He had charge of a civil hospital, a small one com- 



ME ore A L EXPERIENCES IN SOUTH A FR/CA N WA R. 23 

paratively of only about 150 beds. He had a very able military 
medical oflScer to run that hospital. In articles which he has 
since published he attributes to the presence of that able military 
oflScer the success of his own hospital, and, moreover, he re- 
marks that no civil surgeon is capable in war-time of running a 
military hospital; and even in the big hospitals where civil sur- 
geons were employed for professional duties, he .said there is a 
limit even in the.se hospitals to which civil surgeons should be 
employed, and con.sidered that in South Africa that limit was 
passed. That, gentlemen, coming from an experienced civil sur- 
geon, ought to be a very strong argument against relying too 
much upon civil aid in war time. In our Army at one time, 
among our very senior officers, there was a disposition to imagine 
that only a very small medical personnel was necessary to be 
maintained, and that in war time, as a very high oflScer in our 
Army, now retired, remarked: "I can at any time in war-time 
get as many civil surgeons as I want, and I don't want trained 
medical ofl&cers.'* I think the experience in South Africa has 
proved that we were right and that he was wrong. 

ABUSES OF THE RED CROSS BADGE. 

Deputy Inspector General Porter remarked at the la.st meet- 
ing of the British Medical A.ssociation, that in the war in South 
Africa regrettable recriminations took place on both sides regard- 
ing alleged abuses of the Geneva Cross. After making all pos- 
sible allowances cases of deliberate abuse of the Cross occurred. 
Perhaps the wonder is they were not more numerous when one 
remembers the lax discipline and the character of many of the 
mercenaries in the enemy's ranks. Besides, the badge being of 
no particular size or material, any one could fashion it, and wear 
or hide it away at will: for example, it enabled recruits for the 
Boers to cross the Portugese frontier at Komati Poort. Again, 
the Boers when hard pressed, as at Jacobsdal, calmly hid their 
Mausers, donned Red Cross badges, and so, evading capture, 
were able to fight once more and under more favorable conditions. 



NOTE ITPON THE PATHOLOGICAL ANATOMY OF 

CEREBRAL CONCUSSION.* 

By M. NIMIER, 

MKDECIN PRINCIPAL DE PREMIERE CLASSE; PROFESSOR AT THE 

MILITARY MEDICAL SCHOOL OF VAL-DE-GRACE; 

DELEGATE FROM THE FRENCH ARMY. 

THE pathological anatomy of cerebral concussion being still 
a mooted question, it occurred to me that this brief con- 
tribution would be of some interest to the Association, 
even though it afford but a negative result. It does not explain 
the anatomical substratum of the diffuse functional disturbances 
which, in our wounded by gunshot, are superadded to the clini- 
cal manifestations resulting from the destruction of brain matter 
by the projectile. 

A soldier commits suicide with a I^ehel rifle. The bullet 

enters exactly at the cen- 
tre of the suprahyoid re- 
gion and escapes at the 
vertex, slightly to the 
right of the median line. 
In the scalp, the hole of 
exit is small and very 
little lacerated; it con- 
tains a small amount of 
brain matter. The skull 
does not appear de- 
formed, but, when 
stripped of the soft parts, 
presents, as shown in the 
annexed diagrams, a hole 
from which six fissures 
radiate, two antero-pos- 
terior, two transverse, 
and two oblique back- 
^ ward and outward. 
Vertical Antero-posterior Section showing the ^hese fissures, except 
Course of the BulieU the posterior, connect 

♦Translated from the author's MS. by Lieut Col. Valerv Havard, U.S.A. 

(•24. 




PA THOLOGfCAL ANA TOMY OF CEREBRAL CONCUSSION. 25 




with a circular horizoutal fissure which almost completely de- 
taches the cranial vault from the base at the level of the frontal 
bone and temporal fossae. Lastly, the base exhibits, almost cor- 
responding to the sella turcica, the hole of entrance from which 
radiate four fissures, three of which connect with the three an- 
terior fissures of the vault, the 
fourth losing itself to the right 
of the occipital foramen. 

These multiple bony lesions 
[show clearly that the action of 
r.he projectile was not confined to 
I. he two points encountered in 
'its course. Let us now see if, 
likewise, the diffusion of the 
traumatic action is noticeable in 
the encephalic nervous mass. 
In the cerebrum, the bullet 
l^per View of the Caivarium show- has destroyed the optic chiasma 
lag the Wound of Exit and Lines of and the anterior part of the right 
Fracture* optical layer; it has perforated 

the corpus callosum a little to the right of its centre and ground, 
along an upward furrow twice its own diameter, the internal face 
of. the right hemisphere as far as the front of the paracentral 
lobule. All the subarachnoid space is gorged with blood, at the 
base as well as upon the sur- 
face of the hemispheres; the 
two lateral ventricles and the 
fourth ventricle are full of it. 
This hemorrhage alone 
indicates that the traumatic 
action of the bullet was not 
limited to its tract. But it 
remained to ascertain whethei 
the macroscopic integrity of 
the nervous tissue was real, 
and this required an histo- 
logical examination. 

Fragments from the opti- t * t tri x et_ .. ,. . x<. «r j 
cal laver involved, the right ^*«*^ 7^,^* ^k«", sho^ the V^^ 
frontal and occipital horns, of Exit and One. of Frature. 

the protuberance, the medulla and cerebellum were removed and 
my colleague, Assistant Surgeon Dapter, examined them in ac- 
cordance with the best technical histological methods used in 
such cases. The result, which seems to me interesting, was the 
total absence in these specimens, of all anatomical lesion of the 
nerx^ous tissue. 




26 



.v. NlAffER. 



Therefore a bullet endowed with powerful energy has passed 
through the brain, causing an abundant effusion of blood around 
and inside the cavities of this organ, without any diffusion of its 
energy to the nervous tissue, or at least w4thout such diffusion 
producing any appreciable histological lesion. 

Must we then conclude, from this isolated fact, that the clin- 
ical phenomena of cerebral concussion are not dependent upon 
any anatomical lesion, and see therein, for instance, simply the 

effect of a transient retraction 
of the neura, with consequent 
suppression of nervous con- 
tacts? I am unwilling to draw 
any conclusion, but prefer to 
ask you, the opportunity pre- 
senting, to verify this obser- 
vation and examine the con- 
dition of the nervous tissue at 
a distance from the tract of 




a projectile through the en- 
cephalon. 

In my opinion, it would 



View of the Base of the Skull showine 

Wound of Entrance and Lines of 

Fracture. 

even be well to make such examination not only in a case of sui- 
cide by gunshot, with instantaneous death, but also, when possible, 
upon the cadaver of a wounded person who had survived the gun- 
shot a certain period of time,— several days or even several weeks. 
We can, indeed, advance the hypothesis that outside of all pri- 
mary appreciable lesion, the brain cells, from the effect of th^ 
traumatism, undergo a disturbance in their nutritive and dynamic 
exchanges, whence could secondarily result histological alter- 
ations. Do not the functional troubles persisting in some pa- 
tients who suffered from concussion, support this supposition? 



CHARACTER STUDY IN THE EXAMINATION OF 
PERSONS FOR MILITARY SERVICE. 

Bv FRANKLIN BACHE STEPHENSON, AM., M.D., A.A.S. 

MBMBRB TITULAIRE PE LA SOCIETE D*ANTHROPOLOGlE DE PARIS: 

MEDICAL INSPECTOR IN THE UNITED STATES NAVY; 

MEMBER OF THE PHI BETA KAPPA SOCIETY. 

IT appears that modem thought has established the soldidarity 
of the physical and mental in man, each being conditioned 
by the other. Hence, from what we see — with an experi- 
enced eye — ^in the physique of a man (and the same applies to all 
living things), and in his manner of u.sing the various parts of 
his body, we may judge of his mentality, of his intellectual and 
moral tendencies. From the form of the different portions of the 
human body we may know the innate trend of the person — men- 
tal and moral. The effects of environment may be seen in the 
expression, not only of the face, but of all other parts of the 
body. • 

For example: a .short, quick step indicates the same traits of 
mind. A slow, slouching gait does not mean force of character 
or promptitude in action. A- low, narrow forehead does not tell 
of high moral qualities. The small or retreating chin reveals a 
very different future from that betrayed by a wide, prominent 
jaw. From thin bony fingers we do not infer constitutional vigor. 
Good proportions among the parts of the head, of the face, and 
of the entire body, shows excellence in general product. Ex- 
tremes in form — plus or minus — have the same germal origin as 
the peculiar or eccentric traits of character — mental or moral. A 
general average of relative size is prophetic. 

Similar indications are found — ^by searching — in the head, 
hands, feet, manner of holding the body in various postures, the 
walk, gesture; and in all other manifestations, physical or mental. 
Observe the varied impressions you receive by different ways of 

(27) 



28 MEDICAL INSPECTOR F, B, STEPHENSON. 

shaking hands. Such impreasions are due to fundamental traits 
of character in giver and receiver. 

The physician has learned to know the conditions of internal 
organs by what he may see outside of the body. Even the aver- 
age citizen is aware of the significance of difference in form and 
expression of the good and bad man — physical, mental, and moral. 

The varieties of botanical growth are recognized by their 
external marks. The grades of excellence in the lower animals 
are, likewise, noted by thoughtful observers. Are the results of 
these labors of value? 

Why not use similar scientific procedure for the selection of 
the best in man? 

There are minute directions for the strictly physical exam- 
ination of recruits, wherein external signs tell of the possible 
force and endurance of parts out of sight. The mental and moral 
capacity are as surely constituent of the personality as the merely 
material; and much may be done, in recognizing their existence, 
from a study of gross appearances, and of form in detail. 
^ Such kind of investigation may be applied to improvement 
in the manner of making examination of persons for the military 
service, thus procuring a better personnel; and con.sequently ob- 
taining better work, through greater physical endurance, through 
higher quality of mental and moral ability. 

There are books — treatises and manuals — in which may be 
found full details anent the science (principles) and practice (with 
results), of these ideas — showing their usefulness in the diagnosis 
of excellent qualities —material and spiritual. 

When the individual is of an age to be guided by physical 
means t)r suasion, prognosis and treatment may become of service. 

An experience of twenty years has caused the writer to have 
faith in this method. 

When Washington advised his fellow-countrymen to choose 
gentlemen for military officers, he meant those who were men of 
character, as the v^or^ gens implies; for to establish a family, in 
the stem times of the ancient Roman republic required strength — 
physical, mental, moral. With our modem views of personal 
liberty and worth, we may not limit the gens to any class, save 



CHARACTER STODY IN EXAMINA T/OJV OF RKCRC/ITS. 29 

those who are able, in body, mind and heart. For any sort of 
service, the best are none too good; and all available means should 
be utilized to secure such. 

The ideas contained in the following critique are so pertinent 
that the author has taken the liberty of incorporating them with 
the initial portion of this paper. 

It is hoped that the medical officers — and others — who are 
considerate enough to read the first few paragraphs of this article, 
will be interested in pursuing the argumentation to the end of 
the text. 

The purpose of the book entitled The Menkd Functions df 
Ihe Brain, by Dr. Bernard Hollander (Putnam's), is to prove 
that all the fundamental psychical functions are localized in the 
brain. For the most part, previous .investigators have confined 
their attention to the intellect alone, but the author of the work 
before us considers also the emotions and passions of man, whether 
normal or abnormal, and undertakes to demonstrate their con- 
nection with the cerebral matter. It is pointed out in a preface 
that even recent text books describe insanity as a disease of the 
brain, implicating the whole of that organ. Whether a person 
be melancholic, violently maniacal, homicidal or a sufferer from 
the delusions of persecution; whether he be a kleptomaniac, a re- 
ligious maniac or an imaginary millionaire— in every case it is 
assumed that the. whole cortex is affected, whereas Dr. Hollander 
submits that the evidence here adduced by him shows that the 
principal varieties of mental derangement are localized in definite, 
circumscribed regions, and frequently are in the early stages at 
least, amenable to treatment. It is certain that, if future inves- 
tigators shall confirm the author\s obsen^ations, brain surgery 
will receive an immense stimulus; and it must be acknowledged 
that the data already amassed by Dr. Hollander, and now pub- 
lished, are so considerable as to open a new field for research. 

It will be observed that the localizations are based chiefly on 
clinical and pathological investigations. Over 800 cases are here 
adduced illustrating not merely the recognized yarities of mental 
derangement, but all kinds of deviations from the normal mind, 
including manifestations of hunger and thirst. It is to be par- 
ticularly noted that the author's localizations confirm those made 
a century ago by Gall, upon whose discoveries in the anatomy 
and physiology of the brain Spurzheim built the system of phre- 
nology which has been so long discredited. A history o\ Gall and 
his doctrine is given in these pages, and should prove a revelation 
to the reader, if it be true, as Dr. Hollander asserts, that not one 



30 MEDICAL INSPECTOR F. B. STEPHENSON. 

man of scientific repute has ever written anything which would 
indicate that he had examined Gall's chief work. As to the evi- 
dence produced in this book after fifteen years of investigation, 
every candid person will echo the hope expressed by the author 
that it will be received with an open and unprejudiced mind, in 
view of the bearing which the facts exhibited may possibly have 
on mental science, on the study and treatment of lunacy, on the 
education of precocious and feeble-minded youth, on moral reform, 
the diminution of crime and many other problems affecting the 
well-being of the community. 

The author of this book begins with a review of the present 
state of mental science, after which nearly 300 pages are allotted 
to a detailed statement of the results of his own investigations 
and those of other pathologists. The conclusions to which Dr. 
Hollander has been led are set forth in a final chapter, which is 
preceded by essays on the relations between the brain and the 
skull, on the history of Gall's 'doctrine and on .the truth and use- 
fulness of phrenology. It is some of the salient points of these 
discussions to which we would here direct attention. 



Is it possible to ascertain the relative size of the different 
convolutions of the brain during life by observing the different 
forms of the skull? That is to say. Does the shape of the skull 
harmonize with the conformation of the brain? Dr. Hollander 
answers: **The best modern authorities have now established as 
much as was ever claimed by Gall. I do not know of a single 
anatomist who denies that it is the brain which gives the form to 
the skull." It is well known that the want of entire and abso- 
lute parallelism between the outer and inner tables of the skull 
has sometimes been put forward as if it constituted an insuper- 
able objection to the computation of the size of the brain by a 
measurement of the skull. Even admitting that such a want of 
parallelism is sometimes observed, Dr. Hollander suggests that 
the objection based on this fact will be minimized for those who 
know that the thickness of the skull seldom exceeds one to three 
lines (one-fifth of an inch, according to Treves), whereas the dif- 
ferences in the development of the brain are reckoned by inches. 
When a head is described as being high, wide or long, it is the 
brain that is developed in those directions and it matters little 
whether the enveloping cranium is a line or two thicker at some 
jwints or not. 

We are reminded that some objectors to phrenology assume 
a patronizing tone, and supply the phrenologist with elementary- 
information concerning cranial and integumentary irregularities; 



CHAR A CTER STUD Y IN EXAMINA T/ON OF RECRUITS. 31 

all take for granted that the phrenologist has never studied the 
relations of the brain to the skull. Dr. Hollander undertakes to 
demonstrate that these self-complacent objectors have themselves 
neglected to study anatomical text books. He begins by quot- 
ing from Sir G. M. Humphrey's * 'Treatise on the Human Skele- 
ton.*' *'The skull is moulded upon the brain, and grows in ac- 
cordance with it. The size and general shape of the brain maj' 
be estimated with tolerable accuracy by the size and general shape 
of the skull. The opponents of phrenology by denying this as- 
sertion do not in the least advantage their cause in the estimation 
of thinking persons, because the statement is of a kind at once to 
commend itself to common sense as being highly probable. The. 
frontal sinuses and the projecting ridges, the inequalities on the 
surface of the skull, which have no correspondence in the in- 
terior, do not amount to much, and show only that allowances 
must be made, and that we must not expect in this way to form 
an accurate estimate; they do not affect the principle that the 
skull is moulded upon, and fitted to, the brain, and that its ex~ 
"terior does as a general rule convey pretty accurate information 
respecting the size and shape of that organ. . The arguments 
against phrenology must be of a deeper kind than this to con- 
vince any one who has carefully considered the subject.'' Sir 
William Flower in his lectures at the College of Surgeons in 1879 
said: **The skull is a fair index to the development of the brain 
in its different regions, and ought, therefore, to be studied." He 
added that the longer he lived he saw fresh beauty and meaning 
in every line and configuration of the cranium, and that the fact 
that he could recognize particular skulls presented to him as be- 
longing to certain nations, was a proof that there existed certain 
fixed and uniform laws in regard to ihem. 

Prof. Moriz Benedikt says: "The best insight into the psy- 
chological nature of man is obtained by two methods. The first 
investigates the historical development of mankmd. The second 
method is biological, in so far as it teaches us to recognize the 
structure and functions of the brain — the outer and exact cast of 
which is the skull * * * We must recognize that a special part 
of the brain belongs to every special part of the skull, and there- 
fore we must acknowledge that every deficient evolution of a 
special part of the skull corresponds to a deficiency in a special 
part of the brain, and, consequently, there must be a deficiency 
in the function of the latter. * * * It has been objected that 
there are in the skull ver>' many accidental secondary promi- 
nences which have no counterparts in the brain. Fairly consid- 
ered, however, this objection is not very material, inasmuch as it 
refers only to unimportant and changeable details and compara- 



3f AfEBICAL INSPECTOR F. B. STEPHENSON, 

lively rare abnormities. No scientific man, even if he does not al- 
together agree with Gall, disputes the doctrine that the construc- 
tion of the skull is remarkably proportionate to the whole anthro- 
pological organization in brutes and in man; and the whole of 
craniology, as it is understood by anatomists and anthropologists, 
would have no meaning if this idea were not the leading one. ' ' 
To the same effect spoke Prof. Alexander Macallister, at the 
meeting of the British Association held in Edinburgh in 1892: 
**The largest part of the skull is that which is at once the recep- 
tacle and the protector of the brain; it is a part which, when un- 
modified by external pressure, premature synostosis, or other ad- 
ventitious conditions, owes its form to that of the cerebral hemis- 
pheres which it contains. * * And again: * 'The study of the brain's 
development shows that the convolutioning of the cerebral hemis- 
phere is primarily due to the connection and different rate of 
growth of the superficial layer of cells with the underlying lay- 
ers of white nerve fibres; and that, so far from the shape of the 
brain being seriously modified by the constraining influence of 
the surroun4ing embryonic skull, the form of the soft mem- 
branous brain-case is previously moulded upon the brain within 
it. whose shape, however, it may be. to some extent, a secondar>' 
agent in modifying in later growth. We have also learned that 
the cerebrum is not a single organ acting as a functional unit, 
but consists of parts, each of which has its specific province; 
that the increase in the number of cells in any area is correlated 
with an increase in the size and the complexity of pattern of the 
convolutions of that area; and that this, in turn, influences the 
shape of the inclosing shell of membrane, and, subsequently, of 
bone. * ' At the German Anthropological Congriess which met at 
Canzig in 1891, J. Ranke stated in an address, * 'On the Relations 
of Brain and Skull,'* that the difference in the form of the skull 
are entirely due to the differences in thedevelopment of the brain. 
Dr. Hollander next draws attention to the fact that Gall hin^*- 
self was the first to point out the irregularities of the skull in his 
article on the "Cranium," in the "Dictionary of Medical Science. " 
It was presumption, therefore, on the part of anti-phrenologists, 
like Dr. O. W. Holmes, to write as if the founders of phrenology 
had been ignorant of elementary anatomy, Gall wrote: "The cir- 
cumstance that the two tables of the cranium are not parallel in 
their whole circumference and at all periods of life would cer- 
tainly be of the greatest importance if I had ever pretended to 
judge of all the minute shades of differences that exist in the con- 
volutions of the brain. On the contrary, I have endeavored to 
acquaint my hearers and readers with all the circumstance in 
question. I have spoken of the frontal sinus, of the separation of 



CHAR A CTER STUD Y IN EXAMINA TION OF RECRUITS. 33 

the two tables of the cranium in men and in animals. I wrote 
upon it in my article, ^Cranium' in the Dictionary of Medical 
Science. ' ' I was the first to mention that it was impossible for 
us to determine with exactness the development of certain convo- 
lutions by the inspection of the external surface of the cranium. 
I was the first to treat in detail the variations in the thickness of 
the cranium which occur in old age, in insanity, &c. I was the 
first to teach that in certain cases the external table of the cranium 
is not parallel to the internal one. I have called the attention of 
anatomists to all these circumstances. Is it, fair, then, of these 
anatomists to turn these facts into weapons against craniology? 
Why had they not the frankness to state by what means I have 
removed many of these difficulties, and to confess that I pursued 
my researches with candor, and considered the subject in all its 
aspects with impartiality." Dr. Hollander submits that the best 
proof that there really exists a uniform correspondence between 
certain forms of head, skull or brain and certain characters of 
mind is found in the numerous confirmations that the localiza- 
tions made by Gall have received from clinical evidence in recent 
times; to which confirmations Dr. Hollander would add the testi- 
mony furnished in the 800 cases described in the book before us. 

II. 

In a chapter on '*The Significance of Cranial Contours," our 
author quotes the judgment pronounced on practical phrenolog>' 
by Dr. Henry Maudsley, lately professorof medical jurisprudence 
in University College, London. *'A11 broad-headed people," Dr. 
Maudsley writes, * 'that I have examined are very selfish ; that is 
to say, all who have the head broad in proportion to its length." 
He accepts the observation of the phrenologists that **an undue 
preponderance of the breadth of head throughout the region in 
which they place the propensities indicates with certainty an ani- 
mal self-love, which can scarcely be trusted at all times to adopt 
only fair means for its gratification." Undue preponderance, be 
it observed, for **it is justifiable to expect a favorable result, 
even with a rather broad head which has a proportionately good 
length and which has, so to say, the power of its length placed in 
the anterior half thereof. And why? Simply because there is 
in the front the greatest natural power, the force of intellect, 
which by exercise and development is able to control the object- 
ionable propensities indicated in the animal broadness of skull. ' ' 

To the question, What constitutes a noble head? Dr. Maud- 
sley replies: * 'From the forehead the passage backward above 
should be through a lofty vault, a genuine dome, with no disturb- 
ing depressions or vile irregularities to mar its beauty; there 



M MEDICAL INSPECTOR F. B. STEPHENSON. 

should be no marked projections on the human skull formed after 
the noblest type, but rather a general evenness of contour.'* On 
the question, What is a brutal head? Dr. Maudsley remarks: 
'*The bad features of a badly formed head would include a nar- 
rowness and lowness of the forehead, a flatness of the upper part 
of the head, a bulging of the sides toward the base and a great de- 
volopment of the lower and posterior part; with those grievous 
characters might be associated a wideness of the zygomatic arch, 
as in the carnivorous animal, and massive jaws. A man so formed 
might be expected with some confidence to be given over hope- 
lessly to his brutal instincts." 

Is a man, then, hoj^elessly chained down by the weight of his 
inheritance? "By no means," Dr. Maudsley answers, **for there 
is something besides inheritance which makes fate, and that is ed- 
ucation. It is a physiological law that the brain throughout in- 
fancy, childhood and youth, grows to the circumstances which it 
is placed among; and, therefore, the actual development of a 
brain may be much influenced by the sort of nutriment supplied 
to it as long as it grows. It would be rash, indeed to venture to 
limit the effect which a right, reasonable, moral, physical and in- 
tellectual education may have on the worst inheritance. But, 
given an in'dividual at the meridian of life, with a bad inheritance 
and a bad education, the benevolent enthusiast may, indeed, hope 
for the individual's reformation, and, all honor to him, labor for 
it; but the careful observer will be prone to smile at his expecta- 
tions, and, regarding them as a devout imagination, to compare 
them to those made to wash a blackamoor white. ' ' 

Here we would add that in a lecture reported in the British 
Medical Journal, Prof. Graves of Dublin pointed out that in all 
cases where the difference between the intellectual powers of the 
men examined is extreme, "there also we invariably find a .strik- 
ing difference between the form and size of their skull, the most 
highly gifted always presenting a greater relative proportion of 
brain. So far. then, must every reflecting man be a phrenologist 
-so far must all concede that cerebral development and mental 
powers are mutually proportioned to each other. But can we ad- 
vance further than this general proposition, and may. we not af- 
firm that the anterior portion of the brain is proportioned in size 
to the intellectual faculty? Experiments on animals and obser- 
vations on man afford very striking reasons for arriving at such a 
conclusion which tends to establish the leading principle of the 
phrenologist, 'that different portions of the brain perform differ- 
ent intellectual functions. ' It would appear certainly that the 
anterior portion of the brain is devoted to the intellectual faculty, 



CHA RA CTER STUD Y IN EX A MI N A TION OF RECRUITS. 35 

but that the'strength of the moral feelings and animal propensi- 
ties is regulated by the development of the remaining portions of 
the encephalic mass. ' ' 

III. 

In his twelfth chapter the author brings forward further 
testimony to the truth and usefulness of phrenology from emi- 
nent medical men, all specialists for the treatment of the insane, 
who have been so misguided as to place belief in those who have 
been described by B/ackzi'ood' s Magazine as "those infernal 
idiots, the phrenologists," and to adopt what the Edinburgh 
Revieix: has denounced as "thorough quackery" and "despicable 
trumpery.** The Journal of Medical Science in July, 1879, 
called Dr. Conolly as a witness: "To those who were person- 
ally acquainted with Dr. Conolly, his favorite opinion of the sys- 
tem of Gall and Spurzheim is well known. In his 'Indications 
of Insanity,' he maintains that *the first principles of phrenolog>' 
are founded in nature,' and adds: 'I can see nothing which 
merits the praise of being philosophical in the real or affected 
contempt professed by so many anatomists and physiologists for 
a science which, however, imperfect, has for its object the dem- 
onstration that for other functions [than the intellectual] , theex- 
i.steuce of which none can deny, there are further separations and 
distinctions of hitherto unexplained portions of nervous matter. ' 
In a letter to George Combe [the eminent English phrenologist] 
Dr. Conolly expresses his 'conviction of the great usefulness of 
habitual regard to the principles of phrenology, especially in my 
department of practice and of the confusion and imperfection of 
the views which seem to me to be taken, both of sound and un- 
sound mind, by those who reject the aid of obser\^ations confirmed 
now by vast experience, and most of which may be daily verified 
*in asylums for the insane. I am also convinced that attention to 
the form of the head, conjoined with that cautious consideration 
of all other physical circumstances, which no prudent phrenolo- 
gist disregards, will often enable the practitioner to form an ac- 
curate prognosis in cases of mental disorder, and to foretell the 
chances of recovery or amelioration, or of hopeless and gradual 
deterioration.* " 

We pass to the testimony of Sir James Coxe, her Majesty's 
Commissioner in Lunacy. This testimony was outlined in the 
presidential address delivered at the Royal College of Phj'sicians, 
London, July 26, 1878, by Sir J. Crichton- Browne. "From the 
commencement of his career. Sir James Coxe interested himself 
in insanity. During the earlier stages of his professional train- 
ing, he enjoyed no opportunities of coming into contact with the 



36 AfEDlCAL INSPECTOR F, B, STEPHENSON. 

cloistered insane, nor of observing the modes of treatment then 
resorted to, as lunatic asylums were not in those days open to stu- 
dents, and were unprovided with medical assistance; but this dis- 
advantage was, to a great extent, compensated by his having ac- 
quired from his relatives, George and Andrew Combe, a thor- 
ough knowledge of phrenology, which — not then fallen on evil 
days of charlatanism, and into the evil companionship of mesmer- 
ism — encouraged the accurate observation of mental states, ac- 
centuated the relations subsisting between these and states of the 
nervous system, and had even some curious glimpses of foresight 
into the revelations of modern physiology. He saw the phreno- 
logical method of inquiry applied in cases of insanity and of pe- 
culiar turpitude in the communities of lunatics and criminals that 
he visited during a long sojourn on the Continent, and the in- 
fluence of the infonnation thus obtained, cooperating with the 
natural bent of a comprehensive but unimaginative mind, maybe 
discerned in all his subsequent public and official acts. ' ' Let us 
look next at the conviction expressed by W. A. F. Browne, her 
Majesty's Commissioner in Lunacj'^ for Scotland, father of Sir 
James Crich ton- Browne: "To those who are acquainted with the 
doctrines of phrenology the extent of my obligations will be 
readily recognized; and to those who are still ignorant of these 
doctrines I have to offer the assurance that insanity can neither 
be understood, nor described, nor treated by the aid of any other 
philosophy. I have long entertained this opinion. I have for 
many years put it to the test of experiment and I now wish to 
record it as my deliberate conviction. ' ' 

In Guy's Hospital Reports for 1879, Vol. 24, will be found 
set forth the reflections of Sir Samuel Wilks, M. D.. lately Pres- 
ident of the Royal College of Physicians, London: **It seems as- 
tonishing at the present time, when phrenological societies have 
ceased to exist and we look calmly back at the achievements of 
their members, to contemplate the bitter animosity which was ex- 
hibited toward them by their opponents in all classes of society. 
Physiologists simply ignored them and looked upon the attempt 
to apportion out the brain into organs corresponding to the func- 
tions of the mind as gratuitous and fanciful whilst the literary 
and religious public became their bitterest antagonists, because 
they made mental processes depend upon physical organization. 
* * * In myself considering phrenological works in an un- 
prejudiced spirit, I cannot but be struck with the great object 
which the writers presented to themselves and the mode in which 
they proposed to prove the truth of their doctrine. Their object 
was the same as that which is now considered mo.st rational. 



CHARA CTER STUD Y IN EXAMJNA T/ON OF RECRUITS. 37 

They discarded the notion that the brain was to be regarded 
simply as associated with the mind and there left, but they looked 
upon it as a compound and complex organ. They were the first 
to replace the old method of anatomists of slicing up the brain by 
unfolding and dissecting it. They showed that it was made up 
of parts, each having its own function. They erred, no doubt, 
in hastily framing a system whose correctness did not admit of 
proof [the system was founded by Spurzheim, not by Gall] ; but 
out of it arose discussions on the different faculties of the body 
and mind which must have made the phrenological societies in 
London overflow with interesting debates. They discussed the 
subject of language in a manner which had never before been at- 
tempted, as well as coordination, time, the muscular sense, the 
feeling of resistance, and kindred subjects. Aphasia, indeed, 
seemed clearly understood, and language was located by them in 
the region where physiologists are now agreed to place it. If 
phrenologists had not stated so strongly their belief in the exist- 
ence of separate organs in the brain, but had used their system 
merely as an hypothesis, no objection sould have been urged 
against it, for it developed, for the first time, a number of theories 
as to the nature of the different faculties ot the mind. The trans- 
actions and reports of the old phrenological societies give accounts 
of debates on subjects of the deepest interest, such as can nowhere 
be found in the records of other learned societies." Sir Samuel 
Wilks also recalls that the electro-biologists, a class of practi- 
tioners produced by a fusion of phrenologists with mesmerists, 
used both to teach and practice what the most advanced physiol- 
ogists are now supposed to do in their laboratories when they ex- 
cite certain convolutions of the brain by the galvanic current. 

It seems worth while to hear some other authoritative testi- 
mony on the same subject. Sir William Turner, professor of 
anatomy in Edinburgh University, writing in 1866, observes in 
•'The Convolutions of the Human Cerebrum, Topographically 
Considered," that "the precise morphological investigations of 
the last few years into the cerebral convolutions have led to the 
revival in Paris of discussions in which the doctrine of Gall and 
his disciples — that the brain is not one organ, but consists of 
many organs — has been supported by new arguments, and the 
opinion has been expressed that the primary convolutions, at 
least, are both morphologically and physiologically distinct or- 
gans." Sir Frederick Bateman testifies in his book ** Aphasia, or 
Loss of Speech," London, 1890, that '*in spite of all that has 
been written in depreciation of his labors, beyond all doubt his 
researches gave an impulse to the cerebral localization of our fac- 
ulties, the effect of which is especially visible in our own day, and 



38 MEDICAL INSPECTOR F. K. STEPHENSON. 

I look upon his work as a vast storehouse of knowledge, and as 
an imperishable monument to the genius and industry of one of 
the greatest philosophers of the present age. ' ' 

We quote, finally, the opinion expressed by Havelock Ellis 
in **The Criminal/' London, 1890: "Gall thrust aside forever 
the credulous fancies of the phj^siognomists; and he has been de- 
scribed, not altogether without reason, as the founder of the 
modern science of criminal anthropology. He was certainly its 
most brilliant pioneer. * * * q^^ studied the brain, sought 
to differentiate the functions of its various parts, and the effects 
of its varying development on the skull." Havelock Ellis goes 
on to recall that "for Gall the varying development of the brain 
was the cause of the divergent mental and moral qualities of the 
individual; he was firmly convinced that all the facts of psychical 
life are rooted in the physical organization; he wished to write 
the natural history of every primitive, moral, and intellectual 
force, in health as well as in disease. To the best of his ability 
he carried out his programme in detail, by an unceasing study of 
all the varieties of the brain and of the living head that he could 
find; he pursued his studies throughout Europe, in lunatic asy- 
lums and in prisons, as well as among the ordinary population, 
and he foresaw the extent of the applications of the science he 
was opening up to medicine and to law, to morality and to edu- 
cation. While his work extended far beyond the borders of what 
we should now call criminal anthropology, he devoted much at- 
tention to the problems of the criminal organization, and even to 
its varieties, many of his observations according well with the re- 
sults of recent investigations." Ellis recognizes that "more than 
this. Gall clearly advocated a method of dealing with the crimi- 
nal which is now rightly regarded as the only right and reason- 
able method. 'There can be no question,' Gall said, 'of culpa- 
bility or of justice in the severe sense; the question is of the ne- 
cessity of society preventing crime. The measure of culpability 
and the measure of punishment cannot be determined by a study 
of the illegal act, but only by a study of the individual commit- 
ting it.' In his great work, T^es Fonctions du nfrzrtf?/, Paris, 
1822, Gall has summed up his conclusions." 

rv. 

Now let us see what Dr. Hollander believes himself to liave 
accomplished in the book before us. In the concluding chapter 
we are reminded that Gall, proceeding on strictly positive and in- 
ductive lines, labelled the regions of the brain in a rough-and- 
ready fashion with the names of habits or actions he found speci- 
ally associated with the developments of the respective parts, as. 



CHAR A CTER STUD Y IN EXAM IN A TION OF RECRUITS, 39 

for example, "mimicry," * 'homicidal mania," &c. Spurzheim 
defined a more abstract conception of the functions of the cerebral 
parts, and the terminology invented by him was adopted by 
Combe and the Edinburgh school; but, although the terminology 
may have been more philosophical, it did but retard the recogni- 
tion of phrenology, inasmuch as Gall's original observations were 
no longer identifiable under such terms as "imitation," "destruc- 
tiveness," &c., hence, they could not be easily verified. Dr. 
Hollander has himself made no attempt at a scientific revision of 
the terms employed, contenting himself with showing that Gall's 
crude observations have been confirmed by recent experiments 
and researches. He is quite alive to the fact that the labors of 
many qualified observers and experimenters will be needed to con- 
struct thereon a complete system. While convinced, however, 
that certain of the * 'localizations" attempted by him may require 
a great deal more of scientific, evidence, such as has been fur- 
nished for "melancholia," "violent mania,'" "mania of persecu- 
tion" and some other identifications of emotions with brain cen- 
tres, the author ventures, after fifteen years of accumulated re- 
search, to formulate as highly probable the following proposi- 
tions: First, the pre-frontal lobes are concerned with purely in- 
tellectual operations. vSecondly, the temporo-sphenoidal lobes 
are in some way connected with the propensities common to man 
with the lower animals. Thirdly, the parietal lobes and the pos- 
terior part of the frontal lobes are involved in the manifestation 
of definite ^/;/rV/(y//5; while the occipital lobes bear a relation to 
the domestic and .social affections. In Dr. Hollander's opinion 
it may be further maintained that size of brain-mass bears a pro- 
portion to the power of manifestation, and that two brains or 
skulls differing in the regions above mentioned will differ in 
character accordingly. "Take," says the author, "the masks, 
brains or skulls of half a dozen persons afflicted with a deficiency 
of some definite mental faculty or emotion or passion, on the one 
hand, and, on the other, those of half a dozen persons who have 
excelled in such faculties; then jumble them together, and any 
individual tolerably versed in Gall's doctrine will find no diffi- 
culty in differentiating the two classes. ' ' 

It is, of course, to be understood that the work before us is 
not a text-book on phrenology. It was not the author's aim to 
dem6nstrate the truth of Gall's doctrine through its whole scope 
and in all its details. He simply claims to have furni.shed mod- 
em specialists in lunacy the key to many of the mysterious prob- 
lems of mental science. lie concedes that the key offered may be 
aide and have spme .strange twists in it, but he submits that it is 
a key. nevertheless, which, despite its defectiveness, may be 



4l) MEDICAL INSPECTOR F. B. STEPHENSON. 

found to correspond with many of the wards of locks hitherto un- 
opened by science and philosophy. He thinks that specialists 
should give the present work at least fair consideration, seeing 
how important it is to diagnose correctly the earliest and slight- 
est deviations from the normal psychic functions. He is far from 
asserting that phrenology is a science to-day. He admits that it 
will be a science only when it shall have been proved such by all 
the different methods of research instead of by the single method 
of a comparison of heads. He believes, however, that if all who 
are in a position to turn it to account would keep phrenology be- 
fore them as a * 'theory," as a working hypothesis, a notable 
amount of progress would speedily be achieved. 

In this book notice by M. W. H., the famous re\aewer 
for The New York Sun, **so much has been said and so well 
said, that anything more would seem superfluous/' inasmuch as 
this contribution is designed to merely call serious attention to 
the subject- 

A CANADIAN VIEW OF THE ASSOCIATION OF MILI- 
TARY SURGEONS OF THE UNITED STATES. 

THE Canadian Military Gazette remarks that last summer 
the Association of Military Surgeons held its annual ses- 
sions for 1902 in Washington, and by invitation, dele- 
gates from the medical staffs of the principal armies of the world 
were present, took part in the proceedings, and expressed their 
views, etc., on the subjects which came up for discussion. Surgi- 
cal and medical science — especially as it relates to operations in 
the field — was largely benefited thereby; more, there was a 
marked increase of the fraternal feeling which exists amongst 
members of a great profession, though drawn from various coun- 
tries, and enrolled in armies which any month may be ranged iu 
hostility to one another; and, better still, the humanitarian spirit 
was further developed, for there it was felt, and there the princi- 
ple was still further impressed upon those present, that in the in- 
terests of all, surgical aid should be to the fullest possible extent 
cosmopolitan, that friend and foe alike should be objects of the 
true physician*s solicitude, and that, therefore, the men of ever>- 
army are interested in the eflficiency of medical men and medical 
appliances belonging to forces other than their own. 



REPORT OF CASES OF BOLO WOUNDS. 

By captain HENRY CLAY FISHER, 
ASSISTANT SURGEON IN THE UNITED STATES ARMY. 

I HAVE the honor to submit the following report of cases of 
bolo wounds that came under my observation while surgeon 
in charge of the Militarv' Hospital at Cebu, Island of Cebti, 
Philippine Islands: — 

1. Juan , native guide, while attending a cock fight in 

the outskirts of Cebti was attacked by insurgent sympathizers 
and slashed with a bolo across the back, incising the skin and 
superficial tissues from one side to the other over the scapula with 
an uncut interval in the depression over the spinal column. After 
disinfection and a lengthy suturing, the incision made an unevent^ 
ful healing. 

2. Copras , a native, cut with bolo while resisting rob- 
bers at Talisay, Cebii, P. I., was admitted to the hospital June 
28, 1900, two days after the accident. The following diagnosis 
was noted, 1. Incised flesh wound, moderately severe, posterior 
surface upper third left leg, 4 inches long. 2. Incised flesh 
wound, moderately severe, posterior surface upper third right 
arm, 4 inches long. 3. Incised wound, left elbow, severe, sev- 
ering olecranon process and attachments. As he left the hospital 
on the 3rd day after his wounds were dressed it is supposed he 
was doing well but his subsequent history was lost. 

3. Sergeant of Battery C, 6th Artillery, while in the 

suberbs of Cebti walking with a comrade was attacked by a crowd 
of bolomen. Throwing up his left ann to ward off a blow aimed 
at his head a bolo made a clean cut through all tisvsues and bones 
of his forearpi two inches below the elbow, with the exception of 
about 2 inches of skin ; the same blow caused an incision from the 
middle of his forehead through the inner angle of the orbit to the 
right cheek severing the outer table of the frontal bone. Another 
blow upon the left shoulder cut off the acromion process, all of the 
deltoid muscle and other tissues upon the outer surface of the arm 

iii) 



42 



CAPTAIN HENRY CLA Y FISHER. 



cleauiug the upper third of the humerus and incising it to a depth 
of half an inch. The Sergeant being unarmed knocked down his 
assailant with his right hand, started to run and fell receiving 
another severe incised wound in the outer side of the upper third 
of his right thigh 4 inches long, down to and incising slightly the 
femur. The insurgents ran off and the Sergeant walked a distance 
of 500 yards to the hospital holding his all but severed left forearm 
in his right hand. The regions of his wounds were carefully disin- 
fected and all possible 
aseptic precautions tak- 
en. An attempt was 
made to cover the stump 
of his already amputated 
left forearm with a skin 
flap taken from the sev- 
ered member, there being 
a connection of about 2 
inches of unsevered .skin. 
The other wounds were 
sutured, and healed by 
first intention. The skin 
flap of the left foreann 
sloughed but there was 
no pus formation. The 
Sergeant was up, feeling 
strong and apparently do- 
ing well when on the 12th 
day symptoms of tet- 
anus developed and he 
died on the fourth day 
thereafter. Undoubtedly 

The crossed knives lust below the shield iire Moro the infection was incur- 
krlses, one a serpent krls, the other a straight krls. , . ^t. * . • r .^ 

The curving bellied knives Just below are boIo8ftx>m red at the time Of the 
the Island of Cebu,— there are various shapes of bolos ..... . 

according to the locality. Lying on the shelf, In ongUial Ul j ury ; theonset 
ttont of tlie water bottle, is the weapon of which r . i . r . . 

every Moro carries one or two In his sash. If he has Ol tfie symptoms of tet- 
not a kris,— the barong. To the left and right re- j i j t 

spectlvely are a beheading knife and a capllan. The an US was aelayed bUt 
kris daggo™ «re carried by women. ^j^j^j^ ^^^ recognized in- 




Trophy of Filipino Weapons. 



REPORT OF CASES OF BOLO WOUNDS. 43 

cubation period. There had been no suppuration in his wounds 
and no other cases of tetanus occurred at the hospital. 

4. Private — — , of Company C, 44th U.S.I. Vols., was ad- 
mitted September 4, 1900, with severe incised wound, 5 inches 
long, located on the left side of the back, opposite floating ribs: 
slight punctured wound J^ inch long, located on the right side of 
the back, opposite floating ribs; punctured wound one inch long, 
located on the anterior surface, lower third, left shin, slight. Cut 
with a bolo in action against insurgents, near Carmen, Island of 
Bobol, P. I., August 31, 1900. This soldier was returned to duty 
November 6, 1900. 

5. Private , of Company C, 44th U.S. I. Vols., was ad- 
mitted September 4, 1900, with severe incised wound five inches 
long, located on the anterior and inner side of left hand, with 
compound fracture of the middle 5th metacarpal bone of the left 
hand. Cut with a bolo in action against insurgents, near Carmen, 
Island of Bohol, P. I., August 31, 1900. He was returned to 
duty November 10, 1900. 

6. Corporal , of Company C, 44th U.S. I. Vols., was ad- 
mitted September 4, 1900, with severe incised wound, six inches 
long, extending through the middle of left ear and located along 
the neck downward and backward, with compound fracture of 
the mastoid process and with a severe incised wound, about seven- 
inches long, of right arm and forearm, opening back of right 
elbow joint. Cut with bolo in action against the insurgents, near 
Carmen, Island of Bohol. P. I., August 31, 1900. This soldier 
was transferred to another hospital October 27, 1900, and was 
treated in other hospitals between the date last mentioned and 
February 19, 1901, when he was discharged the service on sur- 
geon's certificate of disability because of fixation of right elbow 
joint at an angle of 135 degrees, from a bolo cut, posterior sur- 
face of arm, from three inches above to two inches below elbow, 
penetrating the joint. Deafness in left ear, one-half, caused by 
a bolo cut located from a point one inch anterior to ear, through 
the external ear backward, five inches, causing partial occlusion 
of the external auditor)^ meatus, 

7. 1st Sergeant , of Company A, 43 U.S. I. Vols. , was ad- 



44 CA P TA IN HENR Y CLA Y FISHER. 

mitted November 9, 1900, with bolo wound located in the lower 
left inguinal region, passipg through the superficial structures, 
and striking the crest of the ilium, severe. He was injured dur- 
ing an attack on Polo, Le)^e, P. I., May 29, 1900, and was trans- 
ferred to another hospital between the date last mentioned and 
February 27, 1901, where the diagnosis was recorded as punct- 
ured bolo wound in the left iliac region, which extended from a 
point on alevel with, and one inch to the left of, the anterior su- 
perior iliac spine, downward and inward for 1J^2 inches, parallel 
to Poupart's ligament. He arrived at the Presidio, San Fran- 
cisco, California, Februar>' 27, 1901; was examined and found to 
be convalescent and able to travel, and was discharged the service 
September 6, 1900, because his services were not required, with- 
out admission to hospital. 

8. Private , of Company C 44th U.S.I. Vols., was ad- 
mitted December 21, 1000, with incised wound, slight, located on 
the lower third, outer side of the left forearm, three inches long 
and a punctured wound located on the anterior surface of the 
left shoulder,, penetrating the apex of the left lung, severe, cut 
with a bolo during engagement with the insurgents at Hagner, 
Island of Bohol, December 15, 1900. He was returned to duty 
January 21, 1901. 

CONDUCT OF THE NAVAL MEDICAL OFFICER 
DURING AN ACTION. 

IN the din of battle, with men falling thick around their guns, 
temporary aid is all the surgeon can render. When the last 
gun is fired his real work will begin, and it will be impera- 
tive on him to expose himself to risk of injury or death during 
the action as little as possible. By moving about, however, in 
the protected parts of the ship with such necessaries as he can 
carry, he can render much useful service. To remove the seri- 
ously wounded from the various decks to the dressing stations 
during the action will be impracticable. For many reasons the 
use of stretchers will be rendered impossible, and all the bearers 
can do will be to assist by hand the less seriously injured to 
the dressing stations. — Staff Surgeon ColhornCy R.N,, in the 
British Medical JoumaL 



SOME PRACTICAL SUGGESTIONS ON TROPICAL 

HYGIENE. 

By major henry P. BIRMINGHAM, 

SURGEON IN THE UNITED STATES ARMY. 

A GENERAL discussion of the subject of tropical hygiene 
would naturally lead to matters that might take up vol- 
'^ umes, but my desire on this occasion is to consider only 
a few of the points^— in a practical way — that more nearly con- 
cerns us as military surgeons. To those of us who have seen 
tropical service, I have little if anything new to offer, but to those 
who have not and who may — under existing conditions — be sooner 
or later called upon for such service, the points to be discussed 
may be of interest. 

The first part of the subject to be considered is that of re- 
cruitment, and it is easily the first in importance. No matter 
what precautions may be taken to maintain the health and effi- 
ciency of any command, the work will largely go for naught, 
unless the physical make up of the personnel is at least fairly sat- 
isfactory, and that this is doubly true for the tropics goes without 
saying. 

From a somewhat extended hospital experience in our trop- 
ical possessions I believe I am safe in saying that about fifty per- 
cent of the soldiers who were invalided home or who died on those 
islands were men who never should have been sent there, and 
what is of more importance, a careful physical examination of 
those men by medical officers conversant with tropical conditions 
would have unquestionably resulted in their rejection. 

These defectives might be classified under the following 
beads: 
I. The immature youth. 

The number of undeveloped boys ranging in age from 17 

to 21, met with in the hospitals, whose only chance for life 

(45) 



46 MAJOR HENRY P. BIRMINGHAM. 

lay in building up their strength sufficiently to admit of their 
being put on the first transport sailing for home, was simply 
deplorable. 

II. The man of poor physique. 

Under this head should be comprised all men who do not 
absolutely and unqualifiedly meet the requirementsof Green- 
leaf's Epitome of Tripler*s Manual in the matter of weight, 
height, chest expansion and general physical development. 

Among this class I desire to invite particular attention 
to the tuberculous subject, for although he may not always 
have apparent physical stigmata, for the most part he has, 
and he is the least desirable of all. I have not at hand the 
statistics, but the number of men who either died of, or were 
sent home for tuberculosis formed quite a large percentage 
of the general non -effectiveness in the Philippine Islands. 

It is practically signing the death warrant of an indi- 
vidual with even the most remote tuberculous tendency to 
send him to the tropics. 

III. The aged and the neurotic: 

I have included these two classes under the same head 
for the reason that many narcotic and alcoholic neurotics 
show undoubted evidences of premature senility, and con- 
versely the fact of a man's presenting himself as a recruit 
after middle age is presumptive evidence that his life has 
been more or less a failure, and in such cases this is ver>' 
often due to the causes set forth above. 

Life in the tropics has a pronounced depressing effect on 
the man from the temperate zone, and this is particularly the 
case for one who is subjected to hard service or unwonted 
conditions. Neurasthenia in its various forms, and often of 
decided severity was a common ailment — most often as an 
accompaniment of, or sequel to, some of the depressing dis- 
eases, such as malarial fever and dysentery, but now and 
then cases were met with where the climatic conditions 
seemed to affect the nervous system alone, and these latter 
not infrequently eventuated in some form of insanity. 
The number of this combined class, viz: — The aged, or pre- 



PR A CTICAL SUGGESTIONS ON TROPICAL HYGIENE, 47 

maturely aged, and the neurotic found in the hospitals was al- 
ways large, not so often from these conditions per se, but from 
the ordinary tropical diseases to which their low resisting power 
made them easy victims. Very few of these men were ever re- 
turned to duty; they either died or were sent home. 

The men that I have particularly in mind were largely those 
who were recruited under the volunteer act of March 3i 1899, to 
serve in the Philippines until June 30, 1901, and as they were 
most hastily recruited (some of the regiments were enroute to the 
Islands within a few weeks after receiving the order for organi- 
zation) physical perfection was hardly to be expected. The les- 
son learned, however, was an impressive one and should not be 
lost sight of. 

There were some notable exceptions in these regiments, the 
comparatively small sick list showing that great care, and perhaps 
some good fortune had attended their recruitment. 

To summarize in the matter of the tropical recruit, I would 
to begin with unhesitatingly place the age — ^and that with few if 
any exceptions between 25 and 35. 

Tropical service demands mature bone and sinew of the best 
quality and while a certain percentage of men above and below 
this age, who would prove effective, might be secured, I am con- 
vinced that the best interests of the service would be conserved 
by a close adherence to the above age limit. 

The prescribed regulation of weight to height should be ab- 
solutely adhered to, and the slim, lanky individual invariably re- 
jected. The excessively tall man, no matter what his weight 
may be is undesirable, for in the tropics he is very prone to lose 
weight and degenerate into the tall lanky weakling above re- 
ferred to. The obese man, or the man with a paunch should of 
course not be considered. The examination of the chest should 
be carried out with the most scrupulous care, and all individuals 
with weak hearts, relatively deficient chest expansion, any tuber- 
cular tendency, whatsoever, or other chronic ailment of the chest 
or contained organs, rigidly excluded. 

The aged, or prematurely aged man, the neurotic and the 
alcoholic should be unhesitatingly cast aside, no matter what his 
age or apparent physical perfection may be. 



48 MAJOR HENRY P. BIRMINGHAM. 

It may be said with truth that it is often difficult or, at times 
impossible to discover these neurological defects, but they should 
always be carefully looked for, and if the case is at all question- 
able the Government should, by rejection, be given the benefit of 
the doubt. 

Marked caries of the teeth should always be cause for rejec- 
tion, not only for the reason that insufficient mastication is often 
the starting point of grave disturbances of the intestinal tract, but 
furthermore for the reason that in the comparatively young this 
defect is presumptive evidence of some constitutional vice which 
the life of a soldier in the tropics would be sure to accentuate. 

The condition of the skin should be most carefully observed, 
and any evidence of acute or chronic affection of the integument 
should cause the applicant to be rejected. The importance of 
this will be referred to later on. 

This summary may seem on the whole rather sweeping, but 
the nature of the service during active operations in the field, in 
the tropics, is such as only the physically fit man can endure, and 
the physical weakling will not only be a burden to be cared for 
while in the service, but will inevitably be a factor in increasing 
our already large pension list afterward. 

The next part of the subject to be considered is the matter of 
clothing. A great deal has been written (and some of it not 
overly wise) on the equipment of our troops on our first foreign 
expeditions, viz, those against Santiago and Manila; and among 
other things, the fallacy of sending* troops to the tropics, with 
clothing intended only for the north temperate zone, has been 
more or less severely denounced. Notwithstanding all this how- 
ever, the fact remains that many a man who had discarded his 
blouse and blanket, during the heat of the day, on the advance to 
the front, thanked his stars that he had at least his blue-fiannel 
shirt to protect him from the chill that comes before dawn, even 
in the tropical night. 

So that granting that our troops were somewhat overbur- 
dened by heavy clothing, and few will question the fact, it was 



PRACTICAL SUGGESTIONS ON TROPICAL HYGIENE. 49 

not altogether an unmixed evil, and although at the time, we 
were -perforce compelled to err, we rather erred on the right side. 

The question of supplying proper clothing for the soldier in 
the tropics is a many sided one and depends largely upon the 
work he may be called upon to do, but as field service is the most 
important by far, and that for which he was primarily enlisted 
and, as furthermore it is the time above all others when he is sub- 
jected, to situations calculated to try his strength and endurance, 
often beyond the breaking point, I will consider first the necessi- 
ties that pertain more nearly to active operations in the field and 
discuss briefly later on the dress for permanent camp or garrison. 

To begin with, the almost irresistable tendency on the march, 
in intensely hot weather, to discard every thing that can be 
thrown away, must always be borne in mind, and with this in 
view the garments worn should be of such weight and texture as 
to not unduly oppress the man during the day and at the same 
time afiFord him some protection from chill during the night. A 
shirt and trousers is all a man will willingly wear under condi- 
tions such as we are discussing, consequently these two garments 
should be made to fulfill as many of the necessary requirements 
as possible; presupposing that in many instances he will be com- 
pelled to sleep on the field with no other protection than the 
clothing he has marched in. I have in my mind a suit of khaki - 
colored flannel, which, I believe would not be a bad combination 
for * 'hiking*' in the tropics; constructed somewhat as follows. 
The pattern of the shirt to be much the same as that of our reg- 
ulation blue-flannel shirt, and the trousers shaped after the style 
of the ordinary riding trousers, reaching only to the ankle and 
slashed and buttoned at the bottom, so as to admit of their being 
worn inside the socks, or rolled above the knee as occasion might 
require. ' The garments to be connected by loops sewed to the 
waist of the shirt; these loops passing through slits in the waist- 
band of the trousers and through which the cartridge belt could 
be passed, thereby sustaining the weight of the belt in large part 
from the shoulders through the medium of the shirt. This is a 
matter of importance as many men attributed a primary or recur- 
rent attack of dysentery or diarrhoea to the pressure of the car- 



50 MAJOR HENRY P. BIRMINGHAM, 

tridge belt, either before admission or after returning to duty, 
and the truth of this was so well recognized that many advocated 
the wearing of the belt across the shoulders, bandolier fashion, to 
avoid the pressure of the heavy cartridge belt on the abdominal 
organs. 

A light woolen sock should always be worn, the tendency of 
the cotton sock to expand anj^jiuittlde^iuder moisture — other con- 
siderations aside — beine/tf^KlS^iftjft^^^tra pair should invari- 
ably be on hand at th|f^^5l of the march. ''0\ 

Fit, light weightf and ^^dN quality shoStjAal ways govern in 
the matter of leather tt^^t gear; tfie fafiSry ofJ attempting econ- 
qmy in this line has freoue^tly been called #mr attention. 

I mentioned above tnKj^ &j^^^jV fljr^ty of the garments, 
and 1 desire to .say, that it is aTmatter of the very first importance 
that all material should be such as to reduce to the lowest possi- 
ble minimum its irritating effect upon the .skin. The necessity of 
this to all who are acquainted with tropical conditions is obvious 
and will be referred to again later on. 

To meet the first indication set forth above, viz: to prevent 
chill at night, the garment or*gannents would have to be largely, 
if not wholly of woolen material, but the irritating eflFect upon 
the skin of wool as ordinarily woven is well known and hard to 
overcome. My only objection to the blue flannel shirt as issued 
(which as before mentioned has rendered staunch service) is that 
it is entirely too coarse in texture and many men simply cannot 
stand the itching and erythema that it will produce, and more- 
over the irritation thus set up is liable to be the forerunner of 
what all men in the tropics fear — the dreaded dhobie itch. This 
is an opportune time to call attention to the paramount necessity 
of conserving in every possible way healthy skin action. The 
macerating effect on the skin of heat and moisture during the 
rainy season, not only to the man who is '^hiking." but very of- 
ten to others who are less actively engaged, is one that demands 
our most serious consideration and next to scrupulous cleanliness 
the prophylaxis consists largely in supplying the individual with 
clothing that will not unduly irritate the already sensitive skin. 
Right here 1 would like to say a word in regard to the abdominal 



PR A CTICAL SUGGESTIONS ON TROPICA L H YGIENE, 51 

band for the purpose of unqualifiedly condemning it, and for the 
following reasons: If it happens to remain in place it not only 
interferes with abdominal respiration, but is almost sure to induce 
prickly heat or other erythematous condition with subsequent 
skin complications, and if it does not do this it is because it has 
rolled up into a constricting band under the armpits or over the 
pelvis, and in any case will very likely be a source of unending 
discomfort to the wearer. As a matter of fact it belongs to the 
same pernicious class as the neck muffler and the chest protector 
and regional protection in the tropics is as unscientific and irra- 
tional as it is elsewhere. 

Next in order comes the question of headgear, and this is a 
matter of most serious import. The depressing — I might almost 
say the paralyzing — effect of the tropical sun is such that only 
those who have been subjected to its overwhelming rays can fully 
appreciate — and as the head is called upon to bear the brunt of 
this it should be most fully and adequately protected. Our heavy 
felt campaign hat, although generally used by our troops in the 
tropics, has certainly not met the indication. A proper military 
hat or helmet might be constructed on the lines of the average 
native hat which combines lightness of construction, protection 
for the face and neck —more particularly the latter — and thorough 
ventilation; the latter being secured not only by permeability of 
the material used, but more particularly for the reason that the 
average tropical native never allows his hat to be pressed down 
over the vertex, but prevents this by a circular crow^n rim resting 
lightly on the top of the head. He secures his hat when neces- 
sary by a chin strap. The fault of the average helmet is that it 
fails to consider these important essentials, and is made — irrespec- 
tive of the material used — to conform to the shape of the head 
thereby permitting it to be pulled down over the vertex to act as 
a constricting band and consequently seriously interfering with 
its Value as a head protector. 

The general shape of the headgear might be circular or hel- 
met-shaped without detracting in any way from the essentials 
mentioned, and it might be covered with a porous khaki-colored 
material to match the uniform. 



52 MAJOR HENRY P. BIRMINGHAM, 

The dress for permanent camp or garrison is comparatively 
a simple matter and the ordinary clothing issued by the Govern- 
ment, viz: — white or khaki outer garments, the chambray or 
blue-flannel shirt and the campaign hat or khaki cap easily meet 
the indications. 

I shall not attempt to enter into the chemistry of tropical di- 
etetics or discuss the subject, other than in a practical way, and 
consequently my remarks will not be extended. 

The first and most important is that life in the tropics has a 
decided tendency to lower the nutritional standard of the indi- 
vidual from abroad, and this in many instances is largely aug- 
mented by the fact that he is deprived to a greater or less extent 
of his customary aliment. 

Not a little has been written in recent years about the neces- 
sity of eliminating to a considerable degree the nitrogenous and 
fatty elements from the tropical dietary and substituting therefor, 
either wholly or in part the carbo-hydrates, particularly in the 
matter of fruits and tropical cereals, but after a somewhat ex- 
tended experience in the tropics I am convinced that this idea is 
largely erroneous. The individual from the outside, if he is to 
maintain his health in the tropics, must keep his nutrition up to 
the highest point, and he actually needs as much, if not more 
food, and better than he ever required at home. 

The Subsistence Department of the Army in supplying the 
fresh Australian beef and in furnishing the troops generally with 
the liberal ration allowed, was an important factor in sustaining 
the large degree of effectiveness maintained in the Army in the 
Philippines, and the ration as supplied was not in any degree 
lacking in the nitrogenous and fatty elements. 

If I were to epitomize my ideas on this part of the subject 
(or advance anything in the way of a general rule) I would en- 
join the ii\dividual going to the tropics to approximate his diet as 
nearly as consistent to his accustomed fare at home, not except- 
ing a glass of good wine at meals, if the individual is so disposed, 
drinking only distilled, boiled or carefully filtered water when it 
is possible to obtain such, avoiding all excesses in eating and 
drinking, and generally conducting himself as a rational person 
should in any quarter of the globe. 



PR A CTICAL SUGGESTIONS ON TROPICAL H YGIENE. 53 

This all seems very simple, and it is, but as far as my observ- 
ation has extended, it is all that is required in that line to keep 
the average individual in a fairly good state of health in the 
tropics. He may, notwithstanding all this cx)ntract amoebic dys- 
entery (which by the way is the one dread disease of the oriental 
tropics, at least the Philippine part of it) but in most cases he 
will not, and for the matter of that he might have contracted ty- 
phoid fever even had he remained at home, for I believe, notwith- 
standing all our efforts that Eberth*s bacillus is still with us, and ef- 
fects a lodgement on suitable soil with rather astonishing frequency. 

The tropical diseases that concern us as military surgeons are 
perhaps in the order of their frequency and importance, dysen- 
tery, both amoebic and specific, malarial fever, yellow fever, 
dengue, beri-beri, cholera and bubonic plague. Sprue or psilosis 
I have not mentioned, for the reason that I fully agree with Con- 
tract Surgeon Musgrave, U.S. Army, in his recent valuable and 
exhaustive article on the subject, believing it to be a condition 
liable to be engrafted on any depressing disease incident to the 
tropics, and not a distinct morbid entity; neither have I men- 
tioned . diarrhcea for almost without exception in the cases sent 
from the interior to the large hospitals with a diagnosis of diar- 
rhoea, a history of catarrhal dysentery could be elicited and not 
infrequently a microscopical examination of the stools, or an ap- 
plication of the agglutination test, proved the cases to be amoebic 
or specific dysentery. 

The prophylaxis of dysentery as heretofore set forth, consists 
largely in paying the most scrupulous attention to the food and 
drink of the soldier, and measures directed toward the maintain- 
ance of his health at the highest possible standard. 

The prophylaxis of malarial fever is so well known that I 
will not take up your time with it, for preventive measures in 
the tropics are the same as those found essential elsewhere. The 
non-effectiveness due to malaria among troops serving in the 
tropics has always been large and although the lines along which 
it should be combated are now well known, the intelligence and 
thoroughness with which the work is carried out will depend 
very largely on the military surgeon. 



54 MAJOR HENRY P. BIRMINGHAM, 

Yellow fever I have had little personal acquaintance with, 
but fortunately the unprecedented work of our confreres in 
Cuba has placed in our hands means by which this once terror- 
spreading disease may be effectually held in check if not actually 
stamped out. 

Dengue in the Philippines was a common and wide spread 
affection and did not differ in any essential particular from the 
disease as found in our southern states, the epidemic as a rule 
continuing until all susceptible material was exhausted. The 
mortality was nil. 

Beri-beri in its various forms was occasionally met with, but 
as this is undoubtedly a disease of locality, the propagation of 
which is fostered by heat, moisture, filth and overcrowding, the 
chances of our troops ever being seriously affected by it are rather 
remote. The hygienic measures necessary in case an outbreak 
does arise are perfectly plain. 

Bubonic plague need not be a source of alarm to civilized 
troops serving in the tropics. Not an American soldier con- 
tracted the disease during my tour of duty in the Philippine 
Islands, covering a period of two years, although the disease was 
prevalent for a great part of that time in Manila and elsewhere on 
the islands. The work done by medical officers of the army in 
the organization and conduct of the various Boards of Health 
was largely responsible for this, and their work is deserving of 
the highest praise. 

Cholera I have had no personal experience with, but from 
letters received from Manila, the recent outbreak of that disease 
in the Philippines has so far been entirely confined to the natives 
and the Chinese, and the disease in this respect bids fair to act in 
the same manner as the bubonic plague. 

In conclusion I desire to say that with the knowledge we 
have gained of tropical conditions, and the disposition on the part 
of all concerned to further all necessary hygienic and sanitary 
measures, I believe that with due care and perseverance on our 
part the health of our troops in the tropics will never seriously 
suffer. 



fftebtco-flMlttar^ 1 nbei- 

MEDICO-MILITARY ADMINISTRATION. 

African (An) equipment. Climate^ Lond., 1902-3, iv, 152-156. 
Army (The) as a medical career. Lancety Lond., 1902, ii, 645. 
Escuela (La) de Sanidad Militar. An, san. miL, Buenos Aires, 1902, 

Jv, 513-5 15- 

Information for the use of candidates for appointment in the West 
African medical staff. Brit. M.J., Lond., 1902, ii, 565. 

Memorial tablet to the staff of the Welch Hospital. Lancet, Lond., 1902, 
ii. 556. 

' Notizie sommarie suUa statistica sanitaria del Regio Esercito per I'anno 
1899. Gior. med.d. r. esercito ^ Roma, 1902, 1, 785-816. 

Perros (Los) amaestrados para socorier d los heridos en la guerra. An 
san. mil., Buenos Aires, 1902, iv, 522-530. 

Royal Navy (The) and Army and the Indian medical services. [Rules 
governing admission to these services.] Brit. M.J., Lond., 1902, ii, 556-563. 

Afkle (Annie.) The Indian army nursing service. Brit. J. Nursing, 
Lond., 1902, xxix, 196. 

Baer (J. A.) Notes on transportation by a member of the China relief 
expedition. /. Mil. Serv. Inst. U. S,, Governor's Island, N. Y. H., 1902, 
XXX, 623-636. 

Befafcns (F.) Zweck und Ziele der freiwilligen Sanitats-Kolonnen vom 
Rothen Kreutz. Eine Denkschrift zur Gewinnungvon Hiilfskraften fiirdas 
Rothe Kreuz und Anleitung zur Bildung von Sanitats-Kolonnen. [Aims and 
purposes of the volunteer service of the Red Cross.] 8.* Berlin, [1902.] 

fienedu Le service de santd en campagne; donn^es pratiques k I'usage 
des officiers d'dtat-major et des m^ecins chefs, v. ii. 12,* Paris, 1902. 

Cal^ari (G. B.) [The small field hospital]. Gior. med. d. r. esercito, 
Roma, 1902, 1, 897-941, I plan. 

G>]borDe (W* J*) The duties of medical officers in connexion with naval 
action. Brit. M.J., Lond., 1902, ii, 1021--1023. 

de Alarcon (C L) £1 servicio de sanidad alem^ en la campafia de 
China (1900-1901.) Rev, de. san. mil., Madrid, 1902, xvi, 189-192. 

Douglas (C E*) Edinburgh graduates (Boer and Briton) in South Africa. 
Edinb. M.J., 1902, n. s., xii, 453-457. 

Dudot Projet d*un sac-ambulance. [Abstr.] Arch. de. mid. nav. 

Par., 1902, baviii, 131-134. 

(66) 



56 AfED/CO-MILITARV INDEX. 

MEDICO-MILITARY HISTORY AND BIOGRAPHY. 

Army surgeon (The) in CromwclPs time. Med, Rec,^ N. Y., 1902, Ixii, 379. 

[Surgeon-inspector Marvaud (Louis- Angel) 1844-1902.] France m(d.^ 
Par., 1902, xlix, 412. 

Reed (Walter.) [1851-1902.] [Obituary.] Atn, Af^^/., Phila., 1902, iv, 
845. Also; Boston M. &*S./., 1902, cxlvii, 630. Also: Brti. M,/.y Lond., 
1903, i, 53. Also: Indiana M.J.^ Indianapolis, 1902, xxi, 205 Also:/. Am. 
Af. Ass.y Chicago, 1902, xxxix, 1403. Also: Med. Rec. N. Y., 1902, Ixii, 858. 
Also: N. York M.J. 1902, Ixxvi, 948 Also: Phila M.J., 1902, x, 858. 

Roland* Oberstabsarzt Paul Kiibler [1833^1902.] Deutsche miL-drstl 
Ztschr.y Berl., 1902, xxxi, 452-454. 

Tebault (C H) Hospitals of the Confederacy. South. Pract.. Nash- 
ville, 1902, xxiv, 499-509. 

vanLier(L*) Vovedracht over de militaire geneeskunde in het laatste 
decennium. Mil.-geneesk. Tijdschr.^ Haarlem, 1902, vi, 141-157. 

MILITARY MEDICINE. 

Andevion (S«) Some cases of sudden death in native regiments. Indian 
M. Gaz.^ Calcutta, 1902, xxxvii, 386-389. 

Caldwell (R.) Some means by which disease spread.s on active service, 
y. State M., Lond., 1902, x, 685-688. 

de Santi. [Concentration of wine from the military point of view.] Ca- 
ducie^ Par., 1902, ii, 295-297. 

Eckert (P. O.) [*Three cases of insanity following sunstroke in .soldiers.] 
8." Berlin, 1902. 

MarottefA. C H*) [Epidemic of typhoid in troops.] Arch, de med. et 
pharm. mil., Par., 1902, xl, 369-376. 

Masbfenler. L'ali^nation mentale dans Tarm^e. /. de. med. de Par., 
1902, 2. s., xiv, 338. 

Mouly (G.) [Tuberculosis in the army; military sanatoria.] 8* Paris, 1 901 . 

Redondo Flores ( A*) Fiebre tifoidea grave. Rev. de san. mil., Madrid, 
1902, xvi, 229-232. 

Whittlngton (R.) Enteric fever: prophylactic measures in armies. 
Treatment, Lond., 1902-3, vi, 571-592. 

MILITARY SURGERY. 

Basarns. [Immediate dressing of gunshot wounds.] Arch de. mkd. et 
pharm. mil.. Par., 1902, xl, 191; 268. 

Bonnette. Du pausement en chirurgie d'armde. Les .sachets de charbon 
de paille. Caducee^'P^r., 1902, ii, no. 15, annexes. 

[Mortal wound of the abdomen b> a weapon, model 1874.] 

Arch de mtd et pharm. mil., Par., 1902, xl, 305-317. 

Plaie p^ndtrante de Tabdomen par coup d'dp^e baYonnette 

Lebel; rupture k 18 centimetres de la baVonnette enclave daus la sacrum: 
laparotomie lat^ale; extraction: n^rite du nerf crural gauche; gu6-ison. 
Caducte, Par., 1902, 11,211, 



lEbttodal H)epartment 



AN AUSTRO-HUNGARIAN VIEW OF THE MEDICAL 
ORGANIZATION OF THE UNITED STATES 
ARMY IN ACTIVE SERVICE. 

THE question of the most suitable medical organization of 
the United States Army in active service has recently 
come again into greater prominence, and it is one of 
great interest also for the non-American medical officer. 

While keeping in view the excellent articles of Lieutenant- 
Colonel Valery Havard, Captain Frederick P. Reynolds, Cap- 
tain John Stewart Kulp and others published in this journal, 
may a foreigner be permitted from a general point of view hum- 
bly to express his opinions, despite the fact that of course many 
particulars regarding conditions in the American army are un- 
known to him ? 

Among the best features of the American military medical 
organization are the military rank, there granted to the army 
doctor, and the military authority with which he is invested, as 
well as the equipment of the military hospitals, which is much 
better than that of other armies. • 

In regard to the first matter the United States Army has 
long been a pattern for most of the military medical staffs of the 
Old World, and to this day only the army doctors of the Swiss, 
Norwegian, Italian and English armies in regard to their mili- 
tary authority are equal to those of the American army, which 
finds expression also in their military titles. In the other armies 
of the Old World the medical officer is still more or less limited 
in his military authority. Effective service of the medical appa- 
ratus can only be obtained when the specialist, and that the army 

doctor is, is absolute master in his own house. 

(OT) 



58 EDITORIAL DEPARTMENT, 

Therefore Lieutenant Colonel Havard is quite right when 
he says **The best results will be obtained by granting it com- 
plete autonomy, including the full control of its personal and 
material. ' ' 

However advisable it may be for the military doctors to be 
commanders of the medical formations and independent managers 
of the entire medical service in the army, yet one must admit that 
for the management of the pharmaceutical, administrative, pay 
^ and transport departments special officials should be appointed. 
But if any high degree of intelligence is required of them they 
must be officers, or military officials, namely apothecaries, ad- 
ministrative and pay-office officials, transport officers etc. In 
most armies the commanders of the combatant troops have laid 
upon them duties connected with the administration, paying, com- 
missariat, etc. 

In Austria are found both in peace and war, besides the doc- 
tors also pay departmental officers, apothecaries, — administrative 
officers attached to the medical department; in Germany there 
are apothecaries and administrative officials: in France apothe- 
caries, administrative and transport -officers; in England quarter- 
masters, etc. 

By means of such officials the army doctors are at least par- 
tially relieved of administrative duties, and can consequently bet- 
ter devote themselves to higher duties, commanding and medical 
matters respectively; but it is a sine qua non that all these assist- 
ants should in every respect be under the command of the doctor 
on duty. 

In the American army medical organization this arrange- 
ment is wanting, and all the administrative business as far as it 
is not carried out by the non-commissioned officers of the hospi- 
tal corps falls to the share of the doctors. Captain Kulp is of 
opinion that this division of labor in the administrative service is 
"certainly in the direction of increased efficiency;" and Lieuten- 
ant Colonel Havard demands two line officers for each division 
as acting assistant quartermasters and commissaries for the am- 
bulance and the field hospital. 

The fact that hitherto both in peace and in war the Ameri- 



EDITORIAL DEPARTMENT. 59 

can anny doctors performed the whole administrative service of 
the medical organization to the complete satisfaction of those 
concerned, is only a proof of the practical talents of those doctors, 
and it is fully acknowledged abroad. 

The institution of dental surgeons is to be hailed with joy. 
In Europe it has been introduced into but very few armies; but 
Germany attached a dentist (with the rank of a military official) 
to her Asiatic expeditionary corps. In Austria- Hungary the 
training of military dentists has for some years had particular 
attention paid to it, but at present there are no army dentists here 

Female nurses are not so extensively employed in any Euro- 
pean army, except the English one, as they are in the American. 
Quite recently in Austria- Hungary in some large garrison hos-" 
pitals sisters of mercy have been engaged as nurses for the serious- 
ly ill. In the field there is no prospect of their being engaged, 
nor is it their place, despite the distinguished services rendered 
there by some few of them. One cannot but share Captain 
Kulp's opinion that for the field only the **well instructed sani- 
tar>' soldier" is suited, although that without doubt female 
nurses can do good service in the base hospitals. 

The staff of the hospital corps should be subject to strict 
discipline and maintain a true military spirit. The latter should 
be kept up by the recollection of the glorious deeds performed in 
war by single divisions or members of the corps. The sanitary 
soldier ought to have the same military rights as the other troops. 
In Austria- Hungary the noncommissioned officers of the sanitary 
corps have the same titles as other noncommissioned officers, and 
in America it would be better to give them such titles instead of 
the present ** hospital steward," and "acting hospital steward," 
namely **sergeant" and "corporal.'' 

One of the most important duties is training the hospital 
corps for war continually. Peace service must not wholly absorb 
the corps any more than the other troops. In this respect cir- 
cumstances are unfavorable in most European armies. For 
economy's sake the sanitary corps is kept small in times of peace, 
and the constant hard service in the hospitals prevents train- 
ing for the field. 



60 EDITORIAL DEPARTAfETT. 

We entirely agree with Lieutenant Colonel Havard when he 
demands a homogenous hospital corps, and when he declares the 
German system of * 'acting regimental litter bearers'* one not to 
be followed. In Austria- Hungary besides the sanitary corps, 
which does the work in the sanitary establishments, in most 
branches of the army there are * 'regimental litter bearers, " who, 
unlike the Gennan acting regimental litter bearers, are not pro- 
vided with rifles, but only with a sanitary equipment, and conse- 
qaently are destined exclusively for sanitary service behind the 
front, and at the ''dressing stations." Besides these bearers 
there are in the Austrian-Hungarian army also "sanitary assist- 
ants" (who are more highly trained noncommissioned officers) 
and orderlies, at the disposal of the army doctors. 

The members of the hospital corps ought to be armed, and 
they are so in all European armies, with at least side arms. This 
firstly increases the men's self-esteem, and then in the vicissitudes 
of war he may need a weapon to defend himself, or those en- 
trusted to his care, e. g. from the hyenas of the battlefield, or 
against uncivilized peoples, of which there still are some in 
Europe (e. g. the Albanians). 

As for the sanitary service during a battle, we share the 
opinion of Lieutenant Colonel Havard, namely that the ambu- 
lance station, as the Americans call it (the dressing station of the 
.English, ambulance of the French, Hauptverbandplatz of the 
Germans) will in future mostly be superfluous. In consequence 
of the small calibre bullets the dressing stations during the ac- 
tion, or at least when one's own side advances, or in pauses in the 
fighting, will come into activity. It is hardly possible for the am- 
bulance station to be set up only after the fighting; it must take 
place at a time, when the field hospitals (which for military 
reasons will remain at a considerable distance in the rear) have 
not yet arrived. But Lieutenant Colonel Havard is right when 
he says that it will not be necessary to fit up the ambulance like 
field hospitals, if these later will soon take the place of the former. 

In order to adapt the first aid to the wounded, during an en- 
gagement, to the military situation, but on the other hand not to 
scatter the medical assistance too much, it is intended in the Aus- 



EDITORIAL DEPARTMENT. 61 

tro-Hungarian army to assign the dressing stations according 
to the fighting groups^ and not according to the usual fixed 
troops. 

In all wars it has been found that the slightly wounded who 
have already had their wounds dressed are a disturbing and dis- 
quieting element at the ambulance stations. Therefore it is pro- 
posed in Austria-Hungary to establish special **stations for the 
slightly wounded,'* which should be placed about as far forward 
as the dressing stations, or a little farther back, in an easily en- 
closed place, a farmyard for example; and such wounded men as 
could walk should be sent direct from the dressing stations, in 
charge of a slightly wounded officer, or noncommissioned officer. 
The severely wounded would be transported from the ambulance 
stations to the field hospitals, whereas the slightly wounded a5 a 
matter of principle, should be sent to the hospitals for slight cases 
of illness and light wounds, in order after their restoration to re- 
turn to their troops. 

Such stations for the slightly wounded (German: Leichtver- 
wundeten-Stationen, French: d^p6ts d'eclop^s) we miss in the 
organization of the American army, and yet they certainly would 
be very useful for relieving the hospitals. 

One cannot but agree with the figures given by Lieutenant 
Colonel Havard respecting losses on the field of battle. It may 
interest the reader to learn what percentage is reckoned on in the 
Austrian- Hungarian army in the **Kriegsspiel." On the basis of 
the most recent experiences in war 10 % is taken to be the normal 
loss in a bloody engagement, while 15% is considered an excep- 
tion; of the total loss 20% is calculated as meeting with instant 
death, 20% severely wounded and untransportable, 15% able to 
inarch, 20% to be transported lying and 25% sitting. 

The regulations laid down by Lieutenant Colonel Havard 
for the sanitary service during a fight are excellent, and adapted 
to the modem manner of fighting. We understand why the 
Americans send one doctor to accompany each regiment into bat- 
tle. In some European armies recently there has been an incli- 
nation to abandon that practice. Just at the present time, when 
dressing stations cannot begin their work so soon as in former 



62 EDITORIAL DEPARTMENT, 

Wars, it is absolutely necessary to have doctors with the troops to 
save lives, to superintend the litter bearers, and for moral reasons. 
Of course these doctors sent forward must, like the fighters, make 
use of all shelter afforded by the ground, in order not needlessly 
to expose themselves. The loss of some doctors in engagements 
is inevitable. 

The Spanish -American War and the South- African War 
have furnished numerous examples of courage and self-sacrifice 
on the part of army doctors; the names of these victims will be 
honored by the members of the sanitary corps of all armies, and 
will remain unforgotten as shining examples for coming militar>' 
medical generations. 

Great wars are always the occasion for improvements in the 
military sanitary service. For the United States this was again 
proved by the war with Spain, The reorganization of February, 
1901 certainly removed some defects brought to light by the war 
of 1898. The great achievements of the United States army 
medical department under the prudent and energetic manage- 
ment of its former head. Surgeon General George M. Sternberg, 
who deserved so well of it, is sure of recognition on the'part of the 
sanitar>' officers of all foreign armies. 

JoHANN vSteiner, k, und k, Regmientsarzt (Vienna). 

AN ADEQUATE PENSION FOR THE WIDOW OF THE 
LATE MAJOR WALTER REED. 

A MONG the greatest losses suffered by the Association dur- 
/-% ing its historj' is that occasioned by the death of the late 
-^ ^ Major Walter Reed of the Army. The loss to the As- 
sociation however was no greater than the loss to the world. One 
of those rare natures to whom came the opportunity to contribute 
largely to the welfare of the race, Major Reed's name is written 
in letters of light upon the roll of Humanity's benefactors. His 
services to mankind and in particular to our own country were so 
great as not to be recited in ordinary phraseology. We are wont 
to glorify our country for its altruistic act in accomplishing the 
freedom of Cuba. What a nation did for Cuba politically, Walter 



EDITORIAL DEPARTMENT. 63 

Reed did for her hygieuically . Even more, by control of the pest 
which constantly devastated Cuba, he removed the constant men- 
ace of an epidemic from our own shores. In terms of cold cash 
his services were incalculable. In terms of health and suffering 
the results of his work were even more inexpressible. It is then 
but a modest request which is being made of Congress to grant a 
pension of $4 000 a year to the widow of one who deserves so 
much at the hands of his country, and favorable action should be 
promptly taken. 

ON SOLDIERS' FEET. 

REFERRING to the critique on the work of Capt. H. 
Brjn of the Norwegian army, published in the Jour- 
nal of October last, the figures as to length and 
breadth of feet seem to be fully dealt with, but there does not 
appear to be sufficient attention paid to the fact that A^ 
there are two broad classes of feet, characterized by \^\ 
the relative length of the great toe. [\ 

In one class the great toe is the longest, causing U 
a shape of foot in which the inner border is fairly [f / 
straight, and the fifth toe has a tendency to under- ^) ( 
ride — in fact in many cases it shows a marked tend- { J 
ency towards future elimination. 

In another class the second toe is the longest, causing a 
roundness of the front of the foot. This is the foot of the 

classical statues; but the practical view of it is that its 
possessor requires a properly rounded end to his boot. 
In the former case a square-toed boot means waste 
of leather on the outer side. 
These broad classes do not appear to receive that 
recognition by bootmakers which is especially desir- 
able in the manufacture of ready-made boots, such as it 
is necessary to keep in stock for the shoeing of an army. 

B. Skinner, 
London, England, Dec. 2, '02. Lt. Col. R.A.M.C. 



\ 



IRevtews of Boohs. 



MILITARY AND NAVAL SURGERY IN THE INTER- 
NATIONAL TEXTBOOK OF SURGERY.* 

THE second edition of the International Textbook of Sur- 
gery presents constant evidences of revision, by which 
all the advances in surgical theory and practice have 
been incorporated into its text. The comprehensive chapters on 
the various' branches of surgery, written by accomplished sur- 
geons of Great Britain and the United States, might all be con- 
sidered with much advantage, but the present review is neces- 
sarily concerned with the divisions relating to military amd naval 
surgery, — the former by Surgeon General Forwood, the latter by 
the late Medical Inspector Siegfried and revised by Surgeon Henry 
G. Beyer. 

General Forwood has made many changes in the practical 
portion of his article, as would be expected in vie\v of the experi- 
ences of recent hostilities in various countries. The space de- 
voted to deformity of the bullet in the revised article is largely 
increased, and illustrated by a new plate .showing various degrees 
and types of deformation. The section on wounds of the head 
has been re- written and illustrated by a new cut. An extensive 
addition has been made to the discussion of wounds of the chest 
and the account of gunshot wounds of the abdomen has also been 
materially expanded. The comment upon wounds by tl^e old 
army revolver has been dropped as obsolete. 

The treatment of military sanitary organization has been 
modified much less than that upon gunshot wounds. The new 

*The InternatioaAl Textbook of Surgery by American and British AutfaorB^ 
Edited by J. Collins Warren, Mro., LL.D. and A. Pearce Gould, 
M.S., F. R.C.S. Second Edition, 2 volumes; Roy. 8vo; pp. 965, 1122; 960 il- 
lustrations and 17 full page plates in colors. Philadelphia and London, W. 
B. Saunders & Co., 1902. 

(64^ 



REVIEWS OF BOOKS. 65 

nomenclature, **medical and surgical chests," has been substi- 
tuted for the expression, * 'medicine-panniers," and a few other 
minor changes calculated to more effectively round out this ad- 
mirable article have been made. 

The section on Naval Surgery has been subjected to much 
greater change than that on military surgery. It is in effect an 
entirely new article, presenting of course many of the points and 
illustrations employed in its predecessor, but in many cases, treat- 
ing them independently and with individuality. The introduc- 
tion is entirely new and consists of a valuable statistical discus- 
sion of the diseases and injuries prevalent in the naval service 
accompanied by exhaustive mortality tables. Transportation of 
the wounded on shipboard is carefully considered. The ambu- 
lance sleigh of Kirker is fully described but the Ames Board has 
evidently been overlooked; and the article closes with an account of 
the work of the hospital ship Bay State based upon the report of 
the medical work of the Massachusetts Volunteer Aid Asso£iation 
during the Spanish war. 

These articles set for the International Textbook a high 
standard, which so far as we have been able to judge has been 
amply maintained throughout the work. 

OCHSNER'S CLINICAL SURGERY.* 

THIS book is written on original lines and illustrates the 
up to date surgery of the author. It is authoritative 
and bears the imprint of individuality. Among the 
many good things that will bear frequent reading, are the boiled 
down facts grouped under the heading of ''General Surgical Con- 
siderations." They are concise, almost epigramatic, and deserve 
close study from the reader. 

The article on hernia is graphic and the various steps in the 
different varieties of hernia are clearly illustrated by the numer- 
ous plates. 

The operations employed in abdominal surgery are well illus- 
trated by plates and in the text. The author's results in the 
treatment of advanced cases of appendicitis by his method seem 

*CIiiiicaI Surgeiy for tbe Instruction of Practitlonen and Students of Surgery. 
By A. J. OCHSNER, B.S., F.R.M.S,, M.D. Roy. 8vo; pp 481; 100 illustra- 
tions: Chicae:o Cleveland Press, 1002. 



6ly REVIEWS OF BOOKS. 

phenomenal and almost incredible; with others, the treatment, 
with the exception of stopping the nausea and vomiting and reliev- 
ing the distention, has been unsuccessful. How it can limit gan- 
grene of the appendix, prevent the formation of pus or the spread 
of peritoneal inflammation is not described. In the claims of a 
reduction of mortality it is unfortunate that the author has not 
fully explained the means by which this treatment relieves the 
above condition. It is greatly to be feared that owing to this 
teaching, others will not have the same good results, and that 
the benefits from early and prompt operation will be neglected. 

The illustrations are new and original. The clear text, wide 
margins and high quality of the paper add greatly to the value 
and appearance of the book. 

The work is essentially clinical in character and represents 
modem surgery and advanced technique, presented with force and 
conviction by one of the leading surgeons of the day. — A. R. Allen . 

SCUDDER'vS TREATMENT OF FRACTURES.* 

THE demand for a third edition of this work, following so 
soon after the .second edition, is the highest testimony 
the profession can give as to its value. The writer had 
the pleasure of reviewing the second edition in a previous number 
of the Journal, and felt at that time that little could be added 
to enhance the value of the book to the profession. The author, 
nevertheless, has taken advantage of all the latest literature, and 
has carefully revised and enlarged the book, drawing on the ex- 
perience of Mr. Makins in South Africa and other surgeons in 
the field during the recent wars and recorded the results in the 
new chapter on gunshot wounds of the long bones. 

The uses of plaster of Paris as a splint material have been 
more fully illustrated and descriptions of several new fractures 
have been added, thus bringing the volume up to date in every- 
way. A. R. Allen. 



•The Treatment of Fractures* By Chas. L. Scudder, M. D., AssisUnt 
in Clinical and Operative Surgery, Harvard Medical School. Third Edition j 
revised and enlarged Octavo. 480 pages, with 645 original illustrations. 
Philadelphia and London: W. B. Saunders & Co., 1902. 



THE LAWS OF PHYvSICS AND BALLISTICS THE TRUE 
EXPLANATION OF THE LODGMENT AND DE- 
FLECTION OF THE MAJORITY OF MODERN 
SMALL-ARM PROJECTILES, NOT THE 
RICOCHET HYPOTHESIS 

By major CHARLES BEYLARD NANCREDE, 

ANN ARBOR, MICH. 

CHIEF SURGEON OF UNITED STATES VOLUNTEERS; PROFESSOR OF 

SURGERY IN THE UNIVERSITY OF MICHIGAN AND 

DARTMOUTH MEDICAL COLLEGE. 

IF we believe in the truth of the much quoted, but seldom fol- 
lowed opinion of Delorme, it is requisite for the military 
surgeon to know the ' *calibre of the arms, the weight of 
their projectiles, their diameters," their "initial velocities" and 

their '* remaining velocities" **at the diiferent distances" to 

appreciate the "characters" "of the wounds he will have to 

treat." Hence, although according to the same author, "the 
laws of Ballistics are a difficult and thankless study, a knowledge 
of them is of inestimable value to the army surgeon." 

While all the dry data I shall mention may be known to my 
audience, the proper marshalling of the facts will enable me to 
mass them in such overwhelming force as to require the expen- 
diture of only a few words in argument. 

My reasons for this paper are two-fold, the chief one being 
the too common assumption that because a modern military small- 
arm projectile has lodged or is deflected, this is the result of 
ricochet. My minor one is, that this occasion will enable me to 
call attention to, and correct an error in a former paper read be- 
fore the American Surgical Associaiion at its Chicago meeting, 
where the mathematician who made the computations failed to 
indicate foot pounda/s instead of foot pounds in the final result. 

«7 



68 MAJOR CHARLES BEYLARD NANCREDE. 

The reduction of foot poundals into foot pounds in no way alters 
the facts or conclusions of that paper, but merely renders the 
actual amount of 'energy" more comprehensible. 

The first point which I beg you to bear in mind throughout 
the whole of this paper and any discussion which may follow, is 
the physical configuration of the modern projectiles and that of 
their trajector\\ A modern projectile is iiot a ball, but a bolt pro- 
jected endwise, whose inevitable tendency, unless counteracted, is 
to revolve around its shorter axis. At every portion of its flight 
this tendency exists if the force which prevents it from rotating 
around its shorter axis is partially or totally suspended. The 
force which maintains the bullet in its flight endwise is the rota- 
tion around its long axis imparted by the rifling, and the speed of 
this rotation steadily diminishes from atmospheric resistance as 
the distance from the muzzle of the weapon increases. The high 
sectional density requisite to overcome air resistance is secured by 
the small area of the cross section of the bullet as compared with 
its weight. This necessary weight with small sectional area can 
only be secured by a long bolt of lead, but to insure sufficient ra- 
pidity of revolution to overcomethecertainty of revolution around 
the shorter axis one turn in about twelve inches is given to the 
rifling. This necessitates shallow rifling and a hard mantle for 
the projectile, otherwise the bolt would strip, "leading" the 
grooves and reducing the weapon to a smooth bore one. This in- 
creased number of complete turns in a given length of barrel de- 
mands a powder leaving little residue, for with black powder the 
shallow grooves would soon become fouled sufl5ciently to prevent 
the ball acquiring the proper "twist;" yet smokeless powder does 
leave some residue, and the shallow grooves wear in certain in- 
stances sufficiently, so that in combination with such fouling as 
the smokeless powder produces the balls do not ' 'take the grooves' ' 
properly, hence do not revolve with sufficient rapidity to over- 
come their tendency to rotate around their shorter axes. It is 
hardly necessary to point out that this diminution of rapidity of 
revolution if marked must determine deflection if slight resistance 
is met with, indeed the entrance of the ball sideways or "butt" 
foremost has been obserx^ed in some instances, without having en- 



LODGEMENT AND DEFLECTION OF BULLETS. f,'| 

countered any obstacle in its flight to lessen its force ordircction 
of impact; in other words these deflections need not be due to 
ricochet. 

It cannot be said that this is a theory incapable of proof out- 
side the laboratory or study, because bullets have been extracted 
showing plainly marks of such imperfect or almost missing rifling 
as demonstrated imperfect revolution, and thus accounted for 
their deflection or lodgment, or for both. 

From the instant the projectile leaves the mu^izle, gravity is 
drawing it towards the ground, whicB it must reach at the same 
time, whether the bullet moves rapidly or slowly, but in the 
fonner case it will have traversed a much greater distance in space 
than under the latter condition: in other words, in both instances 
it will describe a parabola of greater or lesser cur\'^ature, and the 
bolt-like projectile always strikes an object at an angle, which 
mode of impact still further favors the tendency to turn around 
the shorter axis. 

Again, such a bolt-like missile striking even a vertical plane 
at a slight angle, as it must always do, would tend to be deflected, 
pursuing a course approximating the line of the resultant of the 
two forces. Although this influence might be only slightly op- 
erative as compared with the force exercised in Producing the on- 
ward flight of the projectile, it distinctly favors the deflection of 
any missile which by having one axis shorter than any other 
possesses an inherent tendency to rotate around this axis. 

Only a few more data require statement, when their applica- 
tions to sustain my contentions will require only a few sentences. 
Would any one feel surprise or express doubt that at 1000 or 1500 
yards range the Springfield bullet should be deflected if it met 
with resistance, or that it would lodge under similar circum- 
stances, although its form does not readily lend itself to these ac- 
cidents? Yet the actual ''remaining energy" of Krag or Mauser 
projectiles at such ranges is only one-sixth to one-ninth their 
"initial energy," and actually much less than the Springfield 
po.ssesses at the same ranges. A brief review of the following 
tables will give a clearer idea of how much less powerful modem 
weapons are at the ranges where a large number of wounds are 



70 



MAJOR CHARLES REYLARD NANCREDE. 



inflicted, viz: 1000-1500 yards. At the former range, although 
the "remaining velocities" do not differ much, it must be remem- 
bered that the "remaining energy" only equals one-half the "re- 
maining velocity" squared, multiplied by the mass of the ball, 
and that this, the mass of the modem projectile, is less than half 
of the Springfield and other old fashioned balls. 







SPRINGFIELD 


MAUSER 


KRAG 


Muzzle velocity 




1300 ft. S. 


2285 ft. s. 


2000 fl. S. 


Velocity at 300 > 


-ards 


930." 


1660 " 


1390" 


600 


it 


830 '* 


I2I0 " 


1020 " 


1000 


<( 


680 " 


920 " 


800 '* 


1500 


u 


520 *' 


730" 


620 " 


Muzzle fenerg>' 


(( 


1876.02 *' pds. 


2504.44 ** pds. 


1952.73 " pds. 


Energy at 300 


i( 


1066. 1 1 " " 


1469.48 " •' 


943.22 " " 


600 


u 


746.73 " " 


780.76 " " 


507.90 " *i 


1000 


(( 


513.29 " " 


451.35 " " 


312.43 " " 


1500 


it 


300.16 " " 


.:84.l8 " " 


187.65 " " 



A long bolt-like projectile, when its "remaining velocity" 
and "remaining rotation" is greatly diminished, as both are at 
the distances at which very many wounds are received, is more 
apt to enter obliquely — possibly "butt" foremost and to be de- 
flected if it strikes oblique planes of bones, tense fascias or ten- 
dons, than the ola projectiles. 

When the long axis of a projectile which has lodged lies at a 
distinct angle with that of the track of entrance, it has been too 
readily assumed that it must have had its course altered and its 
speed retarded by single or repeated contact with extraneous ob- 
jects during its flight, i.e., has ricochetted. If however such 
missiles entered in the direction their position of lodgment would 
indicate the skin opening would be of a corresponding form, 
while if they had -their course changed after entrance, the skin 
wounds would be round and of about the same calibre as that of 
the projectile, or at most, be slightly oval in outline, if the mis- 
sile struck somewhat obliquely. This is the rule for numerous 
such wounds that I have seen where bullets were lodged in pecu- 
liar relation to the wound of entrance, or where their track was 
a devious i. e., a diverted one — while the skin wounds indicating 
ricochet balls were of a different form and were of rare occurrence. 



LODGEMENT AND DEFLECTION OFBULLE TS. 71 

Even when a bullet does enter exactly sideways making a 
key-hole opening, as I have seen more than once, there is no cer- 
tainty that this was due to ricochet, because the ball at the time 
of impact might have been either revolving around its shorter 
axis because the *'spin" of the ball was nearly spent,, or this lat- 
ter force being weakened and the ball striking obliquely this com- 
bination of influences determined the lateral passage of the pro- 
jectile. 

I do not contend that ricochet shot wounds never occur, but 
that the ricochet theory need not be invoked when demonstrable 
physical laws are fully adequate to explain the conditions, and 
when the ball has been deflected by striking objects during its 
flight it usually shows by the form of the entrance wound that it 
has entered sideways and that this may therefore be due to rico- 
chet. Again, its altered form, no bone having been encountered 
during its passage through the soft tissues, may prove that its 
lodgment was probably due to having had its flight artificially re- 
tarded. Under such circumstances the wound of entrance would 
probably show some peculiarity suggestive of a glancing ball. 
Even after a ball has been influenced by ricochet, further deflec- 
tion of its course after contact with the tissues is in most instances 
merely due to the influence of the forces already described as op- 
erative upon a missile whose onward flight and rapidity of revo- 
lution has been materially lessened by the distance it has tra- 
versed in space. 

Finally, while the ricochet theory does account for the irreg- 
ular entrance of some missiles, and because their "energy" is 
thus lessened by contact with extraneous objects, this theory may 
sometimes account for lodgment and deflection, in the majority of 
instances this is not tlie correct explanation, and at the ranges 
where a large number of missiles strike many cases of lodgment 
and deflection are to be expected and accounted for on demon- 
strable scientific principles. 



THE MILITARY MOTOR AMBULANCE. 

By lieutenant CLYDE SINCLAIR FORD, 

MEDICAL DEPARTMENT, I'NITED STATES ARMY. 

IT IS only within the past few years that real and consider- 
able progress has been made in the motor vehicle. Al- 
though at various times during the past twenty years prac- 
tical machines have been produced, and cumbersome attempts 
were made a century ago, it has remained until the past decade 
for the public to become sufficiently interested and to possess 
enough confidence in the future of the self propelling road ma- 
chine to extend the financial support so necessary to attract the 
best inventive and constructive genius essential to any mechani- 
cal advance. 

It is not less than marvelous to see, within these past few 
years, what improvements in design, detail, utilization of new 
material have been made in the application of elements of power 
that have for years been widely enough known to have been al- 
most within the inclusion of "general information." 

And as creditable as the motor car of today is to the mechan- 
ical and inventive genius of its creators, it is quite probable that 
it will compare but little more favorably with its successors of a 
few years hence than Stephenson's early effort compares with the 
mile-a-minute-schedule-time locomotive of the modem railroad. 

The most sanguine advocate of the automobile would hardly 
see, even in the farthest future, an age that would be entirely 
horseless, yet this new mechanical factor in transportation, in its 
destined perfection, will not only relieve the traction animals of 
much of their burden but it will take up new ones of its ovni. 

It is to be expected that no little unfavorable criticism, con- 
tention and some absolute condemnation would be occasioned by 
the advent of an innovation so comprehensive and positive as the 

(72) 



THE MILITARY MOTOR AMBULANCE, 73 

motor car and, too, that the recreative phases of this movement 
should be more in evidence in the beginning, than the utilitarian 
features. The newspaper-reading public, is apt to be best in- 
formed upon the adverse criticism emanating from more or less 
sensational sources rather than to have a technical knowledge 
which can only follow an interested study of the subject. That 
destroying monster which now whirls madly through the land in 
the hideous shape of a "Red Devil" or a "White Ghost,*' will 
soon become as commonplace and as undisturbing a feature of our 
streets and highways as the trolley car, which but a few years 
ago, just after driving the tired and jogging street car horse to 
his long earned rest, was known only as a "juggernaut." 

In the development of new sources of power and improve- 
ment of the old and well known elements of locomotion on the 
common road, there is involved an investment of capital, a busi- 
ness and commercial interest, and an engagement of inventive 
and constructive genius, the magnitude of which, for the few 
years since it has begun, has hardly been equaled in the intro- 
duction of any other invention. 

In France, alone, 200,000 persons are exclusively engaged in 
the manufacture of motor vehicles. 

In military operations, however small or large the body en- 
gaged — whether a company or a corps — and whatever be the or- 
ganization, the problem of transportation constitutes so much of 
the situation that any new element in this important department 
should receive the closest and earliest attention from military 
authorities. 

The armies of Europe have been investigating this subject 
for several years. Careful tests have shown, beyond doubt, that 
motor transportation is applicable, in at least a restricted way, to 
almost every branch of military service. 

The field of usefulness is being extended and only the con- 
tinuation of trials will determine its limits. 

Two years ago the German Emperor offered a prize of 
$20,000.00 for the best automobile for general military use and 
about a year ago the British War Office offered a prize for the 
production of a motor car for military purposes. 



74 LIEUTENANT CLYDE SINCLAIR FORD. 

In a report of Capt. R. S. Walker R.E. there is given a 
great variety of uses to which an ordinary steam -runabout was 
put to on the South African veldts. 

The French amiy during the past few years has employed 
the motor wagon for many purposes. During the maneuvers of 
1898, it was used by couriers and officers making inspections, and 
with a great saving of time. Commissary and artillery supplies 
were transported. An eight-seated twelve-horse-pow^er vehicle 
with a speed of 22 miles an hour was used by staff officers. Be- 
sides a postal car, there was a surgeon's wagon fitted up as a sort 
of field hospital. 

In the United States army the Signal Corps has had an elec- 
tric vehicle in Manila for some time past and this enterprising 
branch of the service has also operated both the steam and gaso- 
line machines. 

The other investigations in our army have been confined to 
two or three hazardous but unsuccessful attempts of a few offi- 
cers to ride in the steam wagons of one maker through from New 
York to Washington. 

But this comparatively slight interest of the United vStates 
army in motor vehicles seems only apparent to a hopeful patriot 
who, in commenting on the subject, assures us: "It must not be 
supposed, however, that because the United States has been some- 
what backward in including the new vehicles in its military out- 
fit, there is any lack of interest here in the experiments of other 
countries." 

Although the entire subject of army transportation need not 
be the concern of the Medical Department, the direct and respon- 
sible interest of the medical officer in the transportation of the 
sick and wounded must be quite apparent, and a consideration of 
the possibilities that iie in a military motor ambulance can not but 
be entirely within the province of this body of military surgeons. 

There are many reasons and much evidence leading to the 
conclusion that this device is of great and increasing importance 
to the medical service of the United States army. And, whatever 
may be the importance when adapted to the general military ser- 



THE MILITARY MOTOR AMBULANCE. 75 

vice, its use as an ambulance will have more advantages and 
fewer disadvantages than in any other place in the army. 

To whatever extent this new machine may be perfected, it 
will not be argued that it will ever supplant entirely the present 
hospital transportation. 

Any vehicle that is propelled by a power that directly turns 
its wheels must have a road-way that is more of a plane, horizon- 
tal and resisting surface than that required by a vehicle drawn by 
animals. A motor ambulance can never be made that can follow the 
present service ambulance through the worst conditions of mire 
and rut, but the particular and special uses to which this ma- 
chine is adapted in military operations must make it a necessary 
part of an army's equipment. 

A considerable portion of an army's ambulances are used 
about the base of operations aud in communication between the 
base and advanced lines, for the transportation of the disabled is 
always towards and at the base. There, roads must' already exist 
or they must be built and the motor ambulance can always be 
used, even though it might not follow pack mules or a n^Juntain 
battery. Yet, the radius of this machine would not be limited 
by the conditions of the highway that . prevent the turning of its 
wheels. It is the bad places in the road that stop the vehicle so, 
with a force of twenty horse-power or more stored in its vitals 
and connected with a capstan carrying a wire rope warp ^of ap- 
propriate length, a motor wagon would not only be able to get 
over or through many pjaces impassable to teams but it might be 
the means of pulling an entire wagon train through besides. 

The transportability of the motor ambulance commends it at 
once to military use, because of the facility and economy with 
which it can be shipped either by rail or by sea to the point of 
mobilization of troops. 

There can be no doubt of the immense saving of time and 
money in supplying an army across the sea with ambulances con- 
taining their own power instead of accompanying each of them 
with a mule team. Besides there is not the unending labor of 
subsequently keeping up the forwarding of great bulk and con- 
siderable weight of forage necessary for animals. The transpor- 
tation of fuel for a motor is a much less laborious task. 



76 LIEUTENANT CL YDE SINCLAIR FORD. 

Of all the principles entering into the organization of an army 
the one of preparedness is, above and • beyond all others, the most 
important. A machine of this kind can be kept in readiness 
without any deterioration or expense in maintenance and it can 
be sent off to a mobilizing point without the least preparation — 
already trained down to service conditions. 

Not the least reason for the adoption of this vehicle is the 
readiness with which it lends itself to become the property of the 
Medical Department, so that it may be entirely controlled 
by those most directly associated with it and interested in it, 
without the roundabout and often unsatisfactory method of hav- 
ing it provided and owned by another department. 

In presenting any new device as a substitute for an old and 
tried one, the question of actual and comparative cost must be 
considered together with its efficiency. To sum up the invoice 
price of the various articles included in a four mule ambu- 
lance outfit, the amount would certainly be much less than 
the first cost of a motor ambulance that could be built today, 
and even the ultimate development of the latter is not 
likely to cheapen it to the cost of a mule-drawn vehicle. But the 
relative economy of these two devices can not be determined by a 
comparison of first cost so that any figures giving this relation 
may be passed by. 

Nor can the relative cost be determined until both vehicles 
are used for a length of time in the military ser\nce and then only 
after being kept in a state of readiness and afterwards placed upon 
the ground from which they are to take their places in a military 
campaign. 

A short time since a statement was made by the Quarter- 
master Department that the mules shipped to Manila were set 
down at their destination at a cost to the Government of about 
$500.00, each. This great cost was due to the heavy casualties at 
sea. After an animal is unloaded at a distant base, even at such 
a great cost as in the instance cited, its value is still further en- 
hanced by its liability to diseases that are incident to the climate, 
and if the service be tropical, by the fewer hours work and 
slighter effort expected. * 

*The recent heavy losses of public animals in the Philippines through 
infectuous diseases emphasize the argument. 



THE MI LIT A RY MO TOR A MBULA NCE. 77 

It holds too, even under temperate climate conditions, 
though much more in lower latitudes, that the slight endurance 
of animal power compared with mechanical power would be such 
as to give the latter two or three times the capacity of the former. 

Only a few weeks ago an ordinary automobile under ordinary 
road conditions over the country highways of Indiana and Ohio 
made a straight-away run of 240 miles in 10 hours. 

Then, there is that very important factor in the maintenance of 
motor vehicles that calls for expenditure of fuel only while the 
wheels are actually turning, while the cost of feeding and caring 
for animals whether used or not used remains the same. 

In the selection of a suitable power it will be necessary to 
examine the three motors, — electric, internal-combustion and 
steam — that have been brought to the greatest state of perfection 
and are to be found in most general use. And, in this examina- 
tion it must be borne, in mind that all the peculiar and exacting 
conditions of military service must be considered. 

The Electric Motor with whatever advantages it may 
possess for civil uses may be dismissed without further considera- 
tion, because of, first, its necessar>' relation with a stationary 
source of power and consequent limited radius of travel; second, 
excessive weight and short life of batteries in proportion to load 
carried. 

The Internal-Combustion Motor which derives its power 
from the explosive force of a hydro-carbon — usually gasoline — 
although it is the most economical in the consumption of fuel, 
has the disadvantage of, first, great vibration; second, complexity 
of not only the motor itself, but of speed changing and reversing 
gear; third, great number and special construction of parts; 
fourth, necessity for special skill and knowledge in making repairs. 
As the power of this motor is generated by the violence of suc- 
cessive explosions of a mixture of definite proportions of air and 
gasoline that must be exactly timed the slightest derangement 
phyiscal or chemical stops the whole process. But the complete- 
ly disqualifying objection to this motor for military service is the 
fuel. Under military conditions it would be more diflScult and 
dangerous to handle than powder, for besides its liability to ex- 
plode it flows and spreads its flame when ignited. 



78 LIEUTENANT CL YDE SINCLAIR FORD. 

Steam furnishes the best power because of first, absence of vi- 
bration when standing or running; second, ease and pliability of 
control at all speeds, forward or backward and under all road con- 
ditions; third, light weight and direct transmission; fourth, easy 
obtainability of fuel and water; fifth, greatest degree torque or 
the ability to develop greatly increased power for short intervals 
necessary to pull out of holes or up especially steep grades; sixth, 
the general distribution of the knowledge and practical training 
required for operation and care; seventh, the few number of parts 
and their ordinary construction, making repairs, after consider- 
able destruction, almost always possible; eighth, the absolute re- 
liability of operation, even when parts are somewhat out of ad- 
justment and considerably out of repair. 

Fomier, the well known French automobilist declares for the 
hydro-carbon motor while Edison promises more for the electric 
motor with his new storage batteries, but objections offered by 
military conditions are not thus overcome. 

In the selection of a motive power for military use the sub- 
ject of fuel demands careful consideration both with respect to its 
obtainibility in the market during peace and in time of war. 

The Germans have appreciated this subject and their war de- 
partment has offered premiums for the invention of a motor that 
wiir burn alcohol for fuel, because the supply of kerosene and 
gasoline, which is imported into Gennany, might be interrupted, 
by a continental war while they can produce their own alcohol. 

With steam as a power, we have to select either gasoline, 
kerosene, or even a low^er oil as a fuel. 

Gasoline has properties that make it a most desirable fuel be- 
cause of its cleanliness and low boiling point. Vaporing at a tem- 
perature less than that of boiling water, it is most easy to control 
and adaptable to the irregular and sudden demands made on the 
power. But it is a by-product in the refining process of petroleum 
and its supply is limited, besides being quite easily subjected to the 
sharp practices of market control and variation in price, and it is not 
so widely distributed or generally used as kerosene. A practical 
kerosene burner, however, has been produced and the general 
distribution of this oil in the military ser\^ice, and the other uses 



THE MI LIT A RY MO TOR A MBULA NCE. 79 

found for it makes it a fuel at once easily and cheaply obtainable. 
It is safe to handle and transport, contains more heat units than 
gasoline and has no qualities that make it objectionable to the 
conditions of military service. 

An American manufacturer of steam vehicles believes that he 
will soon sell his kerosene burning steamers in Paris in econom- 
ical competition with the French gasoline vehicles. 

The type of the motor ambulance should embody some 
general features which may be briefly specified. 

Body, to be mounted on a chassis and to conform with the specifica- 
tions of the Quartermaster Department for the United States Army Ambu- 
lance, pattern 1901. 

Chassis to extend the leng^th and breadth of the bod^ and to securely 
support all the motor elements: to carry firmly attached in front a horizontal 
drum wound with 50 feet of wire rope to be used as a capstan and warp. 

The engine to be geared to counter-shaft so that the capstan can be 
turned without moving the wheels. 

Weight, 2500 to 3000 pounds, equipped. 

Load, 1600 pounds. 

Motor, steam. 

1. Engine^ compound, and if weight be not too great, condensing, 
15 horse-power, location in horizontal line beneath floor behind 
boiler. 

2. Boiler^ flash type or water-tube as the efficiency of either form 
is unquestioned and neither is liable to be burned. Location, 
beneath the seat in front of the litter space. 

3. Burner and Fuel^ Kerosene 

4. Exhaust, through the roof. 

5. Gear, to include a counter shaft extending across the body with 
driving sprockets on each end to carry a chain belt to sprockets 
on the hubs of the gear wheels. This counter shaft to bear the 
differential gear, a speed reducing gear, a gear to actuate the 
capstan on the front of the chassis and a double acting band 
brake. 

Speed, maximum twelve miles per hour. 

Grade, maximum 20^;. 

Wheels, wood, 34 inches in diameter with bronze artillery hubs. 

Tires, heavy construction pneumatic. 

Steering Gear, wheel. 

It is very important that the differential gear be removed from the rear 
axle and that the wheels turn on spindels in order to leave the rear axle clear 
between springs so as to be more easily repaired when injured and to offer 
less obstruction on bad roads. 



80 LIEUTENANT CLYDE SINCLAIR FORD, 

The automobile market does not furnish today nor will it 
furnish in the ordinary course of progress, just the kind of a ve- 
hicle that will meet the conditions of the military service. There 
is no vehicle needed in civil life that is as light as our service 
ambulance and is drawn by four or six mules. Vehicles 
with as much power are heavy and are used for hauling heavy 
loads. 

Our search in the market would have to be for a delivery- 
wagon with the power of a truck. So, a motor- wagon of such de- 
.sign can only be secured by special construction. 

The best and readiest method of procedure is to take the 
motor of a steam touring car of about 15 horse-power and apply 
it to the body of our regular ambulance with necessary modifica- 
tions. Then select the wheels, tires, running gear and other de- 
tails from the best on the market. 

This process will assemble elements that have already been 
tried and found practical and will produce a serviceable motor 
ambulance in the very first construction. 

Yet there must be some experiment. The first machine must 
be put to practical tests under service conditions and the devel- 
oped defects remedied. Only in this way will a satisfactory ve- 
hicle be produced. 

Undoubtedly the responsibility for developing this new form 
of transportation rests upon some department of the army. The 
passive interest that our War Department may have in the trials 
and experiments by foreign governments is hardly sufficient 
reason for lack of activity. 

The policy of waiting for others to lead that we may follow 
is not American and whatever may be the attitude of other de- 
partments of the serv^ice toward this subject, that cannot but in- 
terest them all to some degree, the time is at hand for the Medi- 
cal Department of the United States Army to be equipped with 
the motor Ambulance. 



A SYNOPSIS OF RINGWORM CASES AT THE NAVAL 
ACADEMY DURING THE SESSION OF 1901-1902. 

By J. BENJAMIN DENNIS, M.D. 

PASSED ASSISTANT SURGEON IN THE UNITED STATES NAVY. 

DURING the academic year 1901-02, there have been one 
hundred and twelve of .the battalion of cadets under 
treatment for ringworm. Seven out of sixty-one of the 
first class, eleven out of fifty-two of the second class, and seven- 
ty-three out of one hundred and forty-eight members of the fourth 
class were affected, making a total of one hundred and twelve 
cases in the battalion of three hundred and thirty-three cadets; 
making a percentage of almost thirty-three per cent. 

The disease first appeared on the U.S.S. Indiana during the 
first half of the practice cruise in the summer of 1901. The first 
case, that of a cadet of the second class, was contracted just prior 
to his starting on the summer cruise. Due to close quarters on 
the U.S.S. Indiana, and to the probable common use of toilet ar- 
ticles on that vessel, is to be attributed the spread of the disease 
among the cadets. During the first half, of the smnmer crui.se 
there were no cases of tinea on the U.S.S. Chesapeake, but when 
the exchange of cadets was made at the middle of the cruise, with 
the U.S.S. Indiana, there were about fifteen cadets under treat- 
ment for this affection when they were transferred to the U.S.S. 
Chesapeake. On arriving at Annapolis, when the cadets went 
on leave, these cases were much improved and some of them were 
well. 

In October when the .school term began quite a number of 
cases commenced reporting at sick call, and on the eighth of No- 
vember the entire battalion was inspected, and strict sanitary 
measures were adopted to eradicate the malady. At that date 
there were seventy-five cases found in the school. Under the 
direction of the Surgeon in Charge the following sanitary regula- 

(81) 



82 PA, SURGEON J. BENJA M/N DENNIS, 

tioiis were formulated and carried out. Each cadet was required 
to report at sick quarters twice daily for treatment. They were 
restricted to the use of special water-closets, which were washed 
daily with a strong solution of bichloride of mercury. They 
were prohibited from borrowing or lending toilet articles, or wear- 
ing apparel. All of their soiled clothes were sterilized by heat 
before being sent to the laundr>'. 

There were various treatments tried in these cases, among 
which were: — bichloride of mercury in alcohol, 1-200; formalin 
in alcohol 2^; ungent formalin 4%; tincture of iodine and 
Churchill's tincture of iodine; carbolic ointment 8%; chrysa- 
robin ointment 5%; and iodine in goose grease, — one part of 
iodine in eight parts of goose grease. The iodine preparations, 
in my opinion, gave by far the most satisfactory results, and the 
preparation of iodine in goose grease would be my preference in 
the treatment of tinea cases in the future, for the reason that it 
gives less irritation than any other of the effectual modes of treat- 
ing this malady, and if faithfully applied, will give the most rap- 
id cure and the least number of recurrences. Its one objection 
is that it is not cleanly and soils the patient's clothing. It can be 
applied twice daily and the patient will be able to perform his 
duties with little inconvenience. In the treatment of the cadets 
by other methods, it was found necessar>' to excuse them a great- 
er number of times than when using the goose grease and iodine. 

The parts of the body where the disease most frequently was 
located, were on the inner sides of the thighs, on the buttocks 
and in the axillae, although other parts were, to a less extent, 
found to be the seat of the disease. 

There were quite a number of recurrences in which the cases 
had been apparently cured, but it was possible that in those cases 
the treatment had been discontinued too soon. In length of du- 
ration the cases varied from a few days to several weeks. At the 
present date, May 20th, there are but three cases under treat- 
ment and they are almost well. 

The treatment with the goose grease was adopted after read- 
ing an article in the New York Medical Record, published in 
December, 1901. I regret to be unable to quote the physician's 



RINGWORM CASES A T THE NA VAL ACADEMY. 83 

name who wrote the paper, as the copy of the Record has been 
unfortunately mislaid. In treating patches of tinea on the face 
and arms bichlorid of mercury in alcohol, one part in two hun- 
dred, was found to give good results with no untoward symptoms. 

The great number of cases arising from a single one makes 
it mandatory, to my mind, to adopt most stringent measures in 
regard to isolation of cases occurring in the government and other 
.services. For, while the number of cadet sick days attributed to 
ringworm has been meagre, it has been found necessary to ex- 
cuse a large number of the cases from their drills, and the amount 
of time they have necessarily spent in applying treatment, etc., 
must surely have detracted from the class standing of some of the 
patients. 

In future contagions of this sort I am confident that the im- 
mediate segregation of the primary case or cases would be emi- 
nently proper, and would result in the curtailment of an im- 
mense amount of time to the affected, labor to the surgeons, and 
expense to the government. 



COMPARATIVE MORTALITY OF THE FRENCH AND 
GERMAN ARMlfeS. 

THE mortality of the French army is nearly five times as great 
as that of the German army, and the sick rate is double. 
Since the war of 1871 the German army has lost 13,000 
men by sickness. During the same period the French army has lost 
99,000 men by sickness. The causes for this increased mortality are 
an insufficient number of military medical officers, and the fact that 
those who are in the army have no authority to carry out hygienic 
and sanitary measures, the line officers paying little attention to their 
advice. Typhoid fever and tuberculosis are largely responsible 
for the high mortality. In 1900, 600 soldiers died in French 
garrisons from typhoid fever, and in the same year 87 German 
soldiers lost their lives from the same cause; 1415 French soldiers 
died from tuberculosis against 129 Germans. Respiratory dis- 
eases associated with tuberculosis killed 390 French and 197 
Germans. 



CLASSIFICATION, GEOGRAPHICAL DISTRIBUTION, 

AND SEASONAL FLIGHT OF THE MOSQUITOES 

OF THE PHILIPPINE ISLANDS.* 

By C. S. LUDLOW, M. Sr. 
HISTORY OF THE WORK. 

THE Study of the classification of the mosquitoes of the Phil- 
ippine Islands was originally begun by me in March, 
1901, as a personal investigation relative and prepara- 
tory to quite different work, but quickly showed such a large and 
important field that it seemed worth while to pursue it for itself. 

In April, 1901, it was suggested to the members of the Board 
of Health of Manila, then under the Provost Marshal General, 
and conducted by Medical Officers of the U.S. Anny, as a suit- 
able undertaking for their furthering, but no recognition was ob- 
tained. The collection and classification were, however, contin- 
ued as a personal work at Orion, Bataan, with such interesting 
results both as to geographical distribution and the evident sea- 
sonal periods of flight, that in June the matter was laid before 
Col. B. F. Pope, since deceased, then Chief Surgeon. Division of 
the Philippines, who at once recognized its importance, and took 
.steps to put the plans into execution, referring it to the Board of 
Health. 

Circulars and outfits consi.sting of cyanide bottles and ship- 
ping boxes were sent out to about eighty Post Surgeons in various 
parts of the Islands, and returns began to reach Manila about the 
middle of August. On September 10, on account of the lack of 
laboratory facilities, incident to the change of location necessi- 
tated by the transfer of the Board of Health to the Civil Govern- 
ment, and the serious hindrances which this entailed, the work 
was, with the knowledge and con.sent of the Board of Health, 

♦An investigation carried on by the authority of the Surgeon General, 
and with the cooperation of the Medical Department, V. S. Armv. 

(84.) 



MOSQUITOES OF THE PHILIPPINE ISLANDS. 85 

transferred to the Army Pathological Laboratory, Hospital No. 
3, and was thus returned to Army auspices, under which it had 
begun. 

During the month, Aug. 19-Sept. 10. returns were received 
from five Post Surgeons, four of the Army and one of the Navy, 
but the response to the circulars was far from general. A report 
of this work has been made to the Board of Health, Manila, but 
the results are incorporated here, because as the investigation was 
begun under the authority of the Medical Department, and is now 
being carried on with the cooperation of that corps and under the 
authority of the Surgeon General, it seems better to let the re- 
port cover the whole ground. 

It was intended to make the work continuous for at least a 
year, but a serious interruption was caused by my return to the 
United States, and later by a misconception of the nature, scope 
and authority for my work at the Army Pathological Laboratory, 
Manila. Now it is once more in progress, and it is hoped will 
continue without serious hindrance until the object in view shall 
have been accomplished, at least to a fair degree. 

DISTINGUISHING FEATURES OF THE VARIOUS GENERA OF 
MOSQUITOES. 

During the past year the subject of the classification of mos- 
quitoes has been entirely revolutionized by Mr. F. V. Theobald, 
of Wye, England, which has resulted in the forming of several 
new genera, most of which came from the old omnibus genera 
Culex. It is now no longer possible to say, given a straight pro- 
boscis fitted for piercing, — and. palpi long in both male and fe- 
male. Anopheles: palpi long in male, short in female, — culex; 
palpi short in both male and female, — Aedes, and feel that, save 
the geinera dependent on metallic coloring or peculiar leg scales, 
we have covered the ground fairly well. The old limitation for 
Anopheles practically stands, but Culex has been divided into 
Stegomyia, Mansonia (Panoplites of Theobald), Wyeomjna. Tri- 
choprosopoh, etc. , and these new genera are not based on any- 
thing so easily evident as length of palpi, but on the position and 
structure of scales, position of chaetae, length of certain joints of 
antennae, wing structure, etc., points that require microscopic 



86 C. S. LUDLOW, M.Sc. 

study to discern, and much care» patience and discrimination to 
determine. 

So also with regard to the resting positions, which were for- 
merlj' declared as easily distinctive, as, — in Anopheles the body is 
held in a straight line at an angle with the resting surface; in 
Culex the body is in a bent line but lies in a general parallel with 
the resting surface. These distinctions are still partly true. The 
body of the resting Anopheles is rectilinear, and usually makes 
an angle varying from 30' to 50' or 60* with the resting surface, 
but some Anopheles (A. maculipennis, A. Rossii) at times rest 
with the body nearly parallel to the surface, though I have fre- 
quently seen A, Rossi st^nA at an angle of 60' with the wall, afid 
Theobald says Culex pipiens may stand at an angle equal to that 
ascribed to Anopheles, while Col. Giles, of the English Army has 
found in India an Anopheles Which at rest * 'exactly assumes the 
position of Culex." The sharply dropped abdomen often de- 
picted for Culex is also by no means invariable, for though the 
proboscis is usually somewhat dropped toward the resting surface, 
the abdomen is frequently held nearly parallel to it. Sicgomyia 
fasciata, as studied by me in the Philippine Islands, does not 
usually show this marked dropping of the abdomen, while its 
hind legs are very much raised, much more than in C. faiigans 
with which I had constant opportunity to compare it. 

The distinctions on/ which the new genera are based seem 
discouraging to those who do not care to enter into entomological 
work, but fortunately for the pathologist most of these genera 
have at present little interest, and those which he is called to 
study have, except Culex, a few comparatively easily discernible 
characteristics. 

For this work it is first necessary to determine the sex of the 
mosquito, for with few exceptions only the female is a blood- 
feeder, and this is easily done by the antennae, the male always 
having very plumose organs, indicated in the accompanying 
photograph, so that in some parts of the country they are known 
as ** woolly heads;" the female organs, on the contrary, being 
merely pilose (see photograph) . 



MOSQUITOES OF THE PHILIPPINE ISLANDS. 



87 



This point being satisfactorily settled, the female Anopheles 
is easily determined, having palpi approximately as long as the 
proboscis, and these may lie closely compressed to it, giving the 
effect of an extremely heavy "beak," in some cases so heavily 
scaled as to be nearly as wide at the base as the head itself, or 
the\^ may lie slightly apart at the apex (see drawing), or infre- 
quently in the rather irregular position (this only after death) 
shown in the photograph. 




Fig U Head of Anopheles Rossii» Fig. 2. Head of female Anopheles, 

(proboscis detached). B, palpi, nmch displaced. 

A. male an ton nne 

B, (lalpi, showtn^ spatulate Joint. 

The male Anopheles is not so readily distinguished from other 
males, the principal distinctive feature being the last joint of the 
palpi, which is swollen orspatulate; the wing also shows the pro- 
longation of second and third long vein into the base cells, and 
the shortness of the fork cells. 

Stegomyia is technically based on the scales of the head and 
scutellum, but practically they can usually be easily distinguished 
as rather stoutly built insects, dark brow-n or black w^ith silver 
(w^hite) markings, the legs and abdomen usually white banded. 
Many of them are really beautifully marked. The female palpi 
are short, as in Culex, and those of the male long and generally 
nude. The description of S./asciafa will be given below^ in its 
place. 



8S 



C. S. LUDLOW, M. Sc, 




The genus Culex is extremely difficult to define without 
having recourse to scale structure, because it still includes such a 

variety of forms 
that any lines 
are likely not to 
include them all. 
The palpi of the 
female are short 
(see Fig. 3), 
those of the male 
long, and the 
latter vary in 
the shape of the 
last joints, being 
sometimes svvol- 

Rg. 3. Head of female Culex. len like anophe- 

A, antenna , 

B, palpi . les, sometmies 
narrow and pointed like Stegomyia, and at times having a long 
brush of hairs. 

Theobald gives the distinctions as: 

*'I. Short palpi in the female, long in the male. 

''II. Head with 
narrow curved and 
forked scales on the 
occiput, never fiat 
scales over the top of 
the head as in vSteg- 
omyia. 

"III. Narrow 
curved or spindle- 
shaped scales on the 
s c u t e 1 1 u m, never 
broad flat ones. 

"IV. Wing veins 
with median scales and long thin lateral ones on some or all the 
veins;" — 
and adds: "All these characters are clearly seen with a strong 




Fig. 4. 



Heads of female Anopheles^ showing 
position of palpi. 



^fOSQi/ITOES OF THE PH/ UP PINE ISLANDS. 



89 



hand lens, but are best examined under the microscope with a | 
in. power lens." 

The only one of marked pathological interest as a disease 
host, so far as reported, is Q,Jatigans, 

A diagramatic drawing of a mosquito and wing (Fig. 7) is 
given on page 91 for those who wish to study out these points. 

The panoplites of Theobald will probably be known hereaf- 
ter as Mansonia, as proposed by Blanchard, Theobald's name 
being already occupied in zoology. This is one of the genera 
fonned from the old genus Culex. Its distinguishing mark is the 




Fig. 5. Male Stegomyia Fig. 6. Wing of Mimsonia annulifera» 

A, Antennae; B, palpi, Theobald. 

broad asymmetrical ('*bracket-shaped") scale which densely 

covers the wing, but in this it closely resembles Aedeomyia, so 

that the identity is only assured by the capture of males, which 

in this genus have long palpi. The legs are also usually white 

banded or mottled. M. Africanus has been found to be Filaria- 

bearing in Africa, but so far experiments with malaria have given 

negative results. 

Aedeomyia has palpi in both sexes short, and so far as known 

is of no pathological interest, so that no special mention of it is 

necessary here. 

LIST OF GENERA AND SPECIES COLLECTED TO DATE. 

In classifying the mosquitoes under consideration, the geo- 
graphical position of the Philippine Islands at once suggests that. 



90 C. S. LUDLOW, M. Sc. 

except for widely spread cosmopolitan species, the tropical and 
sub-tropical forms will uniformly be found, and so far asthemos- 
quitos of these countries are known, it would seem fairly certain 
that those of the Malaysian Peninsula, China, and the Islands 
lying to the southward, and more especially of those nearer coun- 
tries with which mercantile connection is well established, would 
be collected. This points at once to the futility of looking for 
European species for pathological study. It may be that 
A. maculipennis (A. clavtger of older writers) will prove present, 
though it has not been found in this part of the world, but even 
the small data now available show sufficient material at hand for 
such study without wasting time looking for a special species. 

Tlte geographical indications suggested above have proven 
largely true, but there occur curious small changes only to be ac- 
counted for as "insular variations.'' These variations prove at 
once of interest and vexation, for when an insect appears with the 
general markings of one species, and very distinct leg-markings 
of another, or we find it conforms in part to the description of 
two or three diflFerent sub-species, and still varies slightly from 
them all, the question of classification becomes rather bewilder- 
ing. Do these changes break down the already existing lines, 
and throw the species or sub-species into one very variable form, 
or are new varieties to be formed, and when will the variation be- 
come large enough to warrant the establishment of new species, 
are questions constantly confronting the investigator. 

In the list given below will be found some mosquitoes which 
do not agree with the description of the types under which they 
are placed, but it has .seemed better to leave them there, noting 
such differences as occur, rather than further complicate the 
species by new varieties, while in two cases the variations have 
seemed large enough to warrant the creation of new species. 

Anopheles sinensis^ Wiedeman. 

Orion Bataan June. 

Sub-species annularis, van der VVulp. 
Hagonoy, Bulacan. Sept. 24-Oct. 5. 

Hospital No. 3, Manila. Sept. 21. 

Under A. sine^isis Wied., Theobald has placed four sub-spe- 
cies, among them afinu/aris, van der Wulp, and pseudopictus^ 




, <i. I St Sub-marginal cell. 
^. 2nd Posterior cell. 

c. Stem of I St sub-marginal cell. 

d. Supernumerary cross-vein. 
^. Mid cross-vein. 
/• Posterior cross-vein. 
g' Scutellum. 
^. Metanotum. 



iarsus 



*J>\^w* j^l 



Fig. 7. Diagramatic Dra^gving of Moviutto. After Theobald, 



92 C, S. LUDLOW, M. Sc. 

Grassi, which differ from each other mostly in some wing mark- 
ings and in the relative length and position of the posterior and 
mid cross-veins. The specimens collected in Manila and sent me 
from Hagonoy, while agreeing largely with anriularis, agree also 
in some points which belong distinctively to pseudopictus, and in 
still others disagree with both, and as this intermediate form prac- 
tically connects both the mentioned sub-species, I am very strongly 
inclined to agree with Giles in preferring to keep all these forms 
as one very variable species. 

I add a generalized description, which will not, however, be 
definite enough for determining the sub-species. 

A. pseudopictus is a host for the estivo-autumnal parasite, 
and this form, which is so closely related, may also prove of pa- 
thological interest. 

Head blackish with white frontal tuft, the dark scales on the 
occipit grey tipped. Antennae brown. Palpi deep brown, apex 
white-scaled, and two white bands, at apices of 3rd and 4th joints. 
Proboscis black. Thorax slaty-grey with brown longitudinal 
stripes. Abdomen brownish black with long golden hairs. Legs 
yellowish brown, tibiae and tarsal joints, except the last, with 
apical light bands, in the mid and fore legs often faint or absent. 
Ungues equal and simple. Wing covered with dark brown or 
black scales, with two light spots on the costa, one sub-apical, the 
other a little in front of the cross- veins; the rest of the wing 
rather dark with a few small pale spots on the field, and the 
fringe pale at the apex. 

Length 4-6 mm. 

Anopheles pseudobarbirosir is, n. sp. 
(female) 
Head very dark brown with some pale scales on top, spread- 
in front toward the sides and partly around the eyes, tuft in front 
white with a few dark hairs, and dark hairs behind the ej-es, 
otherwise covered with rather broad not deeply forked scales with 
fimbriated tops, the tips grey; narrow median space bare. An- 
tennae a lighter brown, minute white apical bands on the joints, 
first joint brown; vertices brown, pubescence white. Palpi very 
heavily scaled with dark brown (almost black) scales, many of 
which are ochraceous tipped, so that the effect is ** rusty," — ^joints 



MOSQUITOES OF THE PHILIPPINE ISLANDS. ^3 

obscure, but can be seen by the breaks in the scales, — as long as 
the proboscis; last joint with brown hairs. Proboscis also heavily 
dark scaled, some ochraceous tipped, tip is lighter but still brown. 
Eyes dark brown, narrow white rim part of the way round. 

Thorax dark brown with grey reflections, and narrow curved 
(almost hairlike) golden scales, arranged in faint, i. e. indefinite 
lines which in some lights seem to converge so as to form a "V" 
from the cephalic edge, the whole length of the thorax, the point 
caudad; pleurae brown with white markings; scutellum brown at 
center, paler laterad^ with slender golden curv-ed scales (such as 
are on the thorax) and golden bristles; metanotum brown. 

Abdomen dark brown, slight greyish reflections, golden hairs; 
on the ventral side are a few scattered white scales, and near the 
caudal end a bunch of rather long brown scales. 

Legs, — coxce and trochanters all dark brown, white tipped; 
femorae and tibiae all dark brown well sprinkled with white scales, 
the rest of the legs a little lighter brown, and in some lights giv- 
ing almost **fawn-colored" reflections; all the joints of the legs 
and feet are white wipped, except the last tarsal joints, and on 
the mid legs these are a little lighter, giving almost * 'clay-col- 
ored** reflections; ungues simple and brown. 

Wings dark with two small yellow spots on costa, one at the 
apex of the wing and extending on the apices of the 1st longitu- 
dinal vein and anterior fork of the 2nd longitudinal, with light 
spots on the fringe at apices of the 1st long, and anterior fork of 
the 2nd longitudinal, and an included dark spot at apex of marginal 
cell, giving the appearance of an incomplete ring (c) ; the other, 
much smaller, on thecosta at the junction of the sub -cost a. The 
costal and bajsal portions of the wiags are dark scaled with a few 
white scales on the costa, sub-costa, 1st and 2nd longitudinal, but 
the 3rd longitudinal is mostly white scaled, and on this appear a 
few round-ended scales with accuminate tips. The 4th longitu- 
dinal is largely dark scaled, but the scales are mostly of the 
roundish sort, which are either black or white; there are dark 
spots at the apices of each fork and light fringe at the apex of the 
anterior fork. The 5th longitudinal has almost exclusively the 
rounder scales and is mostly white, both as to stem and forks; 
dark spots at the apices of each fork, and the stem has a dark 



94 



C. S, LUDLOW, M. Sc. 



base, as have all the veins save the 6th, which islig-ht scaled, ex- 
cept two heavy dark spots, one at the apex and one about the 
middle of the vein. The 6th has entirely the round-ended scales 
in both black and white. 

The fringe is dark except for the three small places indicated, 
i. e,, at the apices of 1st longitudinal, anterior fork of Znd, and 
anterior fork of 4th longitudinal. Most of the veins, even where 
light, have a sprinkling of the dark among the median scales, but 
the larger part of the dark scales on these veins are lateral scales 
and lie close under the median scales, so that the wing looks much 
darker from the under (ventral) view, and in all the veins caudad 






fig. 8. Wing Scales. 

Vein %c&\eB—iinm>hele8 paetuio' 
barbirostria. IajuI, 



Pig. 9. Wfng Scales. 
Fringe scales— anop/^f^x 
pneudobarbiroittrU, 



Lu(L 



of the 3rd the lateral as well ^ the median scales are almost en- 
tirely of the '*round-ended" sort. The wing has, however as a 
whole a dark rather than light appearance, probably due to the 
very heavy scaling of the first two or three veins, which are 
mostly dark scaled. The 1st sub-marginal cell is a little longer 
and narrower than the 2nd posterior, the base of the former nearly 
on a line with the base of the latter, but not near the junction of 
the costa and sub-costa; the stem of the former is about two- 
thirds the length of the cell, and shorter than that of the 2nd pos- 
terior, which is longer than the cell; the cross- veins are close to- 



MOSQUITOES OF THE PHTUPPINE ISLANDS. 95 

gether, the mid vein much the longest, meeting the supernumer- 
ar\- at nearly a right angle ( apex toward the apex of wing) , and 
the posterior cross vein is not half its length from the mid-vein 
and stands at almost the same angle in the reverse direction. The 
halteres have black knobs, stem and base are light. 

Length 5 mm. 

Habitat, Hagonoy, Bulacan. Luzon, P. L 

Caught Oct. 2. 1901. ' 

We have here one of the sinensis group, and evidently near 
.L harbirostris van der Wulp, the "round-ended" scales being un- 
doubtedly the same as those described by Theobald for that spe- 
cies, but apparently more numerous and wider spread on the wing 
than is indicated for that, while the differences in antennae, palpi, 
wings and legs are, especially the latter, so marked as to throw it 
out of that species. 

No pathological work has been done with this species. 

Anopheles Rossi i. Giles. 

Orion, Bataan, May lo-july 25, 

Hagonoy, Bulacan, Oct. 5, 
Batangas, Batangas, Nov. 11, 

San Jose, Abra, Sept. i, 

? ? Banquet Mts. April 15, 1902. 

The Philippine Islands specimens show some very marked 
variations from the type; one which will be instantly noticeable 
being "the curious mottled appearance of the femone and tibiae*' 
which Theobald gives as distinctive of A. cosialis Loew., and it 
may be that this is an intermediate species, but I have left it here 
for the present. * 

I copy the general description given by Col. Cxiles in his 
• Gnats or Mosquitoes. ' ' 

"Wing with the costa pale at apex and base, but generally 
black, interrupted by two large yellowish spots opposite the fork 
cells, and, just in front of the cross-veins respectively; the black 

♦This species has been lately determined by Theobald as new» and described bv 
him ns \. Ludlowii, It Is the first Anopheles taken In coDnectlon with this work, 
and the rtrst specimen was caught flying at midday, tho' they usually fly at night. Ii 
Is also the most widely distributed and much the mostnumerous of tne Anopheles so 
far collected In the P. I., and Its time of prevalence coincides largely with the preva- 
lence of estivo-autumnal and "black-wnter" fevers, so that pathological work on It H 
likely to give positive results. A. Rmttii. Giles has lately been sent from one Sta- 
tion. C. B. Ii. Dec, 1902. 



96 



C .V LUDLOW, M.Sc. 



ar^a next internal to these is very large and is T-shaped, owing 
to the presence of a short length of black upon 2nd longitudinal 
vein beneath the middle of the thrice longer area on the costa and 
auxiliary (sub-costa); internal to this there are only three minute 
white dots; there is a row of sub-apical black dots on every one 
of the long veins, and three or four others, and the fringe is yel- 
low at the tip, and has pale patches at all the longitudinal junc- 
tions, except that of the 6th. Tarsi with yellowish rings on all 
hut the last articulations of the fore and raid legs. Thorax deep 
brown with, in the fresh state, a dorsal, tun-shaped patch of vel- 
vety, pale cinerous bloom. Adbomen dusky, nude, densely 
clothed with golden brown hairs. Length 4.6-6 mm. 




Fig. to. Wing of A. Rossii (male). Fig. U. Wing of A. Rossii (female). 

This is the most numerous and most widely distributed of 
Anopheles so far collected in the Islands. It is a host for the es- 
tivo-autumnal para.site, and for Filaria suNgutnis liominis noc- 
turna, and the A. costalis to which our species seems also related, 
is a host for the same plasmodium and also for filaria. 

Anopheles Philippinensis. n. sp. 
( female) 
Head very dark brown, with white and creamy (.yellowish) 
scales scattered on top, and more thickly toward the front, long 
white tuft in front, a few yellowish scales on the sides, and very 
dark forked scales with fimbriated tops on the occiput, antennae 



MOSQUITOES OF THE PHILIPPINE ISLANDS. 97 

golden brown, some white scales and some brown at the base with 
lighter tips; verticels white, pubescence white» first joint basally 
brown but white at apex; eyes dark brown or black with very 
narrow white rim; palpi golden brown, some scales apparently 
darker tipped, the last joint white and a narrow white band at 
apex of each of the three preceding joints, a few white scales at 
the base; proboscis brown, not so dark as the head but darker 
than the antennae, white or yellowish tip. 

Thorax very dark brown (both it and the head are almost 
black) with scattered white flat and yellowish curved f^cales, no 
design apparent, — cephalad the white scales are much longer: 
scutellum dark brown in the middle and at each end with a lighter 
spot between, on which are a few white scales; metanotum dark 
brown; pleurae dark brown with white markings; when denuded, 
thorax has ashy-grey reflections with dark brown median and 
sub-median lines. 

Abdomen dorsally is ashy-grey, with golden brown hairs, a 
narrow brown apical band on each segment, much broader on the 
last two segments so that they are nearly brown instead of grey. 
Legs, coxae brown, all white tipped, femorae dark, i. e. 
brown scaled dorsally and yellowish on the ventral side, tibia* 
same but a very small apical white spot on fore and mid legs; meta- 
tarsus and two following joints on the fore legs have heavy api- 
cal white bands, mid legs have faint light bands in same positions, 
that on the metatarsus much the heavie.st, but still not by any 
means so broad as on the fore legs; hind legs dorsally brown, and 
yellowish ventrally, much as in the other legs, but the apical Atf//* 
of the first tarsal and all the following joints pure white. Ungues 
on hind legs light (white), those on mid and fore legs brown. 

Wings cream colored, spotted with brown, reminding one of 
-\.Jamesii Theob. Two small and four large brown spots on 
costa, the distal extending back through anterior fork of 2nd 
longitudinal, the next, somewhat larger, through 1st longitudi- 
nal, the third and largest of all, extends as a long spot on the 
costa and sub-costa, and three small ones on the 1st longitudinal, 
so arranged as to resemble an overturned E ( pn), the middle of 
these small spots is the largest and connects with one on the 2nd 
longitudinal: the 4th spot, counting from the apex of the wing. 



98 C. S. LUDLOW, M.Sc. 

includes the sub-costa and 1st longitudinal, and even the two 
small ones include the sub-costa, making all these costal spots 
very distinct. The apex of the costa is, however, light. There 
are two dark spots on anterior fork of the 2nd longitudinal, and 
one on the posterior fork ; two small spots at the bases of the 3rd 
longitudinal, one on the anterior fork of the 4th, a small one near 
apex of the posterior fork, and the stem is dark to posterior cross- 
vein and, after a small white spot, about one half the way to the 
base of the vein; antertor fork of 5th has three dark spots, and 

there is one near the apex on 
the posterior, also on the stem 
of the 5th near base of wing; 
there are three dark spots on 
the 6th, one at the apex, one 
near the middle and one near 
the base. A large part of the 
2nd and 4th are therefore dark, 
while the 5th has a large part 
cream -colored, and a still larg- 
er proportion of the 3rd is 
light. 

The fringe is mottled, 
Fig. J2. Ving of A. Philippincosis. ^ream and brown, nearly equal 
to the 6th longitudinal, after which it is dark. Dark spots occur in 
the fringe at the apex of the anterior fork of the 2nd longitudinal 
and at apices of 1st posterior,2nd posterior, 3rd posterior, anal, aux- 
iliary, and spurious cells (Theobald's naming) with light spots at 
the apices of each intervening vein. The first sub- marginal cell 
is a little longer than the second posterior, the base of the former 
being a little nearer the base of the wing. The posterior cross- 
vein is about one and one-half times its length nearer the base 
of the wing than the mid cross-vein, and the supernumerary about 
its length nearer the apex than the latter. 
Length, including proboscis, 5 mm. 
Habitat, San Jose, Abra, Luzon, P. I. 
Caught, Sept. 1, 1901. 




MOSQUITOES OF THE PHILIPPINE ISLANDS, 99 

Stegomyia fasciata, Fabrici us. 

Angeles, Pampanga, Aug, 19, 

Aparri, Cagayan, Aug. 23- Sept, 24, 

Cavite, Cavite, Aug- 31, 

Dumaguete, Negros, Sept. 24, 

Hagonoy, Bulacan, Aug. 19 -Oct 5, 

Manila, Kizal, July 30,-Oct. 1, 

' " April, 1902, 

Orion, Bataan, May 15-Sept. 10, 

Pasig, Rizai, Aug. 22, 

San Jose, Abra, Sept, i, 

Batangas, Batangas, Nov. 16, 

Cebu, Cebu, March 20, 1902, 

This mosquito was not found in Manila in February or March, 
1901, nor before I went to Orion early in April, nor was it flyinj? 
at Orion at that time, but it appeared in Orion in May, 
and when I returned to Manila in July it was the prev- 
alent mosquito at the Cuartel de Infanteria; it was sent 
me from other districts of the city shortly after and 
continued till I left for the States, Oct. 1, though I did 
not find it at Fort Santiago during Sept, It is, how- 
ever, apparently very widely distributed, being sent 
from every post where collections were made except Fig.J3,Thor- 
the "Banguet Mts, , ' ' and I believe will, in common with «of Stegom- 
Anopheles, prove to have a distinct season of flight. 

< Female. ) 

Head black with white patch in the middle extending back 
to the neck, a white patch on each side, a narrow white border to 
the eyes; antennae blackish with narrow pale bands, pubescence 
and verticels dark brown, palpi black scaled, the last joint tipped 
with pure silvery white scales, sometimes entirely white. 

Thorax dark brown with a heavy pure white curved band on 
each side, curving inwards about the middle of the mesonotum, 
and continued back as a thinner pale line to the scutellum, two 
thia parallel sub-median lines extending over more than half of 
the mesonotum and broken near the scutellum; a short white 
median line in front (cephalad) between these two slender lines 
and another near the scutellum, just cephalad of the broken part 




100 C. S. LUDLOW, M.Sc. 

of these two sub-median lines. Scutelluni with a row of white 
scales, sometimes intermittent: pleurae dark brown with several 
silvery patches. 

Abdomen dark, brownish black with white basal bands and 
white, more or less triangular, patches on the sides. 

Legs rather dark, femorae with white tips, tibiae still darker, 
metatarsi with basal white bands; on the fore and mid legs 
only the first joint of the tarsus white banded, the rest black, 
hind tarsi all basally white except the last joint, which is pure 
white. Fore and mid ungues uni-serrate, hind ungues simple. 

Wings clothed with very long narrow brown scales. 

Length, 3.5-5 mm. 

Darker and somewhat smaller, marked much as the female, 
the palpi black with four white bands, and the thorax more bril- 
liantly marked than in the female. 

This is the mosquito which the experiments in Cuba have 
shown transmits the ** yellow fever." 
Var, Mosquito, Desvoidy. 

Hagonoy, Bulacon, Aug. ig,-()ct. 5. 

San Jose. Abra, Sept. i, 

This differs from the type iti lacking the fine sub-median and 
inedian lines. 
Var, Luciensis^ Theob. 

Batangas, Batangas, Nov. 16, 

The distinctive marking from the type is a black tip to the 
last tarsal joint of the hind feet. 

Stegomyia Sad te Han's, Walker. 

Angeles, Pampagga, Aug. 19, 

Cavite, Cavite, Aug. 31, 

Orion, Bataan, June 4i-i^. 

As this is not known to have pathological value no descrip- 
tion is attempted. 

Var, 

Ls equivalent to Var. Luciensis under S.Jasciala, in that it 
has a black tip on the last tarsal joint of the hind foot. 



XfOSQUITOES OF THE PHILIPPINK ISLANDS. 101 

iulex sitieus, Wied. 

Hagonoy, Bulacan, Oct 5, 

Orion, Bataan, May 2&, 

Vulex AnuuHoris, Theob. 

Hagonoy, Bulacan, Oct. 5, 

i'ulex caecus, Theob. 

Cavite, Cavite, Aug. 31, 

Hospital No. 3, Manila, Sept. 25^ 

Hagonoy, Bulacan, Oct 2, 

i \tlex gr/iduSy Theob. 

Hagonoy, Bulacan, Oct. 5, 

i ulex fatigan$, Wi ed . 

Aparri, Cagayan, Aug. 23-Sept. 24^ 

Cavite, Cavite, Aug. 31-Sept. 14 

Dumaguete, Negros, Sept 24, 

Hagonoy, Bulacan, Aug, i~Oct. 5, 

Manila, Rizal, Feb, - ept 30, 

" ** April 1902, 

Orion, Bataan, April 7-^Sept 10, 

Pasig, Rizal Sept. 3-Nov. 16, 

San Jose, Abra, Sept 1, 

Batangas, Batangas, Nov. 16, 

Cebu, Cebu, March 20, 1902. 

These dates are of course merely dates of collection, and 
must not be taken as indicating the period of flight, either in this 
or any other of the genera, for in some cases only one collection 
was received, while in no case were observations carried on a com- 
plete year. It .seems probable, however, that this mosquito is al- 
ways present; it is the prevalent mosquito in Manila during the 
dry season and in the districts of the city under observation the 
only one taken in Feb., March and early April, 1901, while there 
was certainly no apparent diminution in numbers (though other 
species were also found) in late July, August and September. 

It is well known as a carrier of the embryo of Filaria noc- 
iunia. 

The general description from the British Museum Monograph 
(Theobald) is appended, but it is an extremely variable mos- 
quito, and besides some closely allied species there are four varie- 
ties, so that, to gne not acquainted with it, it is a very trouble- 
some species to determine accurately. 



102 



r. .V. LUDLOIV, M.Sc. 



Thorax brown, with two distinct dark lines on the denuded 
.surface, covered with pale golden curved scales, and with two or 
three rows of dark bristles, ornamentation variable. Abdomen 
dark brown to black with basal white or creamy curved bands 
and white lateral spots; venter white or yellow scaled. Legs 





Figs. {4. (5. )6. VJ^ Culex wings, showing variation in length of stem of first sub- 
marginal cell. 

dark brown: bases of the femorae and coxae pale, knee spot and 
sometimes the apex of the tibiae with faint yellow spot: ungues 
of the female equal and simple; in the male the fore and mid un- 
gues are unequal and uniserrated. the hind equal and simple. 
Wings with the first sub-marginal cell longer and narrower than 



r 



MOSQUITOES OF THE PHILIPPINE ISLANDS. 103 

the second posterior cell, its stem variable in length, never less 
than one-quarter the length of the cell. Posterior cross- vein dis- 
tant twice or more its own length from the mid cross- vein. Head 
brown with pale golden brown to creamy curved scales and a few 
scattered black, dark brown or occasionally ochraceous upright 
forked scales, flat creamy white scales laterally; antennae dark 
brown with pale pubescence; palpi densely covered with deep 
brown (sometimes a few pale grey) scales; proboscis dark brown 
(sometimes paler in the middle) and pale apex. 

Mansonia (Panoplites of Theobald) annulifera Theob. 

Hospital No. 3, Manila, Sept. 2t, 

Pasig, Rizal, Sept. 3-14, 

Mansonia uni/ormis, Theobald. 

Casual Camp, Hosp. No. 3, Manila, Sept. 25, 

Mansonia Africanus^ Theobald. 

Casual Camp, Hosp. No. 3, Manila, Sept 21-25. 

All these mosquitoes are spoken of as **fierce and persistent,*' 
and M. Africanus has been found to carrj' the embryo of Filiara 
nocturfia (Filaria Bancroftii.) 
{Female.) 

Head brown with narrow curved grey scales and flat white 
ones at the sides, a white border round the eyes, and numerous 
long dark brown scales; proboscis dark brown to almost black, 
with broad median yellow band and yellow apex; palpi dark 
brown, apex white scaled and a band toward the base; antennae 
brown, broadly grey banded; thorax dark brown with narrow 
curved hairlike golden brown scales; silvery ones in two sub- 
median lines running on each side of the bare space in front of 
the scutellum and fprming two more or less distinct spots on the 
anterior third of the mesanotum. Abdomen dark brown, the 
basal segments with basal median yellow spots, the apical with 
yellow apical spots; venter pale with creamy scales, apex often 
mostly white scaled; legs dark brown, banded and mottled with 
white. Wings with black and 3'ellow asymmetrical scales. 

(Condensed from Theobald's description). 

Length 3.8-4.5 mm. 

Aedeomyia Squammipenna, Arribalzaga. 

Hagonoy, Bulacan, Oct. 2-5. 



104 



C. S. LUDLOW, Af.Sc. 



NUMBER OF GENERA COLLECTED 5, 

Anopheles Stegomyia, Culex, 

Mansonia, Aedeomyia. 

NUMBER OF SPECIES AND VARIETIES IN EACH GENUS. 

Anopheles 5, Stegomyia 5, Culex 5, 

Mansonki 3, Aedeomyia i. 

Total No. of species and varieties 19. 

LIST OF STATIONS AT WHICH COLLECTIONS WERE MADE. 
Angeles, Pampamga, Luzon, Capt. Ira Ayer, 

Asst. Surg., U.S.V. 
Aparri, Cagayan " CapL G. A. Skinner, 

Asst. Surg., U.S.A. 
Batangas, Batangas. '*■ Maj. W. F. de Nieaman, 

Surgeon, U S.V. 
Cavite, Cavite " Dr. G. A. Lung, 

Surgeon, U.S.N. 
Cebu, Cebu, (en route, 1902) Maj. R. P. Ames, 

Surgeon, U.S.V. 



Dumaguete, Negros, 

Hagonoy, Bulacan, Luzon, 

Manila, Rizal 
Ermita, 



Dr. John N. Merrick, 

Cont. Surg., U.S.A. 

Dr. W. V. Kellogg, 

Cont. Surg., U.S.A. 



Hospital No. 3, 

Casual Camp, Hospital No. 3, 

Sta. Cruz, 

Manila (Walled City), 



Maj. Charles Lynch, 

Surgeon, U.S.V. 
C. S. Ludlow, 
Maj. J. D. Glennan, 

Surgeon, U.S.A. 
Maj. J. D. Glennan, 

Surgeon, U..S.A. 
Dr. Gomez, 

Board of Health. 
Dr. Jobling, 

Board of Health. 
C. S. Ludlow, 
C. S. Ludlow. 
Dr. Pedro del Rosaria, 
Capt. G. S. Wallace, 

Asst. Surgeon, U.S.V. 
Dr. Alonzo Graves, 

Cont. Surg., U.8.A. 
Dr. Alonzo Graves, 

Board of Health. 
No. of stations at which mosquitoes were collected 16. 
No. of collectors 16. 



Orion, Bataan, 
Pasig, Rizal, 
San Jose, Abra, 
Banguet Mts., 



Luzon, 



MOSQUITOES OF THE PHILIPPINE ISLANDS. 105 

GENERAL REMARKS ON THE WORK. 

It has been impossible for me to obtain the elevations of the 
various stations at which collections were made, but a glance at 
the map shows that, with the exception of the mosquitoes from 
Angeles, Pampanga; San Jose, Abra, and **the heart of the Ban- 
guet Mountains," all the mosquitoes taken in Luzon were from 
stations either on the sea coast, or on rivers within a few miles of 
the coast, while even those mentioned were captured at compara- 
tively low elevations, those from Banguet probably coming from 
the highest altitude. 

As to the prevalence of these insects in different parts of the 
Islands, Hagonoy, which lies low, has been by far the most prol- 
ific in numbers and kinds of mosquitoes; Pasig and Orion, also 
low-lying, have shown good supplies, while from San Jose came 
the largest collection (taken at any one time) of Anopheles and 
Stegomyia, though one lot from Hagonoy contained nothing but 
Stegomyia, and the lot from the Banguet Mts. , taken in a camp 
"located on the banks of a small river, in a lone caiion with tall, 
steep mountains on either side" where **we see the sun only be- 
tween 9 A. M. and 4 P. M.,'' contained only Anopheles Rossii. 
Stegomya fasciat2i has been sent in from every collecting station 
except the Banguet Mts. , Culex fatigans has come from nearly 
as many posts, and A. Rossii is also frequently found. These 
seem to be the prevalent mosquitoes, but we have so far almost no 
insects from the interior, and nothing from the really high land, 
and no definite conclusions are possible. 

There are, however, even in the short time that collections 
were made, indications to show periodicity in the flight of some 
of these mosquitoes. The extremely small variations of tempera- 
ture in the Islands as a whole prechide the idea that it is gov- 
erned by that, but apparently the dry season is the resting period 
for some, and this could easily be accounted for by the known 
preference of some mosquitoes for clean fresh water when laying 
eggs. Culex fatigans will lay its eggs in absolute filth, but the 
Anopheles will, as a rule, use only clean freshwater, such as road- 
side pools in which are no frogs or fish, but where the lower (uni- 
cellular) algae are often found. Stegomyia also prefers fresh 



106 C. S. LUDLOW, M.Sc. 

< clean) water, and as these pools drj' up during the dry season, 
the disappearance of these mosquitoes would naturally follow. It 
is claimed that the}' rest in the adult state hidden in the dark cor- 
ners of houses, etc. , only waiting for a new supply of fresh water 
to recommence their activities.* 

A glance at the list given above makes it at once evident 
that while, through the kindness of the Surgeons mentioned we 
have gotten a fair start on the classification of the mosquitoes of 
the Islands, the lack of general response to the original circulars, 
and the unfortunate interruptions in the collections already be- 
gun, have rendered it impossible to form any conclusions as to 
the distribution, and still less of the seasonal period of flight of 
these insects, and the problem we have undertaken is in truth 
hardly begun. New outfits and circulars have, under the author- 
ity of the Surgeon General, been sent to about one hundred posts 
since Jan. 16, 1902, and a few returns have already been re- 
ceived. There has hardly been time for a general response yet, 
but it is hoped that this effort will meet with more success than 
the last, and at the end of another year the report will be able to 
give important data both as to the geographical distribution and 
the seasonal flight of the mosquitoes of the Philippine Islands, 
for the use of those whq may be making especial study of disease 
conditions on these Islands. 

In closing this report I desire to express my thanks to Gen- 
eral Sternberg for his personal interest in and oflBcial recognition 
of the work, without which its continuance would not have been 
possible; to those who gave it efficient aid at its inception, Col. 
B. F. Pope, Maj. F. B. Meacham, who are since deceased, and 
1st Lt. W. J. Calvert, Asst. Surgeon, U.S.A., to Mr. F. V. Theo- 
bald, of England, and Dr. L. O. Howard, Dept. of Agriculture, 
for their friendly interest and help; to the Chief Surgeon, Di- 

*Thl8 is especially true of the seaboard and where fresh water is st^rce during the 
dr>-' season, but inland where fresh water is found at all times of the year, as in the 
Banguel Mts.. the Anopheles are most numerous during the hottest part of the dry 
season, and disappear to a great extent with the scouring lains of the wet season, so 
th-it later In the year they are scarcely to be found. It appears that this is also the 
tlmeof greatest prevalence of malarial fevers so that it seems probable that A. Lud- 
iowii, Theob, the mosquito sent in from these Mts., will be proven a host for Estlvo- 
Autumnai fevers in the P. I. thro' the reporU* ffrom India are contradictory. 

The time of flight cannot, however, be definitely given for the whole of Luzon as 
the wet season In one part of the island does not coincide with that of another part^ 
the provinces lying on the China Sea showing a difference of some weeks fW>m tboBe 
on the Pacific. C.H.L. 



MOSQUITOES OF THE PHILIPPINE ISLANDS, 107 

vision of the Philippines, for his present assistance; to Col. A-. C, 
Girard, Assistant Surgeon General, Commanding Officer of the 
Presidio General Hospital, for his unfailing interest and prompt 
and eBective aid in recommencin^g the work, and finally to Dr, 
Chas. F. Craig, Pathologist to the Hospital, for his unvarying 
courtesj' and encouragement, for many valuable suggestions, and 
for the photo-micrographs which illustrate this report, to whose 
kindness and skill they ane entirely due. 



AVOIDANCE OF SOIL POLLUTION IN CAMPS. 

WHEN the necessary implements and labour are available, 
buckets may be substituted for trench latrines, and all 
refuse removed and buried at such a distance from 
camp as to render pollution of the soil a matter of no practical im- 
portance. When the above method cannot be carried out — and 
this will usually be the case — and sufficient space is available, la- 
trines and refuse pits should be shallow in order to subject their 
contents rapidly to the influence of nitrification, and frequently 
filled in, in order not to overtax the agencies on which the pro- 
cess depends. The contents of latrine trenches and rubbish pits 
dug several feet deep are removed from the influence of those ni- 
trifying agencies, which, it must be remembered, being aerobic, 
are to be found in the upper layers of the soil only. The condi- 
tions in such a case probably resemble those found in a septic 
tank, hquifaction of organic matter taking place under the influ- 
ence of anaerobic organisms. Percolation under these circum- 
stances would seriously endanger neighboring water supplies. 
These disadvantages must, however, at times, be overlooked, and 
under some circumstances need never be considered. In actual 
practice every method is found to have its disadvantages, and 
even with the greatest care and with unremitting attention all 
organic matter will, as already stated, be neither removed nor 
buried, as a certain amount — ^the result largely of f secal pollution 
by cattle — must under ordinary circumstances remain adherent 
to the surface of the soil, — Major, /?, Caldwell in British Med- 
ical JoumaL 



THE SANITARY WORK OP THE UNITED STATES 
ARMY MEDICAL DEPARTMENT IN ALASKA. 

By major RUDOLPH G. EBERT, 

SURGEON IN THE UNITED STATES ARKY; I.ATE CHIEF SURGEON 
OF THE DEPARTMENT OF ALASKA. 

THE principal factor that caused the establishment of a 
military department out of the territory embraced in 
the district of Alaska, was the lack of legal enact- 
ments to enforce order and protect property in a country with- 
out courts and about to be over-run by a horde of searchers 
after wealth in the newly discovered gold fields of the Seward 
peninsula. 

The date of the departure of the Headquarters of this new 
department from Seattle for Nome and St. Michael^ brought 
the information of the passage by Congress, and the signing 
by the President, of the bill, which abrogated the old laws, 
and established the new Alaskan Code. The fact that the 
Federal Judges and other officials, in whom was practically 
vested the authority to establish the new laws, found inferior 
(commissioner's) courts, organize municipal governments,etc., 
had only been named, and would not arrive for some time, and 
a copy of the law itself, as finally passed, not being obtain- 
able, produced a chaotic state, at a time when the community- 
was swamped by an influx of adventurers, amongst whom 
were many of the vicious characters of the West. A state of 
lawlessness and anarchy was fast being reached, as shown by 
three homicides in the twenty-four hours previous to the ar- 
rival of the Department Commander, and the self constituted 
city government of the winter, which had excellently served 
its purpose amongst the miners, was forced to suspend under 
the inrush of the spring ''stampeders." 

At the request of the **Chamber of Commerce," perhaps 

(108) 



SANITARY WORK OF THE ARMY IN ALASKA. 109 

the only responsible body of citizens, General Randall assumed 
control, and until the arrivalof Federal Judge Noyes, it might 
be said that Nome was under martial law; the one company 
of Infantry acting as police force; the commanding officer of 
the troops as mayor; the Judge Advocate temporarily de- 
ciding law problems, and the Chief Surgeon performing the 
duties of Sanitary officer, — all under the direction of the De- 
partment Commander. 

How well that duty was performed, one need but inquire 
of any of the respectable element of society, as to the condi- 
tions existing under the military regime and the times preced- 
ing and subsequent to that period. 

It is with the work of thje Medical Department that this 
paper has to deal, and, to understand the situation, a descrip- 
tion of Nome from a sanitary point as it appeared in the last 
week of June, 1900, is a necessity. 

The first stampede to Nome was in the summer of 1899, 
too late for the people from the States to reach its golden 
beach, in any great numbers. About 2700 inhabitants re- 
mained during the following winter, and a town, housing that 
number, had been hurriedly built on the land situated at the 
edge of the tundra to the east of Snake river, and partially 
extending to the sand spit between that stream and Behring 
sea. As the land was taken by squatter's right, so much being 
allowed as one men could occupy, it resulted in a compact line 
of wooden houses, extending a distance of a quarter of a mile, 
witli only here and there a narrow passage leading from the 
street to the rear of this line of buildings. The main street 
was from 30 to 40 feet wide, and followed the trend of the 
coast, being the upper line of the sandy and gravelly beach. 
At first all buildings were on the north side of this highway, 
the beach having been left open, but soon the south side of 
this thoroughfare was occupied by a variety of structures, and 
at only few points were roadways left to the water. Farther 
back on the tundra and on the low bluff overlooking the Snake 
river, scattering houses were built on so-called streets, which 
in summer, were quagmires, almost impassable to loaded 
vehicles. 



110 MAJOR RUDOLPH G. EBERT. 

The water supply of Nome was obtained from two or 
three shallow wells sunk near the meeting point of tundra and 
beach, and immediately between the line of buildings and the 
sea, this water was peddled in old kerosene cans at the rate 
of fifty cents per five gallons, or else from Snake river, here 
a sluggish stream afifected by the tide, along whose banks the 
town extended and in whose waters were anchored a goodly 
number of river steamers and other craft used as hotels, lodg- 
ing houses and hospitals. 

As the tundra is nothing but a mass of moist, dead and 
decaying vegetation and a little soil, and always frozen at a 
depth of twelve to sixteen inches, it is easily seen that any 
filth or contamination thrown upon its surface in winten 
would easily find its way into either of these sources of water 
supply without much purification, and prove a constant men- 
ace to the health of the community, as soon as the warmth of 
summer melted the snow and permitted the flow through this 
porous mass, into either stream or wells. 

The Fall of 1899, found Nome suffering from an epidemic 
of typhoid fever, imported, beyond a doubt, from Dawson, 
where the death rate had been from 50 to 60 per week. The 
number of cases in Nome was variously stated by the physi- 
cians who had wintered there, as being from three to seven 
hundred. No accurate account was kept, but basing an esti- 
mate upon the mortality, the number of patients was nearer 
the former than the latter figures, out of a population of less 
than three thousand. The poor. facilities for treatment, the 
lack of utensils and disinfectants, the rush and carelessness of 
a mining camp; the entire lack of sanitary regulations, all 
favored an utter disregard of hygienic laws; and typhoid as 
well as other excreta, were thrown broadcast over the soil 
ready to infect the large inflow of people from the States who 
were not immune. 

During the winter the high price of lumber had prevented 
the construction of cess-pits and outhouses; dry earth or sand 
was not obtainable and excreta were deposited promiscuously 
on the tundra. Nearer the buildings, a screen of four upright 



SANITARY WORK OF THE ARMY IN ALASKA, \\\ 

sticks, surrounded by g^unny sackings with possibly a soapbox, 
for earth closet, was a conspicuous mark in the landscape. 
Behind the row of houses constituting the business part of 
town, there were a few privy vaults, but these, dug in the 
frozen ground, rapidly filled with water on the approach of 
summer and overflowed the surface; or in winter their contents 
rose like stalagmites, to the level of the seat. The on^ly sani- 
tary arrangement were two public closets built on piling over 
the beach at a point subjected to overflow by high tides; one 
of these was free, the other demanded an admission rate of 
three tickets for twenty-five cents. As the early summer was 
devoid of storms which would carry "away this filth, it had ac- 
cumulated in the free one to an extent as to become unbear- 
able and required the discontinuance of its use. A small 
wrecked schooner near the barracks was also made a public 
convenience, until it became a public nuisance, which unfor- 
tunately could not be destroyed as it was a subject of litiga- 
tion and in the hands of the court. 

Scavengers were unknown; kitchen and other refuse was 
conveniently pitched out of doors, and, until the influx of the 
thousands from the States increased the amount, it was fairly 
well disposed of by the Malamute dog. Debris of all kinds, 
straw, old clothes, packing material, was thrown into the 
puddles in the rear of the line of houses, so as to form paths 
over the muck and mire. Yards showed an aggregation of 
tins and bottles, in which solid and liquid food had once been • 
conveyedf nor were they always empty, for in an emergency 
some had served the uses of a night vessel. 

The problem of bringing the camptoanything like a san- 
itary condition was made more serious by the high cost of 
labor, material and food supplies. A dollar an hour was the 
wage of an ordinary laborer; mechanics and skilled w-orkmen, 
received a dollar and a half; the use of a team was fixed at ten 
dollars per hour. Lumber ranged from $80.00 to $120.00 per 
thousand; coal, $40.00 to $60.00 per ton. Klondike prices 
were demanded for provisions; restaurant fare being at a rate 
of twenty-five cents for a cup of coffee; seventy-five cents for 



112 MAJOR RUDOLPH G. EBERT, 

ham and two eggs; beefsteak from $2.00 to $5.00 and other 
articles in proportion. 

To further complicate the health conditions, several of 
the steamers from the States had imported smallpox amongst 
their miscellaneous cargoes, and as this had been successfully 
concealed in the case of the **Oregon" until the passengers 
had been landed, the prospects for a widespread epidemic were 
more than favorable. Measles and influenza, finding a virgin 
soil amongst the native population, were decimating its num- 
bers. 

Imagine this community of twenty thousand or more ad- 
venturers, stretched along the narrow strip of beach between 
ordinary high tide and the tundra, living in tents or any tem- 
porary shelter; half a hundred seagoing vessels in the open 
roadstead; steam tugs and gasoline launches pulling and 
pushing lighters loaded with human cargo or merchandise; 
gangs of men unloading all manner of articles of commerce 
upon every open bit of beach; horse and dog teams finding 
their way through the crowded thoroughfares; buildings 
going upon every hand; a wide open mining camp with every 
one intent on his own personal affairs and gains, giving no 
heed to the welfare of others, and you have a picture of Nome 
at any time in the twenty-four hours. 

The military, though in control, had no funds with which 
to do even the most necessary work of policing the commu- 
nity; nor was there authority to obtain the same by levying 
tax or tribute, as would be the case were it foreign or con- 
quered territory. Forced labor was out of the question. The 
small company of Infantry located at Nome barracks, were 
fully occupied in preserving order, protecting the public, and 
guarding the property over which contentions as to owner- 
ship had arisen, pending the arrival of the court. So the 
question of bringing the town to a semblance of cleanliness 
and enforcing the most elementary conditions of sanitation, 
became one of making each individual owner of property at- 
tend to his own premises, first, by a request showing the 
necessity therefor, that failing, by more arbitrary measures. 



SANITARY WORK OF THE ARMY IN ALASKA. \ 13 

A circular was published based on the following recommenda- 
tions, viz: 

1. A thorough cleaning up of all grounds and destruction of 

all filth and refuse, either by burning or throwing into 
the sea, should be undertaken immediately, and failure to 
comply with this will subject the offending parties to ar- 
rest and punishment. All rubbish and garbage should be 
deposited in suitable receptacles for daily removal and 
destruction. To lessen the amount of this material, it is 
suggested that all dry substances be burnt in the ordinary 
cook fires. 

2. All privies and cess-pits which are filled within two feet of 

the surface, should be closed and a layer of quick lime or 
other disinfectant thrown over the fecal matter, and then 
dry earth or sand to fill the pit. In future, the disposal 
of excreta should be by the *'dry earth closet system, "the 
boxes to be emptied daily. The excreta of all patients 
suffering from infectious disease, should be thoroughly 
disinfected, (quick lime being the cheapest and best agent) 
prior to their deposit in closet. 

^' Six or more closets wuth a seating capacity of twenty to 
forty each, according to location, should at once be con- 
structed by the public for general use. 

^' The construction of surface drains running direct from the 
occupied parts of the tundra to the sea at intervals of 200 
feet, should be undertaken without delay. These ditches 
should have a grade sufficient to insure free outflow, 
especial care being taken that water does not stand in 
pools; where drains cross roads, they should be protected 
by suitable culvert. All lateral ditches must be made to 
empty into direct channels; any intentional obstruction of 
a drain, will subject the offender to punishment. 

-'^- As the water supply is to a great extent seepage, it is di- 
rected that no wells be sunk in ravines or gullies; owing 
to the greater liability to contamination. All wat^r for 
cooking- or drinking purposes, should be boiled for at least 
ten minutes, and kept in covered receptacles. If not used 
in twenty-four hours, it should again be boiled. 

^* All decaying meat, vegetables, fruit, etc., should be imme- 
diately destroyed. 

7- All refuse, if deposited in the sea, should be taken to such 
a distance as precludes its being cast upon the beach, 
within the limits of this community. 

^- The Sanitary OflBcer will be promptly notified by the at- 



114 MAJOR RUDOLPH G. EBERT. 

tending physician, of any case of contat^^ious disease oc- 
curring in the community. Upon notification, measures 
will be taken to inform the public, by the display of a red 
flag, bearing the name of the disease in letters of at least 
one inch in height, which flag will be continued to be dis- 
played, until removal or recovery of patient and disinfec- 
tion of premises. 

To carry the operation of this circular into effect, the 
Sanitary Officers, three in number, notified the proprietors of 
the necessity and best methods of placingpremises in hygienic 
condition, announcing a second inspiection in two or three 
days, to see if work had been properly done. With few ex- 
ceptions, fair promises were made and hearty cooperation 
offered, but when again interviewed, the rule was that noth- 
ing had been done. One method of procedure now only was 
open; the offending party was reported to the Commandant 
as maintaining a menace to public health; the premises were 
closed and placed under guard, the proprietor having been in- 
formed that he could resume business when the nuisance had 
been abated and the full comj)liance with instructions had 
been accomplished. 

The effect was instantaneous; three or four examples sat- 
isfied the citizens that the military was determined to enforce 
the orders, and with a cheerful alacrity, the most crying evils 
were remedied. Each section of the town that was cleaned 
and placed under better sanitary arrangements, made the 
labor less arduous, as support to the enforced measures was 
heartily given by those who had already performed their 
duty. Soon the inspectors received reports of especially ob- 
noxious places which had escaped on the first rounds, and 
neighbors vied with each other, not in the cleanlinessof their 
own premises, but in having the other do his share. 

The epidemic of smallpox received more especially, the 
attention of the Treasury Department by its representative, 
Lieutenant Jarvis, U.S.R.M., who had, prior to the arrival 
of the Department of Alaska Headquarters, placed two 
steamships in quarantine. A system of visitation to all re- 
ported cases of this disease, removal of patient to improvised 



. . SANITARY WORK OF THE ARMY IN ALASKA. US 

hospital, and disinfection or destruction of bedding^, clothing 
and tentage, with the insistence upon vaccination for all not 
properly protected, who would proceed up the Yukon or return 
to the States, served to check the epidemic in a fortnig-ht, and 
but two or three isolated cases were discovered after the mid- 
dle of July. When it is considered how widespread was the 
contagiura and the promiscuous intercourse, until isolated, be- 
tween patient and population, the work done is a remarkable 
example of what may oe accomplished if proper authority is 
given. It is pleasant to note that at all times a hearty coop- 
eration existed between the physicians employed by the two 
Departments of the Government; those of the Army acting as 
sanitary inspectors, these of the Treasury as quarantine offi- 
cers. All were actuated by that hig-h motive of the true med- 
ical man, **the securing- of the best welfare of the community," 
and the results were most gratifying-. 

A fortunate factor to the good health of the community 
<lurinor the Fall and Winter of 1900, was the introduction, 
early in August, by a private corporation, of pure spring 
water. F'or two months, however, "the population of **Che- 
chacos" or new comers, had lived under the old conditions of 
the water supply, and that the g-ernis of typhoid were not ab- 
^^nt, Is seen by the report of some twenty cases by the end of 
Auo^ust. The number later was slightly increased, but never 
*>ssumed large proportions. When comparison is made in this 
^^J^pect with the second season of Dawson's existence, Ameri- 
^^ti sanitary methods will not suffer. American sanitarians 
^ave shown that they have fully learned the lesson that 
whether in the Atactics or in the Tropics, **Cleanliness is the 
first step to Health." 

The work of the Medical Department in North Alaska did 
not end here. It was stated that influenza and measles had 
attacked the natives from Cape Vancouver to Cape Prince of 
^^ales. Along the coast and on the islands of Behring sea 
a°^ up the Yukon, these people were stricken by this pesti- 
lence, at a time when they should have been reaping their har- 
vest of fish from the waters. Whole families and villages were 



116 MAJOR RUDOLPH G. EBERT. 

sick at one time, and starvation added to the fearful mortality. 

Army doctors with medicines and supplies, visited such 
villag'es as could be reached, and ministered to the wants of 
the stricken Esquimaux; a chartered vessel gathered up such 
along the coast as could be conveyed to military stations for 
care and treatment. Burial parties were sent out, and fre- 
quently ten or twelve were consigned to one grave. It is es- 
timated that one-third the native population succumbed, and 
this number would have been doubled but for the assistance 
of the governmental authorities. 

The purely military' duties of the Army were not the 
most trying. Building quarters and barracks, moving stores 
and fuel, hauling ice and guarding property, during an arctic 
winter with the thermometer in the 30s or 40s below zero, and 
arctic gales blowing, are not pleasures; but when you add to 
this, field work in the shape of constructing telegraph lines, 
digging through four feet of frozen ground covered by six 
feet of snow, living in Sibley tents with SO" below zero, as it 
is away from the coast, helping the dog teams and exhausted 
mules along the crusted trail sprinkled with blood from the 
cut hoofs and limbs of your animals; on short rations of beans 
and bacon; struggling to keep warm during the long wintry 
nights, to work the harder the few hours of DecembeV day- 
light, you will find that the Service in Alaska is not altogether 
"coffee cooling," but of that strenuous character that tries 
one's physical and moral nature. In these hardships, as in all 
trials of the Line, the members of the Medical Department, 
commissioned and enlisted, bore their full share, receiving as 
their reward the consciousness of a hard duty, honestly and 
faithfully performed. 



TUBERCULOSIS IN THE TROPICS. 
By captain JOSEPH J. CURRY, 
ASSISTANT SURGEON OF UNITED STATES VOLUNTEERS. 

WHILE text books and special articles, which consider 
the g-eographical distribution of the disiease, usual- 
ly state that tuberculosis exists in the tropics in 
common with all other climates, no mention is made as to 
what extent the disease prevails here. In considering* the 
most favorable conditions for the development of pulmo- 
nary tuberculosis it is generally stated that a. cool, moist 
climate stands first. In fact, pulmonary tuberculosis was 
long considered to be especially a disease of the temperate 
zones. This idea was based on a comparatively accurate 
knowledge of the extent and distribution of the disease in the 
temperate zones, and a corresponding lack of knowledge as to 
the nature of the diseases of tropical countries. 

It is only within the past few years that the diseases in 
the tropics have begun to be studied in the same careful and 
scientific way as have, for the past twenty years, the diseases 
of the temperate zones. 

Among the earlier investigators in the tropics were the 
English, French, and German military and naval surgeons, and 
since the Spanish-American War, the surgeons of the U. S. 
Army and Navy have entered actively into this field of inves- 
%ation. It is hardly necessary to speak here of the great 
work accomplished in Cuba by Reed, Carroll, Lazear, and Ag- 
ramonte, who composed the Army Medical Commission for 
the study of yellow fever. Through the discoveries of Sur- 
geons Reed and Ross, we are now able to apply effective pre- 
ventive measures against those diseases which are trans- 
niitted by suctional insects, and recent investigations have 
thrown considerable light on the nature and the mode of 
spreading of other important diseases of the tropics. 

(117) 



118 CAPTAIN JOSEPH J. CURRY. 

There is a disease, however, which claims many more vic- 
tims throughout the tropical world, than malaria and yellow 
fever combined, and strange to say, this disease has received 
but scant attention from writers on tropical diseases. 

In the Philippine Islands, in Cuba, and in Porto Rico, 
pulmonary tuberculosis is probably responsible for a greater 
number of deaths among the natives than any other disease, 
and I have no doubt this is true also of a great part of the 
tropics. The malarial fevers are, on account of their debili- 
tating effects and the accompanying anemia, among the most 
important diseases of the tropics, but their . importance has 
frequently been magnified at the expense of other wide spread 
fatal diseases, and they have often overshadowed the diseases 
in which they frequently occur as a secondary, and often as a 
minor infection. 

The manifestations of tropical malarial fever are so va- 
ried, that it may resemble, in its sj^mptoms and temperature 
curve, a great many, diseases. The custom has generally 
been, in the tropics, to regard all fevers as malarial, unless 
positively proven to be otherwise. I wish I could impress on 
the surgeons in the tropics the importance of approaching 
this subject of diagnosis from the opposite standpoint. Too 
often on this account, has the diagnosis of malarial fever been 
made in cases of tuberculosis, of typhoid fever, and of other 
diseases. In the past, many of our soldiers sick with pulmo- 
nary tuberculosis, have been kept in the islands too long, with 
the diagnosis of malarial fever. I have performed a number 
of autopsies in Manila on men sent to the hospitals with the 
diagnosis of malarial fever, and found death due to pulmo- 
nary tuberculosis. No doubt many of these men had malarial 
fever in the beginning of their illness, or later in the course 
of the disease. 

This brings us to the consideration of the causes of these 
errors of diagnosis in such cases. The first is: that the mala- 
rial fevers here, are prone to occur as secondary infections or 
as exacerbations of an old infection in such more or less chron- 
ic diseases as pulmonary tuberculosis; and secondly, it is not 



TUBERCULOSIS IN THE TROPICS. 119 

generally understood that pulmonary tuberculosis is a very 
common disease in the tropics. That pulmonary tuberculosis 
pursues a very rapid and fatal course in the tropics is well 
known to those surgeons who have served in Cuba, Porto Rico, 
and the Philippines. It is well recognized that the only sal- 
vation for the patient in this disease is to send him. out of the 
tropics as early as possible. 

In Manila, a city of about 250,000 inhabitants, there were 
reported to the Board of Health, from October 1899 to June 
1900 inclusive, 992 deaths from tuberculosis, and 630 deaths 
from acute lung diseases. This gives a death rate of nearly 
6 per 1000, for tuberculosis, and 8 per 1000 for tuberculosis 
and acute lung diseases. During these nine months there 
was a total of 8,535 deaths from all causes. Excluding child- 
ren's diseases, dysentery was responsible for the greatest num- 
ber of deaths, 1,073. Tuberculosis was a close second with 
992, and acute lung diseases third, with 630. In this series, 
malarial fever was reported as the cause of death in 338 cases, 
and typhoid fever in 41. Many medical oflBcers serving at va- 
rious stations throughout the islands, on the coast, and along 
the rivers, have remarked upon the great prevalence of pul- 
monic diseases in these places, and one of the most frequent 
of the causes of rejection of men for the native regiments, is 
pulmonary tuberculosis. This disease is wide spread among 
'^ag^als and the Visayans. The hill tribes and the Moros do 
"ot seem. to have the disease as generally as the other tribes. 

Among the American troops, according to the Surgeon 
General's report for the year 1900, the rate of admission to 
hospital for pulmonary tuberculosis in the Philippines, for 
the year 1898 was 5.95 per 1000 of strength, and in 1899, 4.48 
per 1000. The average rate for these two years is over twice 
as great as the mean annual rate, (2.66,) for the last ten 
years. In 1899 the rate of admission for pulmonary tubercu- 
losis was 5.10 per 1000 for Porto Rico, and 4.49 for Cuba. 

These figures show what a marked increase there has 
been in pulmonary tuberculosis among the troops since they 
began to serve in the tropics. The report of the Director 



120 CAPTAIN JOSEPH J. CURRY. 

General of theEng-lish Armj Medical Department for 1899, also 
shows that the commands serving^ in tropical countries, have a 
higher rate of admission for pulmonary tuberculosis than those 
serving at home and in Canada. The admission rate for the 
United Kingdomwas3.S per 1000 of the strength, while in India 
it was 4.2. Among the non-European (native) troops, the ad- 
mission rate in the English Armj' throughout the tropics, is 
very high. In west Africa the admission rate for these troops 
for 1899 was 15.2 per 1000. In Jamaica 15 per 1000, and in 
the Barbadoes 10.7 per 1000. This high rate among the na- 
tive troops is significant. It shows how wide spread is pul- 
monary tuberculosis among the dark skinned races. It must 
be remembered, too, that these high rates occurred among 
men picked after careful physical examination. 

In Havana, tuberculosis is responsible for a higher mor- 
tality rate than any city in the United States. As shown in 
the report for 1901, of Major Gorgas, Chief Sanitary OflScer 
of Havana, the annual death rate from this disease for nine 
years, from 1890 to 1899, was nearly 8 per 1000. The lowest 
rate was 6 per 1000 inhabitants in 1896, and the highest, 11 
per 1000 in 1898. In marked contrast, the statistics for the 
year 1901, the third year of the American occupation, shows 
a rate of but 3.6 per 1000. 

It is not hard to understand the reason for this great 
prevalence and high mortality of pulmonary tuberculosis. 
The enervating influences of the tropics, and the wi^e preva- 
lence of such anemiating and debilitating diseases as the ma- 
larial fevers and dysentery, lessen the resisting powers of 
those living here, consequently removing the only force capa- 
ble of combatting the disease. Then, too, it is very probable, 
that under such favorable conditions of warmth and moisture, 
present in the tropics, that the tubercle bacillus preserves its 
virulence much longer than in other parts of the world. In 
addition to these influences, the ignorance, which prevails 
among natives of the tropics, of sanitary laws and of the 
mode of dissemination of infectious diseases, constitutes a 
very important factor in the prevalence of tuberculosis here. 



NOTE ON THE UNSAFE CONSTRUCTION OF WATER 
STERILIZERS. 

By F. W. F. WIEBER, M.D., 
SURGEON IN THE UNITED STATES NAVY. 

AS the operating rooms of our Navy Hospitals and probably 
h\ also those of many of the Army Hospitals are fitted up 
with the old water sterilizers as originally furnished, it 
may not be out of place, in these pages, to call attention to an 
accident which happened at the Naval Academy Sick Quarters 
in November last, which but for fortunate circumstances might 
have resulted in the loss of two lives. 

At about 3:15 P. M., on November 24th, 1902, a loud ex- 
plosion occurred in the operating room during the process of 
water sterilization; the building shook; steam escaped through 
broken windows and the door of the room ; and an attendant in the 
operating room was scalded by steam about the shoulders and 
legs. After the steam had cleared away, the water boiler was 
seen in the ceiling, and firmly imbedded in the joists of the floor 
of the room overhead, which is used as a board room and in which 
a niedical board was at that time in session, examining candidates 
for admission to the Naval Academy. The floor was torn open. 
TTie boiler had landed just under the chair of a member of the 
board, who, fortunately, a few minutes before, had left his seat 
to do some work in connection with the examination. 

On examining the boiler later, it was found that the top of 
the boiler had been torn open, and that its sides were collapsed, 
evidently the result of the force of the outrushing^ steam follow- 
ing the break in the top. 

The boiler was originally connected with two water tanks by 
two sets of circulating pipes, each pipe provided with a valve so 
that the tanks could be sterilized singly. It had neither water 
guage nor safety valve independent of the tanks. To sterilize 

(121) 



122 SURGEON F. W. F. WIEBER, 

the water in a tank, both valves on the respective side should 
have been wide open. The nurse in charge of the operating room, 
a man of experience in the work assigned him, stated that he had 
opened the proper valves; however, there is no doubt in my mind 
that he had not opened the valves and that he had heated the 
water in the closed boiler. The superheated and compressed 
steam made its own outlet. 

Had there been a safety vaive to the boiler, the accident 
could not have happened. The water sterilizing apparatus was 
installed in 1897, and bore the name of Sprague-Schuyler Steril- 
izer No. 1 Class B. The boiler to replace the old one will be 
fitted with water guage, steam gauge and independent safety 
valve. 



AN APPLIANCE FOR SUPPORTING DISABLED 
MOUNTED MEN. 

THE following support for the disabled is simple, inex- 
pensive, fits all military saddles without any alterations, 
makes a saddle feel like a comfortable armchair, and will 
prevent an unconscious man from falling from his saddle when his 
horse is galloping. A semicircle of light metal, padded inside and 
leather covered, has two large D's at front extremities and a 
metal leather-covered upright fixed at right angles to middle of 
.semicircle behind. When the patient has been assisted to his 
saddle this upright is placed in the crupper D of saddle, a stirrup 
leather is threaded through the two D*s in front and through the 
middle of the saddle between the wallets, then the strap is buck- 
led. The whole process takes a few seconds only. The weight 
of the patient is supported partly by the saddle and partly by the 
ring pulling against the fixture in front; the upright only keeps 
the ring at a proper height and prevents lateral swaying. A 
padded head rest can be put above upright with protection from 
sun. Six of these supports can be carried face downwards on 
saddle of a spare horse secured by the leather straps, and would 
be ready at once for use with a patrol. — Lieutenant Colonel H, 
Hathaway, R.A.M.C., in British Medical Journal, 



fftebico-flDilitar^ Inbei. 



MEDICO-MILITARY ADMINISTRATION. 

Freufcr (K.) lA folding litter,] Krankenpflege, Berl., 1902, ii, 43-45. 

Giles (?• B*) The brigade medical unit. Brit. M.J., Lond,, 1902, ii, 1032. 

Hamilton, (J. B.) Reform in the army medical service. Brit. M.J.^ 
Und., 1902, li, 1033. 

Hathaway (H. GO A mcfbnted bearer company. Brit. M./., Lond,^ 
1902,11,1165. 

Herr (L*) [Sanitary service of the English army during the Boer war.] 
•V Wien, 1902. 

Hutton(G.A«) Voluntary aid to the sick and wounded in war, with 
special reference to hospital orderlies. Brit. M./., Lond,, 1902, ii, 1025-1027. 

Janosen (H, A.) Du transport des blesses militaires par les voies ferries. 
Caducetj Par., 1902, ii, 236-241. 

Jaffary. [Sanitary condition of the Russian army during 1899] Caiiu- 
":'€, Par., 1902, ii, 247. 

Larking (A. E.) The position of the volunteer regimental medical offi- 
<^cr. Brii. M.J., Lond., 1902, ii, 1030-1032, 

Lancy. Laescuelade aplicaci6n de sanidad militar. Semana mM.^ 
Buenos Aires, 1902, ix, 603-605. 

Lowenthal (J.) [The project of incorporation of auxiliary forces and 
the sanitary condition of non-combatants,] Rev. Scient.^ Par., 1902,4,5., 
xviij, 464-470, 

Maosfield (C.) An ambulance stretcher. Brit. M.J., Lond., 1902, ii, 
'034- 

NkbergalL Tactique du service de sant^. Caduch, Par., 1902, ii, 227- 
229. 

Mhnier. [The medical corps of the United States Army.] Arch. cU 
iihi.et. pharm. miL^ Par.. 1902, xl, 328-344. 

Petit (H*) Guide th^rapeutique des inArmeries r^gimentaires. 12.' 
Paris, 1902. 

Porter. A few observations mainly concerning the Red Cross badge. 
^rit.M.J., Lond., 1902, ii, 1028. 

Radzfcjewski. Die KrankentrageriibungdesXVL Armeekorps. Rotke 
^reug.^ Berl., 1902, xx, 296. 

(128) 



124 MEDICO-MILITARY INDEX, 

Reynolds (F. P.) The most practicable organization for the medical de- 
partment of the United States army in active service. /. Ass, Mil. Surg. 
(7, S,, Carlisle, Pa., 1902-3, xi, 222-241. 

Shelford (R«) A provisional classification of the swords of the Sarawak 
tribes. Rep. Brit^ Ass. Adv. Sc.^ Lond., 1902, Ixxi, 804, 

Svanborg (A*) [The education of ambulance attendants.] Tidskr. i. mil. 
Helsov. Stockholm, 1902, xxvii, 187-195. 

Taylor (W.) An address on the medical profession in relation to the 
army. Lancet, Lond., 1902, ii, 1088-1091. 

Timana. Le service de sant^ sur le champ de bataille avec un expos^ 
historique de ce service au corps d'arm^e de la garde pendant la bataille de 
Saint-Privat. Arch, de, mtd. et.pharm. mil.. Par., 1902, xl, 154-160. 

Freille (A.) [Military service for medical students.] Rev. de mtd. Ug.^ 
Par., 1902, ix, 280-283. • 

MILITARY SURGERY. 

Brinton (J. H.) Remarks on some effects of fire-arms at short range, 
with experimental illustrations. Internal, din., Phila., 1902, 12. s., iii, 148- 
152, I pi. 

Broquet (C.) Fishes dont se servent pour chasser les chiitois Lai de la 
presqu fie de Lei-chau (province du Quang Tong.) Bull, et mfm. Soc, d^an. 
tkrop. de Par. J 1902, 5 s. iii, 181. 

Dubujadotfx* [Operations in the Military Hospital of Blida (Algeria) 
during 1 895-1900]. Bull et. mlm. Socdechir.de. Par., 1902, n. s., xxviii 
969-972. 

Gafda* Julian (L^ £1 descubrimiento de Roentgen y su utilidad en el 
servicio sanitario de paz y de guerra. Rev. de san. mil., Madrid, 1902, xvi, 
149; 169. 

HaoimefBchmidt* [Acute exophthalmic goitre following a gunshot 
wound.] Deutsche mil.-drztl. Ztschr., Berl., 1902, xxxi, 528-535. 

Haasler. Plaie perforante de la joue et du pilier ant^ieur gauche et 
p^n6trante de Tamygdale gauche par ^p^e -baionette d-infanterie. Mem. et, 
Hull. Soc. de. med. et. chir, de Bordeaux, (1900), 235. 

Hildebrandt* Ueberdie Bauchverletzungen durch Kleinkalibergeschosse 
und ihre Behandlung im Feld. Arch f. klin. Chir., Berl., 1902, lxvii.837-873- 

vonHippel. Ueber die Laparotomie im Kriege, Arch. f. klin. Chir. 
Berl., 1902, Ixviii, 715-767. 

Huertas (J*) Los heridos en la explosidn del polvorfn de Carabanchel. 
(Historia clfnica del sargento de artillerfa Manuel Lapuente.) Rev. de san. 
mil., Madrid, 1902, xvi, 309-316. 

Kirker (GJ The treatment of wounded in naval actions. Brit. M. J., 
Lond., 1902, ii, 1019-1021. 

LaGatde (L» A«) Gunshot wounds of the chest and abdomen from a 
military standpoint. Med. News, N. Y,, 1902, Ixxxi, 927-930. 

Gunshot wounds of the knee joint by the projectile of reduced 

caliber. Proc. Phil. Co. M. Soc, Phila., IQ02-3, xxiii, 1-9. 



iBbitodal Depattment- 



THE NEW EPOCH IN THE HISTORY OF THE ASSO- 
CIATION OF MILITARY SURGEONS OF 
THE UNITED STATES, 

THE unanimous passage of the act to incorporate the Asso- 
elation of Military Surgeons of the United States by 
both houses of Congress and its approval by President 
Roosevelt marks the opening of a new era in the history of mili- 
tary and naval medicine. From a modest beginning as the Asso- 
ciation of Military Surgeons of the National Guard of the United 
States in 1891, the organization grew by the addition of the med* 
ical oflBcers of the army and navy in 1893 to be the unofficial 
Association of Military Surgeons of the United States which has 
had so successful and useful a career and which has added so 
much to the position of American Military Medicine. During 
the twelve years of its existence the perwSonnel of the Association 
has been marked by steady growth. 

The work brought forth through its influence is now crys* 
talized in the eleven volumes published by it, — nine volumes of 
Proceedings and two of the Journal. Its influence in developing 
study, thought and investigation along the lines of military and 
naval medicine, surgery, sanitation and equipment is amply dem- 
onstrated by the increasing bulk of the annual contributions to 
its publications. It has thus admirably filled its declared pur- 
pose, *'to promote and improve the science of military surgerj'.** 
In course of the development of the Association, however, 
it became evident that there were points upon which as an unof- 
ficial organization it could not touch. Its work was hampered 
and retarded by the lack of an official status under the law of the 
nation. While the national and most of the state services recog- 
nized it by the detail of official representatives, and while various 
foreign powers extended to it the courtesy of official recognition, 
some still stood aloof on account of its unofficial character. This 

(126) 



126 EDITORIAL DEPARTMENT. 

defect is now fully corrected by the following Act of Congress, 
approved January 30, 1903 : 

[Public— No. 39.] 
An Act To Incorporate the Association of Military Surgeons of 
the United States. 

Be it enacted by the Senate and House of Representatives of the United 
States of America in Congress Assembled^ That George M. Sternberg, of 
the District of Columbia: Presley Marion Rixey, of the District of Colum- 
bia; Walter Wyman, of the District of Columbia; Nicholas Senn, of Illi- 
nois; Jefferson Davis Griffith, of Missouri; John Van Rensselaer Hoff. of 
New York; Robert A. Blood, of Massachusetts; Leonard B. Almy, of Con- 
necticut: Nelson H. Henry, of New York; J. Francis Calef, of Conne"ticut; 
(leorge Henderson, of the District of Columbia; Charles F. W. Myers, of 
New Jersey: John V. Shoemaker, of Pennsylvania; Angelo Festorazzi, of 
Alabama; Edmund C. Brush, of Ohio; Frederick W. Byers, of Wisconsin: 
James T. Priestley, of Iowa; James Evelyn Pilcher, of Pennsylvania; Mar- 
shall O. Terry, of New York; Winslow Anderson, of California; Charles 
H. Alden, of Pennsylvania; William W.Grant, of Colorado; Robert Har- 
vey Reed, of Wyoming; Thomas C. Clark, of Minnesota; Robert A. Marmi- 
on, of the District of Columbia; Myles Standish,of Massachusetts; John C. 
Wise, of Maryland; George T. Vaughan, of Virginia; Albert H. Briggs, of 
New York; William C. Borden, of New York; Otis H. Manon, of Massa- 
chusetts, and their associates and successors, are hereby created a body cor- 
porate and politic in the District of Columbia, by the name of the Associa- 
tion of Military Surgeons of the United States, for the purpose of advancing 
the knowledge of military surgery, medicine, and sanitation in the medical 
departments of the Army, the Navy, and the Marine-Hospital Service of the 
United States and of the militia of the different States, and to increase the 
efficiency of the different services by mutual association and the consider- 
ation of matters pertaining to the medico-military service of the United 
States in peace and in war. 

Sec. 2, That the Secretary of the Treasury, the Secretary of War, the 
Secretary of the Navy, the Surgeon-General of the Army, the Surgeon- 
(jeneral of the Navy, and the Surgeon-General of the Marine-Hospital Ser- 
vice shall be ex-officio members of the Assdtiation of Military Surgeons of 
the United States, and, with the president of tlie association, shall act as an 
advisory board to the said association. 

Sec. 3. That said Association is authorized to hold real and personal 
estate in the United States, so far only as may be necessary to its lawful 
ends, to an amount not exceeding one hundred thousand dollars, and may 
adopt a constitution and make by-laws not inconsistent with law, and may 
adopt a seal and an insignia which may be worn by its members. 

Approved, January 30, 1003. 



EDirORFAL DEPARTAfENT. 



127 



The provisions of the Act will require some modifications of 
the constitution and by-laws of the unincorporated association 
before it is finally adopted by the new corporation. An addi- 
tional class of members, "Ex-Officio Members," comprising the 
Secretaries of the Treasury, War, and the Navy, and the Surg- 
eon Generals of the Army, Navy and Public Health and Marine 
Hospital Service, must be established; an article of the constitu- 
tion must be adopted, providing for an 
Advisory Board; and a by-law must 
be enacted specifying its functions and 
conduct. 

The last .section of the Act officially 
recognizes the insignia of the Associa- 
tion and authorizes it to be worn by 
members. This recognition of the in- 
signia by the national government \\\\\ 
cause its recognition also by the few 
states that have not done so. It there- 
fore renders it necessary to incorpo- 
rate a description of the seal and iu- 
.signia in the constitution. Hitherto 
no description of either has been pub- 
lished, and the only reason for unifor- 
mity has been that but one seal has 
been in existence from the l>eginning 
and the manufacture of the insignia 
has been for the .same perioti in tlie 
hands of the same establishment. The 

^^■^ design for both badge and button, as hitherto fur- 
J^^r^k nished, is admirable and no change is desirable. The- 
M^^HH proper description of them in an additional article of 
l^^^Q^ the constitution will satisfy all requirements. 

^^^^^ In all these cayes the provisionof the constitution 

of the unincorporated Association prohibiting amendment without 
a year's notice may be disregarded, >iiice the official corporation 
established by law is not the s^me organization but a successor to 
it. Once adopted, however, all future amendments will have to 
comply with the article in queytioii. 




Association of Military Surgeons 

Enno^anbcr prise^ 

1902-1903. 

Tht Essayist securing First Place will 
receive 

A Gold Medal, 

off the value of 

One Hundred Dollars. 

/llie Essayist securing First Honorable Men 
tion will receive 

A Life Membership 

in the Association, of the Value of Fifty 
DoUars. 

SUBJECT FOR 1902-1903: 

THE DIFFERENTIAL DIAGNOSIS OF TYPHOID FEVER 

IN ITS EARLIEST STAGES. 




CONDITIONS OF THE COMFFniTlON. 

1. Competition is ojjen to all persons eligible to active or associate 
membership in the Association of Mih'tary Surgeons of the United States. 

2. The prize will be awarded upon the recommendation of a Board of 
Award selected by the Executive Committee. The Board will determine 
upon the essay to which the prize shall be awarded, and will also recom- 
mend such of the other papers .submitted, as it may .see fit for honorable 
mention, the author of the first of which .shall receive a life membership in 
the Association. 

3. In fixing the precedence of the essays submitted, the Board will take 
into consideration — primarily— originalitv, comprehensiveness and the prac- 
ticability and utility of the opinions advanced, and — secondarily — literary 
character. 

4. Es.says will con.sist of not less than ten thousand, nor more than 
twenty thousand word.s, exclusive of tables. 

5. Each competitor will .send three typewritten copies of his essay in a 
sealed envelope to the Secretary of the A.ssociation, .so as to reach that of- 
ficer at least one month before the next ensuing annual meeting. 

6. The essay shall contain nothing to indicate the identity of the author. 
Each one however will be authenticated byanom de plume, a copy of which 
.shall, at the same time as the essay, be transmitted to the Secretary in a 
Sealed envelope together with the author's name, rank and address. 

7. The envelope containing the name of the successful competitor will 
be publicly opened at the next .succeeding annual meeting of the Associ- 
ation, and the prize thereupon awarded. 

8. The succes.sful essay becomes the property of the Association of 
Military Surgeons of the United State.s, and will appear in its publications. 

liOAkb OF AWARD— 190J-1903 

Hri^adicr (ieiicral AisTiN Klint, New York. 

Colonel Calvin Dk Witt, U.S. Army. 

Lieutenant Colonel V'lrTOK C. Vaughan, U.S. Vols. 

Robert Allen Bloody President. James Evelyn Pilcher^ Secretary, 

Carlisle, Pexinsylvania* 

iI28) 



EDITORIAL DEPARTMENT. 129 

THE REORGANIZATION OF THE UNITED STATES 
ARMY HOSPITAL CORPS. 

An important feature of the Army appropriation bill re- 
AA cently enacted provides for the organization of the 
Hospital Corps in harmony with other branches of the 
military service. The titles of Hospital Steward and Acting Hos- 
pital Steward are a survival of a period in the history of medico- 
military organization, when the work of the Medical Department 
was in its infancy and neither understood nor appreciated. ** Hos- 
pital Steward'' was an appropriate title when the medical officer 
was addressed by the obsolete title of * 'Surgeon" or ** Assistant 
Surgeon," but with the emergence of actual military rank and the 
consequent application of military titles to medical officers, a lack 
of harmony became apparent between the commissioned contin- 
gent and the enlisted men of the medical department. This con- 
dition is corrected by the act referred to. 

The army hospital corps, under the reorganization, will con- 
sist of — 

300 First Class Sergeants at $540 per annum. 

300 Sergeants at $300 per annum, 

20 Corporals at $240 per annum. 

1.600 First Class Privates at $216 per annum, 

875 Privates at $192 per annum. 

The First Class Sergeants and Sergeants are respectively the 
former Hospital Stewards and Acting Hospital Stewards under 
more appropriate titles. 

The Corporals represent a new grade not present in the for- 
mer organization, although seriously needed. The new grade 
will, as stated by the Secretary of War, * 'furnish proper positions 
for a number of valuable members of the corps who have the ca- 
pacity to control men and yet very frequently are not sufficiently 
educated to pass an examination for promotion to the higher 
grades. Such men would be invaluable in the control of working 
parties of privates, in policing grounds, caring for transportation, 
canvas, and many things that are required of the medical depart- 
ment particularly in active ser\^ice." The Corporals will sub- 
serve a most important function also as drill-masters in the com- 
panies of instruction. 



130 EDITORIAL DEPARTMENT. 

The division of privates into two classes will contribute mate- 
rially to the efficiency of that grade, by providing an incentive to 
the private to do work which w^ill justify his location in the high- 
er class. It will simplify the detail of members of detachments 
on duty in Hospitals and add essentially to the convenience of 
administration. 

General O'Reilly is to be congratulated upon the success 
which has crowned his efforts to improve the force under his di- 
rection, and the medical department is to be felicitated upon the 
practical ability and energy of its Chief as shown thus early in 
his administration. 



FORWARDING THE JOURNAL BY THE POST 
OFFICE OFFICIALS. 

IN a number of instances, complaints have reached th^ 
Secretary's office that members have failed to receive 
their Journals. In some cases this has been due to fail- 
ure upon the part of the members to notify the Secretary of a 
change of address. In case of officers of the regular service 
even this should not have prevented the receipt of the Jour- 
nals, for Par. 3 of the Postmaster General's order No. 395 
provides: 

**That all mail matter, whatever its class, addressed to 
persons in the United States service (civil, military or naval), 
serving in the United States or its island possessions, or Cuba, 
or enroute to or from the United States or any of its island 
possessions, or Cuba, whose change of address is caused by 
official orders, shall be transmitted as rapidly as possible until 
it reaches the addressee; that the actual location of the ad- 
dressee, for the time being, shall be considered as the original 
destination of the piece of mail matter; that such transmis- 
sion shall not be considered as 'forwarding' in the sense in 
which that word is used in the postal service, and that no ad- 
ditional postage shall be required therefor." 

While then urging members to promptly- notify the Sec- 
retary of change of address, it would be well to remember the 
foregoing order in providing for the forwarding* of mail by 
postmasters at a previous address. 



IRepiews of Books- 

THE NEW MANUAL FOR THE MEDICAL DEPART- 
MENT OF THE UNITED STATES ARMY.* 

MOST of us well remember the thin black books called 
the Standard Supply Tables containing about a 
dozen pages of general directions and thirty or forty 
of listed supplies. Seven years ago the first real manual ap- 
peared, well indexed and comprehensive, and the succeeding 
editions of 1899 and 1900 showed other development during 
that period of transition. 

The last manual contains 232 pages, and for the first time 
there is definite provision for the important duties of cam- 
paign. In a country which must necessarily depend on large 
numbers of civilians to supplement its medical department in 
time of war, the directions under the heading **Medical offi- 
cers in the field," Par. 17-23, are of much importance. 

The paragraphs relating to the hospital corps have been 
practically rewritten, and for the first time companies of in- 
struction are outlined authoritatively. It is interesting to note 
that though these companies actual)}- have existed at differ- 
ent times for about ten years, the first organized by compe- 
tent authority was in the Division of the Philippines May 
23rd, 1900, followed by the First and Second Companies 
November 8th, 1902. The commissioned personnel for both 
hospital trains and hospital ships is insufficient to properly 
care for their disabled. Two medical officers cannot attend 
to 200 sick in addition to other duties. The definite fixing of 
personnel, tentage, mounts, transportation, supplies and 
equipment is now done for the first time for field hospitals, 
ambulance companies, and the detachments serving with vari- 
ous commands. Under the provisions of paragraph 59 there 
are now (or should be) two fully equipped regimental field 
hospitals in each department. 

The hospital fund is still accounted for in an antiquated 
and laborious manner, and we can well copy the more com- 
mon-sense regulations governiug that of a company of the line. 
It is also noted that a strict interpretation of Par. 77 would 

*lVIaniiaI for the Medical Department* Compiled Utider the Direction of 
the Surgeon General. Published by Authority of the Secretary of War, for 
use in the Army of the United States. 12 mo.; pp. 232; Washington, Gov- 
ennment Priuting Office, 1902. 

(131) 



132 REVIEWS OF BOOKS. 

array male nurses in a waist and skirt of suitable white ma- 
terial, bishop collar, and white apron, without which habili- 
ments thej would not be allowed in the wards. Thirty-five 
pages are occupied with directions for reports and returns^ 
and, unless a radical revision and simplification of this sub- 
ject is made it is safe to prophesy even an increase in the space 
devoted to it. 

The genera] supply table is more comprehensive than 
ever before, and too much praise cannot be given to Munson's 
admirable unit system of packing. The detachment case is 
still styled "'emergency'^ despite its contents of snlphonaU 
aloin, brown mixture, calomel, and Dover's powder; while it 
is questionable whether separate alphabetical lists for furni- 
ture, bedding and clothing, stationery, and miscellaneous are 
longer desirable. It is also noted that the hospital corps 
pouch contains eight first aid packets while the drill regula- 
tions call for six. 

As in other parts of the manual the field supply table is 
modern, definite and business-like. We have yet to see afield 
register of convenient size, and sheet 2 form 25 has outlived 
its usefulness for this purpose. The field desk now contains 
a better selection of blanks, and the tent units are far supe- 
rior to the older method of issue. The acetylene outfit makes 
one long for the day when our hospitals shall be free from the 
burden of oil lamps with their smoke, air pollution, expense 
and labor, while the twenty-two pages of obsolete (un-uni- 
form?) instruments, appliances and equipment suggest the 
query as to whether they could not profitably be put entirely 
out of service. 

The index is more complete than ever before, and the 
paper and printing compares very favorably with this year's 
foreign manuals. It is believed that the actual quotation of 
army regulations serves a better purpose than mere reference 
and the British practice of printing a marginal line wherever 
there has been a change from the previous edition has much 
to commend it. 

On the whole we have for the first time a manual for war 
service, one written on broader lines and giving more liberal 
allowances than that of any foreign army, and one upon which 
we can still build. J. S. Kulp. 



A SHORT ACCOUNT OF THE RESULTS OF MOSQUITO 
WORK IN HAVANA, CUBA. 

By colonel WILLIAM CRAWFORD GORGAS, 

ASSISTANT SURGEON GENERAL IN THE UNITED STATES ARMY; 
LATELY CHIEF SANITARY OFFICER OF HAVANA. 

THE Army Board which met in Havana, Cuba, in the fall 
of 1900, for the study of yellow fever, and of which 
the late Major Walter Reed was president, demonstrated 
the mosquito theory, first made known by Dr. Carlos Finlay. and 
showed conclusively that the mosquito is the only means of propa- 
gating this disease. 

Early in the year 1901, after the results of this investigation 
were published, the Sanitary Department of Havana began ex- 
tensive w^ork for the destruction of the mosquito. At that time, 
the prospect for yellow fever was very gloomy. It was evident 
that general sanitary methods would not eradicate this disease in 
any reasonable time. While the death rate of the city had stead- 
ily improved during 1900, yellow fever had been severe; and the 
same can be said of the preceding year, 1899, the first year of 
American occupation. After an entire year of work on the most 
improved sanitary lines, we had one of the worst winter epidem- 
ics that had ever occurred in Havana. 

At the beginning of 1901, there were in the neighborhood of 
40,000 non-immunes scattered in various parts of the city, and 
yellow fever infection was equally scattered. Even with the truth 
of the mosquito theory granted, it seemed impossible, under any 
system of killing mosquitoes, to avoid leaving a sufficient number 
to carry on the infection. No mosquito work in the Havana 
houses could possibly destroy all of these insects and a consider- 
able number must always escape; and these, it was thought, 
would be enough to keep up the infection. 

The work was planned more particularly with regard to yel- 

(188) 



134 COLONEL WILLIAM CRAWFORD GORGAS. 

low fever, and the idea was, first, to prevent in every possible 
way the breeding of mosquitoes; second, to prevent the Steg- 
omyia mosquitoes from biting yellow fever patients; third, to de- 
stroy as far as possible all mosquitoes that had bitten yellow fever 
patients. 

Careful investigation and study of the question showed that 
mosquitoes were breeding in almost every house in Havana. The 
water supplied by the city was hard, and almost every family col- 
lected rain water for washing purposes. These collections were 
found to be the particular habitat of the Stegomyia. There being 
no general system of sewerage, ever>^ house has a cess-pool of 
some kind. These cess- pools were great places for breeding mos- 
quitoes. 

The city is surrounded by gardens and farms which are irri- 
gated for the purpose of raising vegetables and grasses. These 
irrigated farms are favorable to the development of mosquitoes, 
more particularly the Anopheles, and as the city has extended, 
the irrigation ditches have become uncovered sewers. There are 
miles and miles gf such ditches, every square foot of which was 
breeding mosquitoes. The suburbs are overgrown with grasses 
and weeds of all kinds. 

To meet this condition of affairs, three sets of mosquito 
workers were organized: the **Stegomyia Brigade," for working 
in the built-up portions of the city; the "Anopheles Brigade,*' 
for working in the suburbs and neighboring swamps, and the 
"Yellow Fever Brigade," for killing mosquitoes that may have 
become infected. 

For the purpose of systematic work, the city was divided in- 
to seven districts. To each district was assigned an inspector 
and an assistant. The inspector visited every day a number of 
houses assigned to him for inspection that day. He noted the 
condition of the houses with regard to places jv^here mosquitoes 
could breed, and also with regard to the observance of the Mu- 
nicipal Ordinances on the subject. 

Early in the year, the Mayor issued an order requiring that 
everybody having water on their premises should keep it mos- 
quito-proof, and fixed a fine for the non-observance of the ordi- 



RESUL TS OF MOSQUITO WORK IN HA VAN A. 135 

nance. The assistant accompanied the inspector with a couple 
of cans of oil, from which he poured about a pint into each cess- 
pool. If vessels with standing water not protected according to 
law were found, it was reported to the office and the man fined: 
and if, on the next inspection, unprotected receptacles were again 
found, the water was emptied eind the receptacle destroyed. This 
process in Havana has been most successful in its results. 

The first inspection showed every house, almost without ex- 
ception, to have some deposit containing larvae on the premises. 
The last inspection of 16,338 houses, made during the month of 
April, showed only 187 to have larvae. Personal observation as 
to the number of adult mosquitoes bears this out. From many 
houses in Havana they have entirely disappeared, and in nearly 
all, are very much lessened. The officer in charge of this bri- 
gade estimates that there are only about yV the number of mos- 
quitoes in the city now that there were at the time systematic 
work for their destruction was begun, and personal observation 
would tend to confirm this estimate. 

I believe that, practically, in a city such as Havana, the mos- 
quito is bred within the house which he troubles, and that the 
yellow fever mosquito — the Stegomyia — generally breeds in the 
rain water barrel and receptacle. If this be the case, it can be 
seen what a great effect the work of the Stegomyia brigade must 
have had. At the beginning of the work, this mosquito ha'd 26,- 
(XK) different breeding places in the 26,000 different houses of 
Havana; at the end of a year, in these same houses there were 
only 258 breeding places. This brigade has continued its work 
all during the year, the force varying according to the necessity 
of the case, — the maximum employed being 36 and the minimum 
22. 

The Anopheles brigade was organized for the purpose of 
looking after the suburbs where a good deal of ditching had to be 
done. It was found that the larvae were breeding wherever the 
groimd was irrigated and a hole or depression was left to retain 
the water. All these farms and grass lands have been ditched 
and drained by this brigade. All the irrigation ditches and sew- 
ers have been cleaned — both the beds and the banks — of grass 



136 COLONEL WILLIAM CRA WFORD GORGAS. 

and vegetation, the aim of the brigade being to drain ever>'thing 
possible. Such small places as could not be drained were oiled, 
but the use of oil to any great extent has been found impractica- 
ble in the service of this brigade. In the fields and in the grass 
it could not be spread around in any satisfactory' manner, and in 
the larger pools it would be quickly blown to one side. 

There are several square miles of swamp land on the east 
side of the city, and about a mile distant, between Havana and 
Guanabacoa, from which Havana is separated by an arm of the 
bay. No attempt was made to do anything with most of this 
swamp land. The mosquitoes breeding in these places seldom or 
never migrate to the city. As far as we can tell, they are no 
worse on the side of the city next which these swamps lie than in 
other parts. 

The old quarries on the north and west sides of the city gave 
us considerable trouble. In the largest, a pump has been placed 
by the Engineer Department and the depression kept dry by 
pumping. In the other, we found that by digging down to the 
rock and scraping the earth away, the rock would absorb the 
water; so that in many places by digging a hole and baring the 
rock for a couple of yards, we have succeeded in getting rid of 
the water. 

The Anopheles brigade was divided into sections, each sec- 
tion being in charge of a foreman, so that the brigade was gen- 
erally at work in half a dozen different places. The whole brig- 
ade was under the charge of one chief. The force here has also 
varied as necessity indicated, with a maximum of 87 and a mini- 
mum of 14. The work is still being pushed. The suburbs are 
now being well drained, but as the rainy season comes on, the 
whole work of last year will have to be gone over and the grass, 
etc. , cleaned out of the ditches. 

For killing infected mosquitoes, the yellow fever brigade was 
organized, the plan being to kill all the infected insects in the 
suspected house, and on the possibility of some having escaped, 
to treat contiguous houses in the same manner. Fumigation with 
pyrethrum powder is used for this purpose. Pyrethrum is not 
the best mosquitocide, but it injures no fabric and leaves no 



RESl/LTS OF MOSQUITO WORK IN HA VANA. 137 

odor. It intoxicates the mosquito and brings him to the ground, 
where he can be swept up and burned. As a great part of the 
success of any scheme for yellow fever work must depend upon 
having the cases promptly reported, every effort is made to avoid 
inconvenience to the physician and people concerned. By using 
pyrethrum powder you can fumigate a room, kill all the mos- 
quitoes and allow the occupant to come back within a period of 
two hours. No fabric is injured in the room, and no disagree- 
able odor is left. We use sulphur wherever there is nothing that 
can be injured. 

When a suspect of yellow fever is reported, the squad goes 
at once to the house and screens the room or rooms in which the 
patient desires to be kept. The department has ready-made 
screens, and the patient is generally screened within two hours 
after a case is reported. This is done at public expense. The 
other rooms in the house are carefully gone over; each room is 
tightly sealed by pasting paper over the cracks, just as is done in 
the use of formaline, and pyrethrum powder is then burned at 
the rate of a pound for every 1,000 cubic feet. This makes very 
dense fumes and will kill most of the mosquitoes; but as a great 
many of them only become intoxicated and would revive if given 
fresh air, the room is opened at the end of two hours, and the 
mosquitoes swept up and des^oyed. Every room in the house 
and all the contiguous houses are gone over in the same way. On 
an average, ISO pounds of pyrethrum powder are used for each 
case. 

When the case is ended, the rooms which were occupied by 
the patient are treated in the same way. The clothing is not 
disturbed, nor is any other disinfectant used. The patient is quar- 
antined to a certain extent, only one door of entrance or exit 
being allowed in the .screened area, and a guard is placed to see 
that proper precautions are obser\'ed in regard to keeping the door 
closed. The department allows the physician to designate four 
or five immunes who can visit the patient; and very little restric- 
tion is placed upon the taking out of fabrics, bedding, supplies, 
etc., care being taken to shake those in which mosquitoes might 
be conveyed. 



138 COLONEL WILLI A. \f CRAWFORD GORGAS. 

This system has succeeded beyond our fondest expectations. 
We seem in every case to have destroyed practically all the in- 
fected mosquitoes, until gradually all infected mosquitoes in 
Havana have been killed, or died a natural death. 

Since September 26th we have not had a single case of yel- 
low fever; and I believe that, at the present time, there is not an 
infected mosquito left in the city, and that Havana will not have 
any more yellow fever until it is introduced from neighboring 
towns which may become infected during the summer. 

During the summer of 1901, we established a system of inspec- 
tion, employing men in the neighboring infected towns and on the 
lines of trafl&c coming from those towns. — generally selecting na- 
tives who knew everybody in their respective towns, and who re- 
ported every non-immune coming into Havana. No person who 
had been in Cuba less than five years, or who had not had yellow 
fever, was-considered immune. 

During the period of infection, 1275 non-immunes came into 
the city from the two or three towns infected, and from this num- 
ber we got 27 cases of fever. No case of fever was known to have 
escaped the inspectors. The non-immunes reported by the inspector 
were seen on the third and sixth days. If they were all right 
when seen on the second inspection at the end of the sixth day, 
they were dropped. Of course th^ large proportion of these 1200 
non-immunes merely came into the city for a day and returned 
to their homes at the end of the day. No restrictions whatever 
were placed upon the introduction of fabrics and supplies of any 
kind. The results have been ver>' satisfactory. 

This is the first time, far as my information goes, that this 
system of inspection has ever been used with regard . to yellow 
fever. It is the direct outcome of the mosquito theory. We were 
convinced that we had nothing to fear from any belongings of the 
patient, and all that we cared for was to prevent a man from one 
of these towns being taken sick in Havana and poisoning our 
Stegomyia mosquitoes. The immunes, who made up as a rule 
\ % of the population, were allowed to come and go freely, and we 
believed we could prevent the non-immunes from doing any harm 
by seeing each of them on the third and sixth days. While some 



RESUL TS OF MOSQUITO WORK IN HA VANA. 139 

27 of these non-immunes had yellow fever in the city, we seem to 
have gotten hold of all the mosquitoes infected by them. 

We can not only point out with a considerable degree of ac- 
curacy the decrease in the ratio of deaths, but the actual number 
of deaths caused by mosquito borne disease can be compared be- 
fore and after our mosquito work. In yellow fever it has been 
entirely successful. The average number of deaths from this dis- 
ease for the past thirty years has been 706; for the year preced- 
ing our mosquito wbrk, there were 310 deaths, and for the year 
of mosquito work, only 18. Of these 18 deaths 13 occurred be- 
fore the work commenced. 

While the figures for malaria are not so striking, the results 
seem to point just as positively toward mosquito killing as the 
remedial agent. For the past 11 years we had an average of 513 
deaths; for the year 1900 we had 344 deaths, and during the year 
1901, the first year of the mosquito work, 151 deaths. For the 
first four months of the present year^ there have been only 26 
deathr from this disease. 



SUICIDE AxMONG EUROPEAN SOLDIERS. 

THE Matin has recently published some statistics as to the 
relative frequency of suicide in Continental armies* 
Self-destruction is becoming less common in all of them 
with the single exception of the Russian, in which the annual 
average of suicides is said to be 133 per 100,000. The proportion 
is 18 per 100,000 in France, 24 per 100,000 in Italy, 36 per 100,000 
in Germany, and 105 per 100,000 in Austria. The different arms 
of the ser\'ice commit suicide in different proportions. The For- 
eign Legion is the most suicidal branch of the French army, with 
99 suicides per 100,000, whereas there are only 14 suicides per 
100,000 in the Garde R6publicaine. In general it appears that 
the cavalry commit suicide more frequently than the infantry^ 
the infantry more often than the artillery, and the artillery more 
often than the engineers. In the British army at home the rate is 
probably about 23 per 100,000, in India the rate is believed to be 
higher probably about 30 per 100,000. — British Medical Jo urn a/. 



HOSPITALS AND CHARITIES IN CUBA, 

By MAJOR JEFFERSON RANDOLPH KEAN, 

MEDICAI, DEPARTMENT, UNITED STATES ARMY; RECENTLY 

SUPERINTENDENT OF THE DEPARTMENT OF 

CHARITIES OF CUBA. 

AT FIRST sight there wcmld seem to be but little in com- 
/■^^ mon between the work of the Department of Charities 
of Ciiba and the purposes of this Association, and so it 
seemed to me when asked by a member of the Committee to fur- 
nish a paper on this subject. But when it was suggested that 
the special and most important duties of military surgeons, as 
such, are administrative rather than professional, and it is on the 
administrative side that failure is most apt to come to the medical 
officer who lacks military experience, it is thought that in the 
organization, equipment and administration of the 118 institu- 
tions embraced by the Department of Charities in Cuba, which 
included forty hospitals and six training schools for nurses, some- 
thing might be found of interest, and perhaps of profit also. 

Although the principals of modern scientific charity, which 
is a branch of political economy, and which, while relieving dis- 
tress, strives to prevent pauperism and to build up character, had 
little application under the Spanish regime, Cuba was by no means 
without charitable organizations, and was well supplied with 
charitable institutions. P>ery city had its hospitals and its asy- 
lums for orphans and for the aged, while the small towns, if not 
able to support a municipal hospital, joined in the maintenance 
of district hospitals, embracing groups of neighboring munici- 
palities. The teachings of the established church powerfully 
stimulated the custom of giving charitable bequests and endow- 
ments. These endowments, although greatly wasted by war and 
by every sort of maladministration, are still very large. 

Having super\nsion of all such institutions was a bureau of 

(HO) 



HOSPITALS AND CHARITIES IN CUBA, 141 

charities, or, to use the more graceful and more appropriate 
Spanish wofd, **Beneficencia", which was under the supervision 
of the Minister of State and Government. The powers con- 
ferred upon this bureau by the Beneficencia Law of 1875 were 
far greater than those possessed by similar bureaus or depart- 
ments in any of the States of this countr>' or in England. The 
spirit and intent of the law was highly philanthropic, though not 
modem, but, as was usually the case in Cuba, the defect was 
more in the execution of the law than in its construction. 

This elaborate machinery was thrown out of gear by the in- 
surrection and Spanish- American war. All the principal hospi/ 
tals were occupied and used by the military arm. The incomes 
of all institutions, whether proceeding from public or private 
sources, diminished greatly, or were quite cut off, and the Amer- 
ican military' occupation found, in the fall of '98, a chaos of want 
and suflFering that was entirely unrelieved by any organized 
agency. The destitution of an entire people could only be re- 
lieved by a Nation's generosity, and no one who was there can 
recall without a thrill of pride how liberally the great heart of 
the American people responded to the cry of distress of Cuba. A 
flood of supplies, — food, medicine, clothing and utensils, — followed 
the footsteps of the occupying forces. The Spanish flag had 
scarcely disappeared from the flagstaff on Morro before there 
ceased to be hunger in Cuba. In the city of Havana and sub- 
urbs alone, 2,251,000 rations were distributed at this time, be- 
sides great quantities of clothing, medicine and other supplies. 

To be thus the ministers of the Nation's generosity was 
pleasant work, and it was also an easy task when compared with 
the more dificult problem which succeeded of how to get the sur- 
vivors of the Reconcentration back to their homes and their work ; 
how to support them in the country until a house could be built 
and the first crop gathered, and how to bring to an end the free 
distribution of rations without causing a widow or an orphan to 
go hungry. These problems were worked out by the Department 
Commanders, each in his own way and with his own officers, 
according to the varying needs and conditions of the different 
communities, with a degree of patience, tact and skill most cred- 
itable to the Army of Occupation. 



142 MAJOR JEFFERSON RAXDOLPH KEAN. 

In the latter part of 1899, an order was issued from Division 
Headquarters which required Department Commanders in Cuba 
to make, through their staff officers, inspections of hospitals, asy- 
lums, jails and other institutions aided by Insular funds. These 
inspections as a rule devolved upon the Chief Surgeons of the De- 
partments, who thus became in fact Superintendents of Charities 
and Correction. 

These reports showed a most lamentable condition of disor- 
ganization, want and neglect to exist in these institutions, and 
steps were promptly taken to carry out the recommendations of 
the inspecting officers, and to better the conditions existing in 
these institutions. 

Much energy and labor was devoted to this work in the va- 
rious Departments, but it soon became evident that a more cen- 
tralized and uniform system of administration was necessary. 

At the end of the first year of the military occupation, it be- 
came evident that the American military occupation would be 
prolonged until an organized and effective government should be 
established in Cuba, and General Leonard Wood was selected for 
the constructive work and came to Havana as Military Governor. 

With characteristic promptness, he grasped the difficulties of 
the situation, and provided for their solution. He saw that the 
old Bureau of Beneficencia was as valueless for vigorous construc- 
tive work as were the rusted boilers and twisted machinery of 
the destroyed "ingenios" for making sugar, and he determined 
to put the work of reorganization in the hands of a new and in- 
dependent department, and to consult in its organization the best 
expert advice obtainable. 

Accordingly, Mr. Homer Folks, the Secretary of the Chari- 
ties Organization Society, of New York, who has been since se- 
lected by Mayor Low to be the Commissioner of Charities of 
that city, was invited to Cuba to study the situation and assist in 
the draft of a law organizing the new department. As a result 
of his labors, in collaboration with those of Major E. St. John 
Greble, the first Superintendent of the new Department, the 
Charity Law was published in Civil Orders No. 271, dated July 
7th, 1900, and gave to Cuba an organization which is the latest 
expression of modern scientific charities. 



HOSPITALS AND CHARITIES IN CUBA. 143 

The work undertaken by the new Department was immense 
in amount, and most discouraging in its complexity and demands 
on the attention of the Superintendent as to details. The report 
of the Superintendent of Charities for the year 1900 gives a list 
of no less than 188 institutions which had been assisted with 
money and rations since the beginning of the American occupa- 
tion. Many of these were new in.stitutions which had been cre- 
ated to receive and care for the disea.sed and miserable survivors 
of the Reconcent ration, and especially the orphans which filled the 
streets of the Cuban cities. In addition to these there were 
numerous private institutions whose endowments had failed to 
produce anything during the war, and the numerous Municipal 
and District Hospitals, which, under Spanish regime, existed in 
every town of importance, and which during the war had been 
used almost solely for military purposes, and had been stripped 
of instruments and supplies upon the withdrawal of the Spanish 
troops and left with none of the things needed for the care of the 
multitude of destitute sick. Everything was chaos and confu- 
sion and want. 

Into all the.se institutions, order, system and a standard of 
cleanliness had to be introduced, and persons of sufficient energy 
and intelligence found to administer them. Supplies of every 
conceivable variety had to be purchased by the Department and 
distributed to the various institutions. Buildings had to be put 
in repair, proper sources of water obtained, modem and sanitary 
arrangements for the disposal of wastes had to be devised and in- 
troduced. Local needs and local conditions had to be ascertained, 
and extravagance and peculation guarded against. 

Such was the flood of work which poured in upon the De- 
partment, and with it a vast correspondence about details of every 
conceivable variety, mostly in Spanish and written in longhand, 
and all requiring the attention of the Superintendent. 

The disbursments, exclusive of rations, for charitable insti- 
tutions in Cuba, up to December 31st, 1900, amounted to $2,184,- 
232.00. All of this vast amount had to be expended in accord- 
ance with the rigid and complex rules for the disbursement of 
money by the Army, and through agents who, as a rule, were 
entirely unfamiliar with these rules or with American methods. 



144 MAJOR JEFFERSON RANDOLPH KEAN. 

In addition to all these complex questions of expenditure, 
equipment and selection of personnel, the methods and standards 
of administration for institutions had to be revolutionized and set 
upon a diflFerent and higher plane. Cleanliness, sanitation, exact 
acountability for money and property, and proper methods of 
administration had to be taught in many parts of the Island at 
the same time, and through the medium of a foreign language. 
Even the fundamental principles and aims of charitable work had 
to be changed from the mediaeval ideas which were everywhere 
in vogue in Cuba to correspond with modem principles and 
methods. 

It is very difficult to convey any idea of the change which 
has been eflFected in the charitable institutions in Cuba, in three 
years, to persons who did not see these institutions at the be- 
ginning of the American occupation. The writer had in Janu- 
ary, 1899, occasion to inspect the Government asylum for the in- 
sane at Mazorra. At that time the number of inmates was about 
350. More than 50% of the inmates had died during the pre- 
ceding year, the mortality being due to an absolutely insufficient 
and improper diet — in other words disease incident to slow star- 
vation. In one of the patios on the male side, were seen a num- 
ber of cases, apparently not of a violent type, walking about in a 
state of absolute nudity. The agitated cases in both the male 
and female departments were locked in small cells which received 
air and light only through the iron bars of the doors, where all 
their words and actions were in plain hearing and sight of the 
milder cases, who spent their days in the patios upon which theSe 
cells opened. In very few of the cells of the agitated . cases was 
there any bedding, and those of a destructive type were often 
without clothing. The only classification made of cases consisted 
in the locking up of those who were violent. The latrines were 
simply holes made in the stone flooring, and the odor from them 
was indescribable and pervaded all the neighboring apartments. 
The attendants appeared to be entirely ignorant and untrained, 
and were simply hired servants of the laboring classes. The 
bathing facilities were so inadequate that it appeared probable 
that a bath must have been an infrequent event in the life of the 



HOSPITALS AND CHARITIES IN CUBA. 145 

inmates. There seemed to be no effort made at classification or 
appropriate treatment of the diflFerent types of mental disease, nor 
provision for exercise, employment or amusement of the inmates. 
They appeared simply to be kept as prisoners in a prison where 
the sights, sounds and contacts must have been peculiarly un- 
pleasant and injurious to a large number whose conceptions of 
the comforts and decencies of life were iu no way diminished by 
their mental condition. 

This institution is now a well ordered, clean and comfortable 
home for the insane, where the patients are well fed, clothed and 
cared for. The attention and nursing is good, and the classifi- 
cation of types and the proper exercise and employment of the 
patients receive careful consideration. It has now 875 patients, 
and, on account of the rapidity with which the number of in- 
mates has increased, is somewhat crowded, but it is well admin- 
istered and is a credit to the Insular Government. The amount 
of money spent on this institution for all purposes during the 
Military Occupation of the Island was $400,826.56. A new wa- 
ter supply, a complete system of water-closets and sewers, abund- 
ant "bathing facilities for both sexes, a steam laundry and a hos- 
pital for acutely ill male patients are among the permanent im- 
provements which have been effected in this time. 

The same transformation has taken place in the hospitals, 
which were formerly, according to a popular saying in Cuba, 
**only places to die in". They afforded to the sick shelter and 
food, it is true, and a canvas-bottom cot, where usually they lay 
in their rags and received the doctor's visit and the rude and med- 
iaeval but not unkindly ministrations of the "practicante" and 
ward servant. But the clean, sweet wards, the comfortable bed- 
ding and snowy bed linen, the quiet, dexterous and skillful nurse, 
the carefully prepared and daintily ser\^ed foods appropriate to 
the sick, and all the strict ritual of modern surgical cleanliness, 
which are now expected in hospitals, were unknown to those of 
Cuba. 

The working of this revolution has been due to two agencies, 
the introduction of the female trained nurse, and frequent rigid 
and searching inspections on the part of the officials of the De- 



146 MAJOR JEFFERSON RANDOLPH KEAN. 

partment. '*Make frequent inspections" was the standing order 
of the Militar>' Go\'emor, and the energy with which he made 
personal application of this rule was a powerful factor in raising 
and maintaining the standards of all institutions. 

There were numerous endowed institutions for the care of 
destitute children in Cuba prior to the Military Occupation, but 
the object of all these institutions was simply to furnish the child 
food, clothing, shelter and the rudiments of an education. The 
dangers of institutionalizing them were not appreciated, and no 
effort was made to make good citizens of them or teach them self- 
reliance and self-respect. 

In most of these institutions a petition for alms confronted 
the visitor at the door. No stigma was attached to living upon 
the alms of others, and pauperism was the natural result. 

As stated above, a ver>' large number of new asylums were 
established in Cuba by the American Red Cross, or private agen- 
cies, for the care of the orphan children of the Recoiicentrados, 
These institutions were, as a rule, establi.shed without any pro- 
vision for their future support, which was promptly shifted on to 
the Military Government. 

With the establishment of the Department of Charities, a 
Bureau for placing children in families was created, and the De- 
partment set to work to break up the numerous asylums which 
had performed their temporary function, and to place the chil- 
dren in the more normal and wholesome surroundings of family 
life. In the great majority of cases it was found, upon careful 
investigation, that the child had relatives who were, or, in the 
year which had elapsed since the war, had become, able to sup- 
port him. Others were placed in good families, where they were 
subject to frequent and careful inspection. Others were placed 
in the Training Schools for Boys and Girls respectively, w^iich 
were raised to a very high standard of cleanliness and good ad- 
ministration. 

In carrying out the policy of the Department, fifteen orphan 
asylums in the Province of Havana alone were closed in the year 
1900. The polic}' of closing unnecessary institutions, consolidat- 
ing others, and withdrawing subsidies from private endowed in- 



HOSPITALS AND CHARITIES IN CUBA, 147 

slitutions as soon as they could be made self-supporting, has gone 
steadily forward until, instead of the 188 institutions which the 
Superintendent's report shows to have been assisted by the State 
prior to December 31st, 1900, only 59 appeared upon the last es- 
timate prepared for the months of May and June 1902. 

This policy has been attended by great economies to the 
Goverament, and by the establishment of sound principles as to 
the limitations of Government assistance, and has greatly strength- 
ened and improved the surviving institutions. It is believed that 
no useful private institution has been seriously crippled in its 
work in carrying out this policy. 

The following principles have been introduced into Cuban 
Beneficencia by the Charity Law of 1900: 

It declares its preference for bringing up orphan children, 
committed to its care, in families rather than in institutions, be- 
lieving that the institute-bred child, with its affections atrophied, 
its will undeveloped, and its entire ignorance of the economies 
and mutual sacrifices of family life, cannot make a good citizen* 
It acLopts the principle that to confine in prison children who 
have fallen under the penalties of the law, renders their reforma- 
tion hopeless and confirms them in a criminal life; and it provides 
that* all such children between the ages of ten and sixteen years 
shall be sent to reformatory schools with an indeterminate sent- 
ence which can be terminated by the good conduct and reforma- 
tion of the child. 

It adopts the now well established doctrine of political econ- 
omy, that subsidies of public money given to private institutions 
tend constantly to increase in amount, and not only cause ex- 
travagance and waste, but dry up the springs of private charity. 

As an effective ,means of raising the standards of hospital 
work, and for the better care of the sick, as well as to open an 
honorable and useful career to Cuban women, Schools for Train- 
ed Nurses have been established in connection with the princi- 
pal hospitals on the Island. 

It indicates in general terms the proper line of division of char- 
itable work between the State, the Municipalities, and the vari- 
ous agencies acting from private initiative, including in the latter 



148 MAJOR JEFFERSON RANDOLPH KEAN 

all religious organizations and charitable associations. The char- 
ities assumed by the State under this law are: 

1. The care of all destitute children who may be properly 
committed to it. 

2. The charge of all delinquent children between the ages of 
10 and 16 years who have been convicted of crimes and misde- 
meanors. 

3. The establishment of State institutions for the care and 
instruction of deaf, blind and otherwise defective children. 

4. The care of the insane, or the supervision of their care if 
they are treated in private institutions. 

5. The proper inspection of all charitable institutions of 
whatever sort, and the collecting of reports and statistics con- 
cerning them. 

To the Municipalities are assigned the maintenance of hos- 
pitals and dispensaries for the destitute sick, and an asylum for 
the destitute aged and infirm. 

To private associations and persons are left all charitable 
works such as are not provided for by the State or by the Muni- 
cipalities. The investigation of individual cases of destitution 
and their relief, when found not to fall within the classes pro- 
vided for by public charity, is peculiarly the sphere of private 
charity. 

The most important results accomplished by the Department 
in the two years and a half since its creation have been: 

1. The drawing up of the Charity Law of 1900. 

2. The enunciation of sound and modern principles as to the 
care of dependent children, and the establishment of the system 
of placing them in families; also the establishment of the reform 
schools and industrial schools for children. 

3. The great improvement effected in the care of the insane. 

4. The establishment of schools for trained nurses in con- 
nection with the larger hospitals, whereby the standards of hos- 
pital work has been immensely raised, the care of the sick vastly 
improved, and an honorable and useful career of work opened for 
Cuban women. 

5. A radical change has been effected in raising the standard 



HJSPITALS A. WD CHARITIES IN CUBA, 149 

of cleanliness, comfort and good administration of all charitable 
institutions. 

6. The relations between private charitable institutions and 
the State have been accurately defined. 

7. The principles of accurate and complete accountability for 
public money and property have been inculcated. 

8. Annual meetings of the National Conference of Charities 
for Cuba have been inaugurated, which will secure the great 
l^enefits of collective and organized effort, popular enthusiasm 
and popular understanding of the true principles of charity work. 

Whatever may be the changes w^hich the future may have in 
store for Cuba, it is believed that the good effects of the sound 
principles which have been adopted and the high standards which 
^^ave been established can never be whollv lo.st. 



THE NEW CUBA. 

4 T A RECENT meeting of the American Academy of Polit- 
AA ical and Social Science, General Leonard Wood gave an 
account of the work of the American Army in Cuba. 
He described the reorganization of the government of the island, 
the establishment of schools, and the solution of important sani- 
tary problems, concluding that the island * 'was possessed of a 
thoroughly trained and efficient persoujicl in all departments; 
completely equipped buildings for the transaction of public bus- 
iness; the administration of justice was free; habeas corpus was 
put in force: police courts had been established, a new marriage 
law, on lines proposed by the Roman Catholic Bishop of Havana, 
giving equal rights to all denominations, was in operation: the 
people were governed in all municipalities by officials of their own 
choice, elected at the polls; trials in Cuban courts were as prompt 
as in any State in the Union, and life and property were absolute- 
ly safe; sanitary conditions were better than those existing in 
most parts of the United States; and yellow fever had been erad- 
icated from the island." 



Lp-s-^-s-« ^ 



A NEW FIELD AND NAVY UTTER. 

Bv C. ALEXANDER CRAWFORD, M.D. 

PASSED ASSISTANT SURGEON IN THE UNITED STATES NAVY. 

IN looking over the subject of litters, now employed both in 
the field and afloat, one is impressed with their lack of com- 
pactness, ease of transportation, and general adaptedness. 
So far as can be learned, no litter has yet been introduced which 
is complete in itself with all parts firmly united, and ready for 
almost instant use, and yet of suitable shape and of sufficient 
lightness to be carried for hours, like a knapsack, on the shoul- 
ders of one man. Nor, does there seem 
to be any record of a litter which poses- 
ses, in addition to these essentials, the 
property of being raised and lowered 
through any hatch, slid along deck or 
employed, singly or in tiers, as a swing- 
ing cot in the sickbay with perfect safe 
to the wounded. 

The litter, to be described in this 
article, has been constructed with a view 
to combining all these qualities. It 
weighs less than seventeen pounds; is 
thirty seven and one-half inches in length 
when folded, and seventy two inches 
when extended and ready for occupancy. Its breadth is twenty 
two inches. 

The litter has been constructed on the following lines: 
A. — Steel tubing, one inch in diameter, forms the frame. 
This is six feet in length and twenty two inches in breadth over 
all. The corners are rounded and ser\^e as handles or as shoulder 
rests. The tubing is continuous except near the centre of each 
lateral bar, where a telescopic hinge serves to hold the ends firmly 

(160) 




Lhter folded for carrying tike 
a Knapsack* Detail View. 



A NEW FIELD AND NA VY LITTER, 151 

together when the litter is in use; or, by an easy manipulation 
allows it to be folded upon itself. Each hinge is thirty five inches 
from the head of the frame and thirty seven inches from the foot. 
The telescopic portion of either hinge is two and one-half inches 
long. When the litter is folded for carrying on the shoulders of 
one man its total length is thirty-seven and one-half inches. 

B. — The body is made of brown canvas and is pierced along 
its edges by brass eyelets at intervals of three inches. Through 
these eyelets a continuous cord loops over 
the frame and keeps the canvas taut. The 
arrangement of the eyelets at the corners is 
such that the cord does not interfere with 
the parts of the frame grasped 
by the hands of the bearers. 
Across its centre, at the location 
of the hinges in the 
frame, the canvas is 
divided and tlie.se ends 
are united 
b y means 
of a similar 
cord 



Litter prepared for Hoisting. 
DeUil view. 

through similar eyelets. This division of the canvas into two 
equal pieces is made necessary by the telescopic nature of the 
hinges in the frame. 

C. — For securing the occupant, two brown canvas straps, 
four inches in breadth, are employed. These are securely 
fastened to the lateral bars and buckle in the centre. The upper 
strap pa.sses under the arms of the occupant and is attached eleven 
inches from the end of the frame; the lower passes acro.ss the 
pelvis and is attached to the middle of the frame. When the lit- 
ter is folded these straps buckle in the opposite direction and 




152 PASSED ASST. SC/RG. C. ALEXANDER CRA IV FORD. 



hold the two halves of the frame securely 




LHter Prepared for Hoisting* Side vie-v. 

the buckles of all the straps. 

D. — In order that the litter may 
be adapted to use on board ships in 
action, an attachment for lowering 
through hatches has been devised. 
Four riveted steel bands, with edges 
raised one inch above and below and 
each edge pierced by an opening one 
half inch in diameter, encircle the lat- 
eral bars nine inches from the corre- 
sponding corners of the frame. For 
the sake of brevity these four bands 
will be termed eye-bands. From a 
steel ring, two inches in diameter, 
lead four wire cords terminating in 
snap-hooks which hook through the 
upper openings in the eye-bands. 
The cords at the head of the litter are 



together. Two four 
inch adj ustable canvas 
straps, each thirty six 
inches in length, for 
carrying the folded 
Htter after the manner 
of a knapsack, are 
sewed to the under 
surface of the head of 
the canvas. These 
hold the litter in a 
comfortable well-bal- 
anced position on the 
shoulders of the bearer 
and permit perfectly 
free movement of the 
arms and legs. Tan 
leather is used for the 
ends and for securing 




Litter 



Prepared for Hoisting, 
view. 



Front 



A XE U ' FIELD AND NA VY LITTER. 



153 



twenty five inches long and those at the foot, sixty four inches. 

From any line made fast in the steel ring, the litter is suspended 
at an angle of about fifty degrees, which approach 
to the perpendicular greatly facilitates its lower- 
ing through any hatch. The lower edges of the 
eye-bands raise the frame of the litter off the 
deck and permit one man to slide the loaded lit- 
ter along the deck by grasping the steel ring of 
the lowering gear. The upper and lower open- 
ings in the eye-bands 
are used for attaching 
chains, when the lit- 
ters are utilized as 
cots and arranged, 
one above the other, 
in tiers. The ordi- 
nar>' naval hammock 
mattress fits the litter 
very well and is suit- 






Litter Carried as a 

Knapsack. Front 

View- 



Litter Carried as a 

Knapsack, Side 

view. 

able when it is de- 
sired to use the 
litter as a cot. 

E.— The total 
weight of the litter 
is less than seven- 
teen pounds. Not 
more than one minute by actual timing is re- 
quired by the litter-bearer to remove the 
folded litter from his shoulders and prepare it 
on the field or elsewhere for occupancy. 

Attention is directed to the fact that the 
u.sual projecting handles of other litters or 
stretchers have been entirely eliminated in this 
case. The frame tubing near the corners 



Litter Carried as a Knap- 
sack. Rear view. 



154 PASSED ASSr. SURG, C. ALEXANDER CRAirFORD. 




Litter Qdxtwi by Two Bearen* 




Dtter Carried by Four Bearers. 



A .XEir FIELD AM) XAVV LITTER. 



155 





The Telescopic Hinge in 
Section^ 



senses as excellent handles or shoulder rests, and fits well in the 
grasp of the hand in bearing the loaded litter up or down hills, 
hatches, or stairs. 

The construction of the body gives a firm but elastic support 
to the wounded occupant, 
and not even a blanket is 
necessary except for pro- 
tection against cold and 
dampness. The telescope 

of the hinge cannot slip when the litter is occupied, 
as the w^eight of the man firmly binds the invag- 
inated ends of the lateral bars; and slipping is 
further rendered impossible by the lashings in the 
centre, between the two pieces of canvas forming 
the body. 

^^ H^k^itT^^ ^^ compared to the ' 'Ames Board, ' ' now in use 

in the Navy, the following points in favor of this 
litter seem obvious: advantage in weight; greater compactness 
when not in use; adaptability for landing parties, where it is im- 
possible to use the **Ames Board" on account of its weight and 
bulk: reduction in the number of straps, and the fact that this 
litter can be readily used as a swinging cot. 

The accompanying drawings illustrate the litter in its several 
positions, and the photographs show it in actual use in all of 
these positions, excepting that of a swinging cot. Careful tests 
made by the Hospital Corps at the Chelsea Naval Hospital, seem 
to prov^e its practical efficiency in every position. 




ABSCESS OF THE LIVER. 

An A^•ALYSIS OF THE CASES WHICH WERE ObSERV^ED \T THK 

United States Army General Hospital at Presidio of 

San Francisco. California, from July 1st, 

1899, TO January 1st, 1902. 

By COLONKL ALFRED C. GIRAKD, 

ASSISTANT SURGEON GENERAL IN THE UNITED STATES ARMY; 

LATE IN COMMAND OF THE PRESIDIO GENERAL 

HOSPITAL OF THE UNITED STATES ARMY. 

A BSCESS of the liver being a comparatively rare disease and 
/-\ having become a factor of some importance in the nos- 
ology of the Army since our expansion into the Tropics^ 
it was thought that the experiences of the General Hospital at 
the Presidio on the subject would be of value to the Association, 
and worthy of preser\'ation in its archives and for publication in the 
Journal, for dissemination among the Medical Officers serving 
in the Pliilippines. The method pursued by me at this Hospital, 
to have a nosological card index with the Hospital numbers of 
the relative cases, made it possible to segregate from 18,000 clini- 
cal histories those cases of liver abscess which either were di- 
agnosed and operated on, or which were only discovered at the 
post mortem. The work of compiling the data at hand and elab- 
orating the same was done under my direction by Dr. Charles F. 
Craig, Pathologist to the Hospital, to whom much credit is due 
for this, as for all the work of like character done by him at this 
Hospital. 

In the period of time embraced between July 1st, 1899, and 
January 1st, 1902, there have been obvSer\-ed at the U.S.A. Gen- 
eral Hospital, Presidio, S.F. , Cal., twelve cases of abscess of the 
liver, all occurring in soldiers. Of these twelve cases, eight were 
due to the ameba of dysentery, while in four the etiolog\' could 

(156) 



ABSCESS OF THE LIVER, 157 

not be determined. Of the twelve cases, four were diagnosed 
and operated upon successfully, the remainder being discovered 
at the autopsy. Of the four cases that were operated upon, one 
was due to the ameba of dysentery and three were of undeter- 
mined etiolog}' . 

In considering these cases it has been thought best to divide 
them as to their etiology into two classes, amebic and non-amebic. 
AMEBIC CASES. 
The percentage of cases of amebic abscess of the liver fol- 
lowing dysentery observed at this Hospital has been very small. 
During the time mentioned there have been treated 285 cases of 
dysentery in which the ameba were found in the feces and which 
were undoubtedly of amebic origin. This by no means, however, 
includes the total number of cases of amebic dysentery admitted 
to the Hospital, as in many cases no examination of the feces was 
requested, while in others the specimens sent for examination to 
the Laboratory were not of such aicharacter that the amebae could 
have been demonstrated had they been present. From the 285 
cases which showed ameba in the feces it will be seen that the 
percentage of amebic abscess of the liver is remarkably low% only 
8 cases having been observed in a total of 285 cases of amebic dys- 
entery. 

Etiology : Kartulis, in 1887, was the first observer to note the 
presence of ameba in the pus and walls of abscesses of the liver 
occurring in patients suffering from tropical dysentery, and his 
observations were soon confirmed by Osier, Councilman, LaFleur, 
Kruse, Pasquale and numerous other investigators. The large 
number of investigations which have been carried on regarding 
the etiological relationship of the ameba of dysentery to abscess 
formation in the liver have conclusively proven the statement of 
Kartulis that the ameba of dysentery' is capable of and often does 
produce abscess formation in the liver. The percentage of cases 
of tropical or amebic dysentery which present abscesses of the 
liver has not been definitely ascertained, but from the considera- 
tion of a large number of cases reported by different observers it 
has been found that the average is generally 1 to 6, that is; of 
ever\' 6 cases of amebic dy.sentery one will show abscess of the 



158 COLONEL ALFRED C. GIRARD. 

liver. This percentage is either very high or else the cases of 
amebic dysentery obser\'^ed at this Hospital are very exceptional, 
as so small a number of cases showing abscess of the liver have 
been observed. 

The question of the occurrence of other micro-organisms in 
abscess of the liver and their etiological relation thereto is one 
which has been by no means settled. Councilman and La Fleur 
believe that the amebae alone cause the abscess formation, while 
other authorities, notably Kruse and Pasquale, believe that the 
amebae and the micro-organisms associated with them work to- 
gether in the production of the pathological lesions. Of the eight 
cases which have been observed here 7 came to autopsy, and ex- 
aminations made of the scrapings from the abscess wall and from 
the contents of the abscesses showed invariably numerous micro- 
cocci, principally staphj'Iococci and streptococci. As these are 
the pus producing organisms in other localities where they may 
become lodged, it is but reasonable to suppose that the large num- 
' ber encountered in the examinations made of seven cases which 
are here recorded would have much to do in producing the lesions 
found. It is a well known fact that these organisms are capable 
of producing abscesses in the liver and other organs, and it is but 
reasonable to suppose that when associated with the amebae they 
would aid in the production of abscess formation. It is undoubt- 
edly true that the amebae also are capable alone of producing ab- 
scess formation, but when the two are associated it would seem 
almost preposterous to believe that the amebae only acted while 
the other organisms present remained quiescent. 

As to the etiology then of these amebic abscesses of the liver, 
we believe that they were produced by the combined action of the 
amebae and of the micrococci associated therewith. 

Pathological Anatomy: In considering the pathological 
anatomy of the cases it has been thought best to give in detail the 
appearances found at autopsy in the liver and intestines, and a 
general summary of the microscopical pathology as shown by sec- 
tions of the diseased organs. 

Case I. Hospital No, 41 Sg. Upon opening the abdominal 
cavity the diaphragm was found adherent to the liver over the en- 
tire right lobe. The portion of the diaphragm which is adherent 



ABSCESS OF THE LIVER. I59 

covers a portion of a large abscess in the right lobe which has rup- 
tured into the right pleural cavity, filling that cavity with green- 
ish pus streaked with brown. There is also a localized cavity ex- 
isting between the diaphragm and the liver over a portion of the 
left lobe, which is filled with pus. The liver is enormously en- 
larged, measuring 32x28 cm. Externally it appears somewhat 
congested in places. The capsule is smooth, and near the center 
of the left lobe there is a yellowish area which is due to the pres- 
ence of an abscess covered by the capsule only. Upon section of 
the organ, the right lobe is found to contain five abscesses, the 
measurements of which are as follows: the largest 8^ Cm. in diam- 
eter, the next 8 cm., the next 8 cm., the next 7 cm. and the 
last 3 cm. All these abscesses were found to contain greenish 
yellow pus much blood-stained. The left lobe of the liver con- 
tains an abscess cavity 4 cm. in diameter at its extreme border, 
and three other ab.scesses measuring respectively 3J^ cm., 2 cm. 
and 1 cm in diameter. All these abscesses were filled with pus 
of the character described. The largest abscess has ruptured into 
the right pleural cavity. The weight of the liver is 2875 gms. 

Lti»^s: The right hing is bathed with pus over its entire 
surface, but the organ itself is normal upon section. 

Intesiiual Canal: The rectum and sigmoid present numerous 
small ulcerations, irregular in shape and covered with necrotic 
membrane. Above these, for a distance of 20 cm., the mucous 
membrane appears normal, except for a few small ulcerations of 
the character described. Above this area for about 6 cm. there 
are several large irregular ulcerations, penetrating to the muscu- 
lar coat, with raised edges, slightly undermined and covered with 
necrotic membrane. The floor of the ulcerations is formed by the 
muscular coat and is covered by congested patches of still intact 
mucous membrane. From this region to the valve there are nu- 
merous ulcerations of the same character, extending in most in- 
stances to the muscular coat. The ilium shows numerous patches 
of congestion but no ulcerations. The condition present is typical 
of amebic dysenter3\ 

Case 2, Hospital No, 3119, Liver: The liver measures 
30x25 cm. The organ is of a dark purplish red color externally, 
the capsule being smooth. Upon the right lobe there is visible an 
external yellowish area 2 cm. in diameter, which, upon section, 
proves to be an abscess containing brownish pus. Upon the in- 
ferior surface of the right lobe of the liver there is a large abscess 
measuring 8 cm. in diameter, filled with greenish pus. Upon 
section of the organ numerous abscesses are opened, the largest 
4 cm. in diameter, the smallest microscopical in size. The weight 



160 COLONEL ALFRED C. GIRARD. 

of the organ is 2050 gms. No rupture of any of these abscesses 
has occurred. 

Intestinal Canal: The entire large intestine is a mass of 
necrotic tissue. Externally the color varies from a light yellow- 
ish to black. But few individual ulcers can be distinguished. 
These are irregular in shape, have undermined edges, the floor 
covered by shreds of necrotic tissue and formed by the muscular 
coat of the intestine. Some of these ulcerations communicate 
with one another beneath the mucous membrane. These ulcer- 
ations vary in size, the largest entirely encircling the gut, the 
smallest being about \ cm. in diameter. Where the ulcerations 
cannot be distinguished, the mucous and sub-mucous coats are 
simply masses of necrosed tissue bathed with greenish pus. There 
are two perforations of the large intestine, one at the splenic flex- 
ure and one at the hepatic flexure. In some places the coats of 
the intestine are thickened, in others the ulceration has extended 
to the peritoneal coat. The ilium is free from ulceration. The 
conditions present are typical of amebic dy.sentery. 

Case J. Hospital Xo. x^i J, Liver: The liver measures 
33x28 cm. Weight 2690 gms. The organ is a dark purplish 
red color externally. The capsule is smooth. Half of the left 
lobe is occupied by an immense abscess which measures 12 cm. 
in diameter and has ruptured into the left pleural cavity. It is 
filled with dirty greenish pus. The remainder of the left lobe is 
filled with small abscesses and a greatly increased growth of 
fibrous tis.sue. The anterior surface of the right lobe is occupied 
by two abscesses, the larger one measuring about 8 cm. in diam- 
eter, and the smaller 5 cm. Both are filled with a dirty, brown- 
ish pus. Upon the upper border of the right lobe there is an- 
other ab.scess cavity measuring 8 cm. in diameter, filled with dirty, 
greenish pus. The gall bladder contains minute quantities of 
very pale bile. The abscess which has ruptured into the left 
pleural cavity has also emptied into the pericardial cavity, which 
is found filled with pus. The visceral layer of the pericardium is 
very greatly thickened and covered with shreds of fibre. Upon 
examination of the heart it is found somewhat hypertrophied but 
otherwise normal. 

Intestinal Canal: The entire large intestine is covered with 
numerous irregular ulcers, most of which have penetrated to 
the muscular coat. These ulcers are all undergoing healing, 
many of them showing nothing but a cicatrix. Those which are 
most acute communicate often with one another beneath the mu- 
cous membrane. The ilium shows no ulceration. The condition 
present is that found in amebic dysentery. 



ABSCESS OF THE LIVER. 161 

Case ^. Hospital No. 3261), Liv^r: Two large abscesses 
are found situated upon the upper portion of the liver, nearly in 
the region between the right and left lobes. Both of .these ab- 
scesses have ruptured and contain much dirty greenish pus. The 
larger measures *1\ cm. in diameter, the smaller 5 cm. Upon 
section of the liver it is found to contain 11 large abscesses, be- 
sides those mentioned, the largest measuring 10 cm. in diameter. 
The walls of these abscess cavities are formed by necrotic tissue, 
and tlie abscesses are filled with dirty, greenish pus. 

fntestinal Canal: The entire large intestine is thickl}' 
studded with large irregular ulcerations, most of which penetrate 
to the muscular coat. The floor of these ulcers is covered with 
shreds of necrotic membrane. The edges are slightly undermined 
and greatly raised above the floor of the ulcer, and are covered 
also by necrotic membrane. The intervening mucous membrane 
appears little inflamed and in some places almost normal. At the 
valve there is a large ulcer, which nearly encircles it, of the same 
character. The mucous membrane of the small intestine appears 
fairly normal. The condition present is typical of amebic dysen- 
tery. 

Case J. Hospital No, =^646. Liver: The liver measures 
34x28 cm. The organ is greatly enlarg-ed, dark purplish in 
color externally with yellow mottlings, and the capsule is smooth. 
The organ weighs 3460 gnis. Upon section of the organ it is 
found to contain 8 large abscesses, the largest 10 cm. in diam- 
eter, the smallest 4 cm. These abscesses are filled with brow^n- 
ish yellow^ pus. 

Intestinal Canal: The entire large intestine shows the cica- 
trices of a large number of ulcerations, but there are no ulcer- 
ations present in an active condition. The small intestine shows 
a severe chronic enteritis. In this case tlie amebic dysentery, 
which has undoubtedly been present, had healed. 

Case 6, Hospital No, Q02j, Liver: The diaphragm is 
adherent to the liver over the left lobe. Upon separating it a 
large abscess cavity, is found in the liver which is filled with green- 
ish brown pus. This ab.scess has perforated into the lower por- 
tion of the pericardial cavity, which is also filled with pus, and 
into the left pleural cavity. The abscess measures 12 cm. in 
diameter and involves nearly the whole of the left lobe of the 
liver. The right lobe is very dark, purplish red in color and the 
capsule is smooth. Upon section of this lobe no abscesses are 
found. Upon section of the abscess in the left lobe, the wall is 
found from ^ to 1 cm. in thickness, showing that this abscess 
is of long duration. 



162 COLONEL ALFRED C GIRARD. 

Intestinal Canal: The entire large intestine shows numer- 
ous ulcerations varying* in size from a pinhead to those measur- 
ing 1 cm. in diameter. Most of these ulcerations are in a heal- 
ing condition. There is but little congestion of the mucous mem- 
brane in the vicinity of these ulcers, but just below the valve, 
where the ulcers are most numerous, they are found to be also 
most acute. In this region the ulcers penetrate to the muscular 
coat in one or two places. The condition present is that typical of 
amebic dysentery. 

Case J, Hospital No. d^Sj. Liver: The organ measures 
30x18 cm., and weighs 1750 gms. It is light purplish red in 
color externally, with large yellow mottlings scattered over it. 
Upon the right lobe, situated centrally, there is a large discolored 
area measuring about 4 cm. in diameter and depressed about \ 
cm. Upon section of the organ over this depression, a small 
area measuring \ cm. in diameter is cut across, the contents of 
which are undergoing caseation. This area evidently marks the 
site of an abscess. There are no other abscesses present in the 
organ. 

Intestinal Canal: The entire large intestine is covered with 
irregular ulcerations having clear, notched edges, most of them 
penetrating to the muscular coat. Many of these ulcerations com- 
municate with one another beneath the mucous membrane and by 
channels through it. The floor of the ulcers is formed with ne- 
crotic membrane, and the mucous membrane between the ulcer- 
ations is in most places undergoing necrosis. The intestinal walls 
are much thickened, the mucous membrane of the small intestine 
appears normal. The condition present is that typical of amebic 
dysentery. 

In describing the pathological lesions found in these cases the 
character of the abscess wall has not been touched upon, as it 
was the same in all the ca.ses and would have been but repetition. 
In the smaller abscesses the abscess wall, after the pus had been 
evacuated, presented a shaggy appearance, due to fragments of 
necrosed tissue scattered over it. In the larger abscesses the 
shaggy appearance is not so pronounced, the abscess walls being 
ver>^ much more fibrous in character and sometimes very thick. 
The appearance presented by the wall of an abscess due to ameba 
is almo.st characteristic, the peculiar stringy appearance due to 
necrosis of the tissue in irregular areas and in varying amount 
giving the abscess wall the rough, shaggy appearance which is 
always foiuid. 



ACSCESS OF THE LIVER. 163 

Microscopic Pathology. The appearances found by an ex- 
amination of sections of the liver abscesses by the microscope vary 
with the age of the abscess. In the very small, microscopical ab- 
scesses the condition found is that simply of a collection of leuco- 
cytes and connective tissue cells, with some congestion of the capil- 
laries in the vicinity, and by careful staining amebae can some- 
times be seen, but not as a rule. In abscesses which have a well 
defined wall the center of the abscess cavity is generally filled with 
necrotic epithelium and leucocytes, together with bacteria and 
more or less caseous material. In the wall of these abscesses 
ameba may sometimes be demonstrated, but never where the fibre 
is well marked. The liver cells in the vicinity are undergoing 
necrosis and the bile ducts and capillaries are congested, the bile 
ducts often being either obliterated or encroached upon by the 
rapidly growing connective tissue. In the larger abscesses which 
have a rather thick wall, sections through this wall will show 
more or less necrotic material toward the abscess or innermost 
part, while externally the fibrous tissue is very marked, the ap- 
pearance presented being that of a layer of granulation tissue, the 
cells of which are mostly uninuclear, while most externally is a 
layer of fibrous connective tissue, infiltrated with spindle cells 
and small, round connective tissue cells. This infiltration with 
cells varies according to the age of the abscess. Where the fibrous 
wall is very thick the cellular infiltration is not as great as in 
those cases where the fibrous tissue is of earlier foniiation. 

In the portion of the abscess wall which encroaches upon the 
liver tissue within the outermost portion the liver cells are ver>' 
much distorted in shape, and undergoing necrosis in some places. 
Still further out there is found a condition of fibrosis, small areas 
of fibrous tissue encroaching upon the liver substance, generally 
the fibrous tissue situated between the lobules compressing the 
cells and in many places distorting them. The capillaries in this 
region are generally engorged with blood, and small capillary 
hemorrhages are common. 

Throughout the liver substance surrounding the abscess there 
is generally present a chronic venous congestion due to encroach- 
ment upon the capillaries by the fibrous tissue. 

In these large abscesses it is almost impossible, as a rule, to 
demonstrate ameba in the abscess wall. A peculiar condition 



164 COLONEL ALFRED C. GIRARD. 

present in the liver where large abscesses are present is a local- 
ized necrosis of the liver cells around the central vein of the 
lobules. This condition is probably due to some poisonous ma- 
terial which is liberated during the process of abscess formation. 

In all the cases which are here recorded ameba could be dem- 
onstrated in the abscess walls, thus showing the nature of the 
lesion. 

Examination of Abscess Contents. Microscopical examina- 
tion of the pus from the smaller abscesses showed numerous flat 
corpuscles, degenerate liver cells, shreds of necrotic tissue, leuco- 
cytes, various micro-organisms, chiefly micrococci, and ameba. 
Examination of pus from the larger abscesses showed no ameba 
but many leucocytes, a few degenerated liver cells, much necrotic 
material and various micro-organisms, chiefly staphylococci and 
streptococci. 

Examination of Feces, In cases 2 and 3 the feces were not 
examined, as a request for such examination was never made. In 
cases 1, 6 and 7, examination of the feces showed numerous 
ameba; while in cases 4 and 5, examination of the feces was neg- 
ative. In case 4, the feces were examined but once, while it is 
interesting to note that in case 5, the ulcerations of the intestine 
had healed, which probably accounts for the negative result of 
the examination of feces. 

.ANALYSIS OF THE CLINICAL SYMPTOMS PRKSENTKD BY THE 
CASES OF AMEBIC ABSCESS OF THE LIVER. 

Fever: Of the eight cases of amebic abscess of the liver, five 
presented a rise in temperature. Of these five, two showed aiP 
intermittent temperature accompanied by slight chills, the high- 
est point reached in the temperature cur\'e being 103" in both. In 
these cases the temperature was not continuous, there being 
l^riods of several days in which the temperature was normal, 
after which there would be a slight chill accompanied by a rise of 
temperature, which would be intermittent, for a short period of 
time, this being succeeded by a period of normal temperature. 
Two of the cases presented a marked remittent temperature of 
low type, the highest point reached being lOlV, and persisting 
for from seven to ten days, when a short period of normal tem- 
perature would intervene. One case showed a remittent temper- 



ABSCESS OF THE LIVER. 165 

ature which was remarkable because of its height. For a period 
of two weeks this case presented a temperature between 99^ and 
104i'F., the temperature most of the time being above 103". The 
case was considered one of typhoid fever, and sponge baths were 
given. An examination of the feces showed the ameba and 
autopsy showed the lesions of amebic dysentery. All of the fatal 
cases, seven in number, showed a fall in temperature just before 
death, of from two to three degrees, the lowest temperature just 
before death being 96", the highest 100". The temperature of 
these cases does not differ materially from numerous cases of 
amebic dysentery which do not show liver abscess. Where the 
temperature was remittent, the remission occurred in the morn- 
ing, the highest point being reached about 6 o'clock in the even- 
ing. 

Pulse and Respiratio)i\ All the cases showed an acceler- 
ation both of the pulse and respirations, the pulse ranging, as a 
rule, from 80 to 105, the respirations from 18 to 35. Just before 
death the pulse, in all cases, became very rapid, small and of poor 
volume. This was also true of the respirations, which became 
more rapid and very shallow. 

Cough and Expectoration : Cases showing perforation into 
the pleural cavity, as well as into the pericardial cavity, presented 
severe cough and the expectoration of purulent material. 

Jaundice-. All of the cases showed a marked degree of 
jaundice. This is rather exceptional, as jaundice is only occa- 
sionally present as a rule. 

Sweating'. In the clinical notes of the cases of amebic ab- 
scess of the liver, only in two cases is sweating spoken of, and in 
neither of these was it noted as being excessive. 

Pain\ According to all authorities who have studied amebic 
abscess of the liver, pain is said to be one of the earliest and most 
prominent symptoms. According to these authorities the pain 
may be dull or sharp and lancinating and varying in site, being 
most prominent either in the epigastrium, the right hypochon- 
drium, the axillary space or radiating around the shoulder. In 
none of the fatal cases of abscess of the liver observed here has 
pain been at all a prominent symptom. The fact that these cases 
were not recognized until they came to autopsy, although they 



166 COLONEL ALFRED C. GIRARD. 

were examined carefully before death, and in several of the cases 
amebic abscess suspected, is proof that they were not accompan- 
ied by an}' marked degree of pain. None of the clinical histories 
of these cases speak of the patients suffering pain in zxiy of the 
regions mentioned. This would seem to show that the symptom 
of pain cannot be relied upon as much as some authorities would 
have us believe. 

Anorexia was present in all the cases> but as this is a com- 
mon symptom of dysentery, it cannot be considered at all char- 
acteristic of abscess of the liver. 

Physical Sigyis: In the seven fatal cases there were no 
physical signs sufficient to admit of a diagnosis of amebic abscess 
of the liver. In most of the cases the liver was stated to have 
been slightly enlarged, but there were no tender areas present, 
despite the fact that some of these cases showed enormous and 
numerous abscesses. It seems remarkable that an organ riddled 
with abscess cavities, such as was present in some of these cases, 
should have shown so few physical signs, thus making the diag- 
nosis so uncertain. As these cases had all suffered from amebic 
dysentery and gave a clear history of such attacks, it will at once 
he seen how slight must have been the symptoms that abscess of 
the liver was not recognized. 

Of the eight cases of amebic abscess of the liver, seven 
proved fatal and one was operated upon. This case was the only 
one which was diagnosed before death and an operation was per- 
formed which proved successful. The following is a brief history 
of the case: 

Case 8. C. C. D.^ Discharged Soldier, Patient was admitted 
to Hospital Nov. 5, 1899, with a histor>^ of having had chronic 
dysentery for several months. Since about September 1st he had 
had pain in the right side of the abdomen, in the region of the liver, 
severe and cutting at times, but mostly of a dull, aching charac- 
ter. After admission to Hospital there was an irregular fever 
with temperature ranging between 98" and 102", pulse 100 and 
gradual loss of flesh and strength. There was marked dullness 
on the right side of the abdomen, tenderness over the liver, dull- 
ness extending about 5 cm. below the border of the last rib. 
Diagnosis of abscess of the liver was made and operation decided 
upon. 

The operation was performed on Dec. 8, 1899. An incision 



ABSCESS OF THE LIVER, 167 

was made through the abdominal wall to the outer side of the 
right rectus muscle over the area of dullness. This incision 
opened directly into a large abscess cavity situated in the right 
lobe of the liver. About 600 c.c. of thick, bloody pus was evacu- 
ated and the cavity irrigated with normal salt solution. Glass 
drainage tube was left in the wound and gradually shortened un- 
til it was removed. Patient recovered without any complications. 
Since recover}- patient has been on duty at this Hospital and 
has suffered several times from exacerbations of the amebic dj^s- 
entery. the feces showing numerous ameba during each exacer- 
bation, but there has been no recurrence of the liver symptoms. 

xNON-AMEBIC CASES. 

There were four cases of abscess of the liver in which the 
etiology could not be traced. Three of these cases were operated 
upon successfully, and one came to autopsy. This latter case was 
not recognized before death. In describing these cases the one 
fatal case will be first considered. 

Case /. TJ.F, Hospital No. 4^16. Pathological Anat- 
omy : Upon opening tlie abdominal cavity the liver was found 
to measure 24x21 cm. At the superior border of the right lobe 
there was a large abscess cavity measuring 5x6 cm. This cav- 
ity was filled with very bright green pus. This was the only ab- 
scess present in the liver, the remainder of the organ appearing 
to be fairly normal. 

Intestines: The large intestine throughout the entire length 
was covered with ulcerations, irregular in shape, completely 
healed. The base of all these ulcers was much pigmented, and 
they were arranged along the mesenteric attachment. The mucous 
membrane between the ulcerations was in fairly normal condition. 
The mucous membrane of the small intestine showed numerous 
congested areas. 

From the condition found in the intestine in this case, it is 
probable that the abscess in the liver was due to the ameba, but 
no amebae were found in the pus, nor did the walls of the abscess 
cavity present the appearances characteristic of amebic abscess. 
The pus showed immense numbers of strepto- and staphylococci. 

Microscopical Pathology. Sections through the wall of the 
large abscess showed it to con.sist of dense fibrous tissue very 
thinly infiltrated by leucocytes; the inner border of the wall, or 
that lying next to the cavity, was almost smooth, there being no 
masses of necrotic tissue such as are so common in this condition 
of the amebic abscess. There were a few microscopical abscesses 



168 COLONEL ALFRED C, GIRARD. 

scattered throughout the sections, presenting a center composed 
of necrotic tissue surrounded by immense numbers of leucocytes 
and some proliferating connective tissue cells. 

ANALYSIS OP THE CLINICAL SYMPTOMS IN THE NON-AMEBIC CASES. 

Fever-. The three cases of non-amebic abscess which were 
operated upon all presented a rise in temperature. The temper- 
ature curve in these cases was that of a remittent fever, accom- 
panied by slight chilly sensations. The fever oscillated between 
normal and 101". In the fatal case the highest point in the tem- 
perature curve was 99'. This occurred only on two isolated oc- 
casions, the temperature for the rest of the time being normal. 
The patient was in the Hospital for five months before death. 

Pulse cmd Respirations: The pulse and respirations in the 
three cases operated upon were accelerated. In the fatal case the 
pulse and respirations showed nothing of interest. 

Cough and Expectoration-. In none of these cases was there 
any cough or expectoration. This was probably due to the fact 
that in none of thetn the abscess of the liver had perforated into 
the pleural cavity. 

Jaundice: All of the cases showed a slight jaundice, the 
skin being of a pale, yellownsh hue. 

Sweating: None of the clinical histories of these cases speak 
of sweating as a prominent symptom. 

Pain-. In the fatal case there was no pain present, so far as 
the clinical records show. In the other three cases which were 
operated upon, all presented pain and tenderness over the region 
of the liver. The pain in all these cases is described in the clin- 
ical records as being intermittent in character, dull and aching. 

Anorexia: Anorexia was present in all the cases. 

Physical Signs: In the fatal case there were no evidences of 
abscess of the liver, so far as the physical signs went. Of the 
three cases which were operated upon, one presented a fluctuat- 
ing tumor in the right hypochondriac region, which was only 
.slightly tender. The other two showed considerable enlarge- 
ment of the liver and tendeniess upon pressure over the right 
lobe. Inspection did not show any increase in the dimensions of 
the chest wall, save in the case which presented the small tumor. 



ABSCESS OF THE LIVER. 169 

The following is a brief history of the cases of non-amebic 
abscess of the liver which were operated upon; 

Case 2. S.A., Private, Battery ' 'L,'' jrd Artillery, Patient 
was admitted to this Hospital on December 11, 1900, from the 
Philippine Islands, and was found to have a small, fluctuating 
tumor upon the right side of the abdomen. This was only slightly 
tender and gave very little discomfort. He gave a history of 
having had malaria in the Philippine Islands, but said that he 
had never had dysentery or diarrhea. After a few days the tumor 
was found to be increasing slightly m size, and he had some rise 
of temperature in the evening. There was no jaundice or dis- 
turbance of the bowels. 

Operation December 25, 1900: An incision was made over 
the most prominent part of the tumor in the abdominal wall just 
below the margin of the ribs. Quite a large amount of pus was 
found which was apparently confined to a localized area between 
the muscles. The discharge from the wound, however, was very 
profuse during the next few days, and while the wound was being 
dressed, about a week after the operation, a small sinus was found 
just below the margin of the ribs, leading beneath the abdominal 
wall. This was enlarged and found to communicate with a large 
abscess cavity involving the lower portion of the right lobe of ths 
liver. This cavity was irrigated and drained, and the patient 
made a rapid recovery, being discharged on February 26, 1901, in 
good condition, the wound entirely healed. 

Case J. EJ,0,N., Private. Co. ''Kr42nd Vol. Itifantry. 
The patient was admitted to this Hospital on March 1, 1901, 
complaining of pain over the region of the liver and the lower 
portion of the right chest. This pain had been present since De- 
cember, 1900. There was some evening temperature daily and 
a slight cough. Upon auscultation, the lower portion of the right 
chest was found flat and the voice and breathing sounds absent. 
He gave a history of having had dysentery in the Philippine 
Islands in July, 1900. Examination of the sputum for tubercle 
bacilli gave a negative result. An aspirating needle, introduced 
in the eighth interspace in the posterior axillary line withdrew 
bloody pus. 

Operation March 20, 1901: About two inches of the eighth 
rib was removed in the posterior axillary line. Immediately be- 
neath this was found an abscess cav'ity about the size of a large 
orange, filled with thick bloody pus. This was shut off from the 
pleural cavity and extended along the diaphragm for some dis- 
tance. It was thought that it communicated with the upper sur- 
face of the liver, although no opening could be found. The ab- 
scess cavity was irrigated and a drainage tube inserted. After 
the operation the wound healed readily and the patient was dis- 



170 COLONEL ALFRED C. GIRARD. 

charged from the Hospital on April 22, 1901, with the wound en- 
tirely healed. 

Case 4, H.S\, Private, 28th Co, Coast Artillery : Patient 
was admitted to this Hospital on March 13, 1901, complaining of 
pain and tenderness over the right side of the abdomen. The 
patient was a recruit and had never been outside of the United 
States. He stated that these symptoms had been present for 
about a month. The bowels were constipated and there was an 
evening rise of temperature. He denied ever having had dysen- 
tery or other serious illness prior to the onset of the symptoms 
mentioned. 

Operation March 22, 1901: An aspirating needle was intro- 
duced into the right side a little below the margin of the ribs, and 
revealed the presence of pus. An inci.sion was made through the 
abdominal wall at this point, and a large abscess cavity opened, 
which extended upward beneath the lower surface of the liver and 
involved the right lobe. This cavity was irrigated and a drain- 
age tube inserted. 

Improvement was rapid after the oi:)eration and the patient 
was discharged from the Hospital, the wound being entirely 
healed. 

CONCLUSIONS. 

From the study of these twelve cases of abscess of the liver 
the following conclusions may be drawn: 

1st. Amebic abscess of the liver occurred in a very small 
percentage of the cases of amebic dysentery obserx-ed at this hos- 
pital. 

2nd. The recognition of cases of amebic abscess of the liver 
is by no means easy, as of the eight cases obser\^ed here, only one 
presented any clinical symptoms which could not have been re- 
ferred to the accompanying dysentery. 

3rd. Abscess of the liver may occur without the action of 
the ameba of dysentery. 

4th. The symptoms presented in non-amebic abscess of the 
liver do not differ materially from those in the amebic cases, but 
in the cases obsened at this hospital those of non-amebic char- 
acter seemed to have presented symptoms of more severity, as a 
so much larger percentage of these cases were recognized. 

5th. Operation in well selected cases of abscess of the liver 
may be expected to be followed by success where the abscesses 
are not multiple. As shown in the post mortem findings of the 
amebic abscess cases, operation would have been of no benefit to 
the patient in those which presented multiple abscess of the liver. 



GONORRHOEA FROM THE STANDPOINT OF THE 
NAVAL SURGEON. 

By SHELDON GUTHRIE EVANS, M.D. 
SURGEON IN THE UNITED STATES NAVY. 

IT might seem that an apology is called for in presenting the 
hackneyed subject of gonorrhoea to this Association, but it 
has occurred to me, of late, that the amount of time lost to 
the Services through this disease has been very great and too 
little attention has been paid to its management and treatment. 
It is so frequently looked upon as a trivial ailment, requiring in- 
active treatment, and as a result, we have the many complications 
presenting themselves, and not infrequently the seeds are sown 
for more serious trouble in after years, absolutely incapacitating 
the man for active duty, and thus the services of a good soldier 
or sailor are lost. Particularly, has this been brought to my 
mind, by the number of men invalided from the Navy and Marine 
Corps, by reason of gonorrhoea! arthritis and other complications 
and sequelae of gonorrhoea. 

The management and treatment of this disease is, by no 
means a simple matter. I was struck by the remark of a Medi- 
cal Officer not long since who described it as *'the most difficult 
and insubordinate of all diseases that it had been his pleasure to 
treat in the Naval Service." and I think we can all agree with 
him, for one can never be certain when a cure has been affected. 
In regard to my remarks concerning the great loss of time from 
Gonorrhoea and it's complications and sequelae, permit me to 
quote a few figures compiled from the last report of the Surgeon 
General of the Navy. In investigating the subject I have con- 
sidered only those cases that are almost certain to have been 
caused by the infection of the gonococcus, namely, Arthritis Gon- 
orrhoica, Balanitis, Cystitis, Ophthalmia Gonorrhoica, Orchitis. 
Epididymitis, and Stricture ofthe Urethra; omitting Urinae Sup- 

(171) 



172 SURGEON SHELDON GUTHRIE EVANS. 

pressio, Pyelitis and others, that are frequently but not necessarily 
the result of gonorrhoea! infection. The total number of cases 
admitted to the sick list for these diseases was 1232, including 
those continued from the previous year. Gonorrhoea alone con- 
tributing 560 of this number. Total days lost from all the dis- 
eases above mentioned, 25,590, and by gonorrhoea alone 10.794. 
This would give an average duration to each case of gonorrhoea 
of 19 days, but no one will, I am sure, hold that this represents 
the average time required for a cure, for many Medical Officers 
do not put men suffering from Gonorrhoea on the sick list at all 
and one officer informs me that he has not been in the habit of 
excusing these men from any duty, aloft or on deck as he be- 
lieves rest is more or less debilitating. I think it is the general 
practice to discharge patients to duty as soon as the acute symp- 
toms have subsided. 

Forty men were invalided from the ser\-ice during the year 
as a result of some one of the diseases above referred to, the 
greater portion being for Arthritis Gonorrhoica. 

In order to gather information upon this subject I communi- 
cated with quite a number of Medical Officers, neiar at hand and 
to them I am greatly indebted for the prompt and comprehensive 
replies that were received. 

It is not my purpose, in this paper, to pretend to present any 
new or original method of treatment but if I succeed in bringing 
about an active discussion of the methods of treatment I shall 
feel gratified. One officer wrote me that he **had tried practi- 
cally every known treatment in this affection", and it is to get 
the benefit of such trials that I introduce the topic; to hear the 
experience of the members of the various services and to attempt 
to find out what really is the most valuable and effective method 
of treating this disease and preventing complications. 

That the disease is, primarily, an acute local affection all 
admit but too often does it become chronic through lack of treat- 
ment, improper treatment, inactive or overstimulating treatment 
or lack of adherence to dietetic or hygienic regulations. 

Occasionally, as Guiard has pointed out, it is true that the 
disease presents all the appearance of chronicity at the outset. 



GONORRHOEA IN NA VAL SURGER Y. 173 

In a valuable paper presented at the Pan American Medi- 
cal Congress at Havana, in 1901, Dr. Valentine has laid great 
stress on the baneful results of lack of treatment and mentioned 
the fact that many colleagues still dismiss the disease as a trifling 
ailment and that this view is transplanted to the public; this, un- 
fortunately, is, to some extent true in the Naval Service and/ as 
a result, the men frequently and I might say, generally, fail to 
report for treatment until the disease is well advanced and much 
damage is done. 

The same result is brought about by the system of quaran- 
tining in the Navy for venereal disease; far be it from me to ad- 
vocate the abandonment of this practice, for, severe as it seems, 
I believe it due to others that it should be so; but I am convinced 
that if Medical Officers would take a little trouble to explain to 
the men something of the nature of the disease and the import- 
ance of early treatment, much could be gained and a killing blow 
delivered to the opposition dispensary, generally located in a coai 
bunker. 

Men fail to report for treatment for fear of restriction. It 
should be firmly impressed upon their minds that they will, prob- 
ably, eventually have to report for treatment and then the restric- 
tion will be for a much longer period than if they reported at 
once and ended the disease in from tw^o to four weeks. 

Then, the facilities for proper and private treatment (and I 
wish to lay great stress on the latter adjective) are frequently 
lacking on board ship but with a little effort one can, especially 
in our modern ships, have a urinal and closet designated for the 
exclusive use of venereal cases where the treatment can be effect- 
ively carried out. 

One of the chief elements in the proper management of these 
cases is absolute rest in bed until the acute s^^mptoms have sub- 
sided. This is admitted by all, certainly by all to whom I wrote, 
with one exception, and yet the majority admit that they do not, 
as a rule, carry out this important point in the treatment owing to 
unfavorable conditions aboard ship. This is a rfiistake and I^ am 
sure that there are few ships where it could not be done even if 
there were no sick bay. Most of our modem ships, however, 



174 SURGEON SHELDON GUTHRIE E VANS. 

have very good quarters for the sick and as this rest is necessary 
only in the very acute stage of the disease, I believe it can and 
should be accomplished not only for the benefit of the patient but 
to prevent infection of towels, &c. , which are so frequently ex- 
changed by men aboard ship. 

I believe this has a more favorable influence on the course of 
the disease than any single point in the treatment. 

• Diet is another important item in the management of this 
disease and it is only by keeping the patient in bed or in his ham- 
mock that a restriction of diet, or better, if possible an absolute 
milk diet, can be effectively enforced. 

In regard to medicinal treatment I find the corps about 
equally divided upon the question of internal medication and 
some are found who use only internal remedies during the earlier 
stages and resort to irrigations and injections only when the dis- 
charge become gleety. 

Of the remedies most in use Oil of Sandal seems to be the 
most popular one, followed by Salol, Copaiba, Cubebs, and the 
carbonates in about the order named. 

Of the solutions used for injection or irrigation, recommend- 
ed, then are many but there is an absolute unanimity of opinion 
upon one point; that is, that it is not so much what solution is 
used but the frequency and thoroughness of its use and the 
strength of solution employed. The plan of treatment I have 
adopted and which has given good results, with few complications 
and an average duration of treatment of about two to four weeks 
is as follows. 

The gonoccocus having been found, or feeling reasonably 
certain of its presence, the patient is put to bed or in a hammock 
on an unstimulating diet until the acute stage has passed. 

Every precaution is taken to catch all the discharge and to 
keep the parts thoroughly clean. 

For the first few days, injecting, carefully introduced, of 
equal parts of hydrogen peroxide (Standard solution) and water, 
every two hours 'during the day. (The use of the peroxide I be- 
lieve to have been first published by Surgeon von Wedekind,U.S. 
Navy in an article some years ago). When the discharge seems 



GONORRHOEA IN NAVAL SURGERY, 175 

a little less purulent, irrigation, with a double current nozzle or 
catheter, is resorted to, using a hot solution of mercuric chloride 
1-5000 every two hours. 

No internal medication is used unless indicated by much ardor 
urinae or chordee until the last stages are reached, when Ol. San- 
tali is given in large doses. Occasionally should the discharge be- 
come gleety. astringents are used and in such cases Zinc Sulphate 
alone and not combined with other salts and solutions chemically 
incompatible as is often the case, is used in strength varying from 
1 to 2 grains to the ounce. 

This mode of treatment is simple and easily carried out on 
board ship and has alwaj's given satisfactory results. 

One officer reports remarkable results from the internal use 
of methylene blue in grain doses and records 40 cases acute and 
cnronic with no complication and an early cure, but with this 
drug I have had no experience. 



A STOMATITIS EPIDEMIC AMONG THE TROOPS IN 
SOUTH AFRICA. 

IN the Deutsche medicinische Wochenschrift, Dr. J. C. J, 
Bierens de Haan describes an epidemic which broke out 
among the troops in South Africa, and also attacked 
many of the inhabitants who came in contact with them. 
The outbreak of the disease took place simultaneously with a 
great shortage in the supply of salt, and the trouble rapidly sub- 
sided when this article was supplied in sufficient quantity. The 
stomatitis was of the ulcerative variety, but was not attended by 
any constitutional symptoms. As a rule it was readily cured by 
the employment of mild antiseptics and astringents. Bacteriolog- 
ical examination of the cases was not possible, and hence the 
primary etiology is unknown. An accessory cause was undoubt- 
edly the deficient supply of salt above noted. 



PRACTICAL OBSERVATIONS UPON THE TREATMENT 
OF THE VENEREAL DISEASES MOST COMMON 
AMONG THE SOLDIERS OF THE GARRISON 
OF VERACRUZ. 

By lieutenant COLONEL ZACARIAS ROJOS de MOLINA. 

DELEGATE FROM THE MEXICAN ARMY. 

THE Bubo, in the order of frequency, occupies the first 
place, as shown by the* statistics annexed hereto, then 
follows the Chancre and Chancroids; Blennorrhagia 
or Gonorrhoea comes in the third place, and finally, the secondary 
Syphilitic manifestations, 

I will first describe the treatment which I have followed in 
ca.ses of gonorrhea, inasmuch as I consider it of the most practi- 
cal value. 

In order to combat this painful as well as disagreeable affec- 
tion I have limited myself to local treatment, suppressing all med- 
icine through the digestive canal, so commonly applied b}- all 
medical men. 

The following Formula of- - 

Sulphate of Zinc, Gr. i.oo, 

Aqua<Fonti, Gr. 300.00, 

dissolved, 
is the one which I have been using for over thirty years in my 
military as well as civil practice, yet not without having compared 
the effects with those of the treatment by permanganate of potassa, 
or with protargol, which has so extensively been in use during 
these last years. 

The method of applying it is the following: I order the pa- 
tient after urinating to inject with a small syringe filled with said 
solution, as many times per day as he passes urine. In order to 
subdue the pain during micturition, which is never wanting, and 
is one of the most disagreeable symptoms to the patient, I have 

(176) 



VENEREAL DISEASES AT VERA CRUZ. 177 

been using during the past few years the following Formula — 

Sulphate of Zinc, Gr. 0.020, milligr.i 

Muriate of Cocaine, Gr. 0.20, centigr., 

Distilled water, Gr. 20.00, 

with very excellent results, as it mitigates admirably the charac- 
teristic burning pain. The method of application is the follow- 
ing: I advise the patient after the urethal washing, to inject this 
solution with a straight dropper in the urethra. The average 
period of duration of the disease with this treatment has been 
from fifteen to twenty days, in exceptional cases one month at 
the longest. 

In the treatment of the chancre or chancroids, I have never 
employed anything except the most suitable means to cicatrize 
them. After having exhausted all modem means, among which 
occupies the first place the nauseous iodoform, iodol, aristol, and 
all the long series of new medicines without denying their bene- 
fits,— inasmuch as all of them give satisfactory results, — but tak- 
ing into account that a Military Surgeon has to reduce his thera- 
peutic arsenal, to the smallest volume compatible with the object 
of his mission, the writer has fallen back upon the exclusive use 
of the classic Black Wash, without regard to its formula, whether 
French, English or American, in the treatment of chancres. 

This preparation has the advantage, in addition to being very 
clean, cheap, and of easy application. 

The mode of applying it is as follows: I advise the patient to 
take a thin sheet of absorbent cotton, extend it upon a fiat plate 
and then soak it well with the preparation, taking care to shake 
previously the contents of the bottle, and with the sheet of cotton 
thus prepared to cover the ulcer: this I have him repeat four 
times per day. 

When the ulcer takes an indolent character, or a phagedenic 
type, I have with infallible success employed the following pow- 
der: — 

Salicylic acid, Gr. 2.00, 

Talco or Oxid of Zinc, Gr. 10.00. 

After three or four applications of this powder, the ulcer is 
cleaned, and the use of the Black Wash is continued until com- 
plete cicatrization has taken effect. 



178 LIEUT, COL, ZAC ARIAS ROJOS de MOLINA, 

In cases of suppurated bubo, I have employed the following 
practice: I make an incision sufficiently large to completely dis- 
charge the contents: applying then a moist treatment by using a 
thick bandage of absorbent cotton, saturated with a 4% boric so- 
lution, renewing the same three times per day. I never needed 
to employ any other therapeutic agent to obtain the desired ef- 
fect, — this treatment having the same advantages as those which 
I mentioned when describing the treatment of chancres: cheap- 
ness, cleanliness, and easiness of application, which are very im- 
portant advantages in the treatment of persons who almost in 
their totality are ignorant people. 

In indurated chancre I make use of no other topical means 
than that described in the treatment of chancroids, — Black Wash. 

On the appearance of the infarction of the inguinal glands, 
which is a characteristic symptoms of syphilitic infection, I give 
the patient one mercurial pill, formula Ricord, every day; and I 
have observed that with this practice the secondary manifestations 
do not present the usual intensity. 

In the secondary manifestations I have followed a mixed 
treatment: giving one pill of Ricord in the morning, and 0.50 
centigrams of iodide of potash at bedtime. With this treatment 
I have seen disappear in less than one month the most serious 
manifestations in persons, who had been subjected to mercurial 
treatments of different kinds for several months. 

Without denying the efficiency of hypodermic applications, 
which at present are so much in practice, I have never been com- 
pelled to employ them; in my opinion, they are painful and 
troublesome, since, with the method which I have described, I 
have obtained the disappearance of all specific manifestations in 
fifteen, or twenty days at most. Hypodermic treatment should 
be applied only in cases in which mercurial preparations will not 
be tolerated through the digestive canal. 

This method I have followed over twenty years in my prac- 
tice in the women's and children's Hospital of "Nuestra Senora 
de Loreto," as well as in my civil practice, with the most satisfac- 
tory results. 



VENEREAL DISEASES AT VERA CRUZ. 179 

In tertiarj' manifestations the administration of saturated so- 
lution of iodide of potash, in progressive doses, has always given 
the very best results. 

In the employment of iodide of potash it is always very con- 
venient to commence with the smallest dose, increasing it grad- 
ually, until the desired effect is obtained. The method which I 
have always employed is the following: 

Iodide of potash, Gr. 25.00, 

Distilled water, Gr. 25.00, 

dissolved. 
Of this saturated soluti^ I commence to give 20 drops at bedtime 
in any kind of vehicle, compound syrup of sarsaparilla being one 
of the best, increasing the dose from 10 to 20 drops daily until ob- 
taining modification of the tertiary manifestations. 

Lately I have had two cases in which the patients were in 
danger of losing their noses, and I found myself compelled to in- 
crease the above mentioned dose to 200 drops every night, in 
order to arrest the progress of the nasal ulceration, and their noses 
were saved, thanks to this heroic treatment. 

As soon as relief is obtained, I again commence with the 
initial dose, the same as when commencing the treatment, until 
all specific lesions have disappeared. 

To patients of my civil practice I have recommended that, 
upon the slightest signs of the appearance of the disease, to put 
at once in practice the method indicated and in the same heroic 
degree. 

Those cases of tertiary syphilis, whose manifestation did not 
disappear under the influence of this method, have been very ex- 
ceptional. During twenty-five years of experience I remember 
only four cases, in which the treatment was entirely without ef- 
fect, because they were cases of diathetic scrofulous persons, re- 
bellious to any kind of treatment, as is well known to every prac- 
titioner who has had opportunity of observation. 

At the beginning of my practice in V^era Cruz, the treatment 
in general use was that of Zitmann, which I tried over three 
years and then abandoned it as useless and repugnant. It requires 
an uncommon preseverance which will be rarely found among 
patients, in order to carry it to the end. 



180 LIEUT. COL, ZACARIAS ROJOS de MOLINA, 

The efficiency of the "Arab," or dry treatment, which sev- 
eral authors, like Lallemann, L. Boyer, Malinonowski, and others 
mention, is due to the two mercurial pills which the patient has 
to take every day; because such dry alimentation as biscuits, 
almonds, figs and grapes, and decoction of sarsaparilla, cannot 
exercise any influence in syphilitic manifestation, inasmuch as in 
this disease the efficiency of mercurial and iodide of potash prep- 
arations has been clearly demonstrated. 

In describing these well demonstrated facts, I proposed to 
show that the military surgeon can very well reduce the number 
of medicines in his field medicine chest; al least those of common 
use in the tropics. 

The paludal manifestations, so very common in these regions, 
and which cause the greatest proportion of sick in our Hospitals, 
can with full confidence of success be combatted by two prepara- 
tions of the quinine salts: the chloride sulphate for hypodermic 
applications, and the sulphate of quinine with antipyrin through 
the digestive canal. 

In conclusion I give the statistics as taken from the records 
of the Military Hospital under my direction, which have been 
treated according to the description above given. These statistics 
cover the period from 1892 to 1899 inclusive, viz: 

Bubos in general, 569, 

Chancres and Chancroids, 418, 

Blennorrhagia or Gonorrhoea, 287, 

Secondary syphilitic manifestations, 144. 

The average number of soldiers of the garrison, during the 
period embraced by these statistics, has never been less than 1.200, 
which shows that approximately 13% annually were attacked by 
these diseases. 



HOW CAN MEDICAL OFFICERS PROMOTE EXPERT 
MARKSMANSHIP IN THE ARMY? 

By brigadier GENERAL J. FRANCIS CALEF. 

SURGEON GENERAL (RETIRED) OF CONNECTICUT. 

SUPERIOR marksmanship, coupled with superior mobility, is 
sure to win battles; guided by superior strategy, the high- 
est military success is attainable. Into the realms of strat- 
egy the military surgeon may not presume to enter, yet how often 
must the most brilliant strategy fail when the surgeon brings up 
his men physicall}' exhausted. 

As we study the campaigns of Napoleon, we admire his dash 
and resourcefulness, his skill in handling political situations in 
order to promote his military success, but in looking back of the 
bronze cannon and the hardy men, we observe with equal ad- 
miration the wisest medical mind of his generation quietly devot- 
ing his great talents to the minutest details of military hygiene 
and surgery.* The great commander grandiloquently said "An 
army marches upon its belly. * * The great surgeon knew this, but 
he knew also that without sound feet a full belly counted but 
little, and he cared for the feet. He knew that without keen eyes, 
and sound nerves men could not fight and every attention known 
to science in his day was given to conserve the eyesight and ner- 
vous energy of the soldiers. 

♦Drawn In the footsteps of the conqueror throughout his vertiginous course, I .arrey 
filled an Important place In the Napoleonic epic. He was present on every battledeld. 
and established his ambulances In all the capitals of Europe. In this long and glor- 
ious series of campaigns. In this marvelous and dramatic triumphal march when the 
armies of France tulvanced from the Nile to the Danube, from Austerlitz to Madrid, 
from Wagram to Moscow, and from Leipzig to Waterloo, the figure of this army sur- 
geon emerges, stands forth in surprising relief by the side of those warriors whom a 
hundred victoria have consecrated. A character Is revealed wherein science, author- 
ity, valor and humanity are combined in a degree never seen before and probably 
never to be seen again. In spite of a defective oixB>nlzatlon, Larrey contrived, single 
banded, to raise the medical service to a level with the rest of Napoleon's army. By 
the side of the machine made perfect for conquest and for death he placed another 
equally perfect but designed to succor and to preserve. From the inferior and dis- 
credited rank wherein, notwithstanding their talents, their good 8er\Mce and their 
personal sacrifices, the meml)er8 of the healing art were subordinated in old-time 
armies, he raised himself to the level of the most illustrious captains and of the most 
celebrated physicians. From the one class he borrowed talent and intrepidity and 
from the other science and devotion, thus in his own person uniting the virtues of 
both.— /Wa<re'j» Life of Larrey. 

(181) 



182 BRIGADIER GENERAL J. FRANCIS CALEF. 

The valor of the surgeon is sometimes mentioned in reports, 
but his trying daily labor *'for the good of the service'* is never 
fully appreciated even by the commanders of the fighting arm. 

Strategy and tactics aside, the efficiency of an army, is the 
sum of the efficiency of each of its units — the man behind the gun. 
Therefore a close study of how to make each soldier the most ef- 
ficient fighting machine possible is the fundamental aim. This 
must begin in the recruiting station, and none but surgeons of 
keen natural perception, supplemented by wide experience with 
troops in the field, should pass final judgment upon the recruit. 
Any physician can determine the soundness of a man's body, but 
special skill and experience is required to determine his aptitude 
for a soldier, and a marksman. 

Until the Civil war American armies have had the excep- 
tional advantage of a large percentage of recruits who, from en- 
listment were superb marksman, many of them familiar with the 
rifle from childhood, many from experience in warfare with 
aborigines, men of sturdy bodies, Sound nerves and strong con- 
victions as to the righteousness of their course. They fought to 
win ^nd won. The Civil and Spanish American wars found some 
of these hardy frontiersmen left, who became the sharpshooters 
of their respective armies and in many situations in the Civil war 
were numerous enough to hold positions against much larger 
bodies of less expert men. North and South profited by this 
class of men, but in this respect the Confederate Army excelled. 
Most of the marksmen in the Civil war became so, only after long 
and costly training in the field, and many soldiers on both sides 
never became and never could become marksmen in any sense of 
the word. 

With our small standing army, trained to shoot, and with 
every encouragement to form rifle clubs throughout this country, 
our next great war will find us rather better supplied with expert 
marksmen than did our recent wars, but still the enlistment of 
only such as can become good marksmen will be of paramount 
importance. 

How decide this question? Best, I believe, by a careful study 
of the men who have shown themselves experts, a study of their 
physical, intellectual and even moral characteristics. 



EXPERT MARKMANSHIP IN THE ARMY. 



183 



TABLE OF OCULAR AND OTHER CONDITIONS PRESENT IN 
FIFTY EXPERT MARKSMEN OF THE CON- 
NECTICUT NATIONAL GUARD. 



"So 



No. Right 1 Le t 1 Right Left 



9 
9 



I ^ 



I 



1 


16 


24 


2 


16 


24 


3 


16 


16 


4 


16 


16 


5 


16 


24 


6 


16 


16 


7 


16 


16 


8 


10 


10 


9 


16 


16 


10 


10 


24 


11 


16 


10 


12 


10 


10 


13 


10 


10 


14 


10 


10 


\h 


16 


10 


16 


10 


10 


17 


10 


10 


IS 


10 


10 


19 


16 


18 


20 


16 


10 


21 


16 


16 


22 


16 


16 


23 


16 


10 


24 


10 


16 


25 


16 


24 


26 


10 


10 


27 


10 


16 


28 


10 


10 


29 


16 


16 


:» 


10 


16 


31 


16 


16 


32 


10 


24 


33 


16 


24 


M 


16 


16 


35 


16 


24 


36 


16 


16 


37 


10 


16 


38 


16 


16 


39 


16 


16 


40 


24 


24 


41 


IH 


16 


42 


16 


16 


43 


16 


24 


44 


10 


10 


45 


16 


16 


46 


16 


24 


47 


10 


16 


48 


16 


16 


49 


10 


16 


aO 


10 


16 



I Hllght I 

, Riisrht 

I absent! 

.slight I 

absent 

' absent* 

abncnt, 

absent 

absent 

absent 

absent 

absent I 

absent! 

v-sl't 

slight 

V-KPt 

absent 

v-el't 

slight ; 

V-8l't 

. slight ' 
absent 
absent 
absent > 
absent 
absent 
absent 
absent 
slight , 
absent 
v-sl't I 
absent 
absent I 
absent, 
absent; 
absent 

, absent I 
absent' 
slight , 
absent 

I abseht 

I v-sl't 
absent 

, absent 
slight 

, absent 
absent, 

I v-el't I 

I absent 
absent 



slight 
Blight 
absent 
absent 
slight ' 
nb eiit 
absent 
absent 
absent 
absent 
absent 
absent I 
v-sl't 
v-sl't 
slight 
v-sl't 
absent 
slight I 
absent I 
slight 
v-sl't 
absent 
absent 
absent 
slight 
slight 
absent 
absent 
slight 
absent, 
v-«l't 
slight ' 

v-«rt 

absent 
absent I 
absent 
absent 
absent, 
slight ; 
absent 
absent 
slight , 
slight I 
absent 
absent 
absent 
absent' 
v-sl't 
absent' 
slight 



No R 
Yea R 
No R 
No R 
Yes 1 R 
No ! R 



No 

No I 

No 

No 

No 

Yes 

No 

No 

No 



No I R 
No , R 



No 
No 
No 
No 
No 
No 
No 
No 
Yes 
No 



R 

R 
R 
R 

R j 

R 

R I 
H 



No I H 
No i R 
R 



Yes 
No 
No 
No 
No 
Yes 
No 
No 
Yes 
No 
No 
No 
No 
No 
No 
Yes 
No 
No 
No 



brown 
blue (m) 
brown 
gmy 
hazel 
blue(m) 
blue(m) 
blue (d) 
blue (in) 
blue (d) 
blue(m) 
blu('(m) 
blue (ni) 
br. (m^ 
blue (a) 
hazel 
blue (d) 
blue (in) 
blue (m) 
blue (mj 
hazel 
blue (m) 
blue (in) 
blue (ni) 
brown 
blue (m) 
blue [m] 
hazel 
blue [d] 
blue ml 
blue nil 
blue [d] 
K«ay 



No +R 
No I R 






blue 
blue 
blue 
blue - 
brown 
blue [m] 
brown 
blue [m] 
^ray 



blue 
blue 
blue 
blue 
hazel 
blue [ml 
blue [mj 
brown 



.m] 
.ml 



M 
M 

I 

M 

Q 

M 
M 



Q 

M 

i 

M 

a 

m: 

Q 



I 



o 



A 



S 



A 



B 

B 

A 



6 



a 

"§5 
I 



T 

T.A. 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T.A. 

T 

T 

T 

T 

T 

T 

T 

T 

T.A. 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T.A. 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 

T 



With very limited opportunities for these, I have yet exam- 
ined the eyes and nervous systems, and have become somewhat 
acquainted with the intellectual powers and moral character of 
fifty expert marksmen of the Connecticut National Guard with 



184 BRIGADIER GENERAL /. FRANCIS CALEF. 

results shown in the accompanying tables. With the wide experi- 
ence, accessible to the surgeon with troops in barracks, far more 
conclusive deductions might be drawn. 

In explanation of the tables, the soldier was posted 20 ft. 
from a Snellens test card placed in a good light and the numeral 
against each eye indicates the letters easily read. 

Astigmatism was roughly tested, with glasses removed, (if 
worn) with the usual test card. The color of eyes was deter- 
mined by a surgeon familiar with the color cards of the U.S.A. 
qr by myself. 

The muscular action, quick (Q), or moderate (M), was de- 
termined by inspecting the man at target practice and drill, and 
in a few cases by careful measurement of the personal equation. 
The intellect was determined in most cases by personal acquaint- 
ance with the men and knowledge as to their educational advan- 
tages. A total abstainer (T.A.) is a rara avis in camp; but four 
men could certainly be so classed, and the rest without exception 
were moderate users of alcoholic stimulants. In the last column 
2 indicates lack of thrift. 

Every one of these men had won first class marksman's 
badges for at least two years, and many were sharpshooters of 
experience. (Connecticut Marksmanship Regulations). 
With right eye, With left eye, 

19 read Snellens 10 at 20 ft. 14 read Snellens 10 at 20 ft. 

30 ** " 16 " 20 ft. 25 " " 16 " 20 ft. 

I " " 24 " 20ft. II " " 24 " 20ft, 

With right eye, With left eye. 

Astigmatism absent in 34, Astigmatism absent in 29, 

Slight or moderate in 9, Slight or moderate in 13, 

Very slight in 7. Very slight in 8. 

Eight only used glasses. All but one shot right handed, using 
the right eye to sight. That one was left handed and his left eye 
was superior to the right , although slightly astigmatic. He used 
glasses. 35 had blue eyes, of which but 9 are rated M. 7 only 
are brown, 5 hazel and 3 gray. 39 were decidedly quick and 
sprightly in their motions, 11 were deliberate (M), and only one 
or two sluggish. 35 were superior (S) intellectually, the others 
up to the average (A) of National Guardsmen. In morals the 
men ranked above the average citizen of this community. 



fftebtco-flMIttatie Iribcx. 

MEDICO-MILITARY ADMINISTRATION. 

Ausgestaltung (Zur) der Marodenzimmer des K. u K. Heeres, nach den 
Erfahrungen eines Truppenarztes. 8'. Wien, 1902. 

Conference Internationale des Soci^t& de la Croix-Rouge, St. P^ters- 
bourg, i902,VIIme Comit^ central des soci^t^ allemandes de la Croix-Rouge. 
Rapport sur Tactivittf de la Soci^t^ allemande pendant les guerres greco- 
turque et sud africaine et pendant Texp^ition en Chine. 4°. St. Ptftersbourg, 
1902. 

Vllme Rapport present^ au nom de la Soci^ttf francaise de se- 

cours aux blesses militaires des arm^s de terre et de mer. Question: "Appli- 
cation pratique par les Soci^t^s de la Croix- Rouge des principes posfe par 
la convention de La Haye en mati^re de guerres maritimes." 4«. St. Ptfters- 
bourg, 1902. 

Question ; "Les Soci^ti^s de secours aux blesses peuvent-elles et 

doivent-elles se charger des soins k donner aux prisonniers de guerre dans 
les termes du rfeglement de La Haye." 4*^. St. P^tersbourg, 1902. 

Question: "De la meilleure m^thode d'instruction pour preparer 

les dames k remplir, en temps de guerre le rdle d'infirmi^res volontaires." 4*. 
St. P^tersbourg. 1902. 

Vllme Rapport du Comit^ Internationale de Geneve. Du 

secours international en temps de guerre. 4". St. Ptftersbourg, 1902. 

Vllme Rapport duComit^Sup^rieurde la Croix-Rouge k Pretoria 

durant la guerre sud-africaine de 1899. 4". St. Petersbourg, 1902. 

VI lime Rapport du Comittf Central RusseS. apercu des r^sultats 

de Passistance pr^t^e par la Soci^t^ de la Croix-Rouge de Russie pendant les 
guerres ayant ^lat^ depuis la dermi^re conference de Vienne, en 1897. 4". St. 
Petersbourg, 1902. * 

II. Quelle est Tactivittf qui en temps de paix, r^pond le mieux h 

la tiche e.ssentielle de la Croix-Rouge et contribue k preparer le plus efficace- 
ment possible les Socitftfe de la Croix- Rouge hremplirleur mission en temps 
de guerre? 4®. St. Petersbourg, 1902. 

Medical (The) service of the army. Lancet ^ Lond.. 1902, ii, 254. 

Service (Le) de secours de lasoci^t^ de la Croix-Rouge du Japon pendant 
Hntervention des puissances en Chine (1900-1001.) 8". Paris, 1902. 

Suppression « La) de la dispense du service militaire. Rev. gen. de din. 
^tdethtrap.y Par., 1902, xvi, 455. 



186 MEDICO'MIUTA R Y INDEX. 

^ MEDICO-MILITARY OBSERVATIONS. 

G>Ieman (J. RJ Medical experiences in South Africa. 7>. Roy. Acad. 
M. Ireland^ Dubl., i9cx>-i90i, xix, 76-86. 

Ryenon (G. S.) My experiences in war; a contrast, 1885-1900. Buffalo 
il/.y., 1902-3, n.s., xlii, i-io. • 

Sadovski (A» O.) [Reminiscences from the Transvaal and travellers im- 
pressions.] Voyenno Med.J.y St. Petersb-, 1902, Ixxx, med. spec, pt, 1499- 
>534. 

Seaman (G. E.) Some observations of a medical officer in the Philip- 
pines. Milwaukee M.J. y 1902, x, 181-189. 

MILITARY HYGIENE. 

Handbok i gymnastik for arm^en och flottan, utgifeen pS n&digste be- 
fallung 2v. 12*. Stockholm, 1902. 

Duncan (A*) The prophylaxis of sunstroke. Brit. iV. /., Lond., 1902, 
ii, 857. 

Freer (E» L.) Putties and varix in the Army. Brit. M.J. Lond., 1902, 
ii, 1807. 

Hiller (AO Der Hitzschlag auf Marschen, mit Benutzung der Akten 
des Preussischen Kriegsministeriums. Berlin, 1902, 

MILITARY SURGERY. 

Axhauaen (G.) [Antisepsis or asepsis on the battle-field.] 8*. Berlin, 
1902. 

De Crecchio (G.) Sulla perdita di peso dei proiettili da rivoltella nelle 
ferite penetranti del cranio. Arte med.^ Napoli, 1902, iv, 653. 

Habart (J.) Kriegschirurgische Betrachtungen iiber den sudafrikan- 
ischen Krieg. Militaerarzt^ IVien, 1902, xxxvi, 97; 131. 

Hlckson. Gunshot wound of the perineum. Brit. M. /., Lond., 1902, 
ii, 1649. 

Kanenstein (E.) [How gunshot fractures of the diaphysesof long bones 
are produced.] 8^ Berlin, 1992. 

LaGarde (L. A.) (^unshot wounds of the head and cranium. Med. Com- 
municat. Mass. M. Soc, Bost., 1902, xix No. i, 287-291. 

Laval (EJ Les blessures de Tarticulation coxo-f^morale par balles de 
petit calibre. Cadude^ Par., 1902, ii, 197. 

Levy (AO & Ponsot cR.) Accident mortel au ter k la cible par une balle 
Lebel tiree k courte distance. Arch, de med. et pharm. mil., Par^ 1902, xl, 
145-152. 

MathioIltJs» [Observations on the condition of military surgery]. 
Deutsche Ztschr.f. Chir., Leipz., 1902, Ixvi, 199-22 1. 

Nancrede (C. B.) The results of wounds of the large joints made by 
modern military projectiles. Ann. Surg.^ Phila., 1902, xxxvi, 368-378. 

MosherCW*H«) Ancient and modern weapons. Buffalo M, J., 1^1-2^ 
n. s., xli, 906. 



Bbitodal Departments 

ALTERATIONS OF THE CONSTITUTION AND BY-LAWS 

OF THE ASSOCIATION NECESSITATED BY ITS 

INCORPORATION. 

THE following proposed alterations of the Constitution and 
By-Laws of the Association of Military Surgeons thought 
to be demanded by the act of incorporation and the new 
status of the Association secured by it, are presented for the con- 
sideration of the members. Only the amended articles and sec- 
tions are presented, those not requiring change or requiring re- 
numbering only not being reprinted. 

PREAMBLE. 

The Medical Officers of the Army^ of the Navy^ of the Public Health 
and Marine Hospital Service of the United States^ and of the Militia of the 
different States^ under the provisions of an act of Congress approved fanu- 
ary jo^ igoj^ have associated themselves together under the name of " The 
Association of Military Surgeons of the United States.'''' Now y therefore^ 
pursuant to the laws of the United States ^ the* members of said Association 
do hereby ordain and enact the following : 

CONSTITUTION. 

ARTICLE I. 

NAME. 
The Association shall be known as "The Association of Military 

SlTRGEONS OF THE UNITED STATES." 

ARTICLE II. 

OBJECT. 

The object of the Association shall be to increase the efficiency of the 
medical services of the Army, the Navy, the Public Health & Marine Hos- 

(187) 



188 EDITORIAL DEPARTMENT, 

pital Service, and of the Militia of the different States by mutual association 
and the consideration of matters pertaining to the medico-military service of 
the United States both in peace and in war. 

ARTICLE III, 

MEMBERS. 
CLASSIFICATION OF MEMBERSHIP. 

Section i. There shall be Active, Life, Associate, Ex-Officio, Corre- 
sponding and Honorary Members. 

members eligible to office and ENTITLED TO VOTE. 

Section 2 

ACTIVE members. 

Section 3 

LIFE members. 

Section 4. Life membership and exemption from the payment of an- 
nual dues is conferred upon — 

I. Members who obtain first honorable mention in the prize compe- 
titions of the Association. 

2 

associate members. 
Section 5 

EXOFFICIO members. 

Section 6. The Secretary of the Treasury, the Secretary of War, the 
Secretary of the Navy, the Surgeon General of the Army, the Surgeon Gen- 
eral of the Navy, the Surgeon General of the Public Health & Marine 
Hospital Service, in conformity with the Act under which this Constitution 
is adopted, shall be ex-ofiicio members of the Association. 

corriisponding members. 

Section 7 

honorary members. 

Section 8. The President of the United States, the senior General 
officer of the Army, and the senior flag officer of the Navy for the time being, 
shall be honorary members. Other persons who have rendered distinguished 
services to the Association, or who have otherwise attained distinction de- 
serving of recognition by the Association, are eligible to honorary member 
ship. 



EDITORIAL DEPARTMENT. 189 

ARTICLE IV. 

GOVERNMENT OF THE ASSOCIATION. 

ADVISORY BOARD. 

Section i. There shall be an Advisory Board consisting of the Secre- 
tary of the Treasury, the Secretary of War, the Secretary of the Navy, the 
Surgeon General of the Army, the Surgeon General of the Navy, the Sur- 
geon General of the Public Health & Marine Hospital Service and the Pres- 
ident of the Association. 

OFFICERS. 

Section 2. The officers shall be a President, three Vice-Presidents, a 
Secretary and a Treasurer, who shall hold their respective offices until their 
successors are elected and qualified. 

EXECUTIVE COUNCIL. 

Section 3. There shall be an Executive Council, to consist of the of- 
ficers, the ex-presidents and six (6) members, who shall be appointed by the 
President each year. 

STANDING COMMITTEES. 

' Section 4. There shall be the following Standing Committees, to be 
appointed annually by the President, except as hereinafter specified: 

A Literary Committee 

A Publication Committee 

A Necrology Committee to consist of three (3) members. 

A Transportation Committee to consist of one (i) or more members. 

A Committee of Arrangements for the next ensuing meeting, to consist 
of one member, who shall be the chairman, with power to associate with 
himself such other persons, members of the Association or not, as he may 
see fit. 

A Nominating Committee 

boards of award. 

Section 5. Boards of Award shall be appointed by the President for 
the consideration of such prize competitions, as may from time to time be in- 
stituted by the Association. Membership in the Association shall not be re- 
quired of members of the Boards of Award, which shall be selected in each 
instance from men conspicuous for knowledge of the subject of the compe- 
tition. 

ARTICLE V, 

SEAL, INSIGNIA AND ARMS. 

SEAL. 

Section i. The seal of the Association shall consist of a circle, one 



190 EDITORIAL DEPARTMENT. 

and three-eighths (i|) of an inch in diameter, charged with the cross of the 
insignia with the words "Organized 1891, Incorporated by Congress, 1903," 
within a circumferential band bearing the words "Association Military Sur- 
geons United States." 

INSIGNIA. 

Section 2. The Insignia of the Association shall comprise (i) a Cross; 
(2) a Button. 

(i). The Cross shall be of gold, the obverse, enameled with red and 
bordered with gold, upon which shall be superimposed, a white shield, en- 
closing a shield of the United States in its proper colors, — red, white and 
blue, with stars of gold, — ^surrounded by the motto ^^Omnia pro Patriiu Car- 
itate^''\ the reverse, plain gold and bearing its number. Upon the reverse 
may also be engraved the name and address of the owner. The cross sus- 
pended by a ribbon, consisting of two bands of crimson enclosing a band of 
white, may be worn by any member of the Association on ceremonial occa- 
sions, and shall be carried on the left breast, — or at the collar, if the wearer 
be an officer of the Association. 

(2). The Button shall consist of a red enameled cross, outlined in gold, 
upon a field of white enamel surrounded by a blue band, three-fourths (f) of 
an inch in diamete routlinedon either side by circles of gold, and bearing the 
legend also in gold, ^^ Omnia pro Patriae CaritateP It may be worn by all 
members at their discretion in the upper left-hand button-hole of the civilian 
coat. ^ 

COAT OF ARMS, 

Section 3. The Coat of Arms shall consist of a shield, bearing in the 
center the cross of the insignia of the Association and, quartered about it» 
the caduceus, the acorn, the crossed anchor and caduceus and a crossed 
saber and rifle, surmounted by a red-cross guidon,— emblematic of the Med- 
ical Departments of the Army, the Navy, the Public Health & Marine Hos- 
pital Service and the State forces, — with a crest consisting of an eagle with 
butspread wings, bearing a Geneva Cross upon his breast, — emblematic of 
the patriotic and altruistic character of the Association. 

ARTICLE VI 

QUORUM. 



ARTICLE VII. 
amendments. 



EDITOR! A L DEPARTMENT, 191 

BY-LAWS. 
ARTICLE I 

ELECTION TO MEMBERSHIP. 



ARTICLE II 

EXPULSION FROM MEMBERSHIP. 



ARTICLE in. 

MEETINGS. 

ARTICLE IV. 

DUES AND DELINQUENTS. 

ADMISSION FEE. 

Section i. The admission fee to be paid by Active and Associate 
members shall be three dollars, ($3.00), which shall accompany the applica- 
tion for membership. 

ANNUAL DUES. 

Section 2. The annual dues shall be three dollars, ($3.00), due on the 
first of January of each year. No annual dues shall be required of new mem- 
bers for the remaining portion of the calendar year in which their admission 
fees have been paid. 

delinquents 

Section 3 

members exempt from dues. 

Section 4. Honorary, Corresponding, Ex-Oflicio, and Life members 
shall be exempt from the payment of dues. 

ARTICLE V. 

DUTIES OF THE ADVISORY BOARD. 

The Advisory Board shall meet at such times as the interest of the pub. 
He service may demand. Meetings may be called by one or more members 
of the Board and three members shall constitute a quorum. Any action 
taken by the Board shall be reported to the Association through the Presi- 
dent of the Association. 



192 



EDITORIAL DEPARTMENT, 



ARTICLE VL 

DUTIES OF OFFICERS. 
the president. 

Section i 

the vice-presidents. 

Section 2 

the secretary. 
Section 3 

THE treasurer. 

Section 4 

ARTICLE VII. 

THE EXECUTIVE COUNCIL. 
DUTIES. 

Section i. The Executive Council shall be charged with the conduct 
of the affairs of the Association during the intervals between the annual 
meetings, shall elect active and associate members, and perform such other 
duties as may be assigned to it by the Constitution and By Laws or by vote 
of the Association at any stated or special meeting, 

CONDUCT of business. 

Section 2. The business of the Executive Council may be conducted 
by correspondence or at such meetings as may be called by the chairman 
upon his own initiative or at the request of any three members. 

officers. 

Section 3. The president, the secretary and the treasurer of the Asso- 
<^iation respectively shall be ex-officio chairman, secretary, and treasurer of 
the Executive Council. 

quorum. 

Section 4. Five members of the Executive Council shall constitute a 
quorum for the transaction of business. 

ARTICLE VIII. 

DUTIES OF COMMITTEES. 
the literary committee. 

Section 1 

the publication committee, 
Section 2 

THE necrology COMMITTEE. 

Section 3. The Necrology Committee shall report to the Association 
at each annual meeting, the deaths that have occurred during the preceding 



EDITORIAL DEPARTMENT, 193 

year among the members of the Association, with a suitable memoir in each 
case. 

THE TRANSPORTATION COMMITTEE. 

Section 4. The Transportation Committee shall have charge of the iar- 
rangements for the transportation of members to and from the meetings of 
the Association. 

THE COMMITTEE OF ARRANGEMENTS. 

Section 5. The Committee of Arrangements shall have charge of all 
local arrangements for the annual meetings of the Association. 
the nominating committee. 

Section 6 

ARTICLE IX. 

DUTIES OF BOARDS OF AWARD. 

Boards of Award shall be charged with the selection of the person or 
persons to whom prizes shall be awarded, in accordance with the regulations 
of such prize competitions as may, from time to time,be instituted, and shall 
report the results thereof at such time as may be designated by the Asso- 
ciation. 



THE FIRST ARMY HOSPITAL CORPS COMPANY OF 

INSTRUCTION ORGANIZED BY COMPETENT 

AUTHORITY. 

I WISH to invite attention to a misstatement which appears in 
the review of the new Manual for the Medical Depart- 
ment of the United States Army in the February number 
of this Journal. The statement is to the effect that the first 
company of instruction organized by competent authority was in 
the Division of the Philippines, May 23, 1900. 

The Company of Instruction, Washington Barracks, D.C., 
was organized by authority of the Secretary' of War under date of 
August 16, 1893. This authority was in compliance with a re- 
quest of the Surgeon General dated August 5, 1893, that a com- 
pany of instruction be established at this station. The Company 
was designated First Company, November 8, 1902, and at the same 
time the Second Companj' was established which I believe had had 
no previous authority for its existence. Fredebick P. Reynolds. 



IReviews of Books^ 



THE IMPERIAL YEOMANRY HOSPITALS IN SOUTH 

AFRICA.* 

THE work of the Imperial Yeomanry Hospitals in South 
Africa in 1900-1902 is superbly set forth in the three 
sumptuous volumes produced under the direction of the 
Countess Howe. The three volumes are handsomely illustrated 
and devoted respectively to Organization and Administration, Field 
Hospital and Bearer Company, and Medicine and Surgery. Mil- 
itary medical work has rarely had so satisfactory a presentation, 
and both the editor, the publisher and the public, — as well as the 
officers whose service is so well pictured, — are to be congratulated 
upon the magnificent volumes produced. 



MEDICAL MICROSCOPY.! 

CLEARNESS and compactness are the most striking- 
characteristics of this little volume. Designed for the 
beginner in microscopy and particularly for him who 
must work without the advantage of the personal guidance 
of a teacher, the book is free from all accessory matter which 
might confuse the student in the absence of a guide to micro- 
scopical study. For this reason, but one method is given for 
the attainment of a desired result, that which in the author's 
experience has proven the best for routine work and at the same 

*The Imperial Yeomanry HoBpitals in South Africa^ J900-J902. Edited by 
the Countess Howe. 3 vols. Imp. 8 vo. London, Oliver Williams, 116 Vic- 
toria St., 1902. 

Medical MicroKopy.t Designed for Studentsjn Laboratory Work and 
for Practitioners. By T. E. Oertel, M.D. 8vo; pp, xxi, 362; 131 Illustra- 
tions. Philadelphia, P. Blakiston^s Sons & Co., 1902. 

(IM) 



REVIEWS OF BOOKS. 195 

time the simplest and least liable to error. The illustrations 
are good and ample in number, and the mechanical execution 
of the book is excellent. 



HEATH'S PRACTICAL ANATOMY.* 

A NINTH edition of this work has been issued by the pub- 
lishers for the student and practitioner. The volume 
has been curtailed in a manner by lea\Hing out the refer- 
ences to surgery and increasing its usefulness by distributing the 
colored plates throughout the volume, under the appropriate 
heading, instead of the beginning of book, as in previous edition. 
The revision has improved the appearance of the book and 
makes it, what it is intended for, — a ready reference for the stu- 
ent and practitioner. — A. R. Allen. 

PHYSIOLOGY! AND POISONSJ. 

THE little manuals of Brubaker on Physiolog-j and of 
Tanner and Leffmann on Poisons fill a clearly defined 
niche in medical literature as is witnessed by the fact 
that the former has passed through ten and the latter has ex- 
hausted eight prior editions. In each case careful revision 
has brought the work up to date and put it in line for con- 
tinuous usefulness. 



THE VENEREAL PERIL. § 

THE accomplished prize essayist of the Association of Mili- 
tary Surgeons for 1902 has produced a most practical 
and useful little guide book for the young soldier upon 
the most prolific source of disability in the military and naval ser- 

•Heath's Practical Anatomy. Edited hy J. Ernest Lane, F.R.C.S. 8 vo: 
pp. xviii, 696; 321 illustrations. Philadelphia, P. Blakiston's Son & Co., 1902. 

tA Gompeod of Human Physiology. By Albert P. Brubaker, A.M., 
l^.ly,^ Eleventh Edition, Revised and Enlarged. 12 mo; pp 270; 34 illus- 
trations; Philadelphia, P. Blakiston's Son & Co., 1902. 

{Memoranda on PolBons. By Thomas Hawks Tanner, M.D. Ninth 
Revised Edition, By Henry Leffmann, M.D.; 24 mo; pp. 177; Philadel- 
phia, P. Blakiston's Son & Co., 1902. 

§The Veneieal Peril. For the Information and Guidance of Young 
Soldiers. By Lieutenant Colonel Valery Havard, U.S.A. 8 vo; pp. II. 



196 RE VIE WS OF BOOKS. 

vices. Chancroid, gonorrhea, and syphilis are correctly but non- 
technically described, with emphasis upon the sequelae and re- 
mote consequences of infection. The booklet closes with a sec- 
tion consisting of good advice stated in so manly and honest a man- 
ner as to be calculated to deeply impress the young men for whose 
instruction it is designed. 



SAUNDERS* AMERICAN YEAR-BOOK.* 

THE volume on surgery for the year 1903, shows the usual 
careful editing and abstracting displayed in the previous 
volumes. The subjects, covering the different fields of 
surgery, have been carefully selected and represent the leading 
articles published during the past year. In addition the cuts and 
plates of the original articles have in many instances been used to 
elucidate the text. 

The indexing has been well done, and as the articles are 
carefully grouped, reference to any subject is an easy matter. 

The book has become a necessity to the profession for its con- 
ciseness and reliability; as well as for its value as a work of refer- 
ence. — A. R. Allen. 



*The Amcfican Year-Book of Medidnc and Surgery for )903« A vearly 
Digest of Scientific ProCTess and Authoritative Opinions in all branches of 
Medicine and Surjg^ery, drawn from journals^ monographs, and text-books of 
the leading American and foreign authors and investigators. Arranged, with 
critical editorial comments, by eminent American specialists, under the edi- 
torial charge of George M. Gould, A.M., M.D. In two volumes— Volume 
II, General Surgery^ Octavo, 670 pages, fully illustrated. Philadelphia, New 
York, London: W. B. Saunders & Co., 1903. 



OBSERVATIONS ON WOUNDS OF NERVES. 
By captain JAMES P. WARBASSE. 

« 

OF NEW YORK. 
ASSISTANT SURGEON IN THE NATIONAL GUARD OF NEW YORK. 

SINCE Cruikshank's studies in 1776 upon wounds of nerves 
and thei J regeneration, avast amount of literature, embody- 
ing observationson these subjects has accumulated; and in no 
department of scientific work have there been wider discrepancies 
of opinion and greater evidences of inaccuracy of observation than 
in this. These inaccuracies have arisen from our incomplete 
knowledge of the physiology and pathological anatomy of the 
nerves, and from the wide divergence between the respective 
fields of neurology and surgery. The culpability has lain largely 
on the side of the surgeon, who has not appreciated fully the 
highly specialized character of the tissue with which he has been 
dealing; while the neurologist may be accused of a failure to ap- 
preciate the possibilities of the most advanced surgery. The sur- 
geon particularly has oftenest lost sight of the long period which 
may in some cases be required for the regeneration of a nerve and 
the restoration of its function; while both have in many cases 
failed to appreciate the phenomena of nerve anastamosis and an- 
omalous nerve distribution. Thus we have seen the operation of 
nerve suturing declared unsuccessful even before the process of 
degeneration could have been completed. On the other hand the 
operation has been regarded as successful when the restoration of 
function has been through ner^^e intercommunication or has been 
only apparent because of inadequate tests for restoration or be- 
cause of anomalous nerve distribution. 

The wounds of nerves which we are- called upon to treat vary 
from the slight contusion, which causes only a temporary conges- 
tion and local effusion of serum and white cells into the substance 
of the nerve, to lacerations or incised wounds involving the whole 



198 CAPTAIN JAMES P. WARBASSE. 

thickness of the nerve and the surrounding tissues. The charac- 
ter of the injury can not be determined from the immediate symp- 
toms. Identical symptoms may be produced by a severe con- 
tusion, a laceration or a complete division of a nerve trunk. The 
pain at the time of injury of a mixed nerve usually is not severe. 
It may be only a flash of pain or be referred as an instantaneous 
shock felt over the distribution of the nerve. I have had a man 
who was shot through the brachial plexus tell me that he thought 
some one had struck him on the elbow. As soon as the commu- 
nication of a nerve is interrupted the consciousness of pain seems 
to end until the traumatic congestion or inflammation develops. 
Tingling or formication may be present, but these probably de- 
pend upon some condition such as hemorrhage or the irritation of 
parts lying against the wounded nerve. The degree of injury to 
the nerve is best judged by the muscular paralysis. However, 
even in contusions and slight lacerations complete paralysis may 
persist for several days, and then gradually subside. Restoration 
of function does not occur in this way in division of the nerve; 
when the division of a nerve is complete, the muscular paralysis 
is followed, within twenty-four hours by a diminution of far- 
radic contractibility. The muscle becomes flabby and less firm to 
the touch. This softness of the muscle continues to increase, and 
all the while the muscle shows less and less response to the 
faradic current until after a period varying from four to eight 
days there is no response at all. This is the conclusive evidence 
of complete interruption of motor impulses. Responsiveness to 
galvanism continues for a much longer time. This changes after 
some weeks to the reaction of degeneration. 

The symptoms of complete division of a nerve have been sim- 
ulated by pressure of a sharp edge of fractured bone. As a mat- 
ter of fact if the pressure continues, the condition is about the 
same; and the scar forming at the site of pressure may be likened 
to the scar of wounded tissue. ' 

Without seeing the divided nerve a diagnosis of division can 
not be made until all of the functions of the nerve have been 
studied — touch, pain, temperature, pressure, and localization 
senses. Many of the symptoms may point to nerve division: there 



OBSER VA TIONS ON WOUNDS OF NER VES. 199 

may be absence of pain*sensation and muscular impulse, but the 
touch sense may remain. If any evidence of impulse transmis- 
sion remains, it is probable that the nerve has sustained a con- 
tusion or incomplete laceration. But always in determining these 
signs, the various intercommunicating, recurrent, and anastamos- 
ing branches must be borne in mind, and also the possibility of 
anomalous distribution. Because of the fine intercommunicating 
nerve filaments under the skin, practicularly in the more sensi- 
tive parts such as the hand and face, the sensory paralysis never 
seems so complete as that of the muscles. 

Usually after the complete division of a peripheral nerve the 
patient has a sensation of cold in the paralyzed area. Kraussold 
and Rhoden found that after division of the ulnar nerve the tem- 
perature of the paralyzed area fell as much as 10° or 17" F. In 
rare cases a slight elevation of temperature has been observed. 

The large category of subsequent disturbances depend upon 
the less known functions of peripheral nerves. Disturbances of 
the nerves regulating the skin secretions, the vaso motor actions, 
the metabolism and nutrition of the part are all to be counted 
with. Thus there may be manifested burning, prickling pain, 
formication, an increase in the secretion of sweat, or excessive dry- 
ness of the skin. Cutaneous affections such as herpes, eczema, 
erythema, may appear. There may be disturbances in the nutri- 
tion of the skin as the formation of ulcers and gangrene. The 
skin, may become oedematous, shiny, cyanotic or abnormally pale. 
In the periosteum and bones there may be trophic disturbances. 
The joints may become the seat of effusion or exudation with de- 
formity and anchylosis. Even graver neuropathic conditions 
may be present, resulting in destruction of the joint or subluxa- 
tion. All of these conditions are the later symptoms which may 
appear after the degeneration of the nerve. They are important 
to the surgeon for by their presence he may know that the im- 
pulse transmitting capacity of a nerve is defective either before or 
after operation. 

It is not the intention of this paper to enter into the discus- 
sion of phenomena of degeneration. Let it suffice to say that the 
presence or absence of the reaction for degeneration should always 



200 CAPTAIN JAMES P, WARBASSE, 

be determined in cases of supposed traumatic interruption of im- 
pulses, and that the surgeon is usually eminently unqualified to 
make these tests. The occurrence of neuritis in divided nen'es is 
a matter of much surgical importance. The general belief and 
teaching is that a severed nerve will always degenerate, a con- 
tused nerve sometimes, but that there can be no rule for the oc- 
currence of inflammation. This is probably not altogether true 
as far as it applies to wounds of nerves, for it may be set down as 
a rule that the danger of neuritis is inversely as the wound is free 
from infective microorganisms. There is still much confusion re- 
garding this question of neuritis, for a large category of degen- 
erative changes which are not properly inflammations in any 
sense have been designated as neuritis. Striimpell claims that 
traumatic neuritis must always arise from an open wound, and 
that it is only from such wounds that ascending neuritis results. 
Aseptic wounds, he claims, never give rise to neuritis, but only to 
degenerative disturbances, followed by secondary degeneration, 
outgrowth of new connective tissue and finally by regeneration. 
According to the observations of Marinesco ^La Presse Medicale, 
Nov. 23, 1898) in an infected wound associated with neuritis he 
found streptococci infiltrating the diseased nerve near the wound, 
while higher up, near the cord, the sections of the nerve showed 
leucocytic infiltration but no bacteria. This he explained by the 
assumption that the ptomaines of the cocci had been transmitted 
up the course of the nerve through the lymphatics of the nerve 
and had caused the evidences of inflammatory irritation w^hichthe 
microscope had revealed. 

Traumatism to a peripheral nerve may apparently seem un- 
important at the time of injury, and yet the nerve may be left in 
such a condition that years afterwards a trivial cause may be suf- 
ficient to effect its complete paralysis. Weber (^Deutsche Zcitsch, 
fur Nervenheilkunde, Vol. XV, Nos. 3 and 4. p. 181.) has re- 
ported two cases of ulnar paralysis, in one of which an infection 
of the elbow joint preceded the paralysis twenty-seven years, and 
in the other thirty-three years. Careful investigation into many 
obscure cases of nerve paralysis would probably show that an old 
trauma or localized infection was the cause of the palsv. 



OBSERVA TIONS ON WOUNDS OF NERVES. 201 

In the cases of open wounds of nerves, the fact that some 
time always intervenes between the injury and the occurrence of 
the neuritis, and that the inflammation of the ner\'e usually is 
announced by a rigor, points pretty conclusively to the infective 
etiology of this complication. Large nerve trunks are more sus- 
ceptable to this inflammation than small ones, and the centripetal 
spread of the disease is common when infection is present. As 
far as the susceptability to this spreading inflammation goes, con- 
stitutional conditions seem to play an important role. In the 
other tissues of the body the character of the infection is the all 
important determining cause: but in nerve tissue the suscepta- 
bility to spreading inflammation seems very largely dependent 
upon the general resisting capacity. Thus in alcoholics, syphi- 
litics and other individuals whose resisting power, has been low* 
ered or whose tissues have been for a long time subjected to the 
vitality lowering effects of constitutional poisons, neuritis is prone 
to occur. 

When a nerve has been divided, and the reaction of degener- 
ation has supervened, and the wound has healed without compli- 
cations, the fate of the peripheral segment must depend largely 
upon the degree of separation of the divided ends and the amount 
and character of the connective tissue scar interposed. In the ul- 
timate process of regeneration, there is always a tendency for the 
upper segment to proliferate nerve tissue at its cut end. If these new^ 
nerve filaments reach the distal cut end, a communication is rees- 
tablished and nerve tissue may be deposited until the continuity of 
the nerve is fully restored. This is a natural reparative process 
which may always be hoped for, and which has required in some 
cases as long as twenty years for its completion. If there is but little 
intervening scar, and particularly if the fibers of the intervening 
tissue lie mostly in a direction parallel to the nerve, the restora- 
tion of function may be accomplished in a short time. If how- 
ever these favorable conditions do not exist, the reparative effort 
results in the building up of a mass of nerve and fibrous tissue 
at the end of .the proximal segment, which appears as a ball or 
club-shaped termination, while the paralyzed distal portion of the 
nerve lies atrophied and inactive. 



202 CAPTAIN JAMES P. IVARBASSE, 

111 operations for facial neuralgia a nerve has been divided or 
as much as two inches of its substance resected, and later pain 
has returned, by virtue of a restoration of nerve tissue across the 
defective gap. This has been particularly observed in the in- 
ferior dental canal. In such a case the intervening space after 
the operation has been filled by loose tissue, the common direction 
of the fibers of which has been parallel with those of the nerve 
filaments, thereby favoring and directing the new nerve growth 
towards the distal end. 

In the surgical treatment of wounds of nerves, the surgeon 
has these principles for his guide. The treatment of the wound 
should be so conducted as to give rise to the smallest possible 
amount of new connective tissue. In order to accomplish this, 
early suture and the prevention of infection are called for. Not- 
withstanding the reports of primary union of ner\'es and imme- 
diate restoration of function, which appear from time to time, it 
is still questionable whether this can occur in man. The experi- 
ments of Gliick proved that primary union could take place in the 
fowl and rabbit. Ten days after dividing and suturing the vagus 
in a rabbit, he has divided the nerve of the opposite side and the 
animal did not die; but when following this by division of the 
nerve that had been sutured, death has taken place immediately, 
showing that the suture had restored the function of . the nerve 
first divided. In man it is different; although some of Bowlby's 
cases almost suffice to prove the possibility of success. 

All experience up to the present time goes to show the ad- 
vantage of immediate suture. This should be *done as soon as a 
diagnosis of division of a nerve trunk has been made. When 
there is any doubt the nerve should be exposed and examined. In 
fresh wounds in the arm, I have been struck by the extent of re- 
traction which may take place in divided nerve ends. These may 
be found by extending an incision over the course of the nerve. 
When the ends have been secured they should be brought down 
until they will lie in easy contact. I believe it is a mistake to de- 
pend upon the suture to actually hold the ends together. The 
suture should be regarded more in the nature of a splint to steady 
the parts until union takes place. In order that the ends may lie 



OBSERVA TIONS ON WOUNDS OF NERVES. 203 

in easy contact it often becomes advisable to make traction upon 
the stumps to stretch them. This operation is not only not fraught 
with harm to the nerve, but is of positive assistance in securing 
the best result. 

Preeminently the best suture material is very fine chromi- 
cised gut or fine kangaroo tendon. Silk I believe to be seriously 
objectionable. I have seen it used by surgeons for this purpose, 
and I am satisfied that it can not be too strongly condemned. 
Every strand of silk left buried in the tissues, no matter how small, 
is surrounded by a capsule of new connective tissue. This is just 
what the surgeon should strive to eliminate in operations on 
nerves. The ends of the nerve should be evenly trimmed, and, 
having been stretched until they lie in easy contact, the sutures 
passed with the finest ix>ssible needle. In a nerve such as the 
median or musculo-spiral, the most satisfactory suture consists in 
four separate sutures of the four quadrants of the ner\'e's circum- 
ference, passed transversely through the nerve sheath about 3 or 
4 mm. from the end. Having applied these sutures, a layer of 
fascia should be sewed over the nerve wound to act as a splint and 
to further serve the purpose of eliminating dead space in which 
new connective can form. If fascia is not available then muscle 
or other tissue should be sewed over the nerve so as to lie firmly 
and closely in contact with the sutured nerve wound. When this 
operation is done without infection, the surgeon may await with 
confidence the restoration of the function of the ner\'e. It is from 
this time on, however, that the surgeon is wont to display how 
little of a neurologist he is. In all of his work he has accustomed 
himself to see improvement follow a successful operation. His 
mind is habituated to this condition. If improvement does not 
follow, the habit of his faculties evolves the impression of failure. 
These unreasoned impressions prevail the more strongly when, as 
is usually the case after primary suture, the symptoms of paraly- 
sis not only fail to improve but actually grow worse. The sur- 
geon, after his operation, sees the muscles grow more flabby and 
the limb atrophy from week to week, and the faith in his opera- 
tion fails him. On the other hand we have seen the surgeon, 
who discovers that the area supplied by the nerve which he has 



204 CAPTAIN JAMES P, IVARBASSE. 

just sutured is already sensitive to pressure and the prick of a pin, 
almost before degeneration has begun, and the suggestion of 
restoration of function comes to his mind. These are the reasons 
why the reports of the surgeon often are confusing and unre- 
liable. 

The secondary suture of divided ner\'es has become an oper- 
ation of great importance and satisfaction, and has bom witness 
to the persistent vitality of this highly organized tissue. It pre- 
sents the advantage that restoration of function may be accom- 
plished more quickly because the process of degeneration has been 
gone through with. This operation consists in dealing with a 
locus of interrupted nerve, which may be due to actual division 
and separation of the nerve, to a deposit of jBibrous inflammatory 
tissue, or to compression fronk \vithout. When the operation is 
done for division of nerve the two ends should be freely exposed, 
the intervening scar tissue removed, and the bulbous proximal 
extremity cut away until nerve tissue is exposed which is not 
densely infiltrated. In order to bring the ends together stretch- 
ing almost up to the point of evulsion is indicated. When this 
can not be accomplished any of the various neuroplastic operations 
may be attempted. The nerve may be lengthened by turning 
down a flap from one or both sides, by making a sliding flap of 
nerve or by grafting the two separated ends upon a neighboring 
nerve. Gliick has demonstrated the practicability of this latter 
operation. Where the paralysis is due to the presence of ner\'e 
scar strangulating the nerv^e cells or to exertional pressure from 
callus or angle of bone the exciting cause must be removed and 
the structure treated de novo as a divided ner\'e. The cardinal 
principle in all of these operations is the minimizing of the amount 
of scar tissue, and the bringing together of structures which are 
free from fibrous deposits. In wide separations the expedient 
of nerve grafting has been attempted by Atkinson and Moullin 
with doubtful success. The introduction of strands of cat gut to 
act as a trestle through which the new ner\x cells may be guided 
in this growth apparently in a few cases has proven of service. 
Forcible stretching even to concealed separation of the nerve I am 
inclined to look upon as the best of the last resorts. 



OBSERVA TIONS ON WOUNDS OF NERVES. 205 

After the wounds have been closed it is important that the 
limb or part be immobilized by splints in order to insure quiet of 
the muscles about the wound. After a varying period there is a 
return first of sensative and then of motion. The improvement 
in motion has continued as long as twenty years after the injury. 
Gradual improvement in sensation makes the outlook for motion 
encouraging. After two weeks, when the nerve ends have had 
time to unite, massage and electrization of the paralyzed parts is 
indicated, to maintain the nutrition of the soft tissues and pre- 
serve the suppleness of the joints. 

Surgeons do not fully appreciate the value of nerve suturing. 
If a satisfactory operation has been done the result must be 
watched for for months and years. Most cases are lost sight of 
after a few weeks or months, at which time the result looks bad. 
The surgeon mu.st have patience. If the nerve ends have been 
placed in good opposition he may with confidence leave the result 
to time. An examination of the voluminous clinical and physio- 
logical literature corroborates this hope. The failures in nerve 
suturing have been due to infection of the wound, too great ten- 
sion upon the nerve sutures, the use of unabsorbable suture ma- 
terial, and failure to remove or prevent the formation of nerve 
constricting connective scar tissue; notwithstanding these things 
successes have obtained in the presence of these hinderances. 

When in doubt as to the local condition of a wounded or 
sutured nerve the surgeon should have no hesitancy in making 
an exploratory exposure of the trunk in question. By this oper- 
ation many weeks or months of time may be saved. When in 
doubt suture, may be offered as a rule and guide. While time 
may be relied upon to remedy much, both in the removal of scar 
tissue and in the development of new nerve through gaps made 
by wounds, yet surgery' may be called upon in the aid of these 
natural processes. 

Above all the judgment of the neurologist is required, both 
to determine the extent and character of nerve injury in cases in 
which the wound of the nerve is not exposed, and to define the 
prognosis and progress of restoration. Because of the surgeon's 
incompetence to appreciate these things, our surgical literature is 
defective chiefly in this. 



THE EXECUTIVE ELEMENT IN THE TRAINING AND 
SKILL OF THE ARMY SURGEON. 

By JOHN NELSON GOLTRA, A.M., M.D. 

CONTRACT SURGEON IN THE UNITED STATES ARMY. 

I DESIRE to say at the outset that in preparing this paper I 
have been confronted with the thought that I am address- 
ing myself to men who are many times better able to speak 
upon this subject than I am. 

In the language of one whose effort has often been held up 
as one of the very greatest examples of oratory, '*I can but tell 
you that which you yourselves do know," and yet matters that 
are well known are sometimes benefitted by formal statement and 
discussion. It is desired that these remarks be understood to 
apply, not to garrison or even department duties, which are 
already admirably worked out, but to field and division hospital 
assignments — such conditions as are likely to arise under military 
operations. Without further explanation or comment I proceed 
to my first proposition, namely: 

I. The duties of an Army Surgeon are largely adminis- 
trative. 

This item of executive skill is the one component of which 
least may have been thought by either the appointing power or 
the appointee when the assignment to some certain duty or field 
service was made, but when the work is done and the account 
taken, it or the lack of it will always be found to have entered 
largely into the grand resultant of his success or failure. Especi- 
ally is this true of those duties pertaining to the higher ranks. 
A man may be preeminent as a sanitarian ; especially skilled in 
bacteriology and biology; a peerless surgeon; and withal he may 
be thoroughly conversant with the requirements of the Regu- 
lations, and yet not fulfill wholly the expectations and wishes of 
the Surgeon General when military operations are under way. 

(20(i) 



THE EXECUTIVE ELEMENT IN THE ARMY SURGEON. 207 

Reports of the sanitary condition and low death rate of troops 
now in the Philippines, show that both Medical and Line officers 
are making good use of knowledge gained in the severe schooling 
of the past four years. That this may be best preser\^ed; that the 
knowledge and experience of veterans of the Corps, unfortunately 
so soon to retire, may accrue to the newer men coming into the 
Corps; and that still further advances and still better methods of 
training may be evolved is precisely the object of this paper. 

A man is only what he is trained to be. However much 
genius may sometimes come to the aid of the unschooled, it can 
never take the place of training. It is too uncertain, too rare, 
and could not, even if possessed, fit a man for these duties. By 
exeattive faculty is meant that habit which consists, not in doing 
the work one's self, but in seeing that the right man does it at the 
right time and in the right way. Nor, still further, does it con- 
sist m. giving orders, but rather in establishing such a condition 
of affairs that each man, whether the range of his responsibility 
be wide or narrow, gives the orders suitable to his especial station, 
and sees that they are executed. It is not always the man who 
works the hardest that accomplishes the most. Too much de- 
pends uppn the direction of his efforts — his business tactics — in 
other words, his appreciation of the exeatiive principle. It fos- 
ters the esprit de corps, and by it a man is able to wield strong 
influence where he is not. For this reason it is essential in the 
putting into effect of those complex methods used to prevent the 
spread of contagion. Chance and uncertainty must surely be as 
far eliminated as may be, for direful possibilities are ho^fering too 
near. Therefore, 

II. The duties of the Army Surgeon demand, and require- 
ments fully Justify , the widest practical training it is possible to 
give him. 

And this is profoundly true, for the following reasons: 

A. — The enemy encountered by the Medical Corps is the 
deadliest one of all. It has become well established as a rule that 
armies in active service suffer much more and sustain much greater 
losses from disease than from wounds received in battle. But the 
extent of this disparity does not seem to be understood and ap- 
preciated by any but army surgeons themselves. 



208 CONTRACT SURGEON JOHN NELSON GOLTRA, 

To arrive at a fair estimate of it, it is obvious that figures re- 
lating to wars other than those of recent times are useless. Tak- 
ing note of those at hand of the last half century we find that the 
ratio of deaths from disease to that from casualties is approxi- 
mately as follows: 

In the Crimean War, 1854 4 to i 

In the Civil War, 1861-5 (North) 2 to i 

In the Civil War, " " (South) 3 to i 

In the Austro-Prussian War, 1866 ' i J to i 

In the Franco-German War, 1870-1 (exception) \ to i 

In the Russo-Turkish War, 1878 7i to i 

In the War of the French in Madagascar, 1896 560 to i 

In the Spanish-American War, 1898 about 8 to i 

Leaving out of account as -a monstrosity, the Franco-Mada- 
gascar war, the general average of these figures is 4 to 1. 
Again, 

B. — Given a disciplined army, the effectiveness of troops in 
action is measured largely by their health and vigor, and this de- 
pends in no small degree upon sanitary regulations. Disregard- 
ing for the nonce the humanitarian phase of the question, the 
dead soldier, as a burden, is only exceeded by the sick soldier. 
The same also may be said of him as a breeder and dis^minator 
of contagion. As has been well said, * 'The infirm soldier cripples 
the command of which he is supposed to be an effective instead 
of a burdensome part, and the care of him requires men, money, 
and transportation facilities needed for other purposes. Had of- 
ficers and men, during the mobilization of the army for the 
Spanish-American war, been as vigilant and careful in the pres- 
ervation of their own health and vigor as they were eager to get 
to the front, it is safe to say that the non-efficiency rate and the 
total death rate would not have been anywhere near as large as 
they were. 

With better executive training, more authority must come 
to the Surgeon in sanitary matters. He must not be guilty of too 
much official modesty, but must fnagmify his office, 

C. — The great problems of the etiology, transmission and 
prophylaxis of disease epidemics, so destructive to life in militar>' 
movements, are worked out wholly by the Medical Officer. While 
it may be top early to say absolutely that these questions concern- 



THE EXECUTIVE ELEMENT IN THE A RMY SURGEON. 209 

ing yellow fever have reached their final solution, yet indications 
point decidedly that way. And if our country received from the 
Spanish-American war no other bequest, it would be amply 
justified by this one splendid result. 

In view of these facts recent legislation concerning the Med- 
ical Corps must be regarded as * 'shortsighted** to put it in mild- 
est terms. 

Provision is made by the government for the education even 
from boyhood of the Line officer, but the Surgeon must first edu- 
cate himself and then none but the best need apply. Should he 
then and with equal financial and ofiEicial responsibility be offered 
only a volunteer commission, and be unceremoniously dropped 
when the government is through with his services, when he is to 
serve side by side with a Line officer of the permanent establish- 
ment, whose longevity pay and retired pay are guaranteed, and 
whose commission cannot be taken away except for cause? 

Again, the Surgeon is exposed, not only to the dangers of 
the firing line in common with his brother officers; but also to 
those of infection and contagion, fourfold more destructive as the 
figures show. Should then a niggardly policy be pursued toward 
him? That legislation which cripples and stultifies the Medical 
Corps takes rapid steps toward diminishing the effectiveness of 
the Army. 

In Captain Munson's splendid work on Military Hygiene, 
and more explicitly in that very excellent chapter on ** Military* 
Mortality and Morbidity" is shown by a painstaking study of the 
death and non-efficiency rates for very many of the more recent 
wars, an array of fact which we have no right to regard as indif- 
ferently and discuss as coolly as we do. These serve to confirm, 
the conclusions of one's more limited observations; namely: 

{a) That periods of inactivity during hostilities are more de- 
structive to both the health and the life of the soldier than 
are times of actual campaigning: 

(i) That the death rate from disease is apt to be several times 
larger during hostilities than it is in times of peace; and 
(r) That the increase in both the death and non-effective rate 
even in the ranks of the Regular Army, is due almost wholly 
to the increase in infective diseases, general and local. 



210 CONTRA CT SURGEON JOHN NELSON GOL TRA. 

These conditions are accounted for partly by the fact that, with 
the raising of new regiments, unseasoned troops are brought into 
the field, and with them come surgeons and assistant surgeons- 
whose training in sanitary and military matters is not what it 
should be. But they can not thus be fully explained, for the sta- 
tistics given by the author just quoted show nearly the same ratio 
of increase for the Regular Army. 

If some means could be devised or methods adopted for con- 
stituting and training a Reserve Medical Corps it would pay; for 
an untrained, or even a half -trained Medical Officer is by the very- 
nature of things an ally of the enemy. 

Some of the causes which operate to produce the results above 
mentioned are not under man's control, such for instance as in- 
clemencies of the weather, diminished vitality from exposure, and 
unhealthy locality, — but other causes ought to be. 

I do not propose to arraign nor yet to offer apology for the 
administration of any Medical Officer. The record speaks, and 
generally if not always tells of good and faithful work under the 
conditions. Each did the best he could, but most of us, I fancy, 
are conscious of a feeling that we could do better next time. 
Might we not have been so trained that we could have done better 
the first time? And this leads me to say, 

III. To the greater degree of authority of the Army Sur- 
geon should be added a better Executive Training. 

The Army Medical School is a splendid conception. It serves 
to make more thorough the professional skill and the scientific 
training which was and is and ever shall be of paramount im- 
portance. But it reaches only the younger men of the Corps, 
and the demands of the service are such that comparatively few 
can take the course. If its special instruction in military hy- 
giene and sanitary subjects could be supplemented by a careful 
study of the duties of management of some of our large city and 
state hospitals, with complete report of such study, its benefits 
would be multiplied. Much advantage would also accrue to both 
the Department and the Surgeon if the latter could be detailed 
to make brief but thorough examinations into and report upon 
the business methods and details of management of large civil 



THE EXECUTIVE ELEMENT IN THE A RMV SURGEON. 211 

hospitals, and even of the modern department store» as well. I 
once asked the head of A great department store, the stock of 
which was being constantly distributed by an array of delivery 
wagons and repleted by train-loads' of boxes, how he managed 
this enormous business without visible jar or loss, and he replied: 
"System, Doctor, system! That is our secret, and we could not 
run a week without it. ' ' 

The Surgeon ought to be able quickly to establish a Regi- 
mental, Field or Division Hospital on a business basis. He should 
be allowed to look after the transportation of his own supplies, 
and should be held responsible if they are not at hand when 
needed. 

There is a serious Umitaiion to the efforts of the Surgeon 
which ought to be mentioned here. The wisdom of the Hospital 
Corps, as a separate arm, is evident. It has been oft demonstrated. 
But the Surgeon, of whom results are expected, is not allowed to 
employ or choose his men. They are assigned to him. Nex'er- 
theless his success depend.s to a fairly large degree upon their in- 
dividual intelligence and faithfulness. In the Regiment the 
Company is the unit. But in the Hospital Corps the Private is 
the unit. 

He is the ultimate representative of the Surgeon. , In his 
first aid duties and at the bedside more than ordinary mental 
alertness is required. 

Therefore he should be of a higher grade of intelligence and 
stronger purpose than the average man, and to secure this should 
be better paid. 

The Surgeon cannot be too exacting in the training of the 
Hospital Corps and he should be allowed to weed out those found 
incapable of receiving the necessary training. Executive ability 
consists quite as much in getting rid of an incompetent man as it 
does in calling forth the best services of a good man. 

Understand me, I do not mean to insinuate for a moment 
that all these things, — and better than these — have not been con- 
sidered by those in authority of the Medical Department. But 
when you and I begin to talk of them, to urge them, to discuss 
and to educate, then we shall become the better able to hold up 



212 CONTRA CT SURGEON JOHN NELSON GOL TRA. 

the hands of those who strive for better things, and to help \x> 
secure the necessary and much- needed legislation. 

With a Military General Hospital as now, in the West, and 
another one or two in the East, it would seem that by short-term 
assignments to the management of the different departments of 
these, each Surgeon might be given the opportunity to study the 
various questions of hospital management and sanitary evolution,, 
and to determine for himself and develop his own resources. 

And if pending legislation should ever be enacted, as it prob- 
ably will be sooner or later, so that the various organizations of 
State Militia shall become a National Guard in fact as well as in 
name, then the men and officers of this National Guard who con- 
tract disease while in the sen'ice of the United States, should be 
allowed the privileges of these general military hospitals. Medi- 
cal Officers, also, of the National Guard should be allowed the 
privileges of instruction in these hospitals on the same terms as 
other officers of the National Guard are to be allowed the privi- 
lege of the various service schools of the U.S. Army, The ad- 
visibility of such a measure is shown by the f^ct that during the 
Spanish-American war a considerable per cent of the Medical offi- 
cers who entered the service from civil life had been attending some 
militia organization. 

To the possible objection that the measures herein suggested 
would not be practicable, I answer: Anything is practicable which 
will bring about improvemt commensurate with its cost. For 
you and me, that is practical which will make of us the best pos- 
sible men. And for the Goveniment, that is practicable which 
will give it a Medical Corps of the highest degree of efficiency, 
even though the cost be great, which, however, it would not be 
in this case. 

To the objection that few if any would ever put into use such 
training I answer: Not all might, but .some would be certain to. 
Warships of every nation have ru.sted and rotted down without 
ever going into action but no government stops building warships 
for that reason, and it would be difficult to prove that those not 
in action have never done any good. 

Infinitely more to the purpose is it to train well in all his 



THE EXECUTIVE ELEMENT IN THE ARMY SURGEON. 213 

faculties, the Army Surgeon, for his wisdom, his training, his 
skill will crystalize into knowledge of better sanitary regulations 
and better methods, and will become the traditions and habits of 
a better, because a more effective military organization. 
•DISCUvSSION. 

Lieut. Col. Valery Havard, U.S.A.:— I am certain I 
heartily favor the education of medical men so far as it is possible, 
and all classes of medical men. Our regular medical officers 
already receive a practical training at a special school, and I do 
not see why this training should not also be imparted to the civ- 
ilian doctor or contract surgeon. We know that the great ma- 
jority of our soldiers are in the hands of civilian doctors and con- 
tract surgeons; that the number of medical officers is always too 
small to answer the demand. Now our soldiers are entitled to 
the very best medical attendance, to the ver>' best skill of medical 
ofl5cers, and I am afraid that they do not get it, and that a very 
great injustice is done on that account. As we know, a civilian 
or contract surgeon may be a very skilled practitioner, he may be 
a very experienced doctor, but what avail will it be to him if he 
does not know how^ to draw a ration, to select a good cook, if he 
does not know how to prevent disease? I know that in Cuba 
where I had charge at one time of 25 or more hospitals, I do not 
believe there were more than three or four in charge of regular 
medical officers. All the others were in charge of contract surg- 
eons, most of them excellent men, but without this training, with 
little practical knowledge of their duties as medical officers — most 
of them good physicians but indifferent medical officers, with no 
idea of their duties as sanitary officers so as to prevent disease 
and get everything that was obtainable for their patients. And 
in that way, as I said before, a great injustice has been done and 
will continue to be done to our patients in the future unless our 
civilian doctors or contract surgeons receive a special training in 
the duties of medical oflBcers in addition to their professional 
knowledge. I do not see why a school of that kind could not be 
established and maintained here, for instance, in connection wit]i 
the regular school, or as part of that .school already established 
for regular officers. Certainly it is very necessary if not indis- 
pensable, 'and would certainly be of the greatest benefit to our 
soldiers, especially in the field where they are in need of attention 
and entitled to every care. 

The President: — Major Appel has charge of the Sanatorium 
at Fort Bayard, a very extensive hospital. Perhaps he would 
enhghten us as to its administration in the line of discussion of 
this paper. 



2 14 CONTRA CT SURGEON JOHN NELSON GOL TRA . 

Major D. M. Appel, U.S.A.: — I hardly understand in what 
respect the President desires me to discuss this paper in connec- 
tion with the Sanatorium. 

The President: — From the administrative point of view. 

Major Appel: — The General Hospital at Fort Bayard was 
established for the treatment of a special class of diseases. It 
was an entirely new idea to have a hospital for the treatment of 
cases of tuberculosis, and the order establishing it said that it 
shall be conducted according to rules and regulations prescribed 
by the Secretary of War. Shortly after the hospital was estab- 
lished, the Surgeon General visited it and after inspecting it, 
noting the administration and organization, I asked him when I 
would receive the rules and regulations from the Secretary of 
of War, — some six months after it has been established. He in- 
formed me that the Secretary of war had delegated him to make 
the rules and regulations and that he would delegate me. I then 
asked him for suggestions, and he said *'goon." Every rule and 
regulation, therefore, of the hospital was framed by myself, and 
it being a special institution for the treatment of a special class 
of cases the conditions are in many respects unique and peculiar, 
to which the regulations will frequently not apply. Therefore 
all the regulations are the result of experience in the hospital. 
Patients there — differing from those in ordinary hospitals — are 
expected to remain a long period of time. The large majority 
are not confined to the bed. and they are divided therefore into 
ambulant cases and bed-ridden cases. Most of the ambulant cases 
are apparently as well able to take care of themselves as any one 
in this room. It is necessary in spite of this to have very rigid 
rules, disciplinary rules, which would not apply in ordinary cases. 
These rules apply of course to the general hygienic regime. 
Probably 90 per cent of the cases are not bed-ridden, and it was 
necessary to make rules to compel them to live as prescribed. Of 
course the principal treatment in our hospital is the out-door 
treatment. The next important factor is the rest, both physical 
and mental. Probably in no other military' hospital would it be 
required to make regulations to prevent patients from playing 
poker. It was necessary also to establish a rule forbidding the 
.smoking of cigarettes, establishing the hours when the patients 
should retire, rules for the length of time they must remain at 
the table during each meal, etc. All these questions arose and 
were met as the result of experience. Of course the most im- 
portant prohibitory rule is that patients shall not expectorate on 
the ground or anywhere else except in their paper cups. Out- 
side of the special rules it was necessary to establish at the hospi- 
tal, all the ordinary regulations of every general hospital would 



THE EXECUTIVE ELEMENT IN THE ARMY SURGEON. 215 

apply, excepting of course that in our hospital we have men who 
have been discharged from the service, but being military service 
men who are entitled to the benefits of the soldiers' home, and 
being in a military hospital they understand that they must sub- 
mit to military control; but frequently after committing offenses 
they protest against being punished as soldiers. I have always 
insisted, however, that they must first suffer such punishment, 
and then they can leave if they desire; but having voluntarily re- 
mained in the hospital as patients they must first submit to pun- 
ishment whether still in the ser\''ice or not. There are a great 
many points in the administration of such an institution. New 
points continually arise. It is a good school for the study of ad- 
ministration, and the assistants who are in charge now continue 
the rules that have been adopted in the regulations. We have 
very few general hospitals in the service and therefore very little 
opportunity for the medical officer to study their administration. 
Until the recent war we had but one general hospital, that at Hot 
Springs, Arkansas. It would therefore be very desirable to es- 
tablish such a school as the writer of the paper recommended for 
the instruction in administration of medical officers. 

The President: The question of administration might be 
discussed for the great benefit of the Association by Colonel Niel- 
son, who is the administrative medical officer of the Canadian 
forces. Will Colonel Nielson favor the Association with his views? 

Colonel J. L. H. Nielson: I feel honored by being called 
upon by you to address this meeting. I thank you. I doubt 
whether anything I could say on the subject would be of very great 
value to my hearers. Our conditions of service are entirely dif- 
ferent from yours. Across the border we have a citizen army. 
We have hardly any regular soldiers. We have an administra- 
tive staff and a few regularly enlisted men forming a regiment 
called the Royal Canadian Infantry. We have two batteries of 
field artillery, and two squadrons of cavalry. These form an in- 
structional school for our citizen soldiery. We therefore, have 
not large permanent hospitals, not does it call for much adminis- 
trative ability in our own medical officers who have charge of the 
small infirmaries connected with these regular soldiers. But 
should occasion offer, and during our annual camps of training 
exercise, we have larger establi.shments of a very temporary na- 
ture. We have small field hospitals, and so on, where our militia 
surgeons receive their annual training as well as the combatant 
officers receive their training in artillery, in infantry, and in cav- 
alry. This period of training being short it is necessarily ele- 
mentary. We, however, endeavor to convey to these militia 
medical officers a fairly good knowledge of what they would be 
required to do if embodied in case of emergency. We have for 



2 16 CONTRA CT SURGEOiXJOHN NELSON GOL TRA, 

that purpose classes, and the militia surgeons before being con- 
firmed in their commissions are obliged to take a course of in- 
struction in these camps, or sometimes a satisfactory course of 
training at one of the large military centers. There all these 
junior officers who have just been appointed gather together and 
follow a course of seven days. You cannot expect that in seven 
days they will be very thoroughly grounded in the necessary 
knowledge of their duties, but they are eye-openers of consider- 
able value; and when these courses are repeated every 12 months,, 
after two or three years of attendance our military .surgeons get 
to have a fairly good idea of what will be required of them were 
they embodied or mobilized for actual service. In Ottawa next 
week there will be one of these courses. A number of recently 
appointed militia medical officers will be gathered there and will 
follow that course. It consists of nearly ten hours of work a day, 
practical and theoretical, and at the end of it all is an examin- 
ation, oral and written, and only after an officer has qualified and 
has passed with 70 per cent or more of marks will he be confirmed 
in his commission, and if he fails to pass a first examination he 
may take a second; but if he fails in that his name will likely be 
dropped from the militia list. So I do not see that our services 
are in any way parallel, but I wish simply to emphasize the fact 
that we are fully aware of the necessity of training for our militia 
officers in their executive and administrative work. 

Captain E. L. Mitnson, U.S.A.: — It seems to me that the 
remarks of the President of the United States* this morning were 
particularly fortunate in that respect. He brought out the neces- 
sity for .special study along professional lines. He emphasized 
the fact that administrative ability was of special importance. 
That is a point which we cannot lay before the general public too 
forcibly or too frequently. The practitioner in civil life, no mat- 
ter how good he may be along his special lines of practice, fails 
as a military surgeon unless he has had special training in the 
military surgeon's special duty. The doctor in civil life cannot 
take the place of the army surgeon. He can do subordinate duty 
in his restricted line of work, but until he has had special train- 
ing in administrative work he will fail completely in the handling 
of large problems, in the performance of the very varied class of 
business which the anny medical officer is necessarily called upon 
to do. I think that the President spoke from his own experience. 
He showed that he appreciated that a good doctor was not neces- 
sarily a good medical officer; and that is the point that we should 
emphasize, that we must have trained men with troops, and that 
the doctor does not answer the purpose. 

♦See Journal, vol. xi, page 44. 



THE EXECUTIVE ELEMENT IN THE ARMY SURGEON. 217 

Lieut. Col. N. S. Jarvis, N.Y.: — This is a subject that par- 
ticularly interests me because since becoming a medical officer of 
the New York Guard I have been the senior surgeon of what we 
consider the most important brigade in a body of 15,000 men. We 
have in ray brigade in New York City about 3,500 men, and the 
medical officers of that brigade have always prided themselves on 
having obtained an unusual reputation as military doctors, and 
that reputation has been kept up to this day. Within the last two 
or three years the legislature has passed .some laws and regula- 
tions requiring a fairly rigid examination for appointment as med- 
ical officers. It consists, first, as to the officer's physical fitness; 
second, a so-called civil service examination; and third, a profes- 
sional examination. The latter also includes an examination in 
military hygiene and general .sanitation. Now the great majority 
of us as students in medical colleges learned nothing of military 
hygiene— I am certain I never learned anything about it, it was 
not considered at all. There are very few colleges in this country 
that teach the subject of military hygiene, so that however com- 
petent, however intelligent the doctor may be who is nominated 
for a commission in a New York regiment, he rarely knows any- 
thing about military hygiene; so that if we applied the limitation 
of 70 per cent in order to receive a commission in a New York 
regiment we would get no medical officers. As far as their knowl- 
edge of medicine is concerned very few are incompetent. So it 
has been our unfortunate experience to reject this winter one 
v^ery excellent man. Now I have by virtue of being the senior 
medical officer carried out the rule of sending for the young doc- 
tor as soon as his name is submitted to the board and informing 
him that he would be examined fairly rigidly on military hygiene, 
that we had to comply with the regulations, and in order that he 
might have plenty of time to prepare himself we would postpone 
the examination for one or two months if necessary. Of course 
his commission would be held up during that time; and I have 
gone so far as to designate works that he should look up, all of 
which can be obtained in the iVcademy of Medicine. So by fol- 
lowing that routine we have passed quite a number of competent 
men — at any rate, they have a foundation upon which to work. 
I only mention this fact because it is rather new in our State, and 
ours is the only brigade in the State that has a medical examin- 
ing board, and I made up my mind that as long as I am president 
of that board I would see to it that no man passed who did not 
know something about military hygiene, at least in a theoretical 
way. 

Captain A. R. Jarrett, N.Y. : — The evident desire to im- 
press upon our minds the necessity of knowing as much about 
questions of administration as we know about medicine hardly 



218 CONTRA CT SURGEON JOHN NELSON GOL TRA . 

strikes me as the proper thing. It seems to me that the first and 
primary aim of the medical man is that he should be a medical 
man, that his knowledge of medicine and surgery should be so 
far superior to and above his knowledge of administration that the 
officer and soldier with whom he comes in contact and with whom 
he must treat will have that confidence which mere knowledge of 
administration would not inspire; and I have noticed that a great 
many officers of the line have been very much more impressed 
with the idea that the medical officer was typically a first-class 
surgeon or a physician than that he was a man who knew more 
or paid more attention to the administration of his office. I thmk 
the patient will be far more benefited by his knowledge that the 
officer paid more attention to the treatment of his patient than to 
the correct signing of a paper or of straightening out some tangle 
with reference to the drawing of a ration, or the issuing of cloth- 
ing, or of the disciplining of a man, and would I think go a 
greater way toward helping the patient to recover than if he 
thought that he had more ability in the line of administration than 
he had in treating the patient. My attention has been called to 
that frequently on account of the line officers saying to me that 
they notice very often that after a doctor comes to be a captain or 
a major he has a great deal more interest in the paperwork or the 
work of administration than he has in the practice of medicine; 
and that has been brought to my mind on account of the great 
stress that has been laid upon the training of an officer chiefly in 
the administrative part of his work. A great deal of that has been 
done very faithfully by the hospital stewards, who help out so 
wonderfully the medical officer; but at the same time, without 
wanting to dissent for the sake of dissenting, I feel it is a great 
deal better to think of myself trained more as an able surgeon and 
medical officer and have the admiration and respect that I would 
produce by my ability than to have the soldier feel that I was pay- 
ing more attention to something that is outside the line he ex- 
pected me to do. 

Major A. H. Briggs, N. Y. : — One word only to correct a 
statement of Colonel Jarvis'. I believe he stated that the First 
Brigade was the only brigade in our State that had an examining 
board for medical officers. Inasmuch as that remark will be crys- 
tallized in our report, I wish to say that the Fourth Brigade of 
the State of New York had a medical examining board five years 
before the legislature passed that bill, and every medical officer is 
rigidly and thoroughly examined as to his qualifications, and has 
been for several years. 

Major AzEL Ames, U.vS.V.: — I hate to have occasion to dif- 
fer from my very dear comrade [Capt. Jarrett] in his conclusions 
on any matter, but I am not wholly in accord with the expression 
he has just made. I don't know but that the matter resolves it- 



THE EXECUrn'E ELEMENT IN THE A RM Y SURGEON ^ 219 

self a little into the old question that used to be agitated in the 
debating societies of the country: "Which is the more important, 
the hen that laid the ^%% or the hen that hatched it?" I do not 
know that it has ever been settled, but I do know that both were 
needed; and I do know, and you all know, that executive capac- 
ity and scientific ability must go hand in hand or both fail. The 
simple fact is that there is no better word or expression in our 
language than that of applied science. We must have our Stem- 
bergs, our Reeds, our Carrolls, our Bordens, our Appels. and all 
others who are hard at work on the scientific features, because 
those are the basis knowledge; but who is going to apply these 
things? I remember a very dismal time in an experience in the 
campaign of the Gulf, in 1863. The regiment marched into a 
field to camp for the night in two inches of water, and the men 
had to get along the best they could. They had to stay there 
two or three days. We had some capital surgeons; they embraced 
good, loyal men whose names you would recall. But there was 
just one man in that outfit who knew enough to drain that field. 
He had the practical sagacity and the required know^ledge to put 
a lot of men at work to rig up an Egyptian pump and drain that 
field, and in less than eight hours he had that field dry and was 
throwing up a trench around it. That is the sort of practical sa- 
gacity it seems to me we most need in times of emergency for the 
welfare of an army quite as much as whether or not this, that or 
the other bacteria or bacillus or some other unknown cause is at 
the bottom. You cannot have too much knowledge, that is im- 
possible — just as it is impossible to have an over-production of 
wealth; you may have over-distribution but you do not get over- 
production of wealth. It is true that if you have not the knowl- 
edge you cannot apply it, but w^hat is the knowledge worth if you 
cannot apply it? I have had an experience covering two wars, 
and I want to express my very cordial appreciation of Dr. Goltra's 
paper as being along lines of practical development. I remember 
that our honored President said to me in Porto Rico one day that 
"In the regular army, especially the medical corps of the regular 
army, we have a different line of thought, we use a different lan- 
guage to a great extent, have different ideas from our brethren in 
civil life because our liife is so largely a matter of regulations, 
training, and of limitations; while you men who come in from 
the larger life bring in a freshness and a different range of 
thoughts which applied to our own oftentimes help both.'* And 
that is so I think. The department store idea is not such a bad 
one after all. There are business elements, there are capacities 
for great and effective work along the lines of system developed 
in these great caravansaries of industry, that we need, and if we 
can apply them, so much the better for the service and so much 
the better for humanity. 



SOME POINTS IN THE TRAINING OF HOSPITAL 
CORPS SOLDIERS. 

By captain FRANCIS A. WINTER. 

ASSISTANT SURGKON IN THE UNITED STATES ARMY; LATE MAJOR 
AND SURGEON OF UNITED STATES VOLUNTEERS. 

THERE are many lessons which have come to the Mili- 
tary Surg-eon from the Spanish-American and Philip- 
pine wars, and one subject which has g-otten a pretty 
thorough elucidation is that which looks to the provision of 
suitable care and attention for the sick of armies in the field. 
The prime element in this provision must necessarily come 
from the personnel of the Corps, which is charg-ed with the 
duty of looking after sanitary matters, and this must serve as 
my reason for selecting^ as the subject of this paper, the rather 
threshed out subject of Hospital Corps training*. I do not ap- 
proach the subject, with any very sang-uine hope that I am 
g-oing- to be able to contribute any thing- emphatically new, 
but it is rather my desire to set forth some of the observations 
and opinions, which have come to me, in the practical hand- 
ling- of the subject during- the past three years. 

I would first invite your attention to a consideration of 
the matter of Litter and First-Aid Drill. Like most military 
evolutions, the results to be obtained from this particular 
feature of Hospital Corps training-, reach very far beyond the 
mere facility of carrying out a routine, and, as a part of a 
g-eneral training- it has a very g-reat deal to commend it. I 
think that a g-reat many officers have questioned the benefit 
coming from it, as being- rather small, considering^ the amount 
of time necessary to the perfection of the averag-e soldier in 
its details. It does involve no inconsiderable study and prac- 
tice to master all the details of the drill reg-ulations, and there 
is a good deal to confuse the beginner, and make him think 

(220) 



TRAINING OF HOSPITAL CORPS SOLDIERS. 221 

that he has struck a rather complex affair, when he first goes 
at it. 

I have heard many discussions as to this question of ben- 
efit, and our friends of the Line have had much sportive dal- 
liance with many of us, over our hypothecations of injury, 
etc., in the case of our supposedly **wounded." At the same 
time there are none of these jocular scoffers, who have seen the 
practical workings of the system on the battle field who are 
^not willing to concede the immense amount of real good which 
follows the trail of a Hospital Corps detachment, which has 
been well instructed in the handling of wounded, litters, etc. 
One of the most signal instances of this revulsion of feeling, 
of which I ever heard, happened in the case of a Cavalry offi- 
cer, who was in his way an iconoclast on the military features 
of the Medical Department, as elaborated at his station. This 
officer was a participant in an Indian fight, wherein this same 
butt of his "pretty wit," proved itself, by saving the lives of a 
good many men of his regiment on the firing line. When he 
got back to his station he had seen the good which follows 
thorough training, and he became a pretty thorough and en- 
thusiastic convert to first aid drill and all that it implies, when 
it is carried out properly. I have heard that officer say that 
he was not only '^willing to call that Doctor 'Major', but he 
can have any other title he wants." 

Certainly any one who has seen the clean, neat, precise 
transfer of a helpless man from the ground to a litter, from a 
litter to a bed, etc., when it is done by the rule of art, must 
concede, even on this basis, that the teaching is well worth 
while. This sort of handling certainly lessens pain and pus, 
and it saves life. The wounded soldier who receives such as- 
sistance in his misfortune is very much to be congratulated. 
But beyond the result attained in the rapid and merciful hand- 
ling of the sick, we can reckon upon the sure effect of the drill 
on the general conduct and efficiency of the man who is drilled. 
It really drills him, teaches him that he is preeminently an 
agent, and this realization is good and salutary for him. 
Show me a detachment at a post, where Utter drill is carried 



222 CAPTAIN FRANCIS A. WINTER, 

out regularly and profitably and I shall expect, with the ut- 
most confidence, that there will be no dirt in the wards of the 
hospital, that the beds will have clean sheets upon them, and 
that the bed patients will have clean fing-er nails. In my opin- 
ion it is very much the keystone of the whole fabric, in the 
making- of the sanitary soldier, and its results are, as I have 
said, very far reaching in the promotion of general efficiency. 

Nevertheless I think that it is possible to overdo the mat- 
ter of this drill and make it an irksome affair, begetting in 
the mind of the soldier a distaste for the drill hour, which is 
almost insupportable, and fostering in him a spirit which 
makes him indifferent to the instruction he receives. 

The vast majority of the men we attempt to teach are re- 
ceptive up to a certain point only, and most efforts to carry 
them beyond the rudiments, result very unsatisfactorily, both 
for the pupil and the instructor. In this connection I shall 
not soon forget the soldier who told me, with great satisfac- 
tion to himself, '*that wounds of the abdomen were not anti- 
speptic, because there vi?L% facial matter in them." 

It is often very difficult to tell just how far one may go 
with propriety, and avoid getting beyond the faculties of the 
men who are listening to his instruction. A too frequent re- 
currence of instruction in first aid work, implies a very oft re- 
peated reference to the same thing, unless the subject ns am- 
plified beyond the point where the comprehension of most of 
our men ends, and then, of course, the work becomes at once 
flat and unprofitable. I do not think that a daily drill of an 
hour will hold the interest gf the men, who have learned the 
essentials of first aid, because of the endless iteration of the 
same thing, over and over again. The only remedy to this 
satiety, lies in an amplification of the subject, and as I have 
said this is apt to prove a dangerous expedient. It is a good 
practice, I think to avoid more than two first aid drills in any 
one week. The two hours, properly employed will perfect the 
average man in the things he ought to know, and the subject 
will not become a bug-bear to him. 

I do not know of a better system of teaching first aid, than 
the old method by means of tags applied to the "wounded," 



TRAINING OF HOSPITAL CORPS SOLDIERS. 223 

and I think that the very great importance of this matter of 
tag'g'ing- should receive emphasis, in our instruction; proper 
tagging facilitates to such a degree, the final handling of 
wounds, and is of such incalculable help to the surgeons in the 
hospitals, at the rear of an army. 

It is my opinion that we make an error in our first aid, in- 
struction, by failing to teach the man to act more as a unit. In 
reality, our unit is entirely too much the squad of four men 
and not sufficiently the individual man. Accustomed as the 
soldier becomes to the cooperation of his three fellow squad 
men, he is apt to take on a considerable degree of dependence 
upon them, and things are prone to go awry in his estimate, 
when there is any disruption of the established order of things. 
My limited experience leads me to believe that in the thick of 
a fight, the squad of four goes to pieces very uniformly and 
rapidly, for the simple reason that it is entirely too cumbrous 
a unit. The individual hospital corps man is more or less of 
a luxury in the immediate vicinity of the firing line, simply 
because the proportion of hospital corps men to line soldiers is 
so small. 

I would therefore attempt to impress the fact that the in- 
dividual himself, rather than the squad is the factor of real 
work and good on the battle field. Put one man at a fracture 
of the tibia, for instance and he is rather nonplussed, unless 
he has been required to meet just such contingencies in the 
course of his training. The handling of such cases is very 
much nearer the ideal, when it is done by four men, but if 
there be any thing, singularly conspicuous by its absence from 
the vicinity of the average battle field, that thing is the ideal. 

Again the Medical Officer is so often hitched on to a fly- 
ing column, with only one hospital corps man that the culti- 
vation of the individuality of that one man is a matter of very 
great moment, to that particular Medical Officer. I am sure 
this point needs no emphasis, to those of you gentlemen who 
have been after our recalcitrant ''little brown brother" in the 
tropics. 

The training of the ward man is of great moment. The 
trained female nurse has become so much a fixture in the mod- 



224 CAPTAIN FRANCIS A. WINTER. 

ern hospital, that we are all rather prone to conclude that first 
rate conditions are only possible of attainment, in her pres- 
ence. This opinion comes to us very naturally, for all modern 
civil hospitals are supplied with them, and their work in these 
institutions, is manifest in the general air of nicety which per- 
vades them. While I am a strong- advocate of the female 
nurse under most conditions, I am none the less sure that a de- 
gree of pronounced excellence can be made manifest about a 
hospital ward, with the exclusive use of male nurses, and con- 
ditions are such in the military service, that we must rely al- 
most altogether on the hospital corps man to look after the 
sick. 

There is at the outset of this itiatter an important differ- 
ence in the hospital-corps man and the male nurse in civil life. 
The soldier is absolutely under control during his enlistment, 
and if he does not do just as he is told, there are means of 
making him do it, and if he is specifically directed in a certain 
line and kept sedulously on that particular tack, he can gen- 
erally be made to do things of which he did not at first seem 
capable. I found this to be true in the Philippines, and the 
work of my wards went forward with a system, which enabled 
me to conduct a ninety bed hospital, without any occasion to 
deplore the lack of female nurses in the institution. 

In starting out I think one must select his man, and let 
him know that as a result of the confidence felt in his ifltelli- 
gence and integrity, he has been chosen as a ward man. The 
generality of men are pleased with this recognition, and the}' 
are willing to heed the instruction given them, to fit them as 
nurses in charge, after they have passed through a period of 
service, as understudies. 

The man so selected is first impressed with the idea that 
dirt in a hospital ward is of all human errors the most^ repre- 
hensible, and unpardonable.- A few weeks in the prevention 
and rectification of this condition, along with training in the 
matter of temperatures, pulses, etc., permits the man to be ad- 
vanced a few steps, and so on, until at the end of three months, 
or thereabouts, promising always that our subject has been an 



TRAINING OF HOSPITAL CORPS SOLDIERS. 225 

earnest seeker after correct methods, and has the proper con- 
ception of his obligation to do the rig-ht thing- by his patients, 
one can g-o into his ward feeling* pretty sure that it is fitted to 
stand a rigid inspection. 

In the matter of this training there are so many little 
points that one can impress upon his man, with such good re- 
sults in the general improvement of his attitude towards a sick 
man. I remember, that it was always a source of great pride 
with my nurses, that no man sick in that particular hospital, 
had dirty finger nails, and where one can get a response in 
such matters as^ this, he is pretty apt to find that the whole 
matter of the care of the sick is looked after, in a manner to 
disarm any reasonable criticism. 

Again it is very easily possible to successfully appeal to 
the humanitarian side of the better class of men, and I seldom, 
or never had a complaint, declared or covert, even from the 
querulously sick of the tropics that their treatment, at the 
hands of the ward men, was not as it should be. I do not wish 
to be understood as advocating the idea that this result can be 
gotten out of all hospital corps men. There are some of course, 
who will never develop, no matter how much efiFort and how 
much training is expended on them, but there are always 
duties about a hospital, to which such men can be assigned, 
and one can generally find a quota of men suitable to the work 
of the wards. It is no easy matter to get a status of this kind 
in any hospital, whether civil or military, and it requires 
work and plenty of it, to establish such conditions. 

I had always thought that it could be done, and my ex- 
cuse for adverting to a purely personal experience of it, is that 
I may emphasize the fact, that even in so remote a place as the 
interior of the Philippine Islands, it is possible to conduct a* 
hospital, using the enlisted man only, in such a way that an 
Inspector is willing to say that the absence of trained female 
nurses is not evident, upon inspection. 

In the matter of general training, it has often seemed to 
me that a mistake is made in our scheme of instruction, in that 
there is not more specializing of the subjects, according to the 
capacity of the men, whom we are attempting to teach. I 



226 CAPTAIN FRANCIS A. WINTER, 

have frequently found that a man with a fair aptitude for one 
subject, would show an almost total inability to grasp the de- 
tails of the instruction, in another. Some men, for instance 
are in a large measure born to the work in wards^ while others 
are unable to present any sort of a showing, even after the 
expenditure of prolonged efifort to implant some idea of the 
matter in their heads. This applies with especial truth to the 
question of cooks, and I do not know of a more bootless task 
than that which goes on attempting to evolve a cook out of a 
man, who has absolutely no capacity in that direction. 

Again there are now, and probably always will be a great 
many men in the corps whom nature has not fitted for the 
more refined work about a hospital, I need not mention the 
quota of men, for instance, who are apparently convinced, if 
we may judge by their general make up, that it is both un- 
seemly and dangerous to go through life with a clean pair of 
hands. There are such, and the time honored silk purse and 
sow's ear matter is not more difficult of solution, than is the 
problem of refining such an individual into a non-infecting 
attendant, about a hospital. 

Both from the standpoint of intellect and habit there are 
men, for whom all instruction is of little avail, and some of it 
worse than useless. Beyond the fact that these men do not 
profit themselves, by the course of lectures, demonstrations, 
etc., they act as a deterrent influence on the rest of the men, 
to say nothing of their dampening effect, upon the efforts of 
the instructor. 

Of course the remedy for all of this lies in the recruitment 

of only that class of men, who can show the personal qualities 

necessary to the making of the sanitary soldier, but here 

•again we are hovering about the ideal, and it will never be 

done. 

With a number of men showing inaptitude to such a de- 
gree that thorough trial shows their inability to take in the 
general features of instruction, there is only one course open, 
and that is to make the best of a bad bargain, and put them 
at the one thing, which seems to promise the best results. I 
have seen men who never got beyond a faint proficiency as 



TRAINING OF HOSPITAL CORPS SOLDIERS. 227 

cooks police, and I do not know of any reason, why such a 
man should not be given an indefinite berth in the kitchen, 
for the prosecution of his specialty. 

I think, however that there are many men, who enlist' in 
the corps, with good intentions and who are discouraged by 
the rather complex situation, which at first confronts them. 
They look upon the polysyllable terms which are rolled out to 
them, very much as most of us would look upon the Rubaiyat 
in the original, and it requires some diplomacy and encour 
agement to convince them, that these are words of their own 
mother tongue, and that the case is really not so bad as it 
might seem at first sight. 

I have found that with a little delicate handling many 
such men have turned out to be enthusiastic and appreciative 
students. In this connection, I would venture the opinion 
that in the matter of teaching, more discretion should be left 
the local authorities, the subject matter being apportioned in 
such way, as in the opinion of the Surgeon it would do the 
most good, to the greatest number. 

The happy and facile Mr. Kipling knew what he was 
talking about, when he made his analogy between the non- 
commissioned officer and the back bone, for it is certainly the 
man in the position of the First Sergeant, who. makes the 
direction of the commissioned hand, come into evidence. He 
is preeminently in the position of the Executive and unless he 
is of the proper stripe, and thoroughly imbued with the idea 
that his position is an important one, and possessed of the 
force and intelligence to sustain his assumption of an impor- 
tant part in the management of an organization, there is small 
hope that any thing, beyond the most indifferent results are 
going to accrue, to the organization over which he has charge. 
A well trained, conscientious first-class sergeant is to the Mili- 
. tary Surgeon, pretty near to being the noblest work of God, 
and Providence is distinctly on the side of the man, who enjoys 
such an auxiliary. 

There is no duty falling to an Officer, which, to my mind, 
is of more moment, than that requiring him to select non- 
commissioned officers of the right kind. I have seen such 



228 CAPTAIN FRANCIS A. WINTER, 

baneful results, follow upon the delegation of grave responsi- 
bilities to men who were not fitted to hold the positions given 
them, whether from intellectual, or other deficiencies, and on 
th^ other hand, I have experienced the trulj invigorating con- 
sciousness of having the right man, in the place where he was 
needed. 

I shall not attempt a detailed citation of the qualities,which 
in my estimate go to the making of a hospital corps sergeant. 
This much I may say, that I think we often use too much haste 
in the selection of men, putting them into the positions before 
they have had the opportunity to prove themselves. I know 
of few things of so great benefit to us in this connection, as 
the regulation, which authorizes the appointment of certain 
privates as probationary non-commissioned officers. Their 
official designation is almost too*heavy for one man to live up 
to with propriety, but that, of course, is another story. A 
man now gets a very good chance to prove himself in the 
actual work of a sergeant, before he is finally appointed, and 
it is a good opportunity to test his capabilities. 

Some features in the training of the non-commissioned 
officer have particularly impressed me. In the first place he 
should have the assurance of the absolute support of his com- 
missioned superior, in all things legal. It is my habit to tell 
a non-commissioned officer, that his word to a subordinate is 
as full of force as any human talk could possibly be, and that 
his stock phrase must be, that **it is the duty of a soldier to 
obey and then protest to higher authority." It is my belief 
that this formula is a most excellent stock mixture of words. 
It has an energizing effect on the superior and the average 
subordinate is somewhat staggered, when he is confronted 
with its sententious quality. 

Non-commissioned officers will sometimes err, but if they 
should, it is the worst possible thing for discipline that they 
be taken to task for it, in the presence of the man who has 
been affected by the error. That is always a matter to be ad- 
justed at an ''executive session," behind closed doors. 

The spirit of democracy, which pervades most of our 
doings on this side of the Atlantic, is very apt to have a per- 



TRAINING OF HOSPITAL CORPS SOLDIERS. 229 

nicious influence with the non-commissioned oflScer, and the 
tendency of our men to live on terms of the most intimate 
familiarity with the private soldier, is a bad thing- for disci- 
pline. In all other armies, the warrant oflficer is very much 
aloof from the private, and it is very much to be desired that 
the same status of affairs should appertain in our own service. 
I knew a very bright man who was a Serg-eant-Major, in one 
of our infantry regiments, and he told me that in Malta, he, 
as a non-commissioned officer, had an eligibility to associations, 
to which no man without chevrons might hope to aspire, and 
that the line separating the non-commissioned officer from the 
private, was no less defined, than that which was thrown 
about the commissioned officer. One can easily believe the 
contention of these men, that the total absence of unseemly 
familiarity in the barracks, makes it the easier for the private 
to heed the dictum of the sergeant on the drill ground. 
There can be no question, I think about the expediency of dis- 
couraging approach to familiarity, on the part of inferiors in 
the military service, just as it is discountenanced in all other 
business enterprises, where there is a difference of status, 
among the personnel. 

I think a great deal can be done towards the improvement 
of any detachment of the hospital corps by the practice of 
making the position of a non-commissioned officer a desirable 
one, in every possible way. It should carry a large degree of 
personal liberty, and the officers' supervision should be exer- 
cised in such a way, as to show the greatest degree of confi- 
dence, in the man who is being looked after. An incompetent 
man, or one who is recreant to his trust, will show his true 
make up, in a very short while, under such latitude, and the 
knowledge that non-commissioned officers are treated with the 
degree of consideration, involved with this policy, will prove 
the best kind of an incentive for the privates of the detach- 
ment, to fit themselves for the examinations preliminary to 
promotion, and this of course, involves the idea of general 
efficiency in the detachment. 

It is to be hoped that in the event of another war, we 
shall be able to get a better class of men as non-commissioned 



230 CAPTAIN FRANCIS A. WINTER, 

officers than we had in the early days of the Spanish-Ameri- 
can disturbance. The selection of so many men, unfitted by 
reason of short service, to exercise any sort of command, was 
one very trying- feature of that situation, and it seems to me 
that we shonld have done better, had our selections been more 
limited to the men who had had some previous service in the 
Corps. It is certainly a very g-rave mistake to take a man, 
who is in no sense acquainted with thingrs military, and invest 
him with the responsibilities and privilegfes of a hospital corps 
sergeant. The fact that a man knows something aoout drugs 
is in no sense a warrant that he will either prove amenable to 
discipline himself, or be capable of enforcing any order in a de- 
tachment. I think that we had many men in theCorps at the 
outbreak of the Spanish war, who, while not thoroughly 
versed, in the more or less technical details of theoretical in- 
struction, were still capable of exerting a very creditable con- 
trol of men. A man absorbs a great deal of this, by the at- 
trition of mere length of service, and his example is worth a 
great deal, especially if it be bolstered up by the authority, 
which goes with a pair of chevrons. 

There is no subject of greater import in the military 
hospital than the matter of instruction in cooking, and there 
is none, from which less result is to be expected in the aver- 
age detachment. It is generally a haphazard sort of an ex- 
periment when a man is put into a kitchen, and the chances 
are that he does not want to be a cook, and no amount of per- 
suasion and pay, is going to make one of him. 

It seems to me that a remedy for this condition might be 
found, in the establishment of a central school where cooking- 
could be taught, to the exclusion of other things. It is cer- 
tainly much of a desideratum that some measures betaken, to 
provide a corps of men, with some competency in this direction. 

It seems to me admissible that I might say a word, at this 
place, on the matter of recruiting for the hospital corps. I am 
of the opinion that our present system of enlistment, for the 
hospital corps, has some material defects. A great many of 
the men whom we get direct from civil life or by re-enlist- 
ment, are in no way fitted to do good service in the particu- 
lar branch, for which they have enlisted. It is really a 
hard matter to make a good sanitary soldier, for he has got 



TRAINING OF HOSPITAL CORPS SOLDIERS. 231 

to learn a great many thing's, and if he has not the necessary 
intelligence, he makes one of the worst possible investments 
for the Government. 

Many of the men who have had service in the line of the 
Array, re-enlist in the sanitary branch, impelled to do so by 
the idea that it is a soft place, where one can rest on the 
laurels of a three years tour in the line, with little to disturb 
the serenity of his "otium cum dignitate," beyond an occa* 
sional signature to a pay voucher, and the obligation to spend 
the pay when it has arrived. The most disgruntled men I 
have cTer encountered in the service have been soldiers, who 
made good line soldiers, and came into the hospital corps with 
the idea that service there was to be one delightful period of 
relief from guard and most of the other vexatious elements of 
the military service. 

It requires some special qualifications to form an opinion 
as to the worth of the average man, as a hospital corps man, 
and I think that the matter of enlistments should be confided 
entirely to representatives of the Medical Department. 

I have at various times encountered men who had repre- 
sented to the recruited officer that they were students of med- 
icine. Most of these men are rank frauds, and if they have 
learned any medicine at all, it is probably of that particular 
variety, not by any means unknown in the Uni'ted States, 
which they might better unlearn. I am always on the de- 
fensive when a man tells me that he has attended a course of 
lectures in some medical college, — generally at some point in 
the progressive West. It has happened to me that the most 
cursory inquiry showed the claim to be absolutely false. 

The system of transfers is beset with many difficulties, 
not the least being that the average company commander does 
not want to lose his good men, even for the sake of a possible 
benefit to the hospital corps. 

The Corps has done excellent service in the recent dis- 
turbances, and I fancy that the best work was uniformly done 
by those detachments which had received the most instruc- 
tion. The end accomplished by this instruction is a truly 
gratifying one, and the man who works with his detachment 
gets a recompense, which richly rewards. 



THE TREATMENT OF YEI.LOW FEVER. 
By lieutenant JAMES CARROLL, 

WASHINGTON, D. C. 

ASSISTANT SURGEON, IN THE UNITED STATES ARMY, PROFESSOR 

OF BACTERIOLOGY AND CLINICAL MICROSCOPY AT THE 

UNITED STATES ARMY MEDICAL SCHOOL; MEltfBER 

OF THE ITNITED STATES ARMY YELLOW 

FEVER COMMISSON. 

THE treatment of yellow fever is a subject of very great 
importance and secondar>' only to the question of 
prophylaxis or prevention. We are now able, by 
promptly instituting the .proper measures, to control the spread 
of this disease, and if the treatment of the persons already af- 
fected be successful, the excitement and panic that so frequently 
follow its invasion may be averted. It is important to bear in 
mind that the disease is one of short duration, and if the patient's 
strength and vitality can be maintained throughout the critical 
period his tecovery is practically assured, provided^ of course, 
that he was previously in good health and free from organic 
lesion. 

Let us first review the treatment pursued by some of the 
older authorities and then, aided by the light of modem pathol- 
ogy, consider what modes of treatment will be simplest, safest and 
at the same time afford the best praspects for success to-day. 

One of the earlier English writers on this subject, Richard 
Towne,^ began his treatment by ordering the patient bled, to the 
extent of eight ounces, and that was to be repeated once in six or 
eight hours as long as the symptoms were not abated, lessening 
the quantity drawn each time. He then administered an emetic 
dose of squill, ipecac or tartar emetic. He directed that the pa- 
tient be given liberal quantities of diluting, refrigerating and sub- 



THE TREATMENT OF YELLOW FEVER. 233 

acid drinks made of oranges, lemons, tamarinds; or the mineral 
acids in barley or spring water. He states that lemon juice di- 
luted aids diaphoresis. He allowed slightly acid fruits, roasted 
plantains and bananas, guava jelly, etc., with barley water ad lib- 
itum. Toward evening he directed a clyster of cream of tartar 
and manna, and at night twenty-five drops of laudanum. 

In the second stage he repeated the bleeding and applied wet 
cups and blisters. He insisted upon the necessity for absolute rest 
in the reclining position. Meats were forbidden and he only per- 
mitted panada or water gruel sweetened and slightly acidulated. 
Cooling and lenitive clysters once in eight hours and a good dose 
of laudanum at night sufficed for this period of the disease. 

In the third or comartose stage he directed that blisters be ap- 
plied freely to the neck, wrists, thighs and legs, but more es- 
pecially a large one to the crown of the head, **to invigorate the 
circulation and give the spirits liberty to expand themselves. " 
"To the soles of the feet,'* he says, "there may be applied lo- 
tions, plasters, pigeons killed and cut open, lungs of sheep, goats, 
calves, etc." Cordials and volatile salts were administered to 
comfort and refresh the languishing patient. Camphor in six- 
grain doses gave him remarkable results in the later stages, when 
the condition was critical. Finally he resorted to the use of pow- 
erful purgative clysters. 

He believed, with others of his day, that the poisonous ele- 
ment was largely an excess of bile in the circulation, and blisters 
were frequently used, because the serum withdrawn by them 
being tinged with bile, it was thought a certain amount of the 
poison had been extracted with the serum. Active purgation was 
used to remove and prevent reabsorption of the supposed poisonous 
material excreted into the stomach and intestine. 

Dr. Henry Warren,' who treated the disease from 1734 to 
1738, condemned the use of calomel, emetics, purgatives and 
blisters and advised the use of mild laxatives in repeated small 
doses for several days. By these means he observed that putrid 
feces were expelled, the secretion of urine increased, the intesti- 
nal glands were cleansed and much of the corrupt and infected 
serum carried off. He wisely said that great care should be had 



234 LIEUTENANT JAMES CARROLL. 

to keep up nature's strength and spirits by giving now and then 
a little warm Madeira wine, Canary or such cardiacs as were not 
too inflaming. In his experience the nitrous and sub-acid reme- 
dies disturbed the stomach. 

When seeing the patient for the first time he ordered a moder- 
ate bleeding, and that he be then covered with a blanket and made 
to perspire freely for twenty-four hours, or as long as the fever 
lasted, by the use of posset drinks. After the first day he al- 
lowed chicken broth as often as the patient desired it. He always 
found this useful and necessary to support the strength and coun- 
teract the exhaustion that would follow the free sweating. In 
addition he allowed now and then a glass of Canarv or Madeira 
wine a little diluted, besides gruels and panadas with wine added 
to them, or sack-whey made richer than usual, and similar forms 
of light nourishment. If there had been no stool for three or four 
days he ordered a clyster of fresh milk and brown sugar or small 
doses of rhubarb and manna. 

If there were frequent stools at a later period he deemed it 
of the highest consequence to suppress them promptly by the use 
of clysters containing Venice turpentine, Venice treacle or burned 
wine or brandy. He attached the greatest importance to the use 
of sudorifics. 

Dr. John Redman of Philadelphia, the first president of the 
College of Physicians of that city and a teacher of the celebrated 
Dr. Benjamin Rush, read a paper before that body in 1793, in 
which he described his treatment of yellow fever in 1762. He is 
said to have been one of the most advanced and successful practi- 
tioners of his time. 

He began his treatment with one-dram doses of that hiuch 
neglected drug, Glauber's salts, repeated every hour or two for 
four, five or six doses until there were free evacuations. He saw 
the advantage of this in 1741 or 1742, during a previous outbreak, 
while he was a pupil to Dr. Kearsley, who had saved most of his 
patients by the use of it, while others who began with an emetic 
lost many or most of their patients. At the same time he ordered 
wine, vinegar-whey, thin gruel or barley water, raisin drink with 
wine. etc. On the second and subsequent days he administered 



THE TREATMENT OF YELLOW FEVER. 235 

one or two doses of the salts to insure having two or three stools 
a da)\ Along with these he gave teaspoonful doses of a neutral 
mixture to keep the skin moist. In the beginning he applied over 
the stomach an anodyne plaster of theriac, etc. , which was re- 
newed at frequent intervals. 

The above-mentioned drinks were alternated with pleasant 
herb teas, water acidulated with the mineral acids, lemonade, 
weak cold punch, fruit waters or weak wine and water. In 
hemorrhagic cases he used mineral acids in all drinks and in ad- 
dition gave red wine and water with a decoction of Peruvian bark 
and Virginia snake-root. He avoided venesection and emetics 
and believed that most other practitioners did the same, because 
of the disastrous results theyr had seen follow these measures in 
the former epidemic. 

After the third day wine was given more freely and beef tea 
or chicken broth was added to the diet which was regulated by 
the taste and desire of the patient. Tea, coffee and weak choco- 
late were permitted under the same condition of their being agree- 
able to the patient. He laid stress upon the necessity for dis- 
charging the morbid matter as fast as possible, first by th^primac 
viae and then by the pores of the skin and urinary passages, at 
the same time stimulating the body by means of strengthening 
nutriment. He attached great importance to the use of mineral 
acids and sulphate of soda. His general line of treatment was 
rational and based upon sound principles. 

Hillary,' who treated the disease in the West Indies from 
1752 to 1756, declared that the objects to be obtained by treat- 
ment were the following: First, "to moderate the too great heat 
and rapid motion of the fluids, and abate the too great heat and 
violence of the fever, in the two first days of the disease, as safely 
and as much as we can. In other words, to diminish the fever." 
To attain*this end he withdrew blood to the extent of from twelve 
to twenty ounces on the first and second days of the fever only. 
He strongly advised against bleeding after the second day. and 
when it was to be performed the quantity of blood to be with- 
drawn was determined by the general condition of the patient. 
The second indication was "to evacuate and carry out of the body 



236 LIEUTENANT JAMES CARROLL. 

as much of that putrid bile and those putrid humors as expe- 
ditiously and as safely as we possibly can. ' ' 

He regarded the administration of emetics, so frequently 
practiced then, as dangerous and likely to prove disastrous. He 
ordered large draughts of warm water. After the vomiting ex- 
cited by these had subsided he gave a grain or a grain and a half 
of extract of opium and nothing more was to be taken into the 
stomach for two hours. If the patient had had no stool a purga- 
tive clyster was given as soon as the vomiting had subsided and 
before the opiate had exerted any effect, and six or eight hours 
later a gentle purge. The treatment then followed was the ad- 
ministration of an infusion of Virginia snake-root with elixir of 
vitriol and Madeira wine. For nourishment barley water and 
wine-whey were given often and in small quantities during the 
first two days of the fever, and after the third day the quantity 
of wine was increased. 

Dr. Brown of Boston* began his discussion of the treatment 
by citing from a letter written in September. 1798, by Dr. Mitchell, 
professor of chemistry and natural history in Columbia College. 
New York. Dr. Mitchell stated that in cases with symptoms of 
gastritis, anorexia, vomiting, etc. , he had obtained happy results 
with watery solutions of lime, potash or soda, aided by a cathar- 
tic, such as castor oil, Rochelle salts, etc. 

He wrote that the alkaline remedies were much used by the 
physicians of New York during the epidemic of that summer. 
They allayed anorexia, nausea and black vomiting. In some 
cases with high fever, dry skin, a full pulse, delirium, etc., he 
pronounced blood-letting a grand remedy and in many instances 
indispensable. 

He exercised an admirable discrimination in the practice of 
venesection, in which regard he differed f fom Rush and others of 
his contemporaries, who advocated bleeding in nearly all cases. 

He summarized the treatment as follows: At the onset a 
thorough evacuation by mercurial cathartics, by diaphoretics and 
by blood-letting; poultices, fomentations, pediluvia, cold and 
warm bathing, blisters, enemas, etc., according to the indications. 



THE TREATMENT OF YELLOW FEVER. 237 

After one or two evacuations he gave mercurial pills hi doses 
of one, two or three grains, frequently repeated, to insure an 
evacuation every day or every other day. The drinks were to be 
subacid, diluent or emollient and were continued until after the 
subsidence of the fever, when he advised wine, bark aud other re- 
storatives. The food was to be light and easily digested, generous 
and gently stimulating; to be given often and in small quantities. 
For primary catharsis he preferred ten or fifteen grains of 
calomel with twenty or twenty-five grains of jalap; calomel was 
given subsequently in doses of one, two or three grains, as before 
stated. He cites Warren,* who asserted that it was the universal 
opinion of physicians in Boston that the most efficacious remedy, 
and the only one to be relied upon, was mercur>\ That in his ob- 
servation more patients recovered under this treatment than under 
any other. It seems that he gave one-grain doses hourly until 
the patient was salivated, and he claimed by this means he 
effected a cure in all but two of his patients. Opium was fre- 
quently administered with the calomel to retain the latter in the 
intestine and insure its absorption. He was a strong advocate of 
the use of mercury in the form of calomeL 

Brown tells us that "when there is a full, hard pulse, dry 
skin, great heat and violent pains in the head, stomach and 
bowels, bleeding is certainly an excellent remedy, if not a sine 
<jua non of a cure." He applied blisters to the back of the neck, 
under the occiput or over the stomach to relieve pain, nausea, 
retchings or vomiting. Laudanum was used to quiet the stom- 
ach. Blisters were also applied to the temples, neck, back, thighs 
and arms, **to arouse the system from the torpor, low delirium 
and extreme debility of the second stage of the disease." Pedi- 
luvia with poultices were frequently used to moderate the violent 
determination of the blood to the head and to bring on perspira- 
tion, but for these purposes he preferred the wann bath. 

He says that Drs. Rush and Grifiiths advised bringing on a 
profuse perspiration by wrapping the patient in blankets and ap- 
plying several hot bricks wet with vinegar to different parts of 
the body, giving at the same time repeated draughts of hot teas, 
lemonade or weak punch, to be repeated once a day for four or 
five hours, as long as the fever continued. 



23K UEUTENANT JAMES CARROLL. 

Brown used cold bathing during the fever, either by spong- 
ing or by dashing the water upon the patient. When the stom- 
ach was extremely irritable he advocated the use of cathartic and 
nutritive enemata at frequent intervals. For this purpose he used 
chicken or veal broth or water gruel, and if a cathartic effect were 
desired a tablespoonful each of Glauber's salt, sweet oil and mo- 
lasses were added. 

In the early period large quantities of diluent and sub-acid 
drinks, such as toast-water, lemonade, tamarind water,, apple or 
barley water, etc., were given, and later these were changed for 
porter and water, claret or milk and water. No food was g^ven 
until after the crisis. Tlien feeding was begun with light, easily- 
digested foods^ such as weak tea or coffee^ thin porridge,, roasted, 
or baked fruits, chocolate, sago^ weak chicken or veal broth. 

Lind* relied mostly upon tartar emetic and blisters together 
with the administration of Peruvian bark. He attributed great 
virtues to fresh air. because he noted that sailors often recovered 
without treatment or care, while patients removed to hospitals 
died in spite of his best treatment, which was hardly to be won- 
dered at. 

Rush, who was a follower of Sydenham, carried the practice 
of venesection to excess. In a published table' he enumerates 
twenty-three patients, each of whom was bled from three to thir- 
teen times, and from each of whom he drew, in all, quantities of 
blood varying from fifty to one hundred and fifty ounces. He 
carried the administration of mercury to the same extreme, for he 
states'* that he gave to one patient one hundred and fifty grains 
of calomel in six days. He thought this a large quantity until he 
read that Dr. Chisholm gave four hundred grains to one patient 
in the course of his fever, and to another fifty grains at a single 
dose three times a day. 

His general treatment was bleeding, purging, blistering, the 
use of cold water internally, externally and by means of clysters. 
He condemned the use of stimulants and found niter and antimo- 
nials to be ineffectual. He ascribed great value to blisters and 
aimed to induce salivation with calomel. He declares that in 
1794 he was delighted with the effect of salivation in ever>' case 



THE tREATMENT OF YELLOW FEVER. 239 

in which it occurred. As compared with some other physicians, 
however. Rush used calomel in moderation, for La Roche cites 
Instances in which patients were given from one to several thous- 
and grains of calomel during the course of an attack. 

Currie' objected to the use of mercury on the ground that it 
protracted the fever and retarded the cure. He asserted that in 
all malignant cases in which he saw it used, whether in large or 
small doses, it hastened the end* He made exception in cases 
where there was coma with dilated pupils. In these he stated 
that it liad saved many lives when given in large and repeated 
doses. The treatment by sweating accompanied by cordial and 
stimulating remedies he regarded as not only unsuccessful but per- 
nicious. Bleeding and catharsis he considered to be of the great- 
est benefit during the three first days in inflammatory cases. In 
adynamic cases he asserted these measures did manifest and ir- 
reparable injury. The cold bath and the use of wine, bark and 
opium were all condemned by him. The juices of lemons, oranges^ 
grapes and currants he found to be grateful and beneficial. 

Clark,** who treated yellow fever in the West Indies in the 
time of Rush and Currie, was opposed to bleeding in most cases. 
Mercury was his **sheet anchor.*' He generally ordered a pedi- 
luvium and a purging clyster at first, then a large dose of calomel 
and jalap, and repeated small doses until a free movement had 
been obtained. Saline draughts, given while effervescing, checked 
the vomiting and were serviceable during the first stage of the 
disease. He encouraged perspiration by gixnng warm drinks when 
the vomiting was not too violent. He found that excessive vom- 
iting and purging were generally restrained by opium; he gave 
as much wine and opium as the stomach could bear; if the purg- 
ing was free he gave chicken broth with sago or panada, Madeira 
wine or old hock, and he laid great stress upon giving nourish- 
ment and wine frequently. He attached great importance to 
careful nursing and the necessity for early treatment, and said 
that in the worst cases or those neglected at the beginning, no 
remedy seemed to retard or arrest the disease. 

La Roche," whose treatise on yellow fever is without doubt 
the most exhaustive one in the English language, divides the 
cases according to their severity into three classes. 



240 LIEUTENANT JAMES CARROLL. 

First, those in which the patient appears to be stricken with 
death from the beginning. In these no treatment avails and re- 
covery, where it occurs, is doe, not to treatment, but to the vital 
resisting power of the patient. 

Second, those cases which are so mild as to recover spon- 
taneously without any treatment, or under the influence of any 
rational or even irrational management. 

Third, those in whcmi the disease assumes an intermediate 
grade, whose chances of life or death are equally or nearly bal- 
anced, and in whom, consequently, it becomes an object of the 
utmost importance to apply means calculated to produce a favor- 
able impression, and thereby arrest the dangerous tendencies. 

He says we must while watching carefully the course of the 
disease, prevent undue mischief being done, especially to organs 
essential to life. We must keep these organs in as healthy a con- 
dition as possible — restore, if posvsible, equilibrium in the play of 
the functions — reduce undue and dangerous excitement, and sus- 
tain the powers of life when these threaten to become impaired 
or are greatly reduced beyond the point of safety. Beyond this^ 
art is of little avail. 

He quotes Harrison'* as follows: "Accidents or acts of im- 
prudence which, in other diseases, are mere trifles, are of tremen- 
dous importance in this. The mere getting out of bed has cost 
many a man his life. A man in this disease, however safe the 
physician may think him, is hovering between life and death — a 
trifle may decide his fate." (This fearful truth is too often only 
sufiiciently impressed upon the physician after he has seen a num- 
ber of deaths occur in patients whose condition would ordinarily 
excite no apprehension. ) 

La Roche insists upon the necessity for absolute rest in bed - 
and cleanliness. In cases of the so-called inflammatory type he 
concludes that the experience of innumerable observers shows 
that sanguine evacuations — bleeding — and purgation are indis- 
pensable parts of the treatment. He says it is everywhere con- 
ceded, even among physicians who are opposed to sanguine evac- 
uations, that in the first stage, antiphlogistic, sedative and evac- 
uant measures must be resorted to. due care being exercised not 



THE TREATMENT OF YELLOW FEVER. 241 

to reduce the strength of the patient beyond the power of recu- 
peration. He advises, in the congestive forms, external stimula- 
tion by means of rubefacients; hot baths, sinapisms, vesicants, 
etc., must be resorted to, with the internal use of stimulants, 
tonics, etc. , by the stomach or bowels, and in milder cases stimu- 
lating and mercurial cathartics with general and topical bleeding 
to relieve congestion, when it can be done. He disapproves the 
use of emetics and finds the use of purgatives universally advo- 
cated. 

Dr. Andrew^ Davidson" states thatT in the milder form little 
more will be necessarj- than^ hot mustard foot-bath ajid a pur- 
gative. When the temperature is moderate, the skin moist and 
irritability of the stomach absent or trifling, a meddlesome line of 
treatment is to be avoided. As a purgative he mentions castor oil 
in capsules or emulsion, or ten grains of calomel with or without 
jalap. He insists upon the necessity for obtaining and keeping 
up a free action of the bowels. As an antipyretic he suggests 
antipyrin if the condition of the heart will permit its use. The 
common saline mixture containing acetate of ammonium, nitrate 
of potassium and spirit of nitrous ether will promote the action 
of the skin and kidneys and five to ten drops of the tincture of 
veratrum viride can be added if the arterial excitement be great. 
He favors the sponging of the body with cold or tepid water and 
the application of ice-cold cloths to the head. A few drops of 
chloroform or one-drop doses of creasote to relieve gastric irrita- 
bility. He refers to the use by Dr. Physick and Dr. Rush of ten- 
drop doses of oil of turpentine in syrup; the latter used it with 
success even in the later stages of the disea.se. The use of opium 
he regards as dangerous, even though it allays gastric irritability. 
He advocates the use of milk and lime water and the swallowing 
of small morsels of ice. A large sinapism should always be ap- 
plied over the epigastrium. 

In the third stage, when vomiting is urgent and prostration 
extreme, moderate doses of iced champagne should be given fre- 
quently. Perchlorid of iron has been given with apparently good 
results in arresting the hemorrhages. 

He refers to the success obtained by Sternberg's method of 



242 LIEUTENANT JAMES CARROLL, 

treatment in which the mortality was only 7^% per cent, in 374 
cases in the United States, Cuba and Brazil. I shall refer to this 
again later. 

Touatre" of New Orleans gives the therapeutic treatment of 
yellow fever as *'rest, aeration of the sick room, the administra- 
tion of warm drinks in abundance and of liquid food such as milk 
and thin broth." He states the two principal indications of treat- 
ment as follows: 

1. To strengthen and sustain the organism by fortifying the 
nen'^ous system, by arresting congestion and by increasing blood 
pressure and diuresis. To meet this he uses cold sponging and 
cold bathing. 

2. To consume, destroy and eliminate the toxin. This is 
met by aeration of the sick room and by the administration of 
two, three or four quarts of Celestin's Vichy water in twenty- 
four hours. ' 

Our interpretation of the result of this admirable line of 
treatment would be that the cold sponging reduced temperature, 
promoted the action of the skin and perhaps toned the nervous 
system. It certainly induces a feeling of comfort. The Vichy 
water, by promoting active diuresis, ameliorates all the symptoms 
by rapidly eliminating the toxin that produces them. This emi- 
nent observer, who passed through nine epidemics in thirty-three 
years' study of the disease," makes the following statements 
which are true and worthy of the greatest attention: "At the 
outset of the infection the patient can be succored, but what can 
be done when organism is poisoned, when the toxin has already 
affected the hepatic cells and the renal parenchyma, and when 
the mucous membranes are bleeding? The physician is practi- 
cally disarmed, for such lesions are nearly always fatal. It is 
during the three first days of the disease that the physician must 
act. When black vomit has come to darken the situation, we can 
yet save some patients, but we are much better prepared to pre- 
vent the occurrence of black vomit than to cure it. The first and 
most indispensable thing for success in the treatment of yellow 
fever is that it be begun as soon as the disease has declared it- 
self." 



THE TREATMENT OF YELLOW FEVER. 2'^2 

At the onset he alwaye ordered a hot mustard foot-bath to 
relieve congestion and produce diaphoresis; a small dose of calo- 
mel, more as an intestinal antiseptic than as a purgative, and an 
enema consisting of a tablespoonful of sulphate of soda or mag- 
nesia in a pint of warm water every morning and night through- 
out the course of the disease. 

He allowed no nourishment whatever during the first seven ty- 
two hours of the fever unless the temperature fell below 102" F. , 
in which case he ordered milk and Vichy every four hours. With 
the temperature above 102® F. he gave only Vichy during the three 
first days. This usually allays nausea and vomiting, and if it is 
not retained he injects it slowly into the bowel at frequent inter- 
vals. For black vomit he advises the application of an ice bag 
over the epigastrium. 

Izett Anderson," after thirty- four years' experience with 
yellow fever in the West Indies, commenced the treatment by 
giving from six to ten grains of calomel combined with the com- 
pound rhubarb pill or colocynth and hyoscyamus. This was fol- 
lowed three or four hours later by a purgative of magnesium sulph- 
ate, two drams, magnesium carbonate and potassium carbon- 
ate of each one scruple, with a tablespoonful of fresh lime juice, 
to be taken ice cold and while effervescing. This was repeated 
every third hour until the bowels had acted freely. This ingenious 
combination shows a wise determination to act upon the kidneys 
as well as the bowel. The systematic treatment after this was 
still diuretic and consisted of a neutral mixture composed of 
thirty grains of potassium bicarbonate and a de.ssertspoonful of 
freshly expressed and strained lime juice with three grains of 
carbolic acid. This was given every second or third hour, ice 
cold and while effervescing, unless the gas appeared to disturb the 
stomach, in which case it would be given after efferv-escence had 
subsided. High temperature in the early stage was treated by 
the wet pack. He states that since the adoption of this method 
of treatment he has never met with any cases of hyperpyrexia re- 
quiring other special treatment, nor has he encountered the pro- 
fuse and uncontrollable black vomit that he had previously met 
with. For partial suppression of urine he used dry cups, warm 



244 LIEUTENANT JAMES CARROLL. 

• 

turpentine stupes, acetate and citrate of potash, but he had most 
faith in dram doses of spirit of nitrous ether given every hour. If 
there were signs of heart failure he used strychnin and alcoholic 
stimulants. The only food allowed throughout the attack was 
ice-cold milk with lime water, and in some instances albumin 
water. No gruels, paps or broths were permitted until the be- 
ginning of convalescence. Stimulants were never used until the 
second stage, and he preferred a sound, iced, Rhenish wine, 
which proved of the highest value. 

Loomis" favored the diaphoretic and expectant plan with the 
use of cracked ice, milk and lime water or hypodermic injections 
of morphia for nausea and vomiting, cold compresses for hematem- 
esis and the judicious use of stimulants to counteract exhaustion. 

Osier" states that careful nursing and a symptomatic plan of 
treatment probably give the best results. He advises hydrother- 
apy for the fever, morphia hypodf rmically and ice in small quan- 
tities for the vomiting, and the hot bath for uremic symptoms. 
Stimulants are to be used freely during the second stage and the 
patient is to be carefully fed, using nutrient enemataif the stom- 
ach be irritable. 

StriimpelP says that the earlier proper treatment can be in- 
stituted the better. He advocates absolute rest; evacuation of 
the bowel: a hot mustard foot-bath early in the attack; opium or 
morphia for lumbar pains, sinapisms, ice and hydrocyanic acid 
or chloroform for gastric irritability; cold spongings, the wet pack 
and cold bath for high fever. 

Sternberg's treatment, referred to by Davidson*' has given 
phenomenal results. In 374 cases treated in the United States, 
Cuba and Brazil, the mortality was only 7/^ per cent. It is not 
to be believed that such brililant results can ever be exceeded by 
any other single line of treatment. A greater percentage of lives 
has been saved by it than by the use of the Brand method in 
typhoid fever. The Brand method reduced the mortality in 
typhoid fever from about 14 to 7.5 per cent.;" the Sternberg 
treatment reduced the mortality of yellow fever from at least 20 
or 25 per cent, to the same figure. 

In addition to the administration of bichlorid of mercury and 



THE TjREATMENT OF YELLOW FEVER. 245 

sodium bicarbonate, the special treatment he advises is as fol- 
lows:^ A hot mustard foot-bath during the first twenty-four 
hours; cold sponging! cold applicatioTis to the head; protection of 
the patient from currents of air; sinapisms over the stomach and 
lumbar region when called for; the promotion of pefspiration, 
and the withholding of food during the first three days; stimu- 
lants in the form of iced champagne or good brandy after the 
fourth day. If the stomach be irritable he advises toilk and lime 
water, and if this do not agree, nutrient enemata. Later on he 
allows milk punch, ale, porter, etc 

Having reviewed the older as 'well as the more modem 
methods of treatment we are in a position to profit by the ex* 
periences of the numerous observers who have placed their 
methods and results on record. 

In yellow fever we are dealing with a disease of short dura- 
tion and one that tests severely the vital powers of the patient. I 
believe, however, that in previously healthy, non -debilitated sub- 
jects, free from organic lesions, the mortality can be reduced 
practically to zero by careful and judicious treatment instituted 
in the incipicnc}" of the attack. On the other hand, if there be 
present debility from any cause, anemia, organic lesions of the 
heart, liver or kidneys, the outlook is always serious and recov- , 
ery doubtful. The treatment must be essentially eliminative and 
supporting, with the incidental use of measures tending to re- 
duce hypei^yrexia, relieve pain and nausea and remove internal 
congestion^ 

Before taking up the treatment in detail it will be better to 
consider briefly the conspicuous pathological lesions that are pres- 
ent and the deductions to be drawn from them. In the first place, 
the lesions and symptoms are produced by a powerful toxin cir- 
culating in the blood and tissue fluids. This poison appears to 
act with greatest intensity upon the liver and next upon the kid- 
neys. The changes in the liver are at first a congestion, which 
is followed by cloudy swelling, granular and fatty degeneration 
with more or less extensive cell necrosis". In cloudy swelling the 
organ is enlarged and firm, and a great deal of the blood is dis- 
placed by the pressure of the swollen cells upon the capillaries. 



246 LIEUTENANT JAMES CARROLL^ 

With giunular and early fatty degeneration the swelling and 
pressure are slightly increased so that there is considerable ob- 
struction to the flow of blood through the organ. Practically all 
of the blood supplied to the Ih^er comes through the portal vein^ 
in which the pressure \s» very low, and any serious obstruction to- 
the flow of blood through that viscus will necessarily result in a 
damming-up of blood primarily in the portal vein, secondarily in 
the vessels from which it receives its supply. 

Of these the duodenal and pyloric veins are the shortest and 
have the least communication with other vessels. On the other 
hand, the mesent^jric veins are of greater length and are distrib- 
uted over large areas. Hence the passive congestion and hem- 
orrhages which result from obstruction to the portal circulation^ 
when of rapid onset, are more intense and manifested earlier in 
pylorus and duodenum than in other portions of the small intes- 
tine. This explains the pain and tenderness on deep pressure in 
the epigastric region, which is so early and constant a symptom 
in yellow fever and which is the result, not of a specific action of 
the toxin upon the mucous membrane itself, but of obstruction to^ 
the portal circulation, causing a backward pressure along these 
short vessels — the pyloric and duodenal veins — that promptly af- 
fects the rich capillary plexus in which each of them originates. 
The hemorrhages which occur later result from capillary sta.sis^ 
aided, passibly, by a condition of toxemia. 

That this is probably the correct explanation appears from 
the fact that we find the same condition of the gastro-intestinal 
mucous membrane with hemorrhages, black vomit oi^bloody dis- 
charges, in other conditions than yellow fever, where the liver is- 
seriously damaged. I refer to advanced cirrhosis, acute yellow- 
atrophy, acute phosphorus poisoning and excessive fatty degenera- 
tion with cell necrosis; occurring with or without infection. And 
more than this, in these latter conditions the patient dies with the 
same cerebral, eclamptic or so-called uremic symptoms that we see 
so very frequently in this disease. And further, the autopsies 
and subsequent microscopic examinations develop the fact that in 
numerous instances the liver and not the kidney is the organ 
most seriously affected. This statement applies also to yellow 



THE TREATMENT OF VELLOn FEVER. 247 

feyer, and I believe that the supposed uremic condition in this 
disease is often more probably one of poisoning from the accumu- 
lation in the circulation of the organic ammonia compounds which 
the liver normally converts into urea, with other waste or end 
products, the constitution of whith is not well knovvTi, though 
some of them are thought to be of an acid nature. These are de- 
veloped as the products of proteid digestion and as the nitro- 
genous end products of cell metabolism throughout the body 
largely in the form of carbonate, lactate and perhaps carbamate 
of ammonium,** Where the liver loses its functioning power, 
therefore, there must be a deficiency in urea,'* and the kidneys 
cease to secrete urine because urea, the normal stimulus to that 
function, is absent. Osier* states that there are cases in which 
anuria is prerenal, and among the conditions in which this oc- 
curs, he qientions fevers and inflammations, acute poisoning by 
phosphorus, etc.; in the collapse after severe injuries or opera- 
tions, and **in the collapse stage of cholera and yellow fever/' 

About two years ago I performed an autopsy on a woman 
who died with uremic symptoms on the third day following a 
laparotomy. The wound was found to be perfectly healed and 
there were no signs of inflammation. The kidneys changes found 
on macroscopical and microscopical examination were compara- 
tively insignificant while the liver showed excessive fatty degen- 
eration with some cell necrosis and a beginning h^'pertnophic 
cirrhosis. Cultures from the abdominal cavity, blo9d, liver, kid- 
ney and spleen were all negative. I believe now that death was 
due to the inability of the previously fatty and cirrhotic liver to 
dispose of the products of greatly increased cell metabolism, the 
result of the operation. As there appeared to be a deficiency of 
bile, the case was supposed to be one of acholia." 

It is quite plain from our text-books that retention of urea 
in the blood is not always the cause of ** uremic symptoms." In 
some cases, no doubt, where the liver and kidneys are both seri- 
ously at fault, the condition may be one of combined uremia and 
ammonemia or other intoxication. Urea seems to exert a toxic 
effect only when it is present in large amount, and patients fre- 
quently recover from pronounced attacks of uremia even iii scar- 
let fever." 



248 L/EC/TEA'AArr /AAfES CARROLL. 

Urea may be present in the blood in large quantity without 
producing symptoms,* and in uremic conditions ten to fifteen 
times the normal amount of urea is sometimes found in the blood, 
Loomis* states that after withdrawal the blood of yellow-fever 
patients undergoes ammoniacal decomposition, and some affirm 
that the blood contains free ammonia. According to Joseph 
Jones** of New Orleans, yellow fever blood contains abnormal 
amounts of urea, extractive matter and ammonia. But carbon- 
ate of ammonia is scarcely ever found in the blood of uremic pa- 
tients, and the theory of the decomposition of urea into ammonia 
in the blood is untenable.". La Roche found the blood in yellow 
fe\'er to be acid or neutral to litmus." 

The primary indication in the treatment of yellow fever is to- 
remove the immediate cause of the condition present, viz., the 
toxin. This is the best and most expeditiously effected through 
the normal channel with the urinary secretion, aided by a moder- 
ately' free action of the skin and moderate depletion of the 
digestive tract by the use of mild saline cathartics. With the 
evacuation of these fluids and the toxin they contain the symp- 
toms abate — speaking of the earjy stage— and the stomach will 
retain an increased amount of fluid To replace that which has been 
removed. Care should be taken to maintain one or more of these 
functions throughout the attack, sustaining the patient "s strength 
by the judicious use of the appropriate stimulants. It is much to- 
be regretted that we have no means of acting directly upon the 
liver. 

In the earliest stage a hot mustard foot-bath is of great ser- 
vice and should be used as a matter of general routine when the 
case is seen sufficiently early. It relieves internal congestions^ 
lessens the headache and promotes diaphoresis. From personal 
experience I think more stress should be laid on the necessitj' for 
confining the hot mustard foot-baths to the earliest stage as laid 
down by Steniberg and nearly all writers. In my own case it 
was used for the first time on the third day, and I shall never 
forget the effect of it. Within about half an hour after the re- 
moval of the bath and while I was oppre&ed by the weight of a 
heavy load of gray blankets, I felt a sudden pain and embarrass- 



THE TREATMENT OF YELLOW FEVER. 249 

ment at the heart. The pain was very acute and accompanied by 
a feeling of distension, as if the organ was much distended and 
was being arrested in diastole. Happily, it lasted but a few 
moments. This was the only time I felt myself to be in immi- 
nent danger. The bath was not repeated and there was no re- 
currence of the paroxysm. 

If nausea be present a sinapism should be applied over the 
region of the stomach and the same application should be used 
for pain in the lumbar region. Cold applications afford most re- 
lief for the pain in the head. The muscular pains usually become 
ameliorated after a few hours, and it is best not to administer 
remedies for them unless they are unusually severe, in which 
case it would be permissible to use very small doses of antipyrin 
or phenacetin. It is advisable and probably necessary to give a 
mild cathartic at the beginning; say several one-sixth grain doses 
of calomel or three or four grains each of calomel, rhubarb and 
soda in capsules. These should be followed by several dram 
doses of sulphate of soda at hourly intervals until there is a free 
evacuation. In small doses this salt is diuretic as well as laxa- 
tive, and, in my opinion, it is the least disagreeable of the saline 
cathartics. The nauseating effect of castor oil should forbid its 
use unless the patient expresses a preference for it. The routine 
administration of a tablespoonful of sulphate of soda in a pint of 
warm water as an enema, night and morning, as practiced by 
Touatre, seems to me an excellent plan. The patient should be 
encouraged to take plenty of fluid in small quantities at frequent 
intervals or cracked ice if there be nausea or irritability of the 
stomach. In this case it would be well to try also small quanti- 
ties of milk and lime water, carbonated Vichy or an effervescing 
neutral mixture given ice cold. Mj' preference is for carbonated 
Vichy ad libitum y and if it be not obtainable, the neutral mixture 
prepared with fresh lime juice as used by Anderson, but omitting 
the carbolic acid. This mixture should be neither acid nor alka- 
line, but neutral. 

If sufficient fluid cannot be taken by the stomach, give very 
slowly high rectal injections of warm or tepid water to which may 
be added bicarbonate of sodium, sulphate of sodium, chlorid of 



250 LIEUTENANT JAMES CARROLL, 

sodium, citrate of potassium or any of the simple alkaline diu- 
retics. Bicarbonate of sodium is probably the best because it is 
said to exert a soothing effect upon the mucous membranes in gen- 
eral, and should be easily retained. As the purpose of this in- 
jection would be chiefly to secure absorption of the fluid and its 
effect upon the kidneys, it should not be too cold. I have seen 
patients complain bitterly after the use of ice- water enemata. If 
the temperature be high and the skin dry, cold or tepid sponge 
baths will give comfort and aid the action of the skin: at the same 
time half-dram doses of spirit of nitrous ether could be given 
every half hour until the skin became moist or the temperature 
began to decline. * The quantity of urine passed must be care- 
fully noted; it is often necessary to use the catheter. If the pain 
in the lumbar region be severe and the bladder remain empty, the 
patient should be placed in a warm bath to which a little mus- 
tard has been added and kept there until the skin becomes red- 
dened. This should be used only in the first stage, to relieve 
congestion and determine the blood to the skin. If the tempera- 
ture be moderate, the skin moist and the bowels and kidneys 
active, the patient should be given absolute rest in bed in a well- 
ventilated, slightly darkened room. He must be lightly covered 
and protected from draughts. The use of mosquito nets and wire 
screens is an important adjunct to the treatment. 

All food should be withheld during the first three days with 
the possible exception of milk and lime water or milk and Vichy 
if it be well retained. Should the patient desire it, I would not 
hesitate to give an occasional small dose, say two or three drams, 
of champagne, ice-cold and diluted. Besides being a grateful 
stimulant, it quiets the stomach and retards tissue waste. The 
necessity for buoying up the heart is apparent when we consider 
that the passive congestion of the stomach and intestine is best 
relieved by strengthening the circulation until the cause can be 
removed by elimination. In the selection of an agent for this 
purpose there is room for choice. The sodium salt appears to 

•There seems to be a hesitancy to use diuretics in this disease probably 
for fear of damaging the kidneys. No simple drug will do so much damage 
as the toxin. If this poison be freely elimmated, the subsequent course of 
the disease will be modified. 



THE TREATMENT OF YELLOW FEVER, 251 

possess several advantages. It is the normal alkaline base of the 
blood plasma: it is bland, non-irritating, acceptable to the stom- 
ach, and mildly diuretic; and, according to high authority," "it 
is reported to be singularly efficient in the suppression of urine 
from renal disease. * ' We must not lose sight of the reported 
diminished alkalinity of the blood in this disease and the possi- 
bility that this may be due to the presence of an acid poison 
which is neutralized by the sodium salt. In the Sternberg treat- 
ment, about two and one-half drams of the bicarbonate of sodium 
are administered in twenty-four hours. The Vichy water treat- 
ment is practically treatment by bicarbonate of sodium. 

Sulphate of sodium, the value of which was first shown by 
Dr. Kearsley of Philadelphia in 1741, is endorsed by Dr. Touatre 
of New Orleans, and Surgeon R. D. Murray of the Marine Hos- 
pital Service gives it the preference over other salines. ** A good 
dry champagne is the best stimulant to begin with; when the 
patient tires of it a sound Rhenish wine should be substituted ; 
Dr. Murray has had good results with dry Catawba.** 

If there are signs of heart failure, str3'chnin should be used 
freely. If the patient is not seen until the second stage the treat- 
ment must be symptomatic. For vomiting, ice bags to the epigas- 
trium are probably the best remedy; they can be supplemented 
by small doses of cocain and hypodermics of morphin according 
to indications, but carbonated Vichy, lime water or champagne 
will probably prove sufficient unless black vomit has set in or is 
impending. In this case turpentine has been recommended and 
is worth considering on account of its properties as a local and 
general stimulant, hemostatic and diuretic. Tincture of capsicum 
is also said to be a valuable local and general stimulant in this 
condition. The patient's strength must be sustained as far as 
possible, the action of the kidneys encouraged through absorp- 
tion of fluid from the bowel and the blood determined to the sur- 
face by friction of the skin with mustard water. The value of the 
hot-air bath in cases of anuria is too well known and appreci- 
ated to require more than a mention of it. Whether the pois- 
onous agent be urea or any other soluble substance it is equally 
important to secure its elimination by this or any other method. 



252 LIEUTENANT JAMES CARROLL, 

The nutrition of the patient is a subject well worthy of con- 
sideration. Food is frequently withheld for varying periods from 
three to five days or a week; in my own case I think for at least 
eight days nothing was allowed but water, Apollinaris, ice and 
champagne. Now, during all this time certain cells of the body 
are fimctioning and using up there own protoplasm, for in condi- 
tions of anemia, debility or malnutrition and in the infectious dis- 
eases we know that the cells of the vital organs undergo degener- 
ation and often necrosis from lack of nutritive material. In 
specific fevers the functions of some of these cells are greatly 
stimulated. The proteid constituents of the cells are cousumed 
in the performance of these functions, *• and converted into waste 
material and end-products which add to the general intoxication. 
Physiologists teach us that there are certain foods that will pre- 
vent this degeneratian of the cells to a considerable extent by 
saving their proteid constituents." Among these are gelatin and 
fat, non-proteid foods, the latter of which, in the form of olive 
oil, has been used with marked success by Spanish physicians in 
the treatment of yellow fever. According to La Roche, of thirty- 
six patients admitted to the hospital at Vera Cruz with black 
vomit, no less than thirty recovered after treatment by inunction 
with the heated oil,'* and other equally remarkable results are 
mentioned. In another place we find that Father Constans aic- 
quired a great reputation in Spain in the early part of the nine- 
teenth century, in the treatment of yellow fever, and his chief re- 
liance was olive oil which he gave in large doses. The rationale 
of this treatment seems to be that the oil is highly nutritious, a 
proteid saver, and is readily absorbed by the epithelial and en- 
dothelial cells of the capillaries. In this way the integrity of the 
latter is preser\'ed and hemorrhage prevented. Pathology teaches 
us that where there is capillary blood stasis, hemorrhage soon 
takes place from deprivation of nutriment, the endothelial cells of 
the capillaries being nourished by the blood that circulates with- 
in them. This suggests the early administration of olive 
oil in emulsion with lime water. 

Animal foods have long been condemned, but the use of 
toast-water or thin barley, rice, sago or hominy water, after pro- 



THE TREATMENT OF YELLOW FEVER. 253 

longed boiling and salting, are probably advantageous. Some of 
these are strongly advocated by Surgeon Murray** and the older 
observers, and one can readily believe that the starches they con- 
tain would be of service in restoring the functioning power of the 
hepatic cells. Murray also records eighty cases that were fed on 
ice cream, ad libitum, with only four deaths. And ice cream is 
rich in fat. So that if the stomach is reasonably quiet, we can 
safely satisfy the gna wings of hunger by the use of barley, rice 
or toast- water, milk and Vichy or lime water, ice cream, lemon 
jelly and fruit juices in addition to mild stimulation and the use 
of olive oil internally or externally. To withhold all nourishment 
throughout the course of the fever seems injudicious and unsafe. 
With the temperature below 102** F., and the stomach 
quiet I believe the patient will be greatly benefited by small quan- 
tities of such of. the foods mentioned above as his taste may call 
for. 

The early involvement of the liver as indicated by the early 
lesion in the duodenum naturally suggests an equally early defect 
in the functioning power of the liver of the elaboration of urea. 
This deficiency which must sooner or later become marked, is 
manifested in the failure of the kidneys to secrete the normal 
amount of urine. As the rate of elimination by these organs in- 
creases normally with an increase of the urea in the blood," it 
would seem justifiable to supply the defect by the medicinal ad- 
ministration of urea either through the stomach or by hypoder- 
mic injection, as soon as the ordinary remedies cease to have the 
desired effect. The injection of urea into the blood soon evokes 
aji'ery copious secretion of urine, "even if, previously to the in- 
jection, the secretion had been at a standstill/'" We can hardly 
do better than follow Nature's method of stimulating these or- 
gans to perform their normal functions. And the danger of an 
excessive accumulation of urea in the blood must be very slight 
in a condition where that substance is manifestly deficient. The 
longer the kidneys are permitted to act imperfectly, the greater 
will be the retention of toxins which will react by increasing the 
damage already done to both liver and kidneys. This is not by 
any means a new suggestion, for urea was proposed as a diuretic 



254 LIEUTENANT JAMES CARROLL. 

by the older French physicians and it was used by Prof. Mauth- 
ner** of Vienna. Fifty years ago Dr. T. H. Tanner" of London 
reported success with it in cases of dropsy. In one case he used 
ten grains every six hours for nine days with the effect of in- 
creasing the flow of urine from 14 to 44 ounces in twenty- four 
hours; during the nine days the quantity passed varied from 35 to 
40 ounces. It was then discontinued because the dropsy had been 
removed. After three weeks it was again resorted to with the 
same satisfactory results. 

In my opinion the services of trained female nurses are in- 
dispensable to secure the very best results. They should be un- 
der strict discipline, and the tour of duty with patients who are 
seriously ill should be eight hours in twenty-four. 

The physician should not treat his patients by proxy, but 
should assure himself that his line of treatment is being faithfully- 
carried out. All meddlesome medication should be prohibited. 

It is well to bear in mind the possibility of the occurrence of 
complications through secondary infection by the streptococcus, 
staphylococcus, colon bacillus or bacilli of the hog cholera group, 
known also under the name of B. icteroides, B. enteritidis^ para- 
colon, paratyphoid, etc.** The chances for the occurrence of such 
infection will probably be greatly diminished by the early insti- 
tution of such treatment as will best maintain the integrity of the 
intestinal mucosa and conserve the patient's strength. 

BIBLIOGRAPHY. 

1. Diseases of the West Indies, London, 1762. 

2. Treatise on the Malignant Fever in Barbadoes, London, 1740. 

3. Rush's Hillary, Philadelphia, 181 1. 

4. A Treatise on Yellow Fever, Samuel Brown, M.B., Boston, 1800. 

5. Tytler, p. 5o;j, given by Brown. • 

6. Diseases of Hot Climates, London, 1808. 

7. Medical Inquiries, Benjamin Rush, M.D., Phila., 1805, vol. iii, p. 407. 

8. Medical Inquiries, Philadelphia, 1815, pp. 220 and 223. 

o. The Malignant Fever in Philadelphia in 1793, William Currie, Phil- 
adelpnia. 1800. 

10. Yellow Fever in the Island of Dominica in 1793-4-5-6, James Clark, 
M.D., London, 1797. 

11. Yellow Fever, Philadelphia, 1855, vol. ii, p 626, et scq. 

12. New Orleans Medical and Surgical Journal, ii, p. 522. 

13. Allbutt's System of Medicine, vol. ii, 1807. 
4. Yellow Fever, by Just Touatre, M.D., New Orleans, 1898, p. 164. 

Ibid., Introduction, p. q. 

Yellow Fever in the West Indies, I^ondon, 1898.* 



\l 



THE TREATMENT OF YELLOW FEVER, 255 

17. Practice of Medicine, Alfred L. Loomis, New York, 1885. 

18. Practice of Medicine, New York, 1898. 

19. Text-Book of Medicine, American Edition, New York, 18J3. 

20. AUbutt's Practice of Medicine, vol. ii. Article on Yellow Fever. 

21. Osier: Practice of Medicine. 

22. Buck's Reference Handbook. New York, 1889, vol. viii, p. 71. 

2\, Text- Book of Physiology, Scnafer, London, 1898, vol. i^PP- 906,^8. 
Practical Urinalysis, Purdy, 4th Edition, pp. 22 and 23; and Clinical Diag- 
nosis, Simon, 1897, pp. 325, 330. 

24. Clinical Diagnosis, von Jaksch, Translation, London, 1890, p. 278. 

25. Practice of Medicine, New York, 1808, p. 851. 

26. Text-Book of Medicine, Striimpell, Am. EcL, 1893, p. 489. 

27. Striimpell: Ibid., p. 42. 

28. Practice of Medicine, Loomis, 1885, p. S38. 

29. Ibid., p. 651. 

30. Transactions of the First Pan-American Congress, vol. ii, p. 1289. 

31. Striimpell: Ibid., p. 831. 

32. La Roche on Yellow Fever, Philadeljjhia, 1885, vol. i, p. 172. 

33 The National Dispensatory, 5th Edition, Philadelphia, p. 14^6. 

34. Annual Report of the Surgeon General of the Marine Hospital 
Service, 1898, p. 305. 

35. Ibid., p. 309. 

36. General Pathology, Thoma, English Edition, vol. i, p. 415. 

37. Text-Book of Physiology, Schafer, London, 1898, vol. i, p. 878. 

38. La Roche, vol. ii, p. 724. 



39. Loc. cit, p. 305. 

40. Am. Text-Book of Physiology, 1900, vol. i, p. 255. 

41. Text-Book of Physiology, Schafer, London, 1898, vol. i, p. 647. 



42. United States Dispensatory, i6th Edition, 1888. 

43. Braithwaite*s Retrospect, xxv, p. 161. 

44. Coleman and Buxton on Paratyphoid Infections, American Journal 
of the Medical Sciences, June, 1902, 



BOSTON. 

THE HISTORIC CITY IN WHICH THE TWELFTH ANNUAL MEETING 

OF THE ASSOCIATION OF MILITARY SURGEONS OF 

THE UNITED STATES IS TO CONVENE. 

THE evolution of a word, — Botolph's town, Dot's town, 
Boston, — gave us the present name of this old New Eng- 
land city. The dissatisfaction of certain English Puri- 
tans gave to the city its first inhabitants. The enterprise, smart- 
ness, and grit of these long ago settlers, created * 'modem Athens* ' , 
and the passing of the years has seen cow-paths merge into streets 
full of traflBc, green fields trodden underfoot by massive buildings, 
a mere handful of people multiplied by hundreds of thousands, 
and the old time stage-coaches replaced by whizzing, steamless, 
noisy things 'that rush along on bands of steel, stretched up high 
in the heavens above, deep down in the earth beneath, and along 
the stone-paved streets wherever is seems best, for the transporta- 
tion of the thronging multitudes. 

In things courageous, in deeds of daring, and paths of learn- 
ing, culture, and art, Boston holds her head high. 

In historic events she takes the New England lead. "No 
taxation without representation", was first declared by her citi- 
zens; that greatest of masquerades, the Boston Tea-party, filled 
the waters of Boston harbor with English tea, and the battle of 
Bunker Hill was fought unflinchingly by the forefathers on her 
soil. The pages of history honor her, and give to her — the 
youngest of the first New England colonies— glory, laud, and 
praise. 

Hidden away in the heart of this busy city at the head of 
State street, stands a small brick building which is held in great- 
er honor than the huge structures by which it is surrounded. It 
is the old State House. Captain Keene gave the land for its 
foundation in 1657 but a fire demolished the building in 1711 and 

(25«) 



BOSTON. 



257 



the edifice that now greets the sight-seeing eye, was erected in 
1713. Every inch of its walls tells of by-gone deeds of courage 
and daring. The Stamp Act documents were burned under its 
roof and ancient courts were held. Washington trod its hallways 
and gazed from its windows to review the troops, and the right- 
eous, wrath of Boston citizens against the English nation was 
shown by the burning of the Lion and the Unicom, that stood upon 
its walls. Through * 'scenes and unscenes' ' this building has finally 
passed into the hands of the Boston Society, and is held sacred to 
the keeping of many old-time relics that are shown to visitors free 
of charge. The bitter feeling of English hatred has gone and 
the English emblems have been replaced, but the American eagle 
has been added and spreads his wings in majestic glory as he pro- 
claims to the present generation, the liberty that is an outgrowth 
of the Boston Massacre, that was enacted almost under its ancient 
balcony. 

Sacred to the memory of by-gone deeds this queer old State 
House stands and cannot even see its beautiful successor. 

The present State House is perched high above the madden- 
ing crowd, on the tip-most top of Beacon Hill. Its tow^er windows 
watch the deep 
blue harbor, its 
great dome 
shines with a 
glint of gold on 
a sunny day, 
and glistens 
with a myriad 
lights at night. 
The land on 
which it stands 
was one of John 
Hancock's cow 

pastures, and its architectural lines had their birth in Charles 
Bulfinch's fertile brain. The proposed modernizing of the famous 
Bulfinch front, not many j^ears ago, was discouraged and fought 
against by many of Boston's ardent citizens who pleaded their 
cause well and won their day. 




258 



BOSTON. 



The corner-stone of this building was laid on July 4, 1795, 
and three years afterwards on January 11, the house was dedi- 
cated to the use of a free people. The building contains many 
things of great historic value. Portraits, battle flags, and antiqui- 
ties innumerable. The first State Library of America was placed 
under its roof, and now numbers thousands of volumes. Its 
smooth green-turfed lawns are guarded by Power's statue of the 
great Webster, and Emma Stebbin's statue of Horace Mann, and 
within its walls sit the "powers that be," who enact and admin- 
ister the laws of the old Bay State. 

Boston saw the beginning of many great events and it is 

quite fitting for 
her to hold 
within her old 
city the **Cradle 
of Liberty,"— 
Faneuil Hall. 

This is a build- 
ing whose every 
rafter could 
write a book, 
for they have 
all resou n d e d 
with eager en- 
treaties; courageous calls, stirring commands, and staunch un- 
yielding declarations at every momentous crisis of the Nation's 
history. It has also posed as the pleasure house of the British 
army, being used in 1775-6 as a sort of theatre to display their 
theatrical productions. There are many portraits and paintings 
of interest hanging on its walls, and the gilded glass-eyed grass- 
hopper that ser\'es as a weather\^ane still turns with every breath 
of wind and never seems to long for grassy fields. 

The Old South Meeting House standing on the corner of 
Milk and Washington streets should be an inspiration to the do- 
ing of many worthy deeds. Here the old Puritan Parsons 
preached of the wrath to come and the joy eternal; and beneath 
its roof was held the public meeting from which the * 'Indians' ' 
went to the Boston Tea-party. Here Benjamin Franklin was 




BOSTON. 



259 



baptised into the faith, and Judge Sevvall came to see the error 
of his ways and how wrong was his belief in witch-craft; and 
here also the English Dragoons 
proved their lawlessness and 
lack of reverence, by using "ye 
house of God" for a riding school 
and for a stable for horses. At 
a cost of $430,000 the Preserva- 
tion Society has assured the fu- 
ture longevity of this historic 
place, and it holds many rare 
curios and relics, furniture 
and pictures, that are viewed by 
numberless visitors every year. 
Wonderful things of the olden 
time are often found in sequest- 
ered and out-of-the-way places, 
and no one is surprised to find 
hidden away down in the midst 
of the squalor and poverty of 

Salem steeet, a tall spire pierc- 
ing the bluew^hich is known the 
length and breadth of the nation, 
for from its tower swung the 
two historic lanterns that start- 
ed Paul Revere on his famous 
midnight ride. This tower con- 
tains a chime of bells, the first 
ever cast in the New World. 
Sacred services are still held in 
this ancient building. 

But higher than the pointing 
North Church .spire ascends the 
white shaft of Bunker Hill Mon- 
ument. It stands tall and 
straight and immovable as the 
determination of the Revolu- 
tionary heroes who fought on 





260 



BOSTON. 



that historic spot. Its erection was begun by Lafayette in 1825, 
and Daniel Webster was the 
orator when its comer-stone 
was laid. A long climb of 295 
stone steps gives one ample re- 
ward, while at its base, the 
bronze statue of the brave and 
dauntless Prescott looks down 
over the peaceful streets, and 
his firm pressed lips seem to 




utter the stern command, "Don't 

fire until you see the whites of 

their eyes." 

The more modern Boston 

shows the City Hall that stands 

just back of King's Chapel; the 

l)eautiful Trinity Church; the 

new Public Library with its 

stately, elegant lines of the Ital- 
ian Renaissance, and the famous mural decorations; the massive 

Boston Post Office; the Chamber of Commerce; the Museum of 

Fine Arts, and 
the Boston City 
Hospital with 
its 810 beds, its 
great corps of 
surgeons and 
nurses, and its 
magnificent 
buildings that 
can be surpass- 
ed by no other 
such institution 

in the Old World, save the hospital at Hamburg. 

Boston holds a mine of good things but her suburbs hold 

other vast and interesting treasure houses. 

Salem boasts of Hawthorn's home, the House of the Seven 

Gables, the* Roger Williams House, the little old Meeting House, 




BOSTON. 261 

and the bare and ghostly Gallows Hill. It shows you also many 
curious relics such as the famous witch pins, and the queer old 
houses where the poor persecuted so-called witches dwelt. 

In Cambridge, the Washington elm rustles its branches. Har- 
vard University spreads its wealth of culture and learning broad- 
cast; Longfellow's home beckons you to visit it and have a peep 
at the old clock on the stairs, and the arm-chair made dear by 
the memories of the **Children's Hour". 

Plymouth calls to you to see her famous "Rock*', and the 
old time burying ground, and the low-roofed houses that could 
tell such wonderful tales of the Puritan forefathers, could they 
but speak. 

Concord will greet you and show to you Hawthorne's Way- 
side, the old Manse, and the bridge where the silent Minute Man 
still keeps guard; and you may tip- toe into Sleepy- Hollow and 
see the graves of New England's greatest literary sons — Emerson, ' 
Hawthorn, and Thoreau; and the last resting-place of a dearly 
loved daughter — Louisa Alcott — who wrote in the midst of trials, 
yet gave to the world books that were sweet and good and pure. 

Narrow and crooked are Boston's streets, curved are her by- 
paths; but broad and big and great is she in the heart of the na- 
tion; staunch, loyal and true. 



IRepdnts anb XCtanslatlons. 

THE MILITARY MEDICAL JOURNALS OF SPAIN 

FOR 1902. 

By lieutenant CHARLES NORTON BARNEY, 

MEDICAL DEPARTMENT, UNITED STATES ARMY. 

TWO military medical journals are published in Spain, 
the Revista dc Sanidad Militar arndLa Medicina Mil- 
itar Espanola. 

REVISTA DE SANIDAD MILITAR. 

The Revista de Sanidad Militar is a semi-monthly octavo 
(9|x6| in.)i of twenty pagfes, printed at the press of the Mili- 
tary Administration in Madrid, and edited by M. G6mez 
Florio. This name appears in the Rank List of the Sanitary 
Corps of the Spanish Army for January 1903 at the foot of the 
list of Sub-Inspectors of the 1st (^lass, a grade nearly corre- 
sponding to that of Lieutenant Colonel and Deputy Surgeon 
General in our Army. 

Of the 448 pages which constitute Volume XVI, made up 
of the 24 semi-monthly numbers issued in 1902, 97 pages 
(20%) are devoted to circular orders to the. Army, on such 
subjects as leaves of absence, uniform, and personal records; 
55 pages (11%) are devoted to miscellaneous notes on such 
subjects as promotions, vacancies, dt^aths, mortality statistics 
of Madrid, distributions of prizes, and even notices of the 
latest collection of short stories; 219 pages (about 45%) are 
occupied by 217 abstracts and synopsesof articles read at med- 
ical meetings or published in the medical press, on subjects 
not related to military medicine, — for example, **Cancer," 
**Anomalies of the Cerebral Circulation in the Insane," ''In- 
termittent Claudication," ''Artificial Feeding of the New- 

(262) 



SPANISH MEDICO-MILITARY JOURNALS, igo2. 263 

born," and *'Tumors of the Corpora Quadrig-emina." Only 19 
pages (less than 4%) are devoted to the 13 abstracts on sub- 
jects bearing- on military medicine; 28 pag-es (about 6%) are 
devoted to 3 original articles on non-military subjects, viz., 
**Review of Recent Work on Tuberculosis," **A Case of Severe 
Typhoid Fever," and "Life of Pasteur;" and out of the whole 
488 pag-es only 65 (13%) are devoted to the 6 original articles 
on medico-military subjects, viz., '*Automobilesinthe Army," 
"Disregarded Causes of Mortality in the Army," "Post-Hem- 
orrhagic Syncope and Anemia, and their Treatment on the 
Battle Field," "Roentgen's Discovery and its Utility in the 
Sanitary Service," "Interesting Test Concerning the Food of 
the Soldier," and "Clinical Report of the Wounded in the Ex- 
plosion of the Carabanchel Powder Magazine." This last 
article occupies nearly half of the few pages which are de- 
voted to original articles on medico-military subjects. 

With each semi-monthly number is issued 8 pages of a 
monograph, in the form of a "feuilleton." From January 1st 
to October 1st the subject of this "feuilleton" was "A Study 
of the Fractures Produced by Small Arm Projectiles." Since 
October ISth the subject has been "Bacteriology in Relation 
to Hygiene." 

Following are abstracts of the original articles on mili- 
tary subjects: 

Automobiles in the Army. ( Unsigned,) — This article 
merely indicates the extent to which experiments in the use 
of automobiles have been carried in various armies of Europe. 

Disregarded Causes of Mortality in the Army. {F. 
G, Deleitd), — The Spanish Army has the highest mortality 
rate of all the armies of Europe. Though the attempts so far 
made to reduce this rate have been inadequate, yet the gov- 
ernment has been and is devoting some attention to the im- 
provement of quarters and rations, defects in which have 
seemed the most prominent causes of the excessive mortality. 
But there are important causes which have not received atten- 
tion; and most important of these is the possibility of secur- 
ing exemption from military service by the payment of 750 
pesetas. 



264 LIEUTENANT CHARLES NORTON BARNEY, 

The author declares that conditions in the Spanish Army 
have been such that nearly all who can scrape together suflS- 
cient money to purchase exemption from service do so, and 
that as a rule only those enter the ranks who, through lack 
of the money necessary for the purchase of exemption, have to 
choose between service and desertion. This means that the 
army is recruited from those who live under the most un- 
hygienic conditions, for not being able to scrape together 750 
pesetas implies poor food, worse lodging, and hard work. 

The theory that men brought up in the country are more 
robust and resistant .than city bred men has been discarded, 
and it is recognized that the peasants, who live poorly, not 
only are weaker than those city bred men who eat and live 
well, but especially in point of resistance to infections, are 
weaker than those city bred men who have to live unhygien- 
ically. It is the very poorest peasant class from which come 
the majority of recruits for the Spanish army, and there does 
not exist in them that robustness which the uninstructed laity ' 
think they see in a physical development attained through 
excessive muscular labor continued from early childhood. 

When the^e peasants are removed from their rural envi- 
ronment and crowded into barracks they take every infection 
there is going, and encounter in an exaggerated form all those 
dangers of city life to which they are so unused. Thus the 
system of purchasing exemption from military service deprives 
the army of a proportion of young men brought up in cities, 
who are much superior to those who come from the rural dis- 
tricts, exempting from service those who are best able to en- 
dure life in barracks. 

Another cause of mortality to which attention has not 
been paid is the reduction in the size of companies. Crowd- 
ing has not been lessened, for two companies are now crowded 
into the space formerly occupied by one; half the barracks is 
left unoccupied while the other half is jammed full. Mean- 
time the number of *'nights in," between guard tours, is of 
course increased, and lack of sleep leads to intemperance. 



SPANISH MEDICO MILITARY JOURNA LS, igo2, 265 

Post-Hemorrhagic Syncope and Anemia; their Treat- 
ment on the Battle Field. (/. Garcia Julian^, — The fre- 
quence of hemorrhage as a complication of wounds received in 
battle has been variously estimated at from 1% to 30%. The 
reason for this discrepancy is that some of the statistics consider 
only the wounded^and not those cases in which death takes place 
at once from primary hemorrhage. Very many die, however, 
from primary hemorrhage before they can be reached by a 
surgeon, and, as a rule, only those cases of hemorrhage can 
receive treatment by the surgeon in which there has been 
some delay in the effusion of blood through syncope or through 
the application of emergency treatment by the soldier himself 
or by his comrades. Thus the surgeon intervenes in the in- 
termediate hemorrhages and of course in the secondary hem- 
orrhages, rather than in the primary. The "Medical & Sur- 
gical History of the War of the Rebellion" attributes 67.8% 
of the deaths on the field of battle to hemorrhage. The per- 
centage has been very high in combats with side arms, not- 
ably in the charge at Gravelotte (1870), where an enormous 
proportion of the combatants, including the commanding gen- 
eral himself (Legrand), died on the field from hemorrhage. 
The fear that the percentage of deaths from hemorrhage in 
modern warfare, with the use of the jacketed bullet travelling 
at high velocity, would be greater than with the old leaden 
ball, which might be expected to tear rather than smoothly 
cut the arterial walls, has not been confirmed by the statistics 
of the Spanish-American War. 

At any rate abundant hemorrhages are the cause of a 
great number of deaths on the battle field; but in other cases 
the loss of blood brings with it syncope, and this, in turn, re- 
sults in transitory hemostasis, a temporary let-up in the bleed- 
ing, which gives time for the transportation of the patient to 
the first aid station. To this point are carried many wounded 
in whom the pallid faces covered with sweat, the coldness of 
the extremities, the panting respiration interrupted by deep 
sighs, the irregularity of the heart beat, the faintness, the 
weakness and rapidity of the pulse, give little hope of life. 



266 LIEUTENANT CHARLES NOR TON BA RNE K 

This post-hemorrhagic syncope and the grave picture we 
have drawn, which may be seen also in the field hospitals in 
such wounded as have received first aid and in whom the tem- 
porary tourniquets applied on the field of battle have become 
loosened in transportation, is produced solely by the diminu- 
tion of the amount of blood in the body, throug-h which the 
heart loses those hydraulic conditions necessary to its normal 
working-. The resulting acute cerebral anemia in its turn 
produces important modifications in the circulation and respir- 
ration. 

Although stimulants such as ammonia and ether, admin- 
istered subcutaneously, succeed in whipping the heart to 
action, yet the relief they give is transitory, and, when the 
hemorrhage has been abundant, is insufficient to allow the 
wounded to undergo the added fatigue of transportation to 
hospital (sometimes not very near), and to prevent a return 
of syncope. The acute and profound anemia which produces 
the syncope must be treated. 

The first means which comes to mind in this connection 
is **auto-transfusion," which is brought into play by strongly 
compressing the extremities by means of elastic bandages, so 
that th& blood is forced from the extremities into the trunk 
and serves to supply the brain and other important vital 
organs which could not withstand any prolonged lack of 
blood. 

But the radical remedy for this syncope and anemia is 
that which, by augmenting the volume of the blood, places 
the heart under conditions most similar to those necessary for 
its normal action. This result is accomplished by the in- 
travenous injection of salt solution. 

The proportion of salt needed to make the solution most 
nearly approximate the blood in specific gravity has been 
variously estimated at from 6 to 10 parts to 1000 of water. 
But the practical points are that cooking salt is always at 
hand, that water can not only be readily sterilized by boiling, 
but, by regulation is required always to be kept ready for use 
in the field hospitals and at the first aid stations, and that the 



SPANISH AfEDlCO-AflUTAR Y JOURNALS, igo2, 267 

difference between the various estimations of the proper per- 
centage of salt is another advantage in the field, where there 
are no means of exactly measuring doses. A heaping tea- 
spoonful of common salt to the quart of water makes a very 
satisfactory solution. 

In the severer cases it is important that the injection be 
given intravenously, in order that it may produce its effects as 
rapidly as possible. The operation does not take much time, 
and once begun may be left to an intelligent assistant. 

Subcutaneous, and even rectal injections, may be used 
when the case is not urgent, or when the conditions as to 
asepsis, material, etc., are not favorable for intra-venous in- 
jection. Frequently the treatment of a post-hemorrhagic 
anemia, begun with intra-venous injections, has to be carried 
on or completed by subcutaneous injections of the same solu- 
tion. 

Although in some cases the loss of blood has been such 
that death is inevitable, yet in practice we can never know 
when the wounded man is certainly doomed, for even in cases 
which appear most desperate the in^ectionof salt solution will 
often change the picture. 

Rcentgen's Discoveky and its Utility in the Sanitary 
•Service IN Peace and War. — /. (warcia Julian enumerates 
the applications of the X ray to diagnosis and treatment; calls 
attention to the radiographic installations of the American 
Army in the Spanish-American war and of various armies in 
the South African and Chinese campaigns; and urges that 
the principal Spanish military hospitals, especially those 
which are likely to be used as base and general hospitals in 
time of war, be supplied with X ray apparatus. He mentions 
the utility of radioscopic and radiographic examinations as a 
means of diagnosis in the following conditions: pulmonary 
tuberculosis, pleurisy, hypertrophy of the heart, atheroma and 
aneurism (especially in the earlier stages), dilatation of the 
stomach (Destoff's method), pigmentation of the skin in dis- 
eases of the liver and pancreas (Jeansalme), alterations in the 
dimensions or location of the kidneys, biliary, ureteral, ureth- 
ral and vesical calculi, chronic rheumatism, gout, arthritis 



268 LIEUTENANT CHARLES NORTON BARNEY, 

deformans, periostitis, osteomyelitis, tumors of bone, fractures 
dislocations and gunshot wounds. The use of X rays in treat- 
ment is mentioned in connection with lupus, sycosis, favus, 
tinea, and psoriasis. The paragraphs of most interest to us 
are those which concern the early diagnosis of tuberculosis. 
Tuberculosis is of special importance in the Spanish 
army, where it not only has been causing 3.7% of the deaths, 
but, in addition has caused the discharge of even a greater 
number of men, who have gone to their homes in an advanced 
stage and there have scattered about them the germs of their 
disease as they had scattered them before in barracks. Some 
improvement, as far as the army is concerned, is to be ex- 
pected as a result of recent orders, which require that cases of 
tuberculosis shall be discharged as soon as the diagnosis has 
been made; and, apart from changes in recruiting require- 
ments, the most important improvements needed are improve- 
ments in the early diagnosis of the disease. Kelchs, Boinon, 
Vaillard, and Laveran have demonstrated that a great num- 
ber of recruits are accepted who, though they appear to be in 
perfect health, are really suffering from latent tuberculosis. 
Alterations in nutrition, tachycardia, scapulo-humeral amyo- 
trophy, Thompson's gingival sigh, tenderness in the upper 
intercostal spaces, and attempts to determine numerically the 
resisting power of individuals are valueless, taken alone, ex- 
cept as indications which make one suspect the existence of 
tuberculosis. Tuberculin injections for early diagnosis have 
been discarded in the German and French armies. Attempts 
to elaborate a serum reaction have given no results. Nothing 
enables us to diagnose tuberculosis before the appearance of 
bacilli in the sputum, (which all recognize as a late phenom- 
enon), except the use of the X ray. These give data of un- 
questionable value, which are: diminution of the transparency 
of the pulmonary apices, and limitation, on the affected side, 
of the descent of the diaphragm on deep inspiration. These 
two phenomena have enabled Claude, B^cl&re, Kelchs and 
Boinon to predict the appearance of bacilli in the sputum in 
many cases in which the classical methods of physical exami- 
nation had given no indications. 



ADebico-rtMUtar^ Inbcx. 

MEDICO-MILITARY ADMINISTRATION. 

AddiBon (C J.) A popular account of the ambulance organization and 
medical arrangements of an English Army Corps in the field. 2 ed. 12*^ 
London, 1902. 

Austin (J. A.) Manual of first aid, being a text-book for ambulance 
classes and a work of reference for domestic and general use. 12^. London, 
1902. 

Qaun. Die Organisation des Militair-Sanitatswesens im Kriege. Rothe 
Kreus, Berl., 1902, xx, 318. 

Cron [KJ Drei Monographieen aus dem Gebiete des Feld-Sanitats 
dienstes. I, Zur Verwendung der Sanitatsformationen im Gefechte. II. 
Die Gliederung einer Infantrie-Divisions-SanitatsanstaU. IH. Einige 
Winke der Maasnahmen des Chefar^tes einer selbstandig operierenden In- 
fantrie-Truppen-Divisiou gelegentlich langer dauernder Ruhestellung und 
bei Reisemarschen. 8°. Wien, 1902. 

Cfon [K.] Zehn Beispiele aus dem Gebiete des Gefechts-Sanitatsdi- 
enstes; kritisch besprochen im Gelande. Ein Supplement zur militarischen 
Propadeutik als Einleitung in das Studium des Feld Sanitatsdienstes 2 
Hft. 8* Wien, 1902. 

Dedeman. [The military convalescent home, Glasewalds-Ruhe bei 
Dresden.] Rothe Kreuz^ Berl., 1902, xx, 417. 

Ghrogre (G. B.) Commemorazione del Geherale medico Prof. Francesco 
Cortese gik ispettore Capo del Corpo Sanitario dal 1873 ^ '880 nelP inaugu- 
razione del suo nionumento alPOspedale militare del Celio in Roma con 
alcuni cenni sulle sue opere principali. 8°. Roma, 1902. 

Henfletta» Sister War nursing in South Africa, 190 1. Brit. J. Nursings 
Lend., 1902, xxix, 254-256. 

Jaiu Le croiseur-^ole d'application le Duguy-Trouin. Arch, de med. 
nav.y Par. 1902, Ixxvii, 321; 401. 

Lowenthal (VO La loi sur le service de deux ans; Pinfluence de I'incor- 
poration des services auxiliaires sur Petat sanitaire de I'arm^e. Rev. scient.^ 
Par., 1902, 4. s., xviii, 45-47. 

Pope (Gcorgina F.) Nursing in South Africa during the Boer war, 1899- 
1900; Am. J. Nursings Phila., 1902-3, iii, 10-14. 

Pope CGcorgina F*) Nursing in South Africa during the Boer war. Brit. 
J. Nursings Lond., 1902, xxix, 232-234. 

(289) 



270 MEDICOMILITA R V INDEX. 

m 

MILITARY HYGIENE. 

Hoenigsberger (L.) Bericht iiber das Konzentrationslager Merebank 
♦ Natal.) Munchen. med. Wchnschr.^ 1902, xlix, 1507-1509. 

von Hoolin (R.) Zum Nachweis der Simulation bei Hysterischen und 
Unfallskranken. Munchen, med, M^^^wj^^r, 1902, xlix, 152 1 -1524. 

Masbrenier. L'ali^nation menfale dans Tarm^e. /. de. mfd. de Par. 
1902, 2. s.,xiv, 33S. 

Mouly (G.) [Tuberculosis in the army; military' sanatoria.] 8". Paris, iqoi . 

Kot (M») [Visual defects in soldiers.] Militaerarzt^ Wien, 1902, xxxvi, 
161--164. 

Radey (F.) [Propositions for simplifying the treatment of gonorrhoea 
.^nd its complications in our military hospitals.] Militaerarst^ Wien, 1902, 
xxxvi, 171-173. 

Redondo Flores (A.) Fiebre tifoidea grave. Rev, de san. mil., Madrid, 
ILJ02, xvi, 229-232. 

Sutdalski (A. D») [Cars used for instruction.] Voyenno-med. /., St, 
*Petersb., 1902, Ixxx med.-spec. pt. 244-249. 

Whittington (R*) Enteric fever; prophylactic measures in armies. Treat- 
mint, Lond., 1902-3, vi, 571-592. 

Yavein(G.YO [Nutritive value of the rations of the St. Petersburg 
Clinical Military Hospital.] IsvUst. Imp. Voyenno-Med. Akad.^Si. Peterb., 
1902, v., 58-67. 

MILITARY SURGERY. 

Nimier (K) & Laval (E.) [Treatment of wounds in war.] An, san. mil., 
[iuenos Aires, 1902, iv, 561; 644. 

Nimier. [Pathology of cerebral commotion in gunshot wounds]. Arch, 
ife med. et.pharm. mil., Par., 1902, xl, 265-268. 

Perani (A.) [Radiography of gunshot wound of the head.] Gior. med. 
it r. esercito, Roma, 1902, 1, 1043- 1049. 

Roberts (C.) The treatment of abdominal wounds in war. Brit. M.J,, 
Lond., 1902, ii, 1027. Also: Med. Press df Circ, Lond., 1902, n. s., Ixxiv,26o. 

Stendro (J.) Ein complicierter operativer Fall. Wien med. Wchnschr.^ 
(r^2, lii, 1568. 

Thalwitzer. Zur Aetiologie der Fussgeschwulst. Deutsche mil,-drztl. 
Ztschr., Berl., 1902, xxxi, 435-440. 

Tiffany (L. M.) The great importance of drainage in bullet wounds of 
intraperitoneal viscera. Am. Med., Phila., 1902, iv, 138. 

Tile (V. A.) [Treatment of gun-.shot wounds in the last war and several 
fundamental principlesof contemporary army-medical field surgery.] Russk. 
Mr. arch,, S. Peterb., 1902, xviii, 817-831. 

Tile (V. A.) [Character of gunshot wounds caused by jacketed bullets 
■ if small caliber.] Russk. chir. arch., S. Peterb., T902, xviii, 345-363. 



Ube Uwelttb Hnnual {fbccting. 

Xo9ton, Obass., Obav 19, 20 an^ 21, 1903. 

PRELIMINARY ANNOUNCEMENT OF THE TWELFTH 
ANNUAL MEETING. 

THE Twelfth Annual Meeting of the Association of Mili- 
tary Surgeons of the United States will convene in 
Boston, Mass., on Tuesday morning, May 19, 1903, and 
continue in session during the two following days. Every mem- 
ber is cordially urged to be present and participate in all the ex- 
ercises, both social and literary. 

The following is a consolidation of the arrangements made for 
the meeting by the Committee of Arrangements, the Literary 
Committee, and the Committee on Transportation. 

proaram of tbc (twclftb Hnnual flDccttng of tbc 

H00ociation of flDilitari? Surgeone of tbe 

1Ilnttc& StatC0. 

TUESDA K, MA Y ig, igoj. 

10..W O'CLOCK A. M. 

OPENING EXERCISES, FANEUIL HALL. 

Selection, ....... Orchestra 

Invocation, Rt. Rev. H''illiam Lawrence^ Bishop of Massachusetts. 

Address, - - - Hon, John L. Bates^ Governor of Massachusetts. 

Address, .... Hon, P. A. Collins^ Mayor of Boston. 

Address, - - Z>r. G^/^/y^ ^. /^r/i«^/j. President of the 

Massachusetts Medical Society. 
President's Annual Address, Brigadier General Robert Allen Blood, 

President of the Association. 

(271) 



272 THE TWELFTH ANNUAL MEETING. 

2 O'C.'I/K'K p. M. 
BUSINESS MEETING AT THE MEDICAL LIBRARY BUILDING. 

1. Report of the Executive Committee. 

2. Report of the Secretary and Editor. 

3. Report of the Treasurer. 

4. Report of the Literary Committee. 

5. Report of the Necrology Committee. 

6. Report of the Transportation Committee. 

7. Report of the Incorporation Committee. 

8. Report of the Public Service Medical School Committee. 

9. Report of the Enno Sander Prize Medal Board of Award. 

10. The Differential Diagnosis of Typhoid Fever in its earliest stages. 
By the Successful Competitor for the Enno Sander Prize for igoj, 

8 (VCLOC^K P. M. 

Reception for members, ladies, and invited guests, at the 
Armory of the First Corps Cadets M. V. M., Columbus Ave. 

IVEDNESDA V. MA Y 20, igoj. 
10 O'CLCK'K A. M. 

BUSINESS MEETING AT THE MEDICAL LIBRARY BUILDING. 

1. The Education of the Medical Officer. By Major William C, 
Borden, U.S. Army. 

2. The Degree of Doctor of Public Health. By Medical Director 
P. Fitzsintons, U.S. Navy. 

3. The United States Army General Hospital at the Presidio of San 
Francisco, California, 1 901 -1902. By Colonel A If red C. Girard^ U.S. Army. 

4. Some Problems for Solution by the Medical Department of the 
Army. By Lieutenant Colonel fohn Van Rensselaer Hoff, U.S.Army. 

5. My First Aid to the Wounded ; the trip of the Steamer S. R. 
Spaulding, transporting our Wounded Prisoners from City Point, Va , to 
Philadelphia after the Seven Days Battles in 1862. By Lieutenant Colonel 
Henry O. Marcy, U.S.V. 

6. The Examination of Recruits for the National Guard. By Colonel 
William f. Maybury, Me.V.M. 

7. The Sanitary Condition of the Town of Surigao, Mindanao, Philip- 
pine Islands. By Captain Henry du R. Phelan, U.S.V. Submitted by 
Permission of the Surgeon General of the Army. 



THE TWELFTH ANNUAL MEETING. 273 

8. The Surgeon Generals of the Army from the Revolution to the 
Close of the Hostilities in the Philippines; Illustrated by a Complete Series 
of Portraits. By Major James Evelyn Pilcher^ U S.V. 

9. New England Men in the Medical Corps of the Navy of the United 
States. By Medical Inspector Franklin Bache Stephenson, U.S. Navy. 

ID. Service Conditions/ Retirement and PensionB. By Medical Dir- 
ector John C. PVisey U.S. Navy. 

II. Appointment of Nominating Committee. 
1 O'CIXXTK P. M. 

On invitation of Dr. Henry O. Marcy, late Medical Director 
U.S. v., the Association will lunch with him at his residence, 
180 Commonwealth Ave. 

2.80 0»(?LO(Tv p. M. 
BUSINESS MEETING AT THE MEDICAL UBRARV BUILDING. 

1. Paiper by Major A gel Ames ylJ.Sy. 

2. On the Prevention of the Spread of Infectious Diseases on Board 
Ship. By Surgeon Henry G, Beyer, U.S Navy. 

3. Epidemic Catarrh on Ship Board. By Passed Assistant Surgeon 
Dudley N Carpenter, U.S. Navy. 

4. The Public Heahh and Marine Hospital Sanatorium at Fort Stan- 
ton, N.M. By Surgeon Paul M. Carrington, P.H.& M.H.S. 

5. Remarks on the History, Cause, and Mode of Transmission of Yel- 
low Fever, and the Occurrence of Similar Types of Fatal Fevers in Places 
where Yellow Fever is not Known to have Existed. By Lieutenant James 
Carroll, U.S. Army. 

6. The Pathology of Latent Malarial Infection as Observed at 
Autopsy. By Lieutenant Charles F, Craig^ U.S. Army. 

7. Practical Methods for Purification of Drinking Water in the Field. 
By Lieutenant Colonel William H. Devine, M.V.M. 

8. Leprosy as seen in the Philippines. By Major Charles B. Ewing, 
U.S. Army. 

9. An Epidemic of Diphtheria on Board the United States Training 
Ship Buffalo. By Medical Inspector G. E. H. Harmon, U.S. Navy. 

10. Report of a Case of Malarial Sciatica. By Surgeon Eton O. 
Huntington, U.S. Navy. 

11. Notes from the Experiences of a Medical Officer in the Tropics. 
By Major Charles F. Mason, U.S. Army. 



274 THE TWELFTH ANNUAL MEETING. 

K(V(»L(X"K P. M. 

The Association is invited by Col. James B. Frye, Command- 
ing First Regiment M.V.M.H.A. to a drill and evening parade 
by that regiment at the South Armory, Irvington St. There 
will also be an exhibition by the Ambulance Corps M.V.M. Capt. 
Robert E. Bell Commanding. 

THC/RSDA K, APRIL 21, /pq?. 
10 (TCLiXJK A. M. 

BUSINESS MEETING AT THE MEDICAL LIBRARY BUILDING. 

1. Circumcision and Flagellation among the Filipinos. By Lieuten- 
ant Charles Norton Barney ^ U.S. Army. 

2. Paper. By Surgeon W. C. Braisted, U.S. Navy. 

3. Paper. By Captain James Brew^ Tenn, N.G. 

4. Paper. By Surgeon S. G. Evans, U.S. Navy. 

5. An External Suture. By Captain Thomas Page Grant, K.S.G. 

6. Gunshot Wounds of the Abdomen. By Major IVallaceNeff^XJ.SN . 

7. Dislocation of the First Metatarsal Bone. By Surgeon Henry W. 
Sawtelle, P.H.&M.H.S. 

8. The Treatment of Abdominal Injuries with Special Reference to 
(iunshot Wounds of the Liver. By Colonel John E. Summers^Jr,^ Nebraska. 

g. Sick Bay Notes. By Surgeon C. F. Stokes, U.S. Navy. 

10. A Case of Intradural Hemorrhage without Fracture, caused by a 
Football Injury; Operation followed by Recovery. By Surgeon F. IV. F. 
Wieber, U.S. Navy. 

11. Paper. By Assistant Surgeon General George Tully Vaughan, 
P.H.&M.H.S. 

12. Report of Nominating Committee. 

13. Election of Officer.«i. 

2 (rCLCK^K p. M. 

Excursion to Lexingtoo, and Concord by Automobiles, 
through the courtesy of members of the Automobile Club of 
Mass. 

FRIDA K, MA Y 22, igoj. 

The committee have arranged several excursions for this day 
among them one to Fort Warren and Boston Harbor at 8.30 



THE TWELFTH ANNUAL MEETING, 275 

o'clock A.M. A trip to Plymouth and Duxbury. One to visit 
Old Boston and Bunker Hill and the Navy Yard, together with 
several to be announced later. 

The Committee of Arrangements wish to call the attention 
of the members to the card-board insertion in this number of the 
Journal and in addition to the information given there to state 
that the railroads will allow the usual concession of one fare and 
a thirds as announced by the committee on transportation. 

Special Httanaementd tot XaMes accompani?fna 
Aembers*. 

A special Committee of ladies with Mrs. Lulu V. Upham as 
chairman will entertain the visiting ladies during the meeting, 
and have arranged for them the following program: 

TUESDA Y P. M,, MA Y ig, igoj. 

The members for the ladies committee will hold themselves 
in readiness to attend the visitors to such places of interest as they 
may wish to visit singly or in parties. 

WEDNESDA K MA Y 20, igoj. 

A private lunch will be given to visiting guests by Mrs. 
Samuel Elliot, Regent of Warren Prescott Chapter, D.A.R., in 
her historic old home at 44 Brimmer St. , to meet Mrs. Julia Ward 
Howe, Mrs. Mary A. Livermore and other noted Massachusetts 
women. 

At 4 P. M. the New England Women's Press Association, 
Mrs. Emeline Ricker President, will tender the ladies a reception, 
inviting in their donor the army and navy contingent and Boston's 
literati. 

THURSDA Y MAY 21, igoj. 

A committee of Cambridge ladies, Mrs. Estelle Hatch Mer- 
rill ex-president of Cantabrigia, Chairman, will show the visitors 
the sights of Cambridge, including the home of Longfellow to 
which his daughter Miss Alice Longfellow cordially invites them. 
A private lunch will be served. 



276 



THE TWELFTH ANNUAL MEETING, 



1le^ttce^ 1lafIroa^ jfares. 

Reduced railroad rates may be obtained by persons coming 
to this meeting at the rate of one fare and a third for the round 
trip. To assure the rate, each person must purchase, not earlier 
than three days before the meeting, one first-class ticket to Boston, 
Mass., and obtain ^'^Sfc^S^fe^^ from the ticket 

agent a certificate ^^fm^B^^. ^^ ^^^ efiPect. The 

certificate is abso- i^m^S^m^^SStS^ hUely essential, as 
the reduced rate of jH^^^^^^^SH ^t^^'third the regu- 
lar return fare will ■HUH^HHRPH ^ allowed only 
upon the presenta- ^M^WppWpMSH ^^^" ^^ ^^ certifi- 
cate, properly en- ^USMvys^ dorsed,to the ticket 
agent in Boston. ^^HMR^mcS^^V '^^^ return fare 
certificate should ^^^^mxjjj^^^^ ^ deposited with 
the Committee] of ^^^^^^r Arrangements im- 
mediately upon ar- ^^^^ rival in Boston. 




Badge of tiie Boetoo 
Meeting. 



RELATION OF VOLUNTEER RELIEF ASSOCIATIONvS 
TO THE GOVERNMENT. 

Bv MAJOR GEORGE G. GROFF, 

LEWISBURGH, PENNSYLVANIA. 

BRIGADE SURGEON OF UNITED STATES VOLUNTEERS; LATE COM- 
MISSIONER OF THE NATIONAL RELIEF COMMISSION IN 
PORTO RICO. 

THE NEED OF VOLUNTEER RELIEF ASSOCIATIONvS. 

IN all emergencies of a national character, volunteer relief is 
essential to supplement the efiForts of the General Govern- 
ment. This is especially true in wars, which generally arise 
suddenly, and are accompanied by such appalling disasters, that 
the aid of the whole nation is often needed to reduce suffering to 
a minimum. 

It will always be true that raw levies of troops, and troops in 
active campaigns, will suffer much more sickness, than troops in 
barracks. During the first year of our Civil War, 104.4 men in 
each thousand in the Northern army were constantly in the hos- 
pitals. During the first three years of the same war, 1,250,000 
men from the Northern armies passed through the hospitals. 
After the battles of the Wilderness. 10,000 sick and woun3ed 
soldiers were transported North by the Christian Commission. 
After the battle of Gettysburg, the U. S. Sanitary Commission 
expended some $75,000.00 on the relief of the sick and wounded 
on that field, and the Christian Commission about $50,000.00. 
During our Civil War, it is estimated that the Sanitar\' and Chris- 
tian Commissions, jointly expended $24,000,000.00 in assisting 
the General Government to care for disabled soldiers. In the 
Crimea, in the British army, the loss rose from 293 perM per an- 
num in July 1854 to 1174 per M per annum in Jan. 1855, and 
for the first three months of 1855, it amounted to 912 per M per 

(277) 



278 MAJOR GEORGE G. GROEF. 

aununi, of which 98% was from disease. This is an indication 
that the government was unable to meet all the demands made 
upon it of a sanitary nature. 

THE EXPERIENCE FROM OUR CIVIL WAR. 
From the experience gained in this war, it is manifest that 
in any great struggle, volunteer relief is needed in several direc- 
tions. 

1. On Battle Fields, and in Camps to supplement the ordinary work of 
the government. 

2. In transportation of sick and wounded to the rear and to their homes. 

3. Special Relief. 

4. Home Relief. 

On great battlefields, like those of Gettysburg, Antietam, be- 
fore Richmond, and many others, the number of wounded and 
disabled was so immense that it was impossible for the array sur- 
geons and the hospital corps to attend to all the demands made 
upon them. Here voluntary relief societies must furnish sur- 
geons, nurses, minute men, and ho.spital supphes. Circular 42 of 
the Sanitary Commission indicates the need of voluntary relief. 
"An examination showed that the condition of the wounded men 
was deplorable. Some were just as they had been left by the for- 
tunes of war. four da\s before: their wounds as yet, undressed, 
smeared with filth and blood, and all their wants un.supplied. 
Others had had their wounds dressed, one, two, or three days be- 
fose: others still were under the overburdened surgeons' charge, 
without an article of clothing to give any one a change, without 
an extra blanket, with few medicines, no stimulants, and noth- 
ing but corn-meal gruel, hard bread, and bacon, to dispense as 
food." 

The Ordinary Work of the relief societies is to gather sup- 
plies and men and to have them where the}' can aid the govern- 
ment when most needed in just such cases as the above. To 
transport the wounded and disabled, special trains, hospital ships, 
and in some ca.ses wagon trains, wholly under charge of the sur- 
geons of the relief societies, may be needed, as in such cases where 
the wounded and sick are necessarily abandoned by their own 
surgeons. Special Relief wdi^ an exceedingly important part of 
the work of the Christian and Sanitary Commis.sions. The work 



VOL UNTEER RELIEF A SSOCIA TIONS. 279 

was in the direction of sustaining soldiers' "Lodges," "Rests," 
"Asylums," "Refuges," and "Homes" where soldiers sick, con- 
valescent, and detached from their commands, received temporary 
relief. At points where large numbers of troops passed, "sol- 
diers' restaurants" were established, where troops enroute to the 
front, or to their homes, were always provided with a substantial 
meal. The sick and wounded were also fed enroute on the hos- 
pital .or other trains, and financially stranded soldiers were fur- 
nished with "meal tickets" which were recognized at leading 
restaurants all over the country. 

Couriers were placed on trains where many sick traveled, to 
assist them in vSecuring transportation, and against sharpers; and 
a claim department maintained in all the larger cities of the 
country, aided soldiers in securing pay, bounties, pensions, and 
in completing and clearing their records: a literary bureau to pre- 
pare hygienic and other circulars was also needed and found to 
be ver>' useful. 

This special relief work is treated of in circular 5*)'* Vol. I; 
circular 77 Vol. II; and circular 69^* Vol. II of the documents of 
the Sanitary Commission, New York 1866. The value of this 
special relief work is beyond estimation. Home relief \^ needed 
for the dependent families of soldiers and for discharged soldiers 
themselves, to secure work for such families, for discharged sol- 
diers and to get disabled soldiers into permanent homes. Here 
may also be noted the securing of accommodation for sick and 
wounded soldiers in local hospitals. With the great recent in- 
crease of these hospitals, and the perfection of transportation, 
this aid can in the future be made of greater use than ever be- 
fore. All volunteer aid societies should furnish their ozi^n trans- 
portatiou. 

RECOrTiNITIOxN OF VOLUNTEER RELIEF SOCIETIES HY THE 
(iENERAL GOVERNMENT. 

During our Civil War, the U. S. Sanitary .Commission was 
by military order given an official standing. The Christian Com- 
mission was also recognized by the Government since that time, 
the National Red Cross Society has secured an international rec- 
ognition. The generosity and humanity of our people, in any 



280 AfAJOR GEORGE G, GROFF. 

war, will cause them at once to organize countless Patriotic and 
Soldiers* Relief Societies. The people of each City, State, Town, 
County, and Township will speedily organize one or more socie- 
ties to look after their own soldiers. 

To say nothing of the waste of energy and of money, if these 
societies should try to operate independently in distribution of 
supplies, as they will certainly try to do, it is manifestly impossi- 
ble for the Government to recognize one hundred and fifty, or 
twenty-five, or even ten volunteer relief societies. They must in 
some manner unite their forces and efforts. Many home societies 
may gather material for relief, bnt a few societies only can be 
recognized in dispensing it. 

SOCIETIES RECOMMENDED FOR RECOgWitION. 

From the experience gained in former wars, it is certain that 
our people will not be willing to confine their gifts to any one 
volunteer society. That relief may be gathered from every source, 
and that all givers may be satisfied with the recipients who are to 
dispense their bounty, the Government will need recognize more 
societies than one. 

It is suggested because the people well remember their mag- 
nificent records, that the Government recognize in future wars, 
as its auxilliaries, the Christian Commission ^ the National Red 
Cross Society, and the U. S. Sanitary Commission. 

The Christian Commission to l^borwith the Chaplains, in all 
moral and religious work; to have exclusive charge of the distri- 
bution of general reading matter. Bibles, stationery, amusements, 
housewives, tobacco, the maintenance of reading rooms, and the 
visitation for consolation of the sick and wounded. This Com- 
mission should furnish its own transportation. It is suggested 
that the Army and Navy Branch of the Young Men's Christian 
Association, being now in the field, develop this work for future 
emergencies. The agents of this Commission should serve per- 
manently where, possible, should reach all ti'oops by traveling 
agents, especially those isolated. No special Government super- 
vision of this work is needed, except a general order requiring 
the agents of the Christian Commission to work with the army 



VOL UNTEER RELIEF A SSOCIA TIONS. 281 

Chaplains, and after great battles, they may be called upon to aid 
the wounded. The agents of this commission should dress as 
civilians, but wear the badge of the Chaplains, (or that of the 
National Red Cross, if this can be agreed upon.) 

It is suggested that the National Red Cross Society be the 
recognized auxiliary of the Government in the ordinary work of 
caring for the sick and wounded on the battle tfelds, and in the 
camps at the seat of war, as well as the transportation of 
wounded from the front, and that all the special forms of relief 
be assigned to the U. S. Sanitary Commission. 

WORK ASSIGNED THE U.S. SANITARY COMMISSION. 

This special work includes: 

(a) The sanitary inspection of all volunteer troops at fre- 
quent intervals, under the same rules that governed the Sanitary 
Commission in the Civil War, with power to report to the vSur- 
geon General and the Honorable Secretary of War. 

(b) The maintenance of a soldiers' "Claim Agency." 

(c) The maintenance of Soldiers* "lodges," "rests," res- 
taurants," etc., at all points where needed. 

(d) The transportation of sick and wounded from general 
and division hospitals to points remote from the seat of war. 

(e) The maintenance of a "literary bureau" for the issuing 
of sanitary and other leaflets. 

(f) A hospital directory of all sick and w^ounded soldiers. 

(g) A Bureau of emergency to maintain lists of nurses, 
cooks, minute men, surgeons, physicians, dressers and all other 
persons who would be of temporary use to the Government and 
who had volunteered to serve when called upon. 

All relief material received by anyone of the .societies recog- 
nized by the Government, shall be turned over to that recognized 
society which is especially charged with the distribution of the 
same. 

RELATIONS OF MEMBERS OP^ VOLUNTEER AID SOCIETIES 

TO THE LOCAL MILITARY AUTHORITIES. 

{Adapted from the British Army Regulations.) 

1. The ^rr5(7//y/r/ and /;/r//rr/V// supplied by societies desirous 

of rendering supplemented aid to sick and wounded in the field, 



282 MAJOR GEORGE G. GROFF, 

will be placed at the disposal of the Chief Medical OflScer of the 
Field Force; and in all matters connected with the care and wel- 
fare of the sick and wounded, the Commissioners and Delegates of 
such societies will cooperate with him and be under his directions. 

2. Only under very exceptional circumstances will societies 
which have not come into association with the National Red Cross 
Society be perhiitted to supplement the medical service in the 
field. ^ 

3. Supplies of all kinds forwarded under the auspices of the 
National Red Cross Society, the U.S. Sanitar>' Commission, the 
Christian Commission, or any local aid society, will be distributed 
to such hospitals as the Chief Surgeon may direct; but such sup- 
plies will not be introduced into a hospital, or issued to patients, 
except with the permission of the Chief Medical Officer of the 
hospital. 

4. The Chief Medical Officer of a Field Force may give orders 
that no civilians be allowed to visit any hospital, unless duly pro- 
vided with a pass signed by him or the Officer in charge thereof. 

5. All members of Voluntarj' Aid Societies will, on arrival 
at, or departure from the base of operations, report themselves to 
the Officer in charge of the General Hospital at the base. 

ORGANIZATION OF THE U.S. SANITARY COMMISSION. 
It is recommended that: 

1. The President of the United States immediately appoint, 
for each State, Territory, Dependency, and for the District of 
Columbia, a Commissioner and shall invite the Governor of each 
State, Territory and Dependency to appoint a second Commis- 
sioner. 

2. These Commissioners shall meet in the City of Washing- 
ton on a date named by the President of the United States, and 
shall elect a President, a General Secretary, a Field Secretary, a 
Treasurer and an Executive Committee. 

3. The President. shall direct the Secretary of War to issue 
an order similar to the order of 1861, by which the Sanitary Com- 
mission was recognized as an auxiliary of the Government. 

4. The U. vS. Sanitary Commission shall recommend the for- 
mation of State, county, city, and township Relief Societies 
throughout the United States. 



VOLUXTEER RELIEF ASSOC I A TIOXS, 283 

5. The Sanitar>' Commission shall cooperate with the Na- 
tional Red Cross Society and with the local relief societies, in the 
collection, storage, and distribution of all material which may be 
needed to supplement the work of the Government in the care of 
its sick and wounded soldiers. 

6. In case of foreign wars, it may equip hospital ships, hos- 
pital trains, and other means of transportation of which the sick 
and wpunded may be most speedily returned to the United States. 

The badge of the U. S. Sanitary Commission shall be a silver 
cross worn on a blue field on the right arm. 

{On Organ izaiiou of Sanitar\ Commission: See Cir, 86 
and g2. Vol. II. U, S. Sanitary Documents. ) 

THE LITERARY BUREAU OF THE U.S. SANITARY COMMIS- 
SION. 

It is believed that army regulations are not grasped readily 
by volunteer officers, who are hastily gathered from civil life. In 
the Civil War, the Sanitary Commission made great ^use of Cir- 
cularSy BulletinSy and Letters. In order that at a future time of 
need, the material then found valuable may be accessible, it is 
recommended that the following circulars and leaflets be issued 
to all volunteer officers and to other persons as indicated. These 
should all be issued /// uniform size, on good but thin paper. 

1. To All Volunteer Officers: 

Rules for preserving the health of .soldiers. (See letter C Medical and 
Surgical Monographs in report II. S. Sanitary Commission.) 

2. To All Volunteer Officers: 

Personal Hygiene for Army Officers. 

3. To All Volunteer Officers: 

What the Quartermaster's Department Furnishes and does not Furnish. 
How to draw supplies from the Quartermaster. 

4. To All Volunteer Officers: 

What the Commissary Department Furnishes and What it does not 
Furnish. How to draw Supplies from the Commi.ssary. 

5. To All Volunteer Medical Officers: 

What the Medical Department Furnishes and What it does not Fur- 
nish. How to draw Supplies from the Medical Department. 

6. To All Volunteer Medical Officers: 

Directions to Army Surgeons, as to what is expected in maintaining ef- 
ficient Sanitary conditions in Camps, 



284 MAJOR GEORGE G. GROFF. 

7. To All Volunteer Medical OflScers: 

Directions to Army Surgeons on the Field of Battle. (See letter B, Med- 
ical and Surgical Monographs of U.S. Sanitary Commission.) 

8. To All Volunteer Medical Officers: 

The. Regimental, Division, and General Hospitals. The Equipment, 
Officers, and Functions of each. 

9. To All Volunteer Company Officers: 

The duties of Company Commanders. (Sanitary Duties e.specially 
elaborated.) 

10. To All Volunteer Company Officers: 

The Company Fund. How to Commence, Sustain, and Administer it. 

11. To All Nurses: 

A Nurse's First Duty. (See circular on same published by U.S. Sani- 
tary Commission.) 

12. To All Soldiers: 

Personal Hygiene for Soldiers. How the Soldier Should try to Live to 
Maintain good Health. 

13. Song Books: 

Patriotic and Religious Songs. 

14. Guide Books for Forei^ Countries: 

Should contain a map and a few simple conversational phrases, and a 
short vocabulary of commonest words. 

15. Leaflet on the Organization of Ciiy and County and Societies 
(for use of State Sanitary Commissions, Local Aid Societies, 
etc.) 

The articles of food needed by the sick soldier. 
The articles of medicine needed by the sick soldier. 
How to make "hou.sewives." 

Tobacco, games, literature, etc., to be gathered, manner of safely pack- 
ing, forwarding, etc. 

It is urged that this Association of Military Surgeons proceed 
to devise by means of legislation or otherwise, to secure the im- 
mediate organization of a permanent Utiited States Sanitary Com- 
mission on the lines above suggested in order that the machinery 
may be in exi.^^tence whenever there may be need for it. 



AMBULANCE AND TRANSPORT VEHICLES OF THE 

TENTH FIELD HOSPITAL OF THE CANADIAN 

ARMY MEDICAL SERVICES.* 

BY COLONEL J. L HUBERT NEILSON, 
DIRECTOR GENERAL OF THE MEDICAL SERVICES OF CANADA. 

I MUST TELL YOU that I did not expect in the lea.st to be 
called upon to address you on any subject whatever, except 
to thank you all most cordially for the fraternal manner in 
which you have received me as a foreign visitor, a delegate from 
Canada. This reception has touched me very deeply and I am 
very grateful personally; and I shall take home to the officers of 
my own service a most gratifying statement of what I have seen 
and heard during my stay among.st you. 

The Chairman calls upon me to address you touching a tran.s- 
port and ambulance wagon which I designed last autumn for the 
10th field ho.spital of the Canadian Army Medical Corps, which 
was being sent to South Africa. The Canadian Medical Corps 
has been organized very recently. It consi.sts of 18 units, 8 bear- 
er companies, 8 field hospital companies, (there should be 9 — 
there are 2 to be organized in the west shortly.) The hospital 
which we sent to South Africa is a part of the 10th, because it 
was not a part of the.se units pre-existing, but was made up of 
the existing units who volunteered to go to South Africa. This 
field hospital is organized according to our own lines. We do 
not follow the British organization at all. We have started out 
for ourselvc'^, adopting an organization and personnel which we 
deem to be the most suitable to modern requirements. Our field 
hospital on a war footing has its own transportation. It has a 
transport section consisting of 21 men, non-commissioned officers, 

•Kemark.s before the nth Annual Meeting of the Association of Mili- 
tary Surereons of the llnited States. 

(2S.-,) 



286 



COLOXELJ. L. HUBERT NEfLSOX. 



drivers, collar-makers, etc., who have charge of the transport ex- 
clusively, and who are trained to act as orderlies on occasion; 
and a hospital section consisting of 40 men, making a total of 61 
officers and men, five being officers. The problem to be solved 
was to provide this unit with a suitable transport. The ordinary 
transport wagon which we have adopted for the Canadian service 
was good in its way; but as you have heard stated this morning 




Tenth Canadian Field HD3pital Transport Wagon or Four Litter Ambulance. 

by Colonel Havard in his admirable treatise— I will not call it 
essay — you know how essential it is to evacuate a field hospital 
as soon as possible: that is, to see that the sick and wounded are 
in the least time possible sent to the rear to a stationary or base 
hospital, if possible, or to a railway or steamboat station where 
they can be shipped to the rear. It then struck me that if the 
transport wa^^o:! of W\i field hospital could on occasion be utilized 



CANADIAN ARAfY MEDICAL TRANSPORT VEHICLES. 287 




as an ambulance wagon it would serve a most useful purpose. I 
therefore hurriedly contrived one transport wagon. Our trans- 
port wagons are very light so as to endow these field hospitals 

with the greatest mo- 
bility possible com- 
patible with the loads 
they have to carry; 
and I contrived means 
of carrying four re- 
clining patients in one 
wagon, two litters be- 
ing on the floor of the 
wagon, and two lit- 
ters on an upper tier, 
the forward handles 
of the stretcher — or 
litter as you call it here 

— resting on the back 
Transport Wagon with Cover Raised. ^^ ^^^ ^^.^^^,^ ^^^^ 

and the rear handles resting on a light folding trestle which I 
contrived and which was found to be exceedingly strong and 
solid and to answer the pur- 
pose very well. 

The wagons are light. 
They weigh about 1100 
pounds. They are made of 
the best materials and run 
ver>' easily. They have a 
cover with hoops which can be 
easily removed. Two years 
ago I came to Washington 
with the idea of examining 
your methods of transporta- 
tion and getting your ideas 
in selecting an ambulance 

wagon. I found here the 

1:^1, ,.^., ..«,.» ,.^of«,- Transport Wagon. Rear View Shew- 
wagon which you saw > ester- P" ^^ ^^ Litter Rests. 




2SS 



COLONEL J. A. HUBERT .VEJLSOX. 



day at the Barrack ,s, I tliought it a v^ery excellent model and 
I got authority to have ten made to thoroughly test them in 
Canada for our bearer companies — not for our field hospitals. 
We found them p^ood. hut we found some objections to them. 
I have made some modifications which I consider improve- 
ments. I think that one of the great objections to your 
ainlnilance wa^on is the difticnlty of transporting it. 
Tl was so higli you could not j^et it in a railway car, 

supposing you had to 




send it 50 or 100 miles 
away. It would not go 



Transport Wagon with Cover down. Rear view. 



bet ween decks of 
steamers; sometimes it 
would if you took off 
the wheels, but even 
then it was only with 
gieat difficulty that you 
could get it down to the 
steamer: and the rigid 
top I found very much 
in the way. It w-ould 
have been impossible to 
send it as a transport 
to South Africa — quite 
out of the question, as it would take np too much room on ac- 
count of tlie high, ri^id top, and so on. Well, the transport 
wagon which I have sent packs in its own box, so to speak. The 
wheels are taken off and placed in the box. The hoops of the 
cover are taken down and tied together in a bundle and placed in 
the box. The seat goes there also. The canvas cover fblds up 
like a small tent and gotfs into the box of the wagon; so that 
each wagon occupies uo more space on board a steamer or trans- 
jxirt than the si/.e of the box, which is 8 feet 6 inches in length, 
4 feet in width, and about 18 inches in depth. 

T will pass among you a tninihcr of photographs which I 
brought for my good fritud. Captain Munson, who has been of 
great service to me and exceedingly kind: I brought these pho- 



CANADIAN ARMY MEDICAL TRANSPORT VEHICLES. 289 

tograpbs simply to give them to him. He was good enough to 
have them mounted, and I pass them to you so that you may see 
them. There are four photographs of the same wagon. They 
explain themselves. 

There are some features about this wagon which also may 
appeal to you. With regard to the cover, it is not buckled down 
or hooked down. It has brass eyelets let into the canvas cover 
and it is fastened by small ropes. The objection to buckles is 
that they get broken or pulled out. The objection to hooks is 
the same — they get lost, pulled out, the buttonholes tear, etc. ; 
while these covers are not likely to give any trouble from that 
cause. On the covers are painted very large Geneva crosses on 
each side, fore and aft, so that the wagon can be recognized as an 
ambulance wagon at a very great distance. This wagon is pro- 
vided with a number of accessories which I deem would be of 
ver>' great use in campaigning. I have made out a list and will 
read it to you: 

ACESSORIES. 
Strapped under Body of each Wagon or in Box of Seat. 
I spade, 

I pickaxe and adze, 
I axe, 

I handsaw, 

I water tank and sterilizer with tres- 
tle (8 gals.) 
I mess kettle, 
I jack, 

I leather water bucket, 
I trestle for upper stretcher. 
1 oil can, 



I axle grease box, 

I package nails, 

I package screws, . 

4 horse shoes, 

I package horseshoe nails, 

I lantern, 

1 screw driver, 

2 field stretchers, (Mark O) 
I bannerol staff, 

I wrench 

I jointed i6 ft. staff for each 4 wagons. 



When this field hospital arrived in South Africa it had its 
first inspection. The Principal Medical Officer was exceedingly 
interested in this equipment and particularly in the appearance 
of these wagons. He was so much impressed that he immedi- 
ately had them measured, specifications taken, and ordered a 
number to be sent to Johannesburg to replace such of the medical 
corps wagons as had broken down or had become unservice- 
able, etc. So, to begin with, they seem to have been very much 



290 



COLONEL J. L. HUBERT NEILSOX. 



pleased with them. Of course I shall receive official reports in 
due time with regard to all this equipment. 

I now pass to you photographs of the water tanks which we 
also designed for this field hospital. We were not quite satisfied 
with the ordinary water tank. The new tank is provided wnth 
^\^ faucets. Another feature is the bunghole. I took the idea 
of the bunghole from the port hole of a ship with which you are 
familiar. Our covers are made exactly on that pattern and we 
find it exceedingly suitable. There is no loss of water. When 
the cover is screwed down it is perfectly secure, and then it has 




Tenth Canadian Field Hospital Water Cart. 

a large opening. It is about the size of a port hole shutter. It 
is exactl}' the size of an ordinary air port and answers the pur- 
pose exceedingly well. 

Field hospitals also require a forage cart. In the British 
service it is a 2-wheeled cart. It is heavy and cumbersome and 
does not carry as much sometimes as one would desire. I think 
that the ordinary light express wagon used for delivery purposes, 
or runabout wagon, would answer better. This runabout wagon is 
provided with a similar cover to the transport or ambulance 
wagon, photographs of which are circulating among you. It is 
also provided with the red cross. This runabout wagon has two 



CANADIAN AR.\ry MEDICAL TRANSTORT VEHICLES. 291 

seats, removable, and it is found most useful in connection with 
the field hospital for various purposes. They can drive fairly 




Tenth Canadian Field Hospital Forage or Runabout Wagon. 

fast with it and can put on a team of horses, if desired. It has 
a pair of shafts, but the poles of any transport or ambulance 
wagon are attachable 
to it; and this wagon 
has been found to be 
of the greatest use in 
connection with each 
field hospital. 

I must tell you, 
gentlemen, if you will 
permit me, that I have 
been very much im- 
pressed with your 
medical and surgical Forage Wagon without Cover. 







T>2 



COI.OXEI.J. /.. HUBERT XEJLSOX. 



chests. We would call them panniers. I prevailed upon our 
authorities to consent that one-half of that field hospital should 
be equipped with a set 
of your panniers or 
chests. The other 
half is provided with 
the ordinary British 
medical service pan 
nier. I know that on 
arrival the British 
medical officers who 
saw these strange pan- 
niers were very much 
impressed by and very 
much interested in 
them; and we shall know how they compared in actual ser\'ice 
with the British pannier. My idea is that the outcome of this 
practical experiment will decide what we shall finally adopt for 
our service. 




Forage Wagon with Cover and Rear Seat Removed. 




Forage Wagon with Cover Down. Front View. 



THE VACCINATION OF PORTO RICO— A LESSON TO 
THE WORLD. 

By AZEL AMES, M.D. 

MAJOR AND BRIGADE SURGEON OF UNITED STATES VOLUNTEERS. 

THE Medical Corps of the Army of the United States, as 
constituted for the Spanish War, and the duties which 
grew out of it, was created and put into the field, as all 
know, in hot haste. 

Its nucleus, consisting of the medical officers of the Regular 
Army and those of the State regiments, hurriedly mustered in as 
U. S. troops, was too small, and was too weak in men of previous 
active service, to do much in the instruction, or even the direc- 
tion, of the host, — chiefly of young, untrained practitioners from 
civil life, — who took the field with the Volunteer contingent, or 
as Acting Assistant Surgeons. 

Overborne, with imperative primary duties, chiefly of gen- 
eral organization and administration, the few officers of the Reg- 
ular establishment had neither time nor strength for more, and 
the new men, often of anomalous military siaius, settled them- 
selves to their complex and multiform duties with only the most 
general instruction from competent authority, often without any. 

The efficiency, general good conduct, and the varied and re- 
markable achievements of this young untrained host (to whom 
by far the most of the medical work of the Spanish War and its 
immediately resultant service, fell), are the highest posi^ible trib- 
utes that could be paid to the patriotism, character, ability and 
esprit du corps of the Medical profession of the United States, 
from which it was so hastily recruited. 

Probably on no other body of medical men in the world could 
equal reliance have been so confidently and safely placed; — prob- 
ably by no other could an equal record have been made. 






294 MAJOR AZEL AAfES. 

I count among the most sagacious and patriotic acts of the 
distinguished officers responsible for the medical efficiency of the 
U. S. Army, Navy and Marine Hospital Service and their asso- 
ciates, of the National Guard, their zealous activities in the or- 
ganization and support of this Association, especially designed as 
it is, to keep alive and virile, to shape and strengthen for service 
with the Forces, when needed, the interest, capacity, adaptabil- 
ity and devotion which made that record possible. 

Although the fighting forces of the United States Army 
raised for the Spanish War, had (until the sequential conflicts in 
the Philippines), but little experience of hardship or battle; con- 
fronted with new and grave matters of governmental organiza- 
tion and administration, they gave, in slow and patient service, 
broad, admirable, and beneficent, the full equivalent of the brief 
but splendid work of the Navy behind its guns. 

In this potential service of the Army, which alone could 
fast-color the results of the National victories at arms, by land or 
sea, the Medical Corps although largely volunteer, has taken 
front rank, as proven by its achievements, whether judged; 

(a) by contrast with the achievements of others; 

(b) by the magnitude and importance of the problems it 
has worked out; 

(,c) by the exceptional — even unique — conditions and dif- 
ficulties under which they were solved; or, 

(d) by their enduring and far-reaching significance, — 
their effects upon mankind at large. 

It is necessary to cite but four examples to bring to mind the 
long possible list which establishes the claim I have made for the 
Medical Corps. I name but four, — widely differing in feature 
and relation, — viz: 

The demonstration, — on a scale and under conditions to 
place it beyond doubt or cavil,— of the ice- bath in enteric 
fever: 

The absolute demonstration by Ash ford and others, — 
whatever the previous knowledge, — of the entozooal origin 
of ankylostomiasis — (or pernicious anemia), and of the effi- 
ciencv of its antidote: 



THE VACCINATION OF PORTO RICO. 



295 



The absolute demonstration by Reed, Carroll, Gorgas 
and others, — whatever had been gleaned before, — of the 
agency of Stegomyia fasciata in the transmission and prop- 
agation of yellow fever, — and lastly. 

The absolute demonstration that comprehensive, com- 
piihory Vaccination, properly conducted, w\\\ alone, certainly 
eradicate small-pox from any region or people, — as estab- 
lished conclusively in Porto Rico, in 1899. 
Of the latter undertaking I may speak with full knowledge, 
and hence may be permitted to invite attention to its peculiar 
value and significance as an object lesson to the world. 

That it is entitled to rank as such and may so serve, its per- 
tinence, its magnitude, its triumphs over many and grave diffi- 
culties, and its entire success, as attested by the known facts and 
its unimpeachable records — written and physical — certainly indi- 
cate. 

That there is grave and wide need of such an object-lesson 
has been but too evident in the recent sweep of the pandemic of 
small-pox on both sides of the Atlantic, -only just now in its 
decadence. 

That its teachings and its competency to instruct were alike 
urgently requisite, the recent history of legislation unfavorable to 
vaccine protection, — even in the oldest and most enlightened com- 
monwealths at home and abroad, — and its baleful results, alarm- 
ingly attest. 

Moreover, it is only by just such clear, incontestible facts as 
the lesson of Porto Rico affords; — equally digestible and convinc- 
ing to the plain people and the honest but half -educated opponent 
everywhere, — that the present belligerent skepticism can be over- 
throvwi. 

This need of a world-lesson as to the imperative necessity of 
. universal compulsory vaccination and re-vaccination is, moreover, 
further emphasized, not only by the world-wide prevalence of 
small-pox and its ready contagion, but also by the facts that long 
iunn unity from serious epidemics in some countries, — owing to 
more or less well-enforced vaccination — has made individuals and 
communities comparatively indifferent to the disease, while the 



2% MAJOR AZEL AMES. 

younger generation of medical men is so unfamiliar with variola 
as to permit frequent and disastrous errors of diagnosis in cases 
simulating it. 

Furthermore, the world's facilities of intercourse by land and 
sea, have grown so marvellously; its congregations of adults 
in the "bee hives of industry" and of children in the public 
schools, have so multiplied; and the dependence of communities 
upon common public conveniences, — such as laundries, barbers, 
baths, milkmen, bakers and other vendors, — has so greatly in- 
creased, that the risks of contagion, calling for every safeguard, 
were never so many and so great as at the present time. 

The compulsory vaccination of Porto Rico was then, no less 
happy and valuable as an object lesson in the matters of time and 
place, than in its inception, scope and results. Probably at no 
time during the last half-century has its influence been equally 
needed, or would it have been equally potent for good, either as a 
barrier to set back the flood-tide of opposition to vaccination both 
in Europe and America, or as proof- positive of the absolute effi- 
ciency and safety of vaccination in the prevention and extermi- 
nation of variola. 

There can be no question that both in Great Britain and the 
United States, considerable honest doubt, (greatly stimulated, 
however, by the unscrupulous) has long existed, as to the efficacy 
of, and the degree of protection afforded by, vaccination, and as 
to the transmissibility thereby of human or bovine disease. Over- 
broad and unwarranted claims as to the permanency of the im- 
munity it gives, made by zealous but half-informed and indiscreet 
advocates, and the very possible ill results of former arm-to-arm 
vaccination and the earlier uncleanly methods, have naturally 
given rise to distrust. 

In Great, Britain, those who honestly held these doubts and 
distrusts— joined with others * 'invincibly ignorant" or vicious, — 
had grown in 1897, despite the splendid results achieved by vacci- 
nation for mankind throughout Christendom, for more than a 
century, sufficiently strong in numbers, organization and influence 
to wring from the reluctant Ministry and Parliament the enact- 
ment of the so-called ' 'conscience clause, ' ' thereby modifying so as 
to emasculate, the compulsory vaccination law of the Kingdom. 



THE VACCINA TION OF PORTO RICO. 



IVl 



It is safe to say that no such step backward, in its relation to 
the physical well-being of mankind has ever been taken by any 
enlightened Nation. Already its cruel effects are seriouslj^ and 
painfully apparent both throughout the United Kingdom and its 
dependencies, and in every land with which it holds intimate in- 
tercourse — , especially in the United States. 

For the originators and donors of this great boon to mankind 
thus to minimize its value and throw d6ubt upon its beneficence 
was a blow to humanity and an encouragement to the ignorant, 
prejudiced and irresponsible, the cost of which can never be com- 
puted, but has already attained fearful figures. The largely in- 
creased percentage of infant mortality from variola and the very 
large falling off in re-vaccinations, already recorded in the United 
Kingdom, are due beyond doubt, to the relaxation of protective 
measures permitted by this change in law. The increased distru.st 
and antagonism created in this country, by the action of the British 
Parliament, has unquestionably been responsible for the neglect 
of thousands to seek the protection of vaccination and re-vaccina- 
tion for themselves and their children, from which neglect has 
already certainly sprung a considerable measure of disease, dis- 
tress, commercial embarrassment and death. 

While it is needhss to recall in this presence, the dread history 
of the ravages of small-pox over the world's surface, until coun- 
tered, first by inoculation and then by vaccination, it is compe- 
tent to note, that, despite the vast improvement wrought by these 
instrumentalities, small-pox still holds the first place in the list 
*6f preventable, readily-disseminated, contagious diseases, com- 
mon to all parts of the habitable globe, — tuberculosis possibly 
alone excepted. 

With all the contrariety of credulity and skepticism; the love 
of sensation; the abnormnal self-assertion of the half-informed; 
and the. mistake of licen.se for liberty, for which this age stands 
preeminent, there is still in the minds of the masses, a hunger 
for truth. Facts, finalities and sure anchorages for beliefs are, in 
general, sought for and welcomed, and, as in all ages, — bring 
sure results. 

It may rightfully therefore be counted, I think, as more than 
fortunate, that, ju.st upon the heels of the lamentable mistake of 



298 MAJOR AZEL AMES. 

Great Britain, the new Nation which has sprung from her loins, 
and taken first-rank as a world-influence, should have been able 
to furnish for all peoples, both check and antidote to the effects 
of her error, in the exceptional work and the assemblage of facts 
and evidence, which it fell to the Medical Corps of her Army to 
develop in the general Compuls6ry Vaccination of Porto Rico. 

All analogous experience indicates that, in proportion as com- 
munities are taught and given confidence, by plain, indubitable 
proofs, first; — that proper vaccination and re-vacci nation will pre- 
vent and eradicate small-pox, and second;— that they will do no 
harm to the individual, — both which propositions have been 
abundantly demonstrated and should be everywhere established — 
opposition, however hostile, will steadily diminish and ultimately, 
practically cease. 

In view of this reasonable certainty, it would seem no less an 
imperative duty of officials and of Government everywhere, to 
gather, and when gathered to make known, in simple, well-di- 
gested form, available for all, the sure and vital evidences in re- 
gard to vaccination and its concomitants, than it is to enact laws 
and enforce them, for the education of youth and the prevention 
and restriction of disease. 

Self-government born of intelligence, calls for little law and 
less enforcement of that law. 

I shall be pardoned, therefore, for suggesting that it is to be 
deeply regretted that any causes, should have kept from becom- 
ing available in proper form, for the present great need of the 
Nations, the unequalled and invaluable data, carefully arranged- 
for and gathered, in the unpredecented vaccination of the million 
population of the only "white" island of the Antilles. 

Comprehensively projected and gathered at great cost, and 
in excellent form for verification, it is alike strange and true, that 
this great volume of data, after being utilized superficially for 
Report-purposes, was cast aside and neglected, till recently res- 
cued, re-assembled and arranged by the writer, under Govern- 
mental authority, that it may officially give, its new, unique and 
invaluable teachings to the medical profession and the world. 

For a consummation so hopefully useful and benificent I 



THE VACCINATION OF PORTO RICO. 



299 



may, I am sure, confidently bespeak the zealous approval and 
support of this Association and the profession at large. 
THE EVIDENCE OF PORTO RICO. 

Hardly had the last of the representatives of Spanish mis- 
rule turned their backs upon the Island before the American mil- 
itary administration, though wholly new to the science and art of 
Colonial government, set on foot, as an act of benificence to her 
newly related people, the compulsory vaccination/ of the entire 
population, and — as primarily essential — the production for that 
purpose, in the island itself, of the requisite bovine lymph. 

The American army under General Miles landed in Porto 
Rico in July, 1898, and gradually occupied the island, working 
eastward, westward, and northward from Guanica, Ponce, and 
Arroyo on the south coast, until it was in full possession. The 
last of the Spanish army and its adherents left the island in Octo- 
ber, 1898. 

A considerable naval squadron; a much larger fleet of army 
transports, quartermaster's vessels, etc.; a Spanish army of some 
11,000 fighting men and attaches, and the American army of 
8,000 men and adherents, had doijbtless contributed each its quota 
to the grand total of cases of variola, always more or less preva- 
lent among the population during the Spanish regime. In some 
of the principal places, such as Ponce and San Juan, the local 
health authorities had kept up a desultory, but altogether inef- 
fectual, oversight and partial isolation of the disease, with a feeble 
effort at vaccination. 

Under the more or less efficient supervision soon established 
by the United States military authority, this local oversight and 
control were sufficient to accomplish for a time, a considerable 
degree of repression of the disease in the chief places. Prac- 
tically unchecked, however, in the outlying villages and the hill- 
country, and aided by the peregrinations of the unsettled inhabi- 
tants and the troops, it steadily took on greater proportions, no 
part of the island being free from it, until nearly all the country 
barrios (precincts) were infested and its reflex tide began to work 
back into the larger towns and cities. For the first time in the 
cognizance of American sanitary officers, the spectacle was pre- 



300 MAJOR AZEL AMES. 

sented of the non-populous regions feeding the disease to the 
cities and towns, a condition of things which it will readily be 
seen, greatly increased the difficulty of control. Where, as in 
the United States, the usual primary centers of the contagion are 
a few large cities or manufacturing towns, the task of restricting 
it is obviously much easier, and its spread is much less rapid, 
than when a score or two of small and scattered communities, 
without sanitary regulation, are sending it daily to the market- 
towns and cities about them. 

It was therefore not only a rapidly spreading and, indeed, a 
general, diffusion of variola throughout the rural population of 
Porto Rico, with but little less activity in the cities and towns, 
embracing altogether nearly a million soiils, that confronted the 
American military authorities at the opening of the year 1899; 
but the conditions favoring its spread, and hampering the only 
measures which could be effective in controlling it, were quite 
exceptional, some of them creating difficulties seemingly almost 
insurmountable. Among the factors especially favoring the 
spread of the disease w-ere (1) the tremendous headway it had 
already attained and the numerous centers of contagion existing; 
(2) the comparative indifference to it on the part of the mass of 
the native population, so long habituated to it that it was appar- 
ently regarded as inevitable and irremediable; (3) the absence of 
systematic sanitary authority, oversight, or regulation, and hence 
the maximum of difficulty in ascertaining the whereabouts of 
cases; (4) the antipathy of the natives to removal from their own 
homes to hospitals or camps, for isolation and treatment, leading 
to habitual concealment of cases both in country and town; (5) 
the unusual facility afforded the spread of the disease by the 
density of the population, its over-crowded habitations and its 
**hand-to-mouth" habits of living, the latter compelling constant 
passing to and fro l)etween country and town with, or for, sup- 
plies; (6) the very congenial climatic conditions, and (7) the un- 
cleanly character of the habitations- and their surroundings, of 
the air, water and food conmionly used, and of the habits of the 
people. 

Among the conditions exceptionally hampering the measures 
of restriction and control, were ( 1) the great difficulty of furnish- 



The vaccina tion of porto rico. 



301 



ing isolated care and treatment in pest-houses and camps for the 
hundreds of Cases simultaneously occurring, owing to the great 
and inaccessible area over which they were spread; the inade- 
quacy of transportation, (there being often no roads) vand the 
paucity of help; (2) the absolute impossibility of isolating the 
stricken in their cfowded and thickly-set homes; (3) the very ' 
small number (proportionately) of physicians and medical ap- 
prentices, to the population; (4) the very great difficulties of 
travel in the hill-country and hence the inaccessibility of a large 
part of the people, either for treatment or for vaccination; (5) 
the seeming impossibility of procuring any considerable supply of 
proper vaccine virus on account of the distance of the ports of the 
United States (from which alone it could be brought in any quan- 
tity) and the attendant cost; (6) the difficulty of preserving the 
virility of the virus in its passage to the Tropics and after its ar- 
rival, it being found that very little virus sent from "the States," 
(especially the glycerinated), retained its efficacy when received; 
and (7) the great difficulty, even with plenty of virus, of vacci- 
nating these hundreds of thousands of unregistered people, 
mostly ignorant and scattered, speaking foreign tongues, and un- 
used to sanitary control. 

The only conditions exceptionally favorable to the suppression 
of the disease were (ff) the facts that, as the population was insular, 
the spread of variola was limited by the sea-boundaries; {b) that 
there were ample authority (civil and military) men, means, and 
material to work with; (r) that the supply of young cattle for 
the production of virus was large, easily gathered and of excel- 
lent quality; and (rf) that a large percentage of the adult popu- 
lation had already had the disease, lessening the number requir- 
ing vaccination and the amount of fuel for variola. Private en- 
terprise had, under the stimulus of Spanish municipal contracts, 
kept feebly alive, two very small farms for the production of 
bovine lymph, but both were nearly moribund at the American 
invasion, and no reliance whatever could be placed on either the 
amo.unt, or the character, of their "output. " Every effort at 
general vaccination made by the Spanish authorities had broken 
down, chiefly from lack of purpose, virus and vim. 



302 MAJOR AZKL AMES. 

Early in December, 1898, General Guy V. Henry, who was 
especially interested in sanitary matters, became Militar>' Gover- 
nor. 

On December 29th, General Henry, "because of the intelli- 
gence received from the Alcaldes of different parts of the island 
of the rapid increase of the disease, "directed the promulgation 
of an "order," by "Circular" of his chief civil officer, the Secre- 
tary of State, to the several Alcaldes (mayors), requiring them, 
as civil officers, to carry out universal vaccination. This purely 
civil "order" was reinforced January 3, 1899, by a military 
"General Order," addressed however, expressly to the Alcaldes 
and boards of health. This "order" indicates how very difficult 
it sometimes was, to keep distinct, in thought, speech and action 
the military and civil functions of the Military Governor, in 
whom, for the first time in the history of the United States, un- 
der such conditions, they were so peculiarly combined, each in- 
terest having independent existence and recognition, independent 
sources of revenue, and a full, independent, official staff. 

It is at this point therefore, though only to the extent of the 
promulgation of civil instructions through a military order, that 
there first appears an Army relation to the great vaccination work, 
later borne principally on Army shoulders. Always in name, a 
civil undertaking: carried on under the direct local supervi.^-ion 
and co-operation of the several .4 /a/M'y; paid for chiefly out of 
Insular and municipal funds, (though in part by the military 
chest), it was organized and directed wholly by medical officers 
of the Army, chiefly volunteer, and largely executed by them 
and the men of the Army Medical Corps. To the great credit of 
both military and civil officers it may be said, that there was at 
no time, any friction between them in the discharge of thtir 
duties. 

On the evening of January 7th, at the urgent request of the 
Chief Surgeon, Col. Hoff , the writer .sought the Commanding 
General and first made the suggestion, already made to the Chief 
Surgeon, that the virus be produced in the island. The sugges- 
tion was warmly approved as .soon as fully understood, the Gen- 
eral saying as the writer left, "I will give you all the authority- 



THE VACCINA TIOJV OF PQRTO RICO. 



303 



you need, all the rneu you need and all the money you need, if 
you will give me that virus and give it tome quick.'* These 
promises he fully redeemed. 

Having received verbal orders, the writer reported to the 
Chief Surgeon the results of his conference, and that he had 
urged that the oversight and direction of the undertaking should 
be placed in charge of the Chief Surgeon of the Department, as 
the liberal use of the Army Medical Corps and the free use of 
Army men and material would be absolutely necessary to success. 
To this proposition the General, after a time, gave a reluctant as- 
sent, premising that it must be an Insular (civil) undertaking, 
conducted through, and in co-operation with, the Alcaldes, 
though having from the Army all possible assistance. 

As the result of this report and to secure the requisite orders, 
the Chief Surgeon sent on January 9th, the following communi- 
cation to the Adjutant General of the Department. 

'*SiR: I have the honor to recommend that a sufficient 
amount be allotted from the civil funds to permit of the imme- 
diate starting of a vaccine farm here, to render effective the order 
requiring universal vaccination among the people of the Island; 
and that Dr. Azel Ames, Acting AwSsistant Surgeon, be placed in 
immediate charge of the work.'* 

The practical inauguration of the vaccination of Porto Rico 
seems to have dated with the definite proposition to produce the 
requisite virus in the island. 

Having selected the field of his cattle operations ( the equi- 
lateral triangle of fine cattle-country having its apex at Coamo 
Baths and for its base-line the south — (Caribbean) — shore of the 
island, stretching eastward from Ponce some thirty miles;) hav- 
ii*g chosen his immediate assistants and largely perfected the work- 
ing plans for the production of a million vaccine points, the writer 
reported the same to the General Commanding and after a long 
conference with the Chief Surgeon over the plans of vaccination- 
organization, etc., asked for the issuance of orders putting the 
entire work into its essential relation to the military authority, 
and under the general charge of the Chief Surgeon. 

The writer would be recreant to every dictate of grateful ap- 
preciation and equity, if he failed to record here, the splendid 



304 M^JOR AZEL AMES. 

support given the undertaking and himself, in its organization 
and conduct, by the late Gen. Guy V. Henry, Military Governor 
of Porto Rico, and the Chief Surgeon, Col. Hoff, our honored Presi- 
dent; by the untiring and zealous staff of young Acting Asst. 
Surgeons, — Drs. Timothy Leary, Louis L. Gilman, Richard Wil- 
son, S. H. Wadhams, J. Reddin Kirk, S. J. White, H. M. Mc- 
Conathy, and Gustave Moret, who chiefly did the work; by the 
fine young men of the Hospital Corps, and by that rare man, Mr. 
Simon Moret, — the Porto Rican cattle-intermediary, upon whose 
broad shoulders the success of the whole fabric rested. 

On January 26th and 27th "orders" were issued carrying the 
organization agreed upon by Colonel Hoff and the writer, into ef- 
fect. The "General Order" (No, 7) of January 27th, reaffirmed 
the previous "orders,*' civil and military, directing universal vac- 
cination, placing the work under military supervision and con- 
duct. — though under civil auspices, and the conjoint control of 
the Alcaldes — and the great, earnest, fully-organized campaign 
against the fast-spreading epidemic was begun. The working 
forces were soon in the field, and from this date the double task 
of virus production and the simultaneous vaccination of all sec- 
tions, never stayed until it ceased,— because completed,— on July 
1st, just five months later, the population vaccinated, the disease 
literally "starved out" and driven from the island. 

The Virus Production. — The Chief vSurgeon (Colonel Hoff) 
in his report of 1899, has truly said: — "To produce the virus a 
vaccine farm was necessary; to introduce the lymph into the arms 
of several hundred thousand people required a subdivi.sion of the 

assignment of Directors, etc But the infinite detail of 

the work and the herculean labor, mental and physical, entailed 
in carrying it to a successful result cannot be appreciated by 
those who have never had a like undertaking to accomplish." 

To create the virus was, of course the prime necessity. The 
grand scale on which the operations were conducted, practically 
in the open air, in a new country, by unskilled hands; the speedy 
accomplishment and the unparalleled success, perhaps entitle this 
part of the undertajcing to more than passing notice. After a 
thorough inspection of every feature of the Vaccine vStation and 



THE VACCINA TION OF PORTO RICO. 



305 



farms, General J. C. Brecken ridge. Inspector General of the 
United States Army, wrote of the work (Report 1899, to the 
Major General Commanding the Army. p. 68): "On the morn- 
ing of the 23d [March] we examined the Vaccine Station under 

the charge of Dr. Ames at the Baths of Coamo ... It seems 

one of the best energized and organized and, despite the consid- 
erable difficulties, the most successful and thorough undertaking 
that has characterized the American occupation. ' ' To establish 
and keep in full operation the Distributing Station of the United 
States Vaccine Corps and the adjacent cattle farms, indeed de- 
manded unremittingly, the exercise of much judgment, careful 
planning, effective organization and hard work. , To get together 
the requisite number (1,240 head) of young cattle as needed, to 
handle successfully, select, test, feed and use them, at minimum 
cost and loss, in a strange country and with 'green' hands, pre- 
sented a series of practical problems each of which afforded ample 
scope for every faculty and acquirement, — all of them rich in in- 
cident. 

It was first of all necessary to secure the supply of j'oung 
cattle without great cost, — which would of itself have been pro- 
hibitive, — to locate them conveniently and subsist them for a 
considerable period; to procure from the United States, (1,800 
miles distant by sea), the best possible (initial) lymph with which 
to vaccinate them, together with the appliances needful for vac- 
cination, such as ivory "points," material for packing, etc. and for 
pathological tests, tuberculin, syringes, etc. It was equally nec- 
essary to organize, fully equip, house and subsist a corps of over 
one hundred men, with expert pathologists, and executive staff, 
surgeons, cattle-experts, guards, couriers, assistants and team- 
sters; to arrange for regular supplies of all kinds; for large num- 
bers of draft and saddle animals and their equipment, and for 
efficient transportation, all under military order and discipline; 
and finally, to keep the whole so effectively at work that there 
should be no loss of time, and as nearly as possible, a daily out- 
put of not less than 16,200 charged virus "points" from the 
farms, of which 15.000 must be sent daily, carefully registered 
and packed, to meet the requirements of the vaccinating forces, 
steadily and .systematically at work in all parts of the island. 



306 MAJOR AZEL AMES. 

The objects to which all lent their utmost endeavor were, 
to turn out daily, the needed amount of the very best lymph; so 
to handle, keep and transmit it that it should preser\*e its virility, 
and, in competent hands and conditions, successfully do its work, 
and finally, both to keep and to transmit with each package of vi- 
rus, the full record of its production, that the origin and full 
history of every "point" used, might be known to its user when- 
ever desirable. The difficulties to be overcome, as suggested by 
the Inspector General, were neither few nor small. They are in 
part mentioned here, only that any who may be called in the fu- 
ture, to a similar undertaking, heavily handicapped, need not be 
dismayed. • 

Glanders and farcy were spreading in the Government cor- 
rals from which it was necessary to take the first fifty or more 
horses and mules, necessary to the very vital transportation of 
station and farms, and. — being dangerous to both men and ani- 
mals, — were, for a time, the source of much anxiety. Many of 
the principal supplies, such as the ivory "points," the initial vi- 
rus, the tuberculin, gutta-percha, and other packings^ instru- 
ments of all kinds, formalin, chloroform, medicines, fresh meats 
and ihuch other food, had to be brought from ''the States." 
Fresh beef and ice in large quantities had to be regularly sup- 
plied and were teamed, almost daily, twenty-three miles, up the 
hilly military road to the camps. Competent men (though all 
inexperienced) and good cooks must be found, able to stand se- 
vere physical strain for months, while a large part of the neces- 
sary "plant" such as vaccinating tables, packages, etc., had to be 
designed by the writer and constructed by the quartermaster me- 
chanics. Refrigerator vService and appliances, while most essen- 
tial, were almost without existence and had, at first, to be crudely 
created, and it was a matter of extreme difficulty so to keep, pack, 
and transmit the fresh lymph, under the tropical sun, that it 
should arrive at its destination still virile. Severe drought, and 
consequent low water and short pasture were grave troubles, and 
at one time seriously threatened to stop the work. 

The screw worm, the larvae producing which is laid in all 
abraded and open wounds of bovine animals in Porto Rico, speed- 



THE VACCINATION OF PORTO RICO. 



307 



ily hatching the worms iu great numbers, gave infinite trouble. 
These worms burrowed deeph' if neglected, and rapidly destroyed 
the soft tissues, and even the life of the infested animal. It was 
perhaps, the most serious of the troubles encountered, doubling 
anxiety and labor and much increasing the cost. The sudden 
loss, (by peremptory general order of the War Department dis- 
charging them) of a large part of the most competent men, 
largely of the Army Hospital Corps, was utterly demoralizing 
and for a few days threatened to disrupt the work. It was nec- 
essary in many cases, to hire the same men at double the wages, 
as civilian employes, leaving only "contract" control over them. 
Losses of cattle by escape and theft and insufficient camp-guard; 
the necessitj' (because new ones were not received) of re-using 
old '^points", weakened and curled by the thorough processes of 
cleaning; and the drinking and gambling habits of a small per- 
centage of the men, were all considerable difficulties at times, 
where absolute regularity and system were indispensable. The 
initial difficulty, and a cause for a time, of the utmost anxiety, 
was the character of the h^mph sent from * 'the States' * with which 
to vaccinate the cattle. Experience had shown all virus so sent 
to be of doubtful value; nearly all, — especially the glycerinated, — 
had proven inert with the troops, and it was a serious matter to 
bring together such an assemblage of men, cattle and materials, 
the success and utility of which must all hinge upon the virility 
of the initial virus. Happily, enough proved virile to start the 
local \stock' and secure safety, though not before the writer had 
experienced a great alarm, had spent the worst and most anxious 
twenty-four hours of his life and had learned some new facts as to 
cattle vaccination '*in the field,'' and in the Tropics. 

After some forty cattle had been duly tested and vaccinated 
and the proper time of incubation had elapsed, search was made 
for the hoped-for typical vesicles which one is accustomed to see 
upon vaccinated calves in "the States". Not one was to be found, 
and the disheartening indications were, that all the virus from 
"the States" had failed, — as indeed most of it did. Twenty- 
four hours later, unwilling to believe that all had failed and that 
the undertaking must be abandoned, or recast, another and most 
careful search was made by the writer and Dr. Timothy Leary, 



308 MAJOR AZEL AMES. 

A. A. Surgeon,— the invaluable pathologist in charge of the cat- 
tle, — whicli changed deep disappointment into jubilation, for 
though no vesicle was then, or afterward, discovered, plenty of 
typical crusts or cones were, which, being removed, gave typical 
lymph-yielding bases in abundance. It soon became evident that 
the heads of the cattle not being confined, as in vaccine stables in 
the United States, their rough tongues doubtless broke the ves- 
icles as soon as formed, as did often the underbrush, and the rough 
stubble and coarse grass on which they lay. The crusts resulted, 
and from their indurated ring-like bases the finest lymph freely 
exuded and was gathered in great quantities, the '.'out-put*' of 
the farms reaching the surprising figures of 27,000 double-charged 
"points" (for a single day), under the efficient management of 
Capt. Fredk. P. Reynolds, Asst. Surgeon, U.S. Army, who took 
charge of the Station at the last of the work, the writer having 
been ordered to "the States" ill. 

The very remarkable and carefully recorded experience de- 
termined conclusively, several basic facts as to vaccine-lymph and 
its use, viz: (1) That vaccine lymph, especially when glycerin- 
ated and in tubes, did not retain its efficacy when exposed— even 
very briefly and without great variation of temperature— to the 
change from a temperate to a tropical climate. Though the rea- 
son does not appear, ihefact is indisputable, and all countries in 
the tropical zone should produce their own virus if so fortunate 
as to start a "stock:" (2) That given virile initial lymph and 
good cattle, the very best of lymph can be secured (by practi- 
cally the same methods) in the tropics, as well as in colder coim- 
tries, provided care is taken to protect it (as soon as 'taken' and 
until used) from alterations of temperature: (3) That the glycer- 
inated virus has nothing to recommend it for tropical use, (if it 
has anywhere, and I share the doubt of Dr. Weston and the N. 
Y. Medical Journal upon this point) and that glass tubes are 
worse than useless: (4) That a good, carefully-kept virus, has. in 
the tropics, equal (if not greater) activity and efficacy with that 
in northern latitudes, though it ought not to be kept as long: (5) 
That it is much better, in the hot countries especially, to confine 
the vaccination upou animals for virus, to a definite number (say 
twenty) of abrasions on each side, rather than to make extensive. 



THE VACCINATION OF PORTO RICO. 309 

parallel, linear incisions and secure thereby many //;/r5 of vesicles. 
By the latter the specific fever created is much too great and is 
most undesirable, while the ravages of the screw worm, if it ef- 
fects a lodgment) in such extensive incisions are difficult to man- 
age: (6) That in field work, nothing is so good with which to 
vaccinate an animal, as the ivory "point'*, the tube being useless, 
and nothing is so good to "take'* virus with. Surely nothing is 
so serviceable" for the vaccination of the people, — or is even prac. 
ticable — in a hot country: (7) That there is every warrant for 
positively asserting that although syphilis, tuberculosis, elephan- 
tiasis, and tetanus are common in Porto Rico, /*;/ no case has it 
followed that any of them ^ or any other disease, bovine or human, 
zcas imparted to an individual by the process of vaccination. I 
fullj'^ agree with Crandall, who truly says, in. his excellent treatise 
on vaccination, that "no disea.se except vaccinia is conveyed by 
the lymph as prepared today by responsible makers. ' ' With 
tetanus so common in the island that 818 cases occurred in seven 
months of 1900-1901, a .single case only (in an infant) occurred 
after vaccination in 860,000 vaccinations, and this, of course, 
would have occurred as readily, with any abrasion: (8) That it 
is not advantageous to use cattle older than yearlings, that 
the .sexes are of equal value, and that there is little or no tuber- 
culosis in cattle living "in the open," and (9) That it is of im- 
portance, and well worth the little it will cost, to keep alive a 
good "stock" of vaccine lymph in any tropical country, (e.speci- 
ally if insular) even when little, or no large, need exists. The 
frequently recurring demands for virus for infants and those who 
will be revaccinated — if wise — call continually for more or less 
lymph, and larger drafts can soon be met, if a good "stock" is 
maintained, as it ea.sily can be. 

The Vaccination of the People. — Of course, in such a coun- 
try and with people in such circum.stances, the difficulties of or- 
ganization and work were many and some of them novel. The 
long habit of submission to authority, the experience already had 
at the hands of the Spaniard, (who had really made some com- 
mendable efforts at general vaccination in former years, but had 
failed), and the wholesome respect for the American officials. 



310 MAJOR AZEL AMES. 

doubtless all contributed to minimize opposition and secure obedi- 
ence to orders. The rapid spread of the disease and its high 
mortality all counted; but the master-stroke which secured 
prompt and personal interest in being vaccinated was the promul- 
gation of a '^circular order" now famous as ''Circular No. 3/' 
prepared hy the writer and issued by General Henry, which made 
the possession of a vaccination certificate a pre- requisite to em- 
ployment or pleasure. As soon as it was made evident by this 
"circular" that it was to be made "a bread-and-butter matter", 
from hills and valleys, hamlets and municipalities, young and old 
flocked to the vaccinators wherever located, and fairly tumbled 
over each other for precedence, — like John Chinn's Wuddahs," 
in Kipling's story ("The Tomb of his Ancestors") of the vaccin- 
ation of the Satpura Bhils. Often two or three hundred, old and 
young, would be still waiting, unvaccinated, when darkness 
closed the day's labors. Sometimes the vaccination was contin- 
ued by lamp-light to relieve the pressure. 

To the Alcaldes and their assistants, the commissarios dc 
barrios and to the local physicians and their practicantes, great 
credit is due. Few of them knew any English, and that they 
so nearly comprehended and carried out the plans and instruc- 
tions of organization, and accomplished so much, so effectively, is 
indeed matter of surprise. Alcaldes were charged with appoint- 
ing the physicians and \\i^\i praciicanies (the vaccinators^ upon 
the nomination of the Directors of the several Divisions: with 
providing clerks, assistants, rooms, and conveniences, and with 
the most important duty of distributing the fresh virus, (daily 
received from the Vaccine Station at Coamo), to the several vac- 
cinators, wherever at work, in their respective Alcaldias. The 
service was marvellou.sly-well performed : largely by foot-runners, 
and with a degree of success that would have been impossible to 
any other agency. 

Vaccination is, of course, in general, much the same where- 
ever performed. There were, however, no breaking tubes, no 
dull and dirty lancets, no diluted and sophisticated virus, but in 
their places the clean, freshly-charged ivory "points" with noth- 
ing but pure lymph on their faces; their sharpened edges most 



THE VACCINA TION OF PORTO RICO. 



311 



excellent substitutes for the always suspicious lancets: and there 
were full records of the work done, and the ardently-sought neat^ 
durable * 'official" certificates. 

Among the new and notable feature developed in the vacci- 
nation itself, w^ere the following: (1) Contrary to the fact in 
northern cities and towns, and even in the country, house-to- 
house vaccination was practically impossible, (except in very few 
places) and the people were obliged, as a rule, to come to the 
vaccinators, the necessity for having their certificates being the 
prime check upon them. Full registration at, and not before, 
wherever possible, was found to be and is, a wise precaution; 
(2) Vaccination with the sharp edges of the virus * 'points'* was 
alone practicable under such conditions; (3) The danger of in- 
fection of the abrasions made, even when but little preliminary 
effort at cleansing occurred, was practically ;///, but it became 
considerable from dirty finger-nails, clothing, etc., when the ves- 
icles formed and scratching resulted. Yet in no case were there 
really serious results, notwithstanding hot water was not readily 
available; (4) Cleanliness, and light antiseptic dressing were all- 
sufficient to prevent infection, and hot water, freely applied, was 
equal to the reduction of all undue inflamation, even in the worst 
and dirtiest of regions. 

There was, possibly, some confirmation of the belief that 
when smallpox is preyalent, vaccinations "take" most readily. 
Certainly an unprecedented percentage of successful results (87 X' 
per rent.) accompanied the Porto Rican epidemic and vaccination 
of 1899. Doubtless the fine quality and entii;^ freshness of the 
virus, and the care with which, under explicit instructions and 
inspection, the work was done, and the fact that full records were 
kept and certificates given, contributed chiefly to this highly 
gratifying result. Twenty-two cases were recorded, of persons 
successfully vacinated, who were '\seamed and furrowed" with 
confluent smallpox. This, of course, indicated, clearly, that the 
immunity usually conferred by the disease itself, is not always 
permanent, even though the first attack be severe, as there can be 
no doubt that a person susceptible of vaccination is equally so to 
variola. A few cases of smallpox were reported in persons who 



312 MAJOR AZEL AMES. 

had evidently had the disease. Such were of course, extremely 
rare. 

That the protection of vaccination against smallpox '* wears 
out" more or less speedily, varying in different individuals, and 
that revaccination is therefore required at varying intervals, were 
determined beyond cavil, by abundant evidence. Numerous cases 
were observed in which the patient was not vaccinated until after 
exposure to small pox, and, being taken ill with the latter, the 
vaccination in every case, clearly operated to modify the attack, 
and in some cases, to cause the variola to abort, usually in the 
third stage. Many hundreds of persons presented themselves for 
vaccination who claimed, with apparent truthfulness, to have had 
repeated attempts made to vaccinate them without success, but 
who "took" perfectly in 1899. Whether previous efforts failed 
from want of care or skill, or from inert virus, or because of the 
former insusceptibility of the person, it is, of course, impossible 
to say. An interesting illustration of how effectively the best in- 
tended efforts may defeat the object in view was furnished by a . 
list of seventy-two persons vaccinated in one of the hill-towns. 
Their arms were cleansed, — under the instructions of one in au- 
thority, — with a solution of bichloride of mercury. Not a single 
vaccination of the whole number "took", though made carefiilh- 
and with fresh virus. The facts being learned, a revaccination 
was ordered and the entire number ivin sit ceessfuUy vaeeinated — 
when the bichloride was left out. 

Not a few cases were noted in which young children had 
evidently received immunity before birth from variola, their 
mothers having had the disease while they were in utero, and a 
few cases were found in which vaccinia had apparently given ex- 
emption to the child from that disease through similar conditions. 
Repeated attempts, made with great care, to vaccinate such chil- 
dren and even young adults, proved in every case ineffectual, 
though previous vaccination was positively denied and no evidence 
of it could be found. 

No death from variola of any who had been succesfully vac- 
cinated in recent years, was reported among those ill of the dis- 
ease, and in but few cases, was there much disfigurement. In no 



THE VA CCINA TION OF FOR TO RICO, 



313 



case did serious results of any kind arising from the vaccination 
itself follow vaccination or revaccination. "Bad arms" were in- 
variably found to be the result of needless infection from filthy or 
careless habits. 

Summary. — In October, 1898, smallpox was endemic in 
Porto Rico; in December it was epidemic; in January, 1899, it 
had "honey-combed** the island; by February, there were over 
3,000 recent cases and th^ disease was spreading "at a gallop." 

In February, systematic compulsory vaccination, carefully 
and scientifically conducted and recorded, was begun simultane- 
ously, and with pretty equal efficiency, in all parts of the island. 
It was vigorously proseci\tedy<:;ryb//r mouths only, till July 1st, 
when 860,000 vaccinations had been made, in a population of 
about 960,000. Of these 87>^ per cent, were successful. The 
work then ceased, — because completed; the disease had practically 
disappeared; the fuel for it to feed upon had been consumed by 
the "head-fire" of vaccination. In the two and a half years that 
have since passed, instead of the former annual average death- 
rate of 621 , the mortality from smallpox has been but two per 
annum in a population of nearly a million. Can any honest, in- 
telligent person doubt, in face of these indisputable and easily 
verified facts, ivhat it was, that /// four short months, drove 
smallpox from its wide and long-time reign in the island and 
has since kept it out? T \iccination alone did it, and will do it 
effectively^ wherever compulsory legislation, properly enforced^ 
secures its benefits to all! 






•'If D 



FAVUS AND ITS TREATMENT. 

Bv SHELDON G. EVANS, M.D., 
SURGEON IN THE UNITED STATES NAA^Y. 

THOUGH Favus or Tinea Favosa is an exceedingly rare 
disease in the United States, it is by no means uncom- 
mon in Scotland; and in Germany, where it is known as 
Wachsgrind, it is of frequent occurrence. 

I was fortunate, or unfortunate enough, during a former 
cruise, to have been brought into close, professional relation with 
139 patients suffering from this disease, all on one ship. For the 
method of treatment about to be described I am indebted to Med- 
ical Director Price U.S. Navy, who, at the time, was senior Med- 
ical Officer of the ship. 

A report of these cases and the method of treatment em- 
ployed may be of interest to the members of this Associatibn, 
particularly to those who are on duty with large bodies of men 
ashore or afloat, for, once the disease gets a foothold on board 
ship or amongst troops, it spreads with great rapidity and unless 
prompt and active measures are taken to exterminate the fungus 
a bald headed crew or company will be the result. With few ex- 
ceptions, all the cases here reported, occurred among the appren- 
tice boys and did not, generally, extend to the men. 

Favus usually attacks the hairy scalp, and in the cases that 
came under my care all were of this character. It may be well 
to state, en passant that it appears to be more severe with 
those who have light hair than those possessed of locks of a 
darker hue. 

It is a contagious, parasitic disease. Schoenlein was the first 
to demonstrate that the straw-colored crusts found in the disease 
formerly known as porri go- favosa or tinea lupinosa, and which 
were regarded as the products of inflammation, really consisted 
of a mass of fungi, the Achorion Schoenleinii. 

(814) 



FA VUS AND ITS TREA TMENT. 



315 



Microscopically examined, the favi, as the yellowish crusts 
are called, are found to be made up entirely of the fungus, con- 
sisting of oval nucleated conidia. ^-^-^ inch in diameter, free, 
jointed or constricted: large branching or tortuous mycelial fila- 
ments g^^^ of an inch in diameter, filled with granules and spores 
and a stroma made up of cellular elements. (Quain). 

Hoffman, who has cultivated the fungus, claims that it is 
identical with the mucor racemosus, but other authorities do not 
corroborate his views. 

Lack of cleanliness seems to be the only predisposing cause 
of the disease, and dirt a favorable nidus for the development of 
the fungus when once implanted. This was however by no 
means true of the cases aboard ship where the strictest hygienic 
regulations prevailed and thorough cleanliness both of person 
and quarters was rigidly enforced. 

The origin of all the cases here reported, was traced to an 
apprentice boy from Germany, who, when sent to the ship, was 
evidently suffering with the disease, though it had not fairly 
manifested itself. From him it appears to have spread to the 
others, mainly through the utensils of the various barbers aboard, 
and perhaps by the changing of watch-caps, a practice very com- 
mon among the apprentices. As soon as the first case was dis- 
covered, the crew was at once inspected and the other cases found. 

The diagnosis of the disease usually presents no difficulties, 
the characteristics being the development of sulphur colored 
crusts or scales (the favi). In the early stages we find the af- 
fected part studded with minute yellow bodies embedded in the 
skin. These spots are at first about the size of a pin-head and 
surround the hair follicle. Subsequently they coalesce and the 
scalp is covered with a thick mass of dirty yellowish scales, hav- 
ing a peculiar pungent and characteristic odor. On removal of 
the scales we find the scalp reddened, inflamed and depressed. 
As the hair follicle becomes overgrown with the fungus, the 
growth of the hair is impeded and it soon dries up and falls out. 
It is however, generally reproduced, but this is not always the 
case. 



3 1 6 SURGEON SHEL DON G. E VA NS. 

Favus is often accompanied by other parasites, but in none of 
my cases were other varieties found. 

By a casual observer, the disease may be mistaken for im- 
petigo, but, on close examination the favi are easily recognized 
and the odor is strikingly characteristic. 

All writers on the subject agree that the treatment is tedious 
and unsatisfactory; but, it gives me pleasure to set forth the 
method suggested by Dr. Price, which I have been unable to find 
in any works at my disposal, and which gave complete satisfac- 
tion. * Various preparations of mercur>', I know have been 
recommended, but not in the form about to be described. 

The hair of every patient was, of course, cropped short and 
kept so during the entire course of the treatment. A solution of 
mercuric chloride in alcohol 1 to 500 was prepared, and two stiff 
brushes provided. The heads of all the patients were thoroughly 
scrubbed with the solution every other day, for a week or ten 
days, within which period all the scales were removed, leaving 
only a yellowish stain on the scalp. Then a solution of the same 
strength, in water and glycerine, was prepared and the patient's 
head bathed therewith, twice a week. ITnder this treatment, all 
the cases rapidly improved and a complete cure was affected in a 
very short time, and none developed a second attack. 

If the scalp is much inflamed or tumefied; a mild sulphur, 
mercurial or zinc oxide ointment will quickly relieve it. 

The old method of treatment, with poultices, &c., w'ould cer- 
tainly have been tedious, especially with such a number of patients. 

These cases were reported, in brief before, but I thought 
them of sufficient interest to present to this body, especially con- 
sidering the liability of meeting the disease in our line of work. 

If any member has met with the disease in the ser\'ice, I 
should be pleased to learn the mod^ of treatment adopted; and 
should they meet them in the future, I would earnestly recom- 
mend a trial of this simple, but effective method. 



REMARKS SUGGESTED BY THREE YEARS SERVICE 

IN CUBA. 

By captain JOHN HAMILTON STONE, 
ASSISTANT SURGEON IN THE UNITED STATES ARMY. 

THE only apolog-j I have to offer for the tax upon your 
patience, which this paper will doubtless levy, is that 
the whole Cuban question, both in its civil and its 
military aspect, has seemed to me to be especially unique from 
the standpoint of the military surg-eon, in its involvement of 
and its direct bearing upon those great principles of health 
and humanity, which rightly fall within the sphere of our 
professional activities and for which we havepledged our lives 
and careers. 

In reviewing the causative conditions which gave rise to 
the armed intervention by the United States in Cuban affairs, 
and in following the subsequent course of events even to the 
present time, one cannot help but be deeply impressed with 
the fact that sanitary considerations, problems and results 
have been fundamental, pre-eminent and of the greatest prac- 
tical importance. 

The history of the military invasion of Cuba and the later 
peaceful occupation of the island, has inseparably interwoven 
with it the story of a dreadful epidemic disease; — of its rav- 
ages; how at times it depressed and even paralyzed commerce 
and industry; how it had served as a great weapon of offence 
and defence in the efforts of a down-trodden people to throw 
off the yoke of bondage of a tyranical government; and how, 
finally, because of its periodical incursions within the limits 
of our own domain, it incited an interest as to its cause and 
manner of propagation which, to the glory and credit of ;;//7/- 
tary surgeons^ has led to its control and which will afford the 
means of completely eradicating it from all countries for all 
time. 

(817) 



318 CAP TA IJV JOHN HA MIL TON STONE, 

And so the pacification of Cuba and the establishing of a 
free and stable form of g-overnment for a people whose deplor- 
able political and miserable economic conditions had excited 
our sympathy and moved us to national action, have been 
neither the sole nor the most important advantages gained by 
the victory of American arms during the war with Spain. 

The numerous sanitary innovations, the remarkably im- 
proved health condition of the island and valuable medical in- 
formation will, in their full fruition, constitute the greatest 
achievements of importance to Cuba, America, and the whole 
world. 

Have not military surgeons taken an active and highly 
efficient part in the attainment of these far-reaching and 
beneficent results? 

In answer to this question it seemsonly necessary to point 
with pride to the names of two military surgeons who have 
risen to international prominence and won for themselves last- 
ing laurels, because of their successful efforts in behalf of the 
lofty purposes for which the Cuban campaign was initiated 
and carried to conclusion. 

To one of them we owe a great triumph for medical sci- 
ence, and to the other a great victory of national policy. To- 
gether, they have in their work exemplified the two-fold na- 
ture of our duties — the professional and the milito-adminis- 
irative. The one, through his scientific research and experi- 
mental work, has shown the highest ideal of professional ex- 
cellence in solving one of the most mysterious problems of 
preventive medicine; and the other, in a no less conspicuous 
degree, has shaped the destinies of a people and won the ap- 
proving plaudits of the intelligent world. 

For these reasons, and because of the ample opportunities 
for experience in the principles and practice of our profession 
both in war and peace which it has afforded, — the Cuban cam- 
paign, — from its very incipiency to its fullest consummation 
— must ever be considered by us as pregnant with importance, 
inasmuch as it has attracted the attention of all peoples to 
a just and serious thoughtfulness of the duties of military 



THREE YEARS SERVICE IN CUBA. 319 

surg-eons when viewed in the ligfht of their broadest field of 
usefulness. 

It was my good fortune to have been permitted to partic- 
ipate in the memorable manoeuvres which culminated in the 
surrender of the city of Santiago de Cuba; to have had an op- 
portunity of doing some first aid work under fire on July 1st, 
during the battle of San Juan; to have assisted in the care of 
the wounded at the field hospital immediately and for several 
days after the engagement; and to have had garrison duty in 
one of the most important provinces of the island during the 
period of reconstruction, and I offer you the results of my ob- 
servations and experiences. 

FIRST AID WORK. 

On the morning of July 1st, Hawkins' brigade, Kent's 
division, 5th corps, consisting of the 6th U.S. Infantry, the 
regiment with which I was surgeon, and the 71st N.Y. Vol. 
Infantry, advanced along the San Juan road in the direction 
of SantiafiTO. As the column moved forward, we passed a 
number of wounded Cubans who were being transported to 
the rear in hammock litters. Their wounds had received at- 
tention but it was found necessary to stimulate them and to 
administer morphine to ameliorate their suffering. One, I 
remember, had been shot through the chest, the aorta pre- 
sumably having been wounded, and was moribund when I 
saw him. Their bearers were directed to the Division Hos- 
pital. When the column had wormed its way around past the 
base of the hill — El Pozo — from the summit of which Grimes' 
battery had begun its cannonade on the Spanish fortifications 
around Santiago, the reports of small arms firing and many 
volleys could be heard ahead. When about a mile beyond El 
Pozo hill and in a wooded terrain, the notorious balloon as- 
cended and remained over the column for a considerable time. 
The firing became very intense in front. The leaves began to 
fall from the trees. Shrapnel, both from our own guns and 
from those of the enemy were flying over us and many ex- 
ploded prematurely. Bullets began to fall thick and fast on 
all sides. The wounded began to drop and soon man}' 



320 CAP TAIN JOHN HA MIL TON STONE. 

wounded men were brought bj their comrades and deposited 
about me. Among- the first was a soldier shot throug-h the 
left side of the chest. He died before the bearers could ex- 
pose his wound. Soon many wounded had accumulated. I 
hastened to locate a suitable dressing* station and calling for 
assistance from one of the companies, had the wounded car- 
ried back to a point where the road was very near the river, 
and there, under the protection of the bank of the stream, 
continued to lend assistance during the afternoon. It was 
necessary to stand in the shallow water and by digging out 
the earth to make a footing in the bank for the wounded 
while I applied the emergency dressings. The shrapnel were 
falling short of El Pozo, the obvious target of the Spanish 
guns, and so it happened that this part of the field was dubbed 
by the men as ''Hell's bottom." 

Experience at this station taught me that first aid packets 
and drinking water are the most essential requisites for first 
aid work. Under existing regulations and the dictates of 
personal needs, these should be found on the wounded soldier. 
The next two most necessary materials were splints and band- 
ages. To a limited extent these are furnished by the pri- 
vates of the Hospital Corps from their pouches, which consti- 
tute the most important part of their field equipment. Truly, 
splints may be extemporized as circumstances permit, but I 
am of the opinion that they should be at hand in greater 
quantities and that in time of actual service it would be ad- 
visable to have them carried by the non-commissioned officers 
of the corps, — preferably by the acting stewards [sergeants], 
who at present carry nothing especially designed for emergency 
work on the firing line. 

Next in importance in this work of alleviating the suffer- 
ing and diminishing the mortality of war, are brandy and 
morphine. These valuable remedies which require careful 
professional judgment as to the indications and contraindi- 
cations to their administration, should be at hand for the ex- 
clusive use of the surgeon. Morphine and the necessary hy- 
podermic syringe for obtaining the most speedy action of the 
drug are supplied in the surgeon's orderly's pouch and brandy 



THREE YEARS SERVICE IN CUBA. 321 

should be there on such occasions also. Those surgeons, who 
have had considerable experience in the early treatment of 
gunshot fractures of the thig-h and other severe gunshot in- 
juries, appreciate the urgent need of morphine to enable the 
patient to tide over the period of transportation to the field 
hospital with the minimum of pain and discomfort. 

In view of our knowledge of the effects of the small cali- 
ber, high velocity projectiles of modern rifles, — shock can no 
longer be rightly considered as the great b^te noire to the 
military surgeon in the proper performance of one of his chief 
duties on the battle-field. And I might say as much in ref- 
erence to hemorrhage, I saw so little of these symptoms, 
mark you, in any degree sufficient to deter the surgeon in 
meeting the indications for active medicinal or surgical pro- 
cedures, that I believe them latterly to have been reduced to 
the minimum of severity and importance. Of course these re- 
marks do not refer to those varieties of shock and hemorrhage 
which give rise to immediate death and which therefore do 
not come under the treatment of the surgeon. Shock has been 
so almost entirely absent in some of the severest cases of gun- 
shot wounds which have fallen to my care, that I have come 
to regard this symptom of little or no importance as compared 
with the pain and the danger of infection attendant upon the 
infliction of wounds on the field of battle. 

The infrequency of severe shock and hemorrhage has 
been remarked upon by the Japanese Surgeons, as a result of 
their observations in the Japan-China war, and also by the 
late Sir William MacCormac, as a result of his experiences in 
South Africa. 

Alcohol, preferably in the form of brandy, is one of the 
most important remedies at the disposal of those interested in 
first aid work, and I do not believe that it should be replaced 
nor substituted for by i ijimonia, the latter drug beingentirely 
too fugacious in its actu>n and having no favorable influence 
over the depressed mental condition of the patient. 

I do not desire to be understood as advocating a reckless 
or indiscriminate use of either morphine or brandy, but it 



322 CAPTAIN JOHN HAAfIL TON STONE. 

would seem that the time- has come when there is a chance to 
extend greatly and with the utmost safety their, as yet, over- 
cautious and restricted use. 

AT THE FIELD HOSPITAL. 

While in charge of the officers' ward at the field hospital 
an opportunity was afforded me of seeing- the different varie- 
ties of gunshot wounds there presented, and of studying the 
effects of the shrapnel fragments, the larg-e, brass-jacketed, 
Remington bullets, and the small caliber, high-velocity, 
Mauser projectiles on osseous and soft tissues as a result of 
war. These effects have for the most part been well described 
in detail by others and there seems to be such unanimity of 
opinion in regard to them that I shall only speak of what 
seemed to me of special interest or importance. 

As would naturally be expected, the wounds varied greatly 
in severity, general appearance, and accompanying symptoms. 
The shrapnel -wounds were the most unsightly. One of the 
most ghastly cases seen was a soldier who had been struck in 
the face by a fragment of shell and had suffered the loss of 
the greater portion of the nose, the entire upper lip, and a 
considerable part of both cheeks. There was left a large cav- 
ity with ragged edges — horrible in the extreme. 

The wounds inflicted by the Manser bullets were for the 
most part less severe in appearance than those due to the 
Remington bullets, which latter were often deformed or had 
parted with their jackets during transit through the body 
structures. In this respect the more modern bullet is certainly 
the more humane. 

The gunshot fracture cases were by far the most trouble- 
some to the surgeon, most, painful to the patient, and did 
least well of those cases entitled to a favorable prognosis. 
The comminuting effect .of the high-velocity bullet was 
especiall}' interesting. One variety^qf bone injury, an impor- 
tant example of which came under wrj attention, is deserving 
of greater consideration. I refer to that condition in which 
the bone is not fractured^ but perforated. While this injury 
can with reasonable certainty be differentiated from fracture 



THREE YEARS SERVICE IN CUBA. 323 

by the absence of the classical symptoms of the latter and by 
the course of the bullet, as judg^ed from the relative locations 
of the wounds of entrance and exit, yet, diagnosticated, it de- 
serves to be treated as a fracture, because it is a most impor- 
tant predisposing cause to such a complication, 

As previously stated, shock and hemorrhage were so in- 
frequent that they did not require serious consideration nor 
active treatment. A notable exception to this, however, was 
a case in which I was called upon to do a ligation of the right 
lingual artery to control an otherwise uncontrollable hemor- 
rhage which resulted from a gunshot wound of the tongue. 
The patient was in a critical condition and would have suc- 
cumbed had not this surgical procedure been done as a der- 
nier ressort. 

The Mauser bullet wounds generally showed a surround- 
ing area of marked' contusion more extensive and pronounced 
about the wound of exit. While this was not invariably seen, 
probably due to differences in velocity, itshowed the^ explosive 
effect upon the soft tissues, and inasmuch as the harmful re- 
sults of the lateral transmission of the energy of the high ve- 
locity bullet have been limited by most writers on the subject 
to bones and fluid saturated and fluid containing organs, ex- 
clusive of muscular tissue and skin, it is made of record that 
at times the discolored area of the bruised parts extended for 
several inches around the wounds. In one case in which the 
bullet entered the middle third of the thigh, the whole thigh 
from hip to knee was black and blue, although the femur had 
not been fractured. In some instances of simple flesh wounds, 
the bruised condition of the soft parts was the most striking as 
well as the most painful and disabling feature of the injury. 

Many bullets had been well spent from distance of flight 
and from ricochet, as was evidenced by the large number of 
lodged bullets extracted at the fleld hospital and afterwards 
when located by the X-rays. 

I saw nothing to indicate that the Spaniards used an ex- 
plosive bullet per se. Under present conditions of warfare, 
traumatic aneurisms and ancurismal varices seem to deserve 



324 CAPTAIN JOHN HAMILTON STONE. 

more attention because of their greater frequency. In m^- 
ward was an oflScer under treatment for an arterio-venous 
aneurism of the left Scarpa's triangle, having resulted from a 
Mauser wound of the femoral vessels. 

- There was one case of traumatic gangrene at the field hos- 
pital. This resulted from a gunshot fracture of the femur, 
lower third, with a complicating injury of the popliteal ves- 
sels. An amputation was done as the operation of necessity. 
There was no tetanus although this disease is so common in 
Cuba if wounds do not receive the proper attention. 

YELLOW FEVEK. 

Yellow fever occurred among the troops stationed at 
Santa Clara in May 1900, and began to spread rapidly. Hav- 
ing been ordered there to take charge of medical matters an 
opportunity was aflfordeS me of gaining an intimate clinical 
acquaintanceship with the disease while it was still able to 
strike down so many innocents in such a mysterious manner. 
The story of the terrible epidemic which had occurred in the 
city only two years previously and which had decimated its 
non-immune population, was yet fresh in the memory of the 
people and did much to cause great anxiety among the mili- 
tary element as to the outcome. In conformity with the well 
known advice of General Sternberg as to the depopulation of 
infected localities, and upon my recommendation, the troops 
were ordered out of the city and placed in camp about five 
miles distant. This almost immediately controlled the out- 
break. Only a few cases which had been incubating were re- 
turned to the hospital. The barracks were thoroughly disin- 
fected and the troops were permitted to return, but they were 
strictly quarantined. The disease lighted up anew. I then 
recommended that the garrison be discontinued and the troops 
ordered elsewhere. This was approved and the men with all 
their equipments, camp equipage and everything which might , 
possibly carry contagion, were thoroughly disinfected and the 
troops marched overland to their new stations. In this way 
a greater loss was prevented. However, 36 cases occurred 
with 10 deaths. Because of the short period of incubation of 



THREE YEARS SERVICE IN CUBA, 325 

the disease, once the secondary cases begfin to appear, the sur- 
geon IS liable to find himself surrounded with the sick and 
djingf, and swamped with work, before he is able to trace the 
infection to its proper focus or take the necessary precautions 
to prevent its spread. This fact and the almost total disre- 
gard of the proper measures of disinfection and isolation on 
the part of their surgeons, account for the terrible epidemics, 
which played such havoc with the Spanish forces during their 
occupation of the island. 

In studying the coQditions which I found upon my arrival 
at Santa Clara I was soon impressed with the fact that the 
disease was not carried by fomites. 

Another observation, which by repetition gained cre- 
dence, was that those non-immunes who came into the wards 
or into close relationship with the patients in the late after- 
noon or at night were most frequently attacked. The night 
nurses became sick with the disease first, while those who were 
on duty during the day, for the most part escaped. I was on 
duty at the hospital, where the cases were treated, every day 
from 8.30 A.M. to 4.30 P.M. and, although a non-immune, es- 
caped. I visited the cases daily and confirmed all diagnoses 
made, but I never visited the hospital at night. One of my 
assistants — a contract surgeon and also a non-immune, was 
not taken ill with the disease until the outbreak had almost 
subsided, after a month's exposure, and in all .probability 
would have escaped also, had he not, contrary to my advice to 
him, visited the hospital at night. He showed the first symp- 
toms about three days subsequently. An acting steward on 
duty in my oflBce at the hospital did not contract the disease. 
He did not sleep at the hospital. Another acting steward 
who slept at the hospital was attacked early. I became a 
strong adherent to the mosquito theory. 

The following case which occurred later on at Hamilton 
Barracks, Matanzas, Cuba, did much to convince me of the 
probability as well as the plausibility of the views which 
Major Reed's board has since so conclusively proved. The 
facts are as follows: 



326 CA P TAIN JOHN HA MIL TON STONE, 

A military. prisoner was admitted to the prison ward at 
the hospital Oct. 18, 1900 and confined therein under treat- 
ment for secondary syphilis. An armed sentinel was con- 
stantly on duty at the door of the ward room. The patient 
was not permitted nor did he leave the room for any reason. 
He was made to use the close stool. All dishes and other 
articles used by this patient were kept separate and were re- 
peatedly disinfected. He was not treated nor attended upon 
by any physician or nurse who came in contact with yellow 
fever cases. No case of yellow fever had ever been treated in 
the room so far as was known. However, this soldier con- 
tracted yellow fever November 10th, 23 days after admission 
and died on the 16th of the same month of a most typical form 
of the disease, characterized by black vomit. The prison 
ward was provided with a barred window kept open for pur- 
poses of ventilation. Other cases had been treated during* the 
previous month in the isolation wards a few hundred yards re- 
moved from the main buildings in which was the prison ward. 
Strict quarantine had t)een enforced. The mosquito theory 
was the only plausible explanation of such a case. 

From my clinical experience with the disease the follow- 
ing* remarks may not be amiss. 

When one has had considerable experience with any par- 
ticular disease, he learns to know it as he would recognize a 
well known person — not by a deliberate consideration of its 
individual characteristics, but by intuition, as it were. So I 
found myself instinctively searching for a common symptom 
— a distinguishing feature— in all these cases. This was a 
marked zi'eakness of the patient from the very onset of the dis- 
ease. The cases varied greatly as to the severity of the in- 
fection, but this /a/ij^'i/o?' wai^ common to them all. It is not 
noticeable in those suffering from malarial infection from 
which the surgeon is most often required to differentiate the 
disease in question. Nor is it necessary for this to be elicited 
by questioning. It is apparent to the examiner. It is seen 
in the Jaries and noticed in the actions of the patient. For 
example, a soldier reports sick. He has walked to the hospi- 



THREE YEARS SERVICE IN CUBA. 327 

tal, states that he has had a chill, savs he feels sick at his 
stomach, remains standing and after his temperature has 
been taken and recorded as 104' Fahrenheit, requests to be 
permitted to return to his quarters to make secure his effecta 
prior to admission. Such a case is not to be considered for 
one moment as a case of yellow fever. Another soldier has 
with difficulty been persuaded by a non-commissioned officer 
to report sick to the surgeon. He complains of slight pains 
in the back and legs and of headache. He appears distressed. 
His eyes are injected, he requests to be permitted to sit down 
and asks the non-commissioned officer to please secyre his ef- 
fects for him. His temperature is only 100" Fahrenheit. Such 
a case is extremely suspicious in yellow fever localities. Yel- 
low fever patients desire to take to bed at once. Thjs weak- 
ness^ the congested conjunctivae, the epigastric tenderness and 
the pains in the legs, seemed to me the earliest symptoms of 
consequence in diagnosing the disease among the f'ever cases 
of the tropics. Later on, the albuminuria, the bleeding gums, 
and the difference in the pulse-temperature ratio were almost 
pathognomonic. Vomiting may be entirely absent in the mild 
cases, although the patient will refuse all food. Later on, 
the jaundice and the hemorrhages confirm the diagnosis. The 
sore throat, spoken of by Osier as a symptom of the first stage, 
has not been present in any of my cases. The microscopic ex- 
amination of the blood cannot be considered positive in dif- 
ferentiating this disease from the pernicious and remittent 
fevers of the tropics, because of the liability of mixed infec- 
tion. I saw one such case at Santa Clara in a so-called ''re- 
peater" i.e., a person who is subject to recurring attacks of 
malarial fever. 

GENEKAL HEALTH CONDITIONS. 

Cuba has entered upon a new era of health conditions. 
So long restrained and crippled by her past well-established 
and well-deserved reputation as one of the most dangerous 
and unhealthful localities, on the face of the earth, it is now 
eminently fit and proper that the greatest publicity be given 
to the facts relative to the new health conditions which ob- 



328 CAPTAIN JOHN HAAfIL TON STONE. 

tain, and which have resulted from the American occupation 
and control. The happiness of health is essential to make 
perfect even the blessing's of liberty. To have rescued this 
people from political bondage and then left them stifled in a 
pest-hole, for Cuba was virtually such, would have been as in- 
adequate and unfortunate as it would have been unwise and 
unjust. 

To-day, were it not for a few insanitary conditions which 
are inseparably connected with the character of construction 
of the living- abodes in the cities, or of the unfortunately lo- 
cated citits themselves, — evils which are almost irremediable 
because rooted in the very form and growth of the country, — I 
would not hesitate to proclaim for Cuba, a sanitary status 
equal to that of any other country of the world. A great 
deal has been accomplished. The streets of the cities have 
been graded, paved aud kept clean. This one improvement 
of itself is doubtless accountable for much good. Some of our 
own cities and towns could profit greatly from sanitary les- 
sons learned in Cuba. House to house inspections have 
brought to light insanitary conditions within doors and these 
have in great measure been corrected or vastly improved. 
Due to the corral rock formation, underground sewerage sys- 
tems have been impracticable in places. Under such circum- 
stances other methods of sewage disposal have been intro- 
duced, — such as the odorless excavator system, the closed can 
system, etc. The compulsory reporting of contagious, in- 
fectious, diseases and the enforcement of the proper measures 
to prevent their spread and to destroy their infection have 
done much to reduce the mortality. The prophylactic meas- 
ures used against the mosquitoes, and the diseases which 
these dipterous insects are now known to disseminate, have 
been most important. 

Some idea of the results attained can be got from a glance 
at the following figures, taken from the health reports of 
Matanzas. In 1898 the total number of deaths from allcauses 
was (April to January) 4252; for 1899, 975; for 1900, 624; for 
1901, 617. 



THREE YEARS SERVICE IN CUBA. 329 

The most important diseases deserve special remarks. In 
Matanzas, as elsewhere on the island, the cases of jellow 
fever have been for the most part traceable to Havana, and 
when Major Gorgfas announced that he had wiped out the in- 
fection from that focus, he sounded the death knell of the dis- 
ease for the rest of the island. The methods of preventing- its 
spread, as suggested by the findings of the yellow fever com- 
mission, have proved eminently satisfactory and certain. 

TUBERCULOSIS. 

The *'Great White Plag-ue" has a firm foothold in the 
cities, which makes it king of diseases, so far as my observa- 
tions and information have led me to believe. To it are di- 
rectly attributable about 20% of the monthly mortality and 
perhaps about 3% more of the fatal cases are in reality due 
to this cause, although they are classified under other head- 
ings, such as bronchitis, pneumonia, enteritis, meningitis, 
and scrofula. If this one preventable disease could be held in 
check, the monthly death rate, now averaging 17 per 1000, 
would be so reduced as to justify for that portion of the island 
at least, the title of a health resort. 

Col. Havard, while chief surgeon of the Department of 
Cuba, began a crusade against this disease by encouraging 
the organization of chapters of the Anti-tuberculosis League 
throughout the island, and it is believed that this will cause 
an awakening of the native physicians and through them of 
the people in general to a full realization of the importance 
of disseminating information as to the contagious nature of 
the disease, and the consequent measures looking to its pre- 
vention. There are many obstacles to a successful effort 
against tuberculosis in Cuba, as elsewhere. Chief among 
these are the dark and damp houses which harbor it and the 
habit, so common, among the lower classes, of expectorating 
on the floors. 

Next in importance to tuberculosis are the acute intesti- 
nal diseases. Because of the lack of uniformity and scientific 
exactness of diagnosis, there is considerable doubt as to the 
true nature of the several diseases reported under this head- 



330 CAPTAIN JOHN HAMIL TON STONE. 

ing-. The health statistics show such causes as diarrhoea, 
fiebre-enteroseptica, fiebre-infecciosa, enteritis, etc. Acute 
tropical (amoebic) dysentery is the most important and fatal 
disease in this category; althoug-h it is believed that tuber- 
culous enteritis, enteric fever, and diseases due to intestinal 
parasites are responsible for a certain proportion of the cases. 

Diseases of the circulatory system have been prominent 
as a factor in the death rates. Valvular disease and arterio- 
sclerosis, with their resultant cerebral hemorrhages, figure fre- 
quently in the civil hospital reports. 

Tetanus, both traumatic and infantile, is exceedingly 
common and fatal. One of the most general and firmly rooted 
superstitions among the ignorant classes is that lockjaw re- 
sults from exposure to the light of the full moon. 

Malarial fever is always more or less prevalent. I failed, 
however, to meet with the frequent pernicious and fatal forms 
so commonly attributed to the tropics, although I saw several 
cases with symptomatic haemo-g-lobinuria. 

Acute follicular tonsillitis has seemed tome the common- 
est ailment in Cuba. It is often diagnosed as diphtheria by 
the native physicians, who then reap the rewards of a speed}- 
and complete cure. 

As would be expected, both muscular and articular rheu- 
matism are frequently seen. 

In my opinion cancer is not less frequent in the tropics 
than here at home. 

Ankylostomiasis or uncinariasis, the common cause of 
anemia in Porto Rico, has not been seen by me in the part of 
Cuba where I have been stationed. Filariasis is not uncom- 
mon. Lumbricoid worms are the commonest of the intestinal 
parasites. 

Dhobie itch and ringworm of the scalp are widespread. 
Mumps and scarlet fever are often seen. Typhoid fever is 
not so rife as in the States and I have been told by the local 
doctors that it has increased in prevalence since the advent of 
the American troops. I believe there is much truth in this 
statement because most of the cases which came under my 



THREE YEARS SERVICE IN CUBA. 331 

treatment were soldiers who had recently arrived from the 
North and, as a rule, recruits. The evidence of the last few 
years seems to point more and more conclusively to the com- 
mon house fly as a chief agent in the spread of enteric fever 
in the tropics and elsewhere. The following- facts relative to 
the sanitary condition of a seacoast town bear upon this 
point. 

Two large streams become subterranean not far distant 
from Cardenas and form an underground current varying 
from 10 to 30 feet beneath the surface. Five-sixths of the 
dwellings are supplied with drinking water from this com- 
mon substratum, tfurnishing as it does, in addition, the con- 
venient function of a natural water-carriage sewage system 
for the city. Holes are bored through the rock for the jieces- 
sary connections either for water supply or waste disposal. 

Nevertheless, the number of deaths from typhoid fever in 
1901 under such condi lions was only 8 out of a population of 
over 24,000 inhabitants. 

CONCLUSIONS. 

In conclusion, the following statements are deduced from 
results of tropical service. 

1. The great dangers to health so long ascribed to the 
tropics have failed to prove so dreadful when actually tried 
under favorable conditions and with the help of modern sani- 
tary science. 

2. Even the strongest constitution will feel the effects of 
tropical service after about two years of residence. 

3. Those with existing cardiac or pulmonary affections 
should not attempt to combat the physical vicissitudes of the 
tropics under an}n:ircumstances. 

4. Those predisposed to tuberculosis should avoid the 
cities on account of the widespread place infection. 

5. The drinking of boiled water and the protection from 
the bites of mosquitoes are the most important measures of 
personal prophylaxis. 



IRepdnts anb tTranslattons. 

THE MILITARY MEDICAL JOURNALS OF SPAIN 

FOR 1902. 

By lieutenant CHARLES NORTON BARNEY, 
MEDICAL DEPARTMENT, UNITED STATES ARMY. 

RE VIST A DE SAN/DAD MILITAR, \Continued). 

T^HE Wounded in the Explosion of the Carabanchel 
Powder Magazine. J. Huertas. — A clinical report 
of two cases. 

The first, a sergeant of artillery, was struck on the head 
by a flying rock, which produced. a contused wound 5 cm. in 
length and of irregular form in the left parietal region, in- 
volving the whole thickness of the scalp. Prolonged uncon- 
sciousness, aphasia, loss of tactile sensibility, complete mus- 
cular relaxation, contraction of the pupil of the right eye, 
the forpiation of a clot the size of a hen's ^gg over the left 
eye, frequent vomiting of partly liquid, partly clotted blood, 
and incontinence of urine and of faE?ces, made the diagnosis of 
fracture of the base of the skull seem probable; but complete 
recovery in three weeks shows the case to have been merely 
aft instance of cerebral contusion. 

The second case was that of a peasant, struck in the face 
and both legs by flying rocks. The-womd in the face ex- 
tended from the left eye through the bridge of the nose to the 
right side of the mouth, leaving uncovered the nasal spine of 
the frontal bone, the nasal bones, the ethmoid, vomer and su- 
perior maxilla. The palatine arch was completely fractured. 
Nearly all the bones of the face were comminuted. The whole 
central portion of the face was moved over to the left. The 
right cornea was lacerated and the aqueous and vitreous hu- 



SPANISH MEDICO-MILITARY JOURNALS, igo2. 333 

mors 6f the right eje had escaped. There was compound 
comminuted fracture of both bones of the rig-ht leg,' compli- 
cated by laceration of the anterior and posterior tibial arteries 
and infiltration of the soft tissues with blood. There was 
compound comminuted fracture of the left astragalus, os cal- 
cis, and lower third of tibia and fibula. 

Loose fragments were removed from th"e wounds, the 
wounds cleaned, and antiseptic dressings applied. A portion 
of the face wound was sewn up. Splints were applied to both 
legs, and means adopted for continuous irrigation of the leg 
wounds. The patient was isolated in a darkened room, put 
upon milk diet, and received injections of artificial serum at 
regular intervals. 

At first he showed enormous recuperative powers. He 
rallied well from the shock, which was extreme. The first 
day after the injury he remained without fever. In view of 
the increasing improvement in the patient's general condition 
it was thought advisable to wait another daj' at least before 
amputating the right leg. 

On the second day there was slight febrile reaction and 
some nervous excitation. It was agreed to put off amputation 
until the patient should be in better condition. 

By the 5th day the nervous excitation had disappeared. 
Temperature was 38.7°C. Pulse, 112. The face wounds 
looked well. Fragments of the comminuted bone began to be 
thrown off. Fragments were thrown off from the wound of 
the right leg also, and a large part of the Achilles tendon 
came away. 

On the 7th day the wounds of the face and of the left leg 
looked well, but amputation of the right leg was determined 
upon on account of gangrene. 

On the 8th day amputation was performed through the 
middle of the right thigh. 

10th day. — Fragments still being thrown off from the 
wounds of the face and left ankle. Temperature 39". • Diar- 
rhoea. Dressings of amputation stump dry, 

12th day. — Wounds of face and left leg aseptic, and the 



334 LIEUTENANT CM A RLES NOR TON BA RNE Y. 

former filling up with granulations. Dressings removed from 
amputation stump and operation wound found dry but atonic. 
Temperature, 38.6\ pulse, 120. 

14th daj. — Wound of face healing. Septic focus in left 
ankle. Stump of right leg atonic, but with neither exuda-* 
tion nor odor. No more diarrhoea. Temperature and pulse 
same as before. Stitches removed, stump rubbed with oil of 
turpentine, depths of operation wound packed with gauze. 

17th day. — Temperature and pulse slightly lower. 
Wound of face healing. Amputation stump in same condi- 
tion as before, — dry but atonic, showing no signs of healing. 
Necrosis of left tarsus progressing, foot mummified. Patient 
showing much weakness. , 

20th day. — Amputation through upper third of left leg. 
Existing arteriosclerosis, the now unfavorable general condi- 
tion of the patient, and the atonic condition of the stump of 
the right thigh had all been considered. 

21st day. — General condition same as during the last 
week. Injections of artificial serum continued. 

22nd day. — Diarrhoea. General weakness increasing. 

24th day. — Wound of face partially healed. Amputation 
stumps apparently aseptic, but showing no signs of healing. 
Oil of turpentine applied to them. 

28th day. — Temperature now normal. Diarrhoea has 
disappeared. Adynamia increasing. Patient continuously 
drowsy. 

29th day. — Sudden rise of temperature to 40» at 10.00 
o'clock at night. Normal again at 6 in the morning. 

32nd day.— Temperature 39.7*, pulse, 120. Stupor be- 
coming more and more profound. The stump of the left leg 
atonic and aseptic: the stump of the right thigh covered with 
a layer of mortified tissue, flaccid, cold, lifeless. 

36th day. — Profound adynamia. Death. 

At the autopsy general arteriosclerosis was found to be 
extreme. 

Study of the Fractures Pkoduced by small Arms 
Projectiles. This is the title of the *'feuilleton" which ac- 



SPANISH MEDICO-MILITARY JOURNALS, igo2. 335 

companies the issues from January to October. It is an ex- 
cellent monograph written by senior students of the Medico- 
Military Academy at Madrid under the direction of D. Miguel 
Blocker de la Pola, Professor of Military Surgery. It is too 
long for abstracting and it will probably be published in 
English at a later date. 

LA MEDICINA MILITAR ESPAJ^OLA, 
La Medicina Militar Espaiiola y Revista de Clinica y de 
Terap^utica y Farmacia," like the '*Revista de Sanidad Mil- 
itar," is published semi-monthly at Madrid in an octavo 6^ by 
9^ inches, but the individual numbers average 17 instead of 
20 pages. It is edited by Dr. Angel de Larra y Cerezo, Major- 
Surgeon of the Sanitary Corps of the Spanish Army, a mam 
of distinguished prominence in the medical profession of 
Spain. 

The 24 numbers issued in 1902 comprise 412 pages. 47 
pages (11%) are devoted to original articles on medico-mili- 
tary subjects, 8 in number, as follows: ''Note on Vaccina- 
tion," ''Compressed Medicines and their Utility in Field Ser- 
vice," "Factors Which Ought to be Considered in Attempt- 
ing to Estimate Numerically the Physical Value of the Soldier," 
''Military Sanatoria for the Tuberculous," "The Workings of 
the Sanitary Service on the Battlefield," "Experiments on 
Cadavers as Tests of the Effects of Firearms," "Medical 
Teaching and the Sanitary Corps," '*The Great Hygienic and 
Social Problems in Relation to Armies." 47 pages also are 
devoted to 10 original articles on non-military subjects, such 
as: "Micrographic Analysis of the Tineas," "A Case of Lud- 
wig's Angina," "Ovariotomy in a Case of Ovarian Cyst," 
"General Anaesthesia oy the Bromide and by the Chloride of 
Ethyl." 8 pages {2%) are devoted to abstracts bearing on 
military medicine; 15 pages (3.5%) to abstracts on subjects 
medical but not military; 50 pages (12%) to original articles 
on pureiy pharmaceutical subjects; and the remaining 245 
pages (nearly 60%) to book reviews, obituaries, official orders, 
changes of station of the medical and pharmaceutical person- 
nel, etc. 



336 LIEUTENANT CHARLES NORTON BARNEY. 

Following- are abstracts of all the orig^inal articles on 
medico-military subjects. 

Note on Vaccination. Virg^ilio Hernando. — As far as 
prophylaxis against small-pox is concerned, military hygiene, 
by the methodical emploj-ment of vaccination, has reached 
perfection. Even at such military posts as are situated in 
the midst of civil populations which constitute endemic foci, 
small-pox has been practically eliminated from the list of dis- 
eases. 

The author believes that, in addition to natural and ac- 
quired immunity and the slight influence of local climatic con- 
ditions, the percentage of successful results after vaccination 
depends on the amount of virus inoculated. 

He vaccinated from the same tube of lymph twenty sol- 
diers who had never before been vaccinated. In the first 10 
he limited the quantity of virus inoculated to that which was 
carried in by the point of the scarificator, and in the second 
10 he scarified as before, but also placed upon the scarified 
surface an additional drop of virus sufficient to fill all the 
minute fissures. Of the first 10 vaccinations only 3 **took," 
while 7 of the second 10 were successful. At a later date the 
7 unsuccessful cases of the first group and the 3 of the second 
group were revaccinated with the same lymph and by the 
same method which had beer^ used in the second group; the 
7 of the first group all developed vaccinia while the 3 of the 
second group still remained unaffected. 

Compressed Medicines and theik Utility in Field 
Sekvice. Isidro Garcia Julidn enumerates the, to us well 
known, advantages of compressed tablets. It would appear 
that these are not well known in the Spanish Army, and that 
the only medicinal tablets furnished Spanish medical officers 
are tablets of antipyrin, 'rhubarb, sodium bicarbonate, and 
bichloride of mercury, recently adopted. The author men- 
tions having used morphine hypodermic tablets froip his own 
private stock during the war in Cuba and describes how he 
dissolved them in ^ teaspoon heated over a candle. He fur- 
ther states * 'Medicines are used in tablet form in the sanitary 



SPANISH MEDICO-MILITAR Y JOURNALS, igo2, 337 

services of the German and Russian armies; and in the army 
and navy of the United States also, as I had an opportunity 
of observing while I was a prisoner of war aboard the gun- 
boats *Nashville' and 'Maple' and at Fort McPherson. In the 
French army tests are now being made to determine the util- 
ity of compressed tablets, and the test will no doubt result in 
the adoption of the tablets." 

Fac1x)rs which ought to be taken into Account in 
Attempting to Estimate Numerically the Physical Value 
OF THE SoLDiEK. Federico G. Deleito. — In a previous article 
on this subject the author contended that the day had not yet 
arrived when the physical value of recruits or their resistance 
to disease could be indicated by figures obtained through a 
mixture of measurements expressed in centimeters and in kil- 
ograms. In further proof of his contention he points out in 
this article how the liability and immunity of recruits to cer- 
tain diseases is affected by the locality from which these re- 
cruits come, and by the locality, and even the arm of the ser- 
vice, to w6ich they are sent. 

"While I was stationed at Pamplona I noticed that an 
overwhelming majority of the soldiers discharged on account 
of tuberculosis were men from Santander, the district which 
supplies recruits for one of the army corps represented in the 
Pamplona garrison, while very few came from Soria, the dis- 
trict which supplies the other corps there represented. The 
conditions under wh>ch these two groups of soldiers lived in 
garrison were exactly alike. Both were infantry, both were 
quartered in barracks which were most detestable from every 
point of view, both had the same duties. By looking at a 
map which shows the prevalence of tuberculosis in Spain, or 
reading the monthly mortality reports of the various provin- 
cial capitals, one sees that Santander contributes in greatest 
degree to the white plague, and Soria least." 

Much the same thing happens with typhoid fever. But 
here the differences in morbidity and mortality depend not so 
much upon the province or region from which the recruits 
come as upon the kind of life, whether rural or urban, which 



338 LIEUTENANT CHARLES NORTON BARNEY, 

the J have led. Typhoid is much more easily acquired by 
those who have lived isolated lives in the open country than 
by those who, habituated to life in cities, have acquired a 
certain degree of immunity. 

Military Sanatoria fok the Tubrkculous. Jesus de 
Bartolom6 y Relimpio strong-ly urges the institution of special 
sanatoria for the observation and treatment not only of those 
who develop tuberculosis after entrance into the afmy, but 
also of those who at the physical examinations to determine 
fitness for service are suspected of having the disease in an 
incipient stage. This he believes to be the only radical, and 
at the same time humane, means of reducing the frightful 
and increasing mortality from tuberculosis in the Spanish 
army. 

Under existing laws in Spain no one can be exempted 
from military service on account of suspected tuberculosis. 
The existence of the disease must be definitely proven. And 
as the diagnosis cannot often be made in the earliest stages 
very many recruits are taken into the ranks suffering from in- 
cipient tuberculosis. This develops under the notoriously bad 
hygienic conditions of life in the great majority of Spanish 
barracks and gives rise to other cases of the disease, which in 
turn become distributing foci. 

Of late years measures intended to improve the hygienic 
environment of the soldier have been prescribed in orders, but 
these measures have not been sufficient. Entirely new bar- 
racks should be built, and pending completion of the barracks 
the soldier should be instructed in the means of avoiding the 
disease. But this is not all. The radical measure needed is 
elimination of the tuberculous from the army. But for the 
safety of society it should be remembered that they still scat- 
ter the seeds of their disease about them wherever they are, 
whether in the army or out of it. 

Even the exemption from service of those who are sus- 
pected of having incipient tuberculosis, together with the dis- 
charge of those who acquire or develop tuberculosis in the ser- 
vice, does nothing more than shift the infectious foci from 



SPANISH MEDICO-MILITARY JOURNALS, igo2. 339 

the military to the civil population. Suspected cases as well 
as developed cases should be isolated under observation and 
treatment in special tuberculosis sanatoria. The adoption of 
this plan would not only diminish the spread of the disease, 
but would g-ive those suffering- from it the very best chance of 
cure. 

Since the first sanatorium was founded by Bremher in 
1859, the establishment of special sanatoria hasg^one on at an 
increasingfly rapid rate. Nearly all of the most civilized 
countries have public civil and military sanatoria for the tu- 
berculous, but unfortunately for Spain she has not followed 
the lead of other nations in this direction. 
(to be concluded.) 

THE INFLUENCE OF POLITICS UPON MILITARY 
HYGIENE IN FRANCE. 

THE Lancety commenting- upon French military sanita- 
tion, remarks that the effort to quarter troops in sa- 
lubrious surroundings where there is a pure water- 
supply is often defeated by political influence. All towns 
seek to be made garrison towns, for the presence of oflScers 
and men is the cause of a wide-spread circulation of money. 
When it is proposed to withdraw a regiment from some no- 
toriously insanitary town in which the municipality is unwill- 
ing to spend any money in securing a wholesome water-sup- 
. ply, it is almost impossible to do so on account of the protests 
of the town deputies, especially those belonging- to the minis- 
terial majority. It is not uncommon for a minister to reward 
a town which voted straight by sending it one or two reg-i- 
ments whose members will spend money in the town, and to 
punish another town by withdrawing- the garrison. Some 
years ago, when the right of having a Faculty was trans- 
ferred from the town of Douai to that of Lille, two engineer 
regiments were sent to Douai as compensation. It is hard to 
carry out hygienic measures when the minister has little re- 
sistance to. the vested interests of electors. 



^ebtco-^ilttarig Inbcx. 



MEDICO-MILITARY ADMINISTRATION. 

Rdnecke (R« J.) [Treatment of sick and wounded in military hospitals 
critical observations based upon experiences in the Boer war.] 8°. Berlin 
1902. 

Rlchter* Franzosische Feld-Sanitatsiibungen. Militaerarzt^ Wien^ 
1902, xxxvi, 1 29-131. 

Robert. Des moyens applicables au transport des malades et des ble.ss^ 
dans Textreme sud alg^rien. Arch, de m^d. et pharm miL^ Par., 1902, xl, 

177-191- 

Ruaia. [(Military order of April 6, 1901, No. 133) List of salaries to 
army medical officers. j Voyenno-Med. /., St. Petersb., 1902, Ixxx, off. pt., 
219-228. 

Russia, [(Order promulgated by the Ministry of War December 24, 1901, 
No. 446.) Temporary rules for assigning students of the Army Medical 
Academy to military divisions so that they m^y become acquainted with 
field service.] Voyenno-Med. J. ^ St. Petersb., 1902, Ixxx off. pt, 113-119. 

S. (J.) L'Ecole de sant^ navale et coloniale de Bordeaux. Gaz. hebd 
d. sc. med. de Bordeaux^ 1902, xxiii, 355. 

Schjerning (O*) Die Organisation des Sanitalsdienstes im Kriege. Klin. 
Jahrb.yJenUy 1902, ix, 229-250, 1 pi. 

Ten Slefhoff (E, G» A.) La convention de Geneve et les ambulances des 
soci^t^s de la Croix Rouge; avec appendicedelad^laration dudocteur F. Al- 
•brecht ex chef d'ambulance chez les Boers. 8*. Amsterdam, [1902.] 

Tishkoff (I. ?♦) [Historical sketch of the Sisters of the Red Cross in 
connection with the marine hospital in Kronstadt.] Med. pribav. k morsk 
sborniku^ St. Petersb., 1902, pt. 2, 145-155. 

Tobold. Organisation de la Croix-Rouge en Allemagne. Caducef, 
Par., 1902, ii. 205-207. 

V* J. L' ficole de santd de -la Marine. /. de mid. de Bordeaux., 1902, 
xxxii, 456. 

Vbaer (L»E.) La convention de Geneve du 22 aofit 1864, et les socidt6i 
de la Croix Rouge. 8". La Haye, 1902. 

Werner, Krankentransport und Unterkunft im Kriege. Klin.Jakrb. 
Jena^ 1902, ix, 251-284. 

(»40) 



MEDIGO-MIUTAR Y INDEX. 341 

MILITARY HYGIENE. 

Biehl (K«) [Do defects in the membrana tympani impair capacity for 
military service?] Militdrarzt^ Wien, 1903, xxxvii, 17-24. 

Blok (D. J.) [Myopia and astigmatism in examination of recruits.] MiL- 
geneesk, Tijdschr.y Haarlem. 1903, vii, 14-25. 

Dumas. [Hygiene in the army.] Echo mfd. d. Chjennes^ Nimes, 1902, 
iii, 172-180. 

Gran|tiz (L.) [Causes of morbidity and mortality in the army.] Rev. 
scient.^ Par., 1903, 4. s,, xix, 289-300. 

Grimm (L V*) [Army sanitation in Bulgaria.] Voyenno-med. /., St. 
Petersb., 1903, Ixxxi, med. spec, pt., 204-302. 

Kalttstratoff (N* M.) [On the clothing and arming of our soldiers.] Voy- 
enno-med, J.^ St. Petersb., 1903, Ixxxi, med. spec, pt., 315-317. 

Kunow- [A simple system of graduated lenses for the business of mus- 
tering and recruiting troops.] Militaerarzt^ Wien, 1903, xxxvii, 37. 

ISIILITARY IVIEDICINE. 

Bonnette. [Alcoholic dyspepsia in the foreign legion; its treatment] 
Caducke^ Par., 1903, iii, 58. 

Brunon (R.) [Typhoid fever in the barracks. Ann. d^kyg. Par., 1903, 
xlix, 241-250. 

Htible. [An epidemic of typhoid fever in the garrrison at Mont^limar.] 
Arch, de mkd. et pharm. mil.^ Par., 1903, xli, 23ib-24i. 

Imbriaco. [Appendicitis in the Italian army.] Caducve, Par., 1903, iii, 62. 

KomatM &: Kaosame (L) Remarks on skin diseases in the 4th regiment 
of infantry. Gun Igaku Kwai Zasskt, Tokyo, 1902, 787-793. 

Malstrian. [Treatment of tuberculous troops in Belgium.] Caducre^ 
Par., 1903, iii. No. 3, annexes. 

Zimmermann. [Severe case of dysentery in a soldier.] Militararzt^ 
Wien, 1903, xxxvii, 30. 

MILITARY SURGERY. 

Van Ex. [Blank cartridge wound of the right parietal region; trephin- 
ing.] Arch, mfd, beiges^ Brux.y 1902, 4. s., xx, 145-156. 

Vorthy (F* W. Fj Modern war wounds. Fort Wayne M. Mag.y 1902, 
xxii No. 6, 225-241. 

Wood (V* ]* N.) Notes on a few cases of bullet wounds in' the Boer 
war. Brit. J. Dent Sc.^ Lond., 1902, xlv, 577-580. 

Walthef, Auszug aus dem Krankenrapport der Pferde des xix. (2. 
Koniglichen sachsischen) Armee corps fur 1901, Ber. u. d. Veterindrw.im 
Konigr. Sachs. 1902, Dresd.^ 1902, xlvi, 134-140. 

Weigt* [Can clothing be set on fire by a discharge from an army re- 
volver?] Deutsche mil.-drztl. Ztschr,^ Berl.,1902, xxxi, 535. 

Yvert (A.) [Wounds of the eye by birdshot.] Gaz.hebd. demed., Par.- 
1902, n. s,, vii, 973-^77. 



iBbttodal Department. 

THE TWELFTH ANNUAL MEETING. 

THE arrangements for the twelfth annual meeting of 
the Association at Boston on the 19th, 20th and 21st 
of May continue to develop most attractively. Large 
delegations of national guard medical oflScers have been made 
by the governors of many of the states; the national services 
of our own country will be amply represented; and notifica- 
tions of delegates from the forces of foreign powers are rap- 
idly arriving. 

A number of important additions to the list of papers to 
be read at the meeting have been added to the program, 
among which may be mentioned the following: 

1. A Mounted Bearer Company By Lieut. Col. H. G. Hathaway^ 
R.A.M.C 

2. The United States Naval Medical School. By Medical Director 
Robert A. Marmion^ U.S. Navy. 

3. The Preservation of the Soldier's Health. By Brigade Surgeon- 
Lieutenant-Colonel William Hill-Climo, A. M.S. England. 

4. The Instruction of the Hospital Corps in Companies and Detach- 
ments. By Captain Frederick P. Reynolds^ U.S. Army. 

5. The Acting Assistant Surgeon, U.S. Army. By Major Azel 
Ames^ U.S.V. 

6. Medical Treatment of Appendicitis in Accordance with Modern 
Views of Therapeutics. By Lieut. Enrico Castelli^ Italian Delegate. 

7. Yellow Fever at Las Animas Hospital — the Hospital of the Sani- 
tary Department during the Epidemic of igoo at Havana, Cuba. By Colonel 
William C. Gorgas^ U.S. Army. 

8. Quarantine as the Picket- Line, By Surgeon Parker C, Kalloch^ 
P.H.&M.H.S. 

9. Hysteria in the Male. By Surgeon Sheldon G. Evans^ U.S.Navv- 

10. A Note on the Surgical Experiences of the Boer Wan By Sur- 
geon-General W. F. Stevenson^ A. M.S. England. 

11. The Treatment of Dislocation of the Shoulder. — Report of a Case 
jn which the Detatched Greater Tuberosity prevented Reduction. By As- 
sistant Surgeon General George Tully Vaughan, P.H.&M.H.S. 

Boston is prepared to receive the Association with doors 
wide open. On her part, nothing will be omitted which can 



EDITORIAL DEPARTMENT. 343 

make the meeting- a most successful convention, and her display 
of hospitality promises to be so unstinted as long to be held 
in the memory of her guests. 

GERMAN ASSOCIATIONS OF MILITARY SURGEONS. 

A SERIES of papers upon the medico-military associa- 
tions of various nations is appearing in LeCaducee 
from the pen of Major Laval, its distinguished man- 
aging editor. The series opened with a comprehensive paper 
upon the Association of Military Surgeons of the United 
States and follows with some remarks upon the similar organ- 
izations of Germany. There are twenty-one exclusively medico- 
military societies in the German empire, each of which holds 
a monthly meeting at the headquarters of the army corps 
with which its members are on duty. The Berliner Militar- 
arztliche Gesellschaft, — the Military Medical Society of Ber- 
lin,— comprises 161 oiBcers of the medical departments of the 
four army corps serving in and about that city. All officers in 
active service are required to attend the meetings of these soci- 
eties, however far they may be located from the place of meet- 
ing. At each meeting the work includes papers, discussions 
and scientific demonstrations. The officers are a chairman 
who presides at the meetings and a secretary who arranges 
the program and prepares the report of the transactions. 

The proceedings of the Berlin society, as well as of the 
other similar associations of Coblenz, Cologne, Trier, Bonn, 
Saarbriicken, Aachen, etc., are published monthly in the 
Deutsche Militaerarztliche Zeitschrift. 

Major Laval remarks that the German societies are quite 
opposite in character to that of the United States. In Amer- 
ica military surgeons are entirely free to join their association 
or not; in Germany each officer is required to be present at 
the meetings at whatever cost of time and travel. In Ameri- 
ca there is but a single meeting a year, which however is "im- 
mense" and lasts for several days; in Germany there are fre- 
quent, generally monthly meetings, at the various military 
centers. The Association of Military Surgeons of the United 
States displays clearly marked international tendencies; the 
German societies absolutely exclude foreign elements. 



IRevtews of Books. 



THE ADRENAL THEORIES OF SAJOUS.* 

^^rT'^HE Internal Secretions and the Principles of Medi- 
I cine" commands the attention of the profession be- 
cause of therecoi^nized ability of its distinguished 
author. A like work by an unknown writer would have been 
deluged with the criticism and an madversions of the reviewers 
of the medical press. The production of such an eminent 
physician as Sajous cannot be thus treated. Yet the columns 
of our esteemed contemporaries as yet have contained no in- 
telligent, detailed criticism of the revolutionary theories so 
boldly advanced by our author. The medical press, with un- 
important exceptions notice the work with an absolute lack 
of discussion concerning its truth, yhe reviewers content 
themselves with statements describing the contents of Sajous 
work, and they use the expletives ''bold and new" in conjunction 
with our author's statements. The truth is that the reviewers, 
as the profession at large, do not know whether the book be- 
fore us is of tremendous importance or of utter futility. There 
are few among us with sufficient data to back arguments for 
or against the theories advanced by Sajous. Our author has 
been working in a field of whose existence we knew, whose 
confines we speculated upon and whose possibilities were al- 
most unknown to us. The result of the labors of Sajous come 
then from the fields of experiment and until the profession 
has for itself explored these fields. and verified the work of 
this investigator of adrenal phenomena it must regard with 
respectful consideration what it cannot intelligently discuss, 

**The Intefnal Secretions and the Principles of Medicine*^ By Charles 
E. De M. Sajous, M.D. etc. In two volumes. Volume I. Octavo 788 
Pages. Illustrated. F. A. Davis Co., Philadelphia, 1903. 

(;w4) 



RE VIE WS OF BOOKS. 345 

let alone disprove. We are fully aware that it will be but a 
short time before controversy will rag-e upon the points raised 
by Sajous, but it will be years before this controversy, save 
in isolated cases, will be based upon fact. It is well then, at 
this early period, to prepare ourselves to disregard the wordy 
warfare and join those to whom silence will be golden, until 
research can give leg-itimate basis to controversy. 

This brief statement of the knowledg-e of the profession 
concerning the subject of Sajous work and the reason for the 
lack of present and immediate future intelligent criticism 
upon it will serve to introduce -a sketch of the contents of the 
first volume of *'The Internal Secretions." 

In Sajous's research his first endeavor was to ascertain 
"whether the physiological functions of the adrenals were 
sufficiently similar in all vertebrates to warrant the use of ex- 
perimental data obtained with lower animals in the study of 
these organs in man." Sajous asserts that such is the fact. 
Proceeding from this fundamental premise, which for the sake 
of argumentative form we accept, our author advances aseries 
of theses that are destructive of accepted beliefs and if main- 
tained are of the greatest importance to medical science. 
The average practitioner will be surprised by such state- 
ments as: /'The adrenals are the key not only to tissue-respi- 
ration but also to the functions of all other organs now 
classed as 'ductless glands' and destined to fulfill the man- 
dates of the latter." He will question the assertion that the 
secretion of the adrenals at the pulmonary alveoli, the point 
to which the observer traced the secretions "hold in combina- 
tion the various constituents — of haemoglobin, and endow both 
the latter and the plasma with their affinity for oxygen." 
Nevertheless these statements will, if they stand, change 
our present theory of the chemistry of respiration and of the 
structural pigmentation of blood. The series of conclusions 
has no more striking member than the statement that the red 
corpuscles are not the only carriers of oxygen but that the 
blood-plasma plays an important part in the distribution of 
the gas. "Indeed" says our author "we subsequently ascer- 
tained that the red corpuscles were secondary factors in this 
important function, i. e., mere carriers, pack-mules, as it were. 



346 REVIEWS OF BOOKS, 

and that it was the oxvgen-laden adrenal secretion dissolved 
in the plasma itself which carried on all the oxidation pro- 
cesses of the org-anism." 

Sajous has given a most luminous exposition of his theory 
of the adrenoxinal movement, his statements concerning^ 
physiological chemistry of cellular elements are particularly 
informing although we are not, as yet, prepared to follow 
him in his conclusions concerning the functions of axis-cylin- 
ders, dendritis of neurons and the neuroglia-fibrils as plasma 
bearing channels. Let our position here be fully understood, 
we cannot now follow, where. presently we may, simply be- 
cause our research has not as yet convinced us of the possi- 
bility of the passage of the adrenoxinal elements through all 
the structures specified by Sajous. Passing our author's con- 
clusions, in verification of physical phenomena^ and his as- 
sumption that the '^immanent source of functional energy" is 
myelin and that the entire nervous system is built up of cylin- 
ders containing adrenoxin surrounded by a layer of myelin 
and that the reaction between the two bodies served to form 
and liberate energy; we come to a cardinal point of our 
au'.hor's work that the anterior pituitary body, hitherto re- 
garded as practically functionless, is the most important organ 
of the body, is in fact the governing center of the adrenals, 
and, therefore, of all oxidation processes. The importanceof 
such a fact when established in the pathogenesis and treat- 
ment of disease is incalculable. Sajous in satisfactory detail 
discusses cause and eifect and by specific instances seems to 
furnish abundant proof of his theory of the functions of the 
anterior pituitary body. 

Sajous, continuing his delineation of purpose, states that 
*'the physiological purpose of the thyroid gland is to sustain 
the functional efficiency of the anterior pituitary body up to a 
certain standard by means of its secretion; iodine in organic 
combination. Excessive production of this secretion, by caus- 
ing overstimulation of the anterior pituitary body, gave rise, 
when prolonged, to 'exophthalmic goiter;' while reduced 
production of thyroid secretion, by inhibiting the functions of 
the anterior pituitary body, caused myxoedema. The thyroid 
gland, the anterior pituitary body, and the adrenals were 



REVIEIVS OF BOOKS. 347 

thus found to be functionally united: i. e., to form an autono- 
mous system, which we termed the 'adrenal system/" The 
posterior pituitary body is stated by Sajous to be second only 
in importance to *4ts mate the anterior pituitary body." In 
fact to be '*the chief functional center of the nervous system, 
its numerous groups of neurons forming* the starting point, or 
highly specialized center, of a single class of nerves." The 
posterior pituitary body '*is an important feature of the mor- 
bid process in influenza, hay fever, hysteria, catalepsy and 
other obscure affections." 

Our author next discusses the functions of the pancreas 
and the spleen and his conclusions are of intense interest. 

In conclusion he sums up the result of his inquiry as fol- 
lows: '*Briefly, our inquiry seems to us to have shown that 
the adrenal system is the source of the secretion which, with 
the oxj'gen of the air, forms the oxidizing substance of the 
blood-plasma. It has also revealed, we believe, the origin 
and mode of distribution of the bodies with which this oxygen 
directly or indirectly combines; i. e., peptones, niyosinogen, 
fibrinogen, haemoglobin, and myelin, to insure the continua- 
tion of life and the efficiency of all organic functions. Finally, 
it has suggested that in addition to these agencies, all leuco- 
cytes and, under certain circumstances, the plasma, contain a 
protective agency, trypsin, which, with Metchnikoff's phago- 
cytic cells, serves to destroy micro-organisms and convert 
their toxins and other albuminoid poisons into harmless 
products. Considered jointly, these various factors seem to 
us to represent the aggregate of vital phenomena." 

But to many physicians the most important part of our 
author's work deals with ''Immunizing Medication" — "the use 
of remedies to arrest diseases during their incipiency by stim- 
ulating tlfe functional activity of the adrenal system." Par- 
ticularly vital to the practitioner are Sajous statements con- 
cerning epidemics, injuries received in places thought to con- 
tain tetanus saprophytes^ after bites of presumably rabid or 
venomous animals or after infections; his assumption that 
vulnerability to tuberculosis is congenital adrenal insufficiency 
and his theories concerning the prevention of death in acute 
diseases. 



348 RE VIE WS OF BOOKS. 

To conclude we summarize the contents of the work be- 
fore us b^' quoting^ the chapter heading's — These are I. *'The 
Physiolog-y of the Adrenals as Viewed from the Standpoint 
of Clinical Pathology." II. ''The Internal Secretion of the 
Adrenals in its Relations to the Respiratory Processes and 
the Composition of the Blood." III. '*The Internal Secretion 
of the Adrenals to the General Oxidation Processes." IV. 
''The Internal Secretion of the Thyroid and Thymus Glands 
in Their Relations to the Adrenals." V. "The Anterior 
Pituitary Body, the Thyroid Gland, and the Adrenals as Parts 
of an Autonomous System." VI. "The Adrenal System and 
Vasomotor Functions.'* VII. "The Adrenal System, the 
General Motor System, and the Pneumogastric Nerve." 

VIII. "The Internal Secretion of the Pancreas and Spleen." 

IX. ""The Adrenal and Vagal Systems in Their Relations to 
Cardiac and Pulmonary Functions." X. "The Posterior 
Pituitary as the Functional Center of the Nervous System, 
and as the Anterior Pituitary's Co-Center in Sustaining the 
Vital Processes." XI. "The Internal Secretions in Their 
Relations to Immunity." XII. '*The Internal Secretion and 
the Preservation of Life." 

We desire to express our appreciation of the modesty 
with which our author submits his work to the profession. 
He does not claim absolute infallibility. He becomingly 
awaits the verdict of contemporary scientists but he firmly 
and properly maintains his conclusions. We have fol- 
lowed his arguments with care and in a few instances, our 
personal research has furnished corroboration of the state- 
ments made by our author, but in other instances the opposite 
result has accrued, and on these we defer judgment until we 
have verified our tests. In the main, however, we may state 
that we are not prepared, at present to accept the conclusions 
of our esteemed author though we give to him full credit for 
his great and laborious research, his brilliant and important 
conclusions. We Jtrust though for Sajous' reputation and for 
the great benefit that must accrue to the science of medicine 
if his theories are correct, that the future may see a substan- 
tiation of the statements So well postulated and convincingly 
discussed in the book before us. Hildegarde H. Langsdorf. 



THE MILITARY MEDICAL OFFICER AT THE OPENING 
OF THE TWENTIETH CENTURY.* 

By dr. JOHN S. BILLINGS, LL.D., D.C.L., 

LIEUTENANT COLONEL IN THE UNITED STATES ARMY, RETIRED; 
DIRECTOR OF THE NEW YORK PUBLIC LIBRARY. 

I SUPPOSE that it is entirely within the bounds of possibility 
that some forty or fifty years hence some member of this 
class will come back here to give the address to the gradu- 
ating class of that date. I am not specially curious as to which 
one of you gentlemen will perform that duty, — but I should very 
much like to know what he will say — if I did, I could probably 
make a very interesting address myself, although I might have to 
make a very careful selection for fear of being thought a crank. 
I can hardly imagine what Dr. McLaren, the President of the 
Army Medical Board which examined me, would have thought 
if I had tried to answer some of his questions as you would prob- 
ably answer them. He thought that great progress had been 
made since he entered the service at the beginning of the Florida 
War, and that we young fellows were going into the War of the Re- 
bellion with great advantages. He had seen the introduction of 
anesthesia, and was enthusiastic over the comparatively new opera- 
tions for excision of joints. He had just heard of the clinical 
thermometer, but doubted whether it would be of much use, and 
had also heard of the hypodermic syringe; and when he found 
I had one of these instruments, he went to Surgeon General 
Finley (this was in 1861,) and had me assigned to duty at the 
hospital under his charge so that he might see how these new 
things actually worked. If, however, in answering his question 
as to the means of preventing malaria and typhoid fevers among 
troops, I had referred to bacilli, haematozoa, flies and mosquitoes, 
as you would probably do, I don't think I should have passed, 

•Address to the graduating class of the Army Medical School at Wash- 
ington, April 14, 1903- ^^^^ 



350 LIEUTENANT COLONEL JOHN S. BILLINGS. 

and if I had referred to antitoxin as a means of treating malig- 
nant sore throat (his name for diphtheria), he would have advised 
me to take a six months' rest in an asylum. I was asked to de- 
scribe laudable pus and the best means of securing healing by the 
second intention. Have any of you ever seen any laudable pus? 
Certainly my knowledge of medicine in those days before you 
were born was not great as compared with yours, but when 
I went to the army of the Potomac I found a few doctors who 
knew less, as appeared from the results of a certain examining 
board of which I was a member. 

When the war was over and the armies of Grant and Sher- 
man had made their last parade, when, thirty- eight years ago to- 
day, President Lincoln was assassinated, and at last rested in the 
peace of death, and the old Ford's Theatre was occupied by the 
Army Medical Museum and Library, the younger medical officers 
in the museum became busy with investigations, and it is inter- 
esting to remember some of the problems which occupied them. 
One was the comparison of high power microscopic objectives as 
tested on Nobert's lines; another was the best way of making 
photo-micrographs; a third was the best method of staining and 
mounting tissues. I clearly recollect the feelings of triumph with 
which I took some slides of stained sections of kidney and intes- 
tines mounted in balsam to Dr. Woodward, who had been very 
incredulous as to the possibility of making such preparations. 
Then Dr. Edward Curtis and myself began the study of minute 
fungi and of Texas cattle fever, looked for the malarial organ- 
isms on Analostan Island, and spent much time on bacteria, fol- 
lowing Pasteur's method. In the absence of the solid isolating 
culture methods devised by Koch, we were groping blindly, but 
I have not regretted the time spent in this groping. It is impos- 
sible for you to appreciate the feelings with which we read Koch's 
first papers, or with which we viewed the commencement and 
progress of antiseptic surgery. 

When I graduated in medicine I had to write a thesis, and 
for divers and sundry reasons, I chose to write on the surgical 
treatment of epilepsy. I undertook to get the history of all re- 
ported cases of such treatment, and in trying to do that I discov- 



THE TWENTIETH CENTURY MEDICAL OFFICER ^ 351 

ered that there was no library in the United States which con- 
tained all the reports. There were no complete files of medical 
journals in this country, and any man who really wanted to write 
a scholarly book on medicine had to go to London or Paris for 
his data. It seemed that that condition of things should be im- 
proved, and when I came here in the Surgeon General's OflSce 
and was detailed to settling the medical accounts of the war, I 
put in some side time in trying to get this library together. 

The work which was done in the old Ford's Theatre in the 
latter sixties and the seventies, in connection with the Museum 
and Library was in part merely incidental to the preparation of 
medical and surgical history of the war, in part for the advance- 
ment of medicine, and in part for the pleasure of the ybung men 
engaged in it. Its direct results on the science and art of medi- 
cine were not great, but its indirect results have been and are 
important. This Army Medical Museum and Library are well 
known to physicians all over the world, and the opportunities 
they have afforded and the aid which they have given to physi- 
cians in the United States have been such as to produce in the 
medical profession a strong interest in the Army Medical Depart- 
ment. It is desirable for all parties that this interest should be 
maintained, and to this end the younger members of the Medical 
Corps should know and feel that this Army Medical Museum and 
Library is an inheritance to be cared for and increased by them 
for their own and the general good. One of the good things 
about this Army Medical School is that it brings the Assistant 
Surgeons in touch with this institution, giving it some of the 
features of a central home club. 

Thirty years ago there were considerable difficulties in ob- 
taining funds for this Institution. I look back at my experience 
with Congressional appropriation committees with more amuse- 
ment than I felt at the time. At present I am told that the dif- 
ficulty is to obtain the funds required to provide shelving for the 
books, rather than to obtain the books. This is also amusing. 

When I asked for suggestions as to what I should talk to 
you about, I was told: — "Oh, the usual thing, congratulations 
and advice." 



352 LIEUTENANT COLONEL JOHN S. BILLINGS. 

As for my congratulations, — you have them, — and they are 
sincere. It is really a very fine thing to be a young army niedi- 
oflBcer, although there are, occasionally, short periods of time 
when he may not think so: He may have some doubts about it 
after he has been for a year at some small, isolated, ver>' healthy 
post, or, for a month before his examination for promotion, or 
when he has to decide without advice as to what he will do for 
his first case of strangulated hernia, or of incipient melancholia, or 
of shot-wound of the abdomen, or of locked twins. He may even 
more than doubt it when he takes a stereoscopic view of his con- 
templated marriage on the one side and his salary and prospects 
on the other. These doubts will pass, but as a rule he will not 
know clearly what a good time he is having and what a fortunate 
man he is until he looks back over his career across the gulf of 
twenty or thirty years. 

If it is true, and I think it is, that "a spice of danger and an 
element of chance add interest to work," then your work will 
have that interest. You are not coming on the stage of action at 
the beginning of a period of peace and content, but in the midst 
of a waxing tide of national struggles for commercial supremacy 
and of discontent among great masses of people. ''That this 
turmoil and unrest can be dealt with wisely and justly, so as to 
preserve that which is most desirable in civilization and in our 
system of representative government, I believe, but here and 
there in special localities, the immediate problems must probably 
be solved by blood and steel, and that you will have a part to play 
in some of these is not at all unlikely." 

You will have some epidemics to face, and no doubt some of 
you will have a chance to hear bullets whistle, arbitration to the 
contrary notwithstanding, but the increased interest which these 
things may give to an army surgeon's life is too uncertain and 
temporary to be worth consideration. The things most to be 
dreaded in your future lives are boredom and waiting, and the 
preventive and remedy is to see to it that you have something to 
do always, — and doing it. It may be, generally must be, routine, 
like a woman's knitting work; sketching or photography, Indian 
languages or calculus, infusoria or ascomycetes will any of them 



THE TWENTIETH CENTURY MEDICAL OFFICER. 353 

keep you busy. But suggesting subjects for work is a little like 
the plan of the man who told Jam^ Russell Lowell that he had 
discovered the way to make a fortune. "As the fine flavor of 
the canvass-back is due to the wild celery on which it feeds, I am 
going to feed tame ducks with it and supply the market. ' ' Some 
weeks later Lowell met him and asked him how the duck feeding 
plan was getting on. **Well/' was the answer, *'they wouldn't 
eat it." 

Forty years ago the microscope was mainly used by physi- 
cians as a plaything, a source of occasional amusement. It was 
the correct thing for the young graduate to buy a thirty dollar 
Oberhauser, and keep it in a conspicuous place in his office, but 
his chief use of it was to show his admiring friends the terrible 
monsters contained in a drop of selected water. 

To-day the microscope is one of our most important tools, 
and you have been taught how to use it, but. it may be well to 
remind you that you can get a great deal of pleasure by using it 
in research work not directly connected with medicine. 

When you obtained your diploma as Doctor of Medicine, it is 
possible that many of you thought you knew it all, or nearly all, 
and that what you did not know could be found in the latest text 
books, monographs and journals. Probably all of you are now 
aware that there are many things in regard to the causes, pre- 
vention and treatment of disease which,, at present, nobody 
knows; or if any one does know, he has not told. There is no 
end to the things we don't know and ought to know, and prob- 
ably will know within your lifetime. 

Some of you have, perhaps, resolved that you will investi- 
gate some of these unsettled questions, and may have even se- 
lected the particular problem which you intend to solve. This is 
good, very good, but remember that in your life as an army med- 
ical ofl&cer the subject for investigation will usually be determined 
by your opportunities rather than by your wishes. I advise 
every young army surgeon to have some research work on hand^ 
for his own mental health and pleasure, just as I advise him to 
take a certain amount of physical exercise, and if he cannot make 
the particular research he would most like, that he try to like the 



354 LIEUTENANT COLONEL JOHN S. BILLINGS, 

research he can make. Of course his selection of a subject for 
study will be largely involuntary; if he feels a strong impulse 
towards some special line of work, it is well for him to follow it, 
but if this work has no relation to his military' duties he must 
bear in mind that these duties have precedence. The fact that 
he is an enthusiastic botanist, ornithologist, or comparative anat- 
omist, is no reason whatever for his neglecting to keep himself 
well informed as to advances in medical science, or not being inter- 
ested in his patients or in the sanitary condition of his post. It 
is also a very poor reason why he should try to obtain posts which 
are specially favorable to his particular hobby, if this hobby is 
not connected with military medicine. If he considers his re- 
search work more important than his army duties, he should re- 
sign from the latter. 

What amount of time and energy should be given to original 
research work by professional men employed in college and uni- 
versity work and in Government departments is a question which 
has been much discussed of late years. The exceptional man, 
who knows all that is known on some one subject and has the 
capacity and the desire to increase knowledge on that subject, 
and for whom many of our Universities and large manufacturing 
and engineering establishments are seeking, is not easily found, 
and when found it is not more than an even chance that he can 
be trusted to fulfill the ordinary every day duties of his profes- 
sion, including administrative work. 

If any of you feel satisfied that you are that sort of man he 
had better communicate with the Carnegie Institution. 

Most of us hold our professional work as the first and most 
important object, and original research as a thing to be done as 
opportunity offers. We belong to the second class mentioned in 
Hesiod, i. e., those who can understand things when explained 
to them. 

I shall not attempt to advise you with regard to your special 
medical, sanitary or surgical work, but merely ask you to re- 
member that ever}' army medical officer has some special oppor- 
tunities for increasing knowledge, but that to enable him to recog- 
nize these opportunities and to take advantage of them usually 



THE TWENTIETH CENTURY MEDICAL OFFICER. 355 

requires long study and training. It was because of this study 
and training that your late teacher and friend Dr. Walter Reed, 
was able to recognize his opportunity and to make the discovery 
with regard to yellow fever which has placed his name high on 
the roll of the famous physicians who have been great benefactors 
to mankind. His work on this subject was not done under direc- 
tion, rather in spite of it, yet the line of work in which he had 
been engaged for the previous ten years was what fitted him for 
the emergency. 

These special opportunities always come to the physician, 
the naturalist, the anthropologist, they are connected with phe- 
nomena which are occasional — rarely just alike and must be se- 
cured at the time or be lost. But you must be able to recognize 
them if you are to use them. Remember the motto of the Wash- 
ington City Directory *'To find a name in this book you must 
know how to spell it.*' 

Permit me to say a word about your social relations and du- 
ties, which are substantially those of the family practitioner, but 
with some special peculiarities. In time of war the surgeon is 
more intimately associated with line officers and their work than 
are the officers of other staff corps, and to a certain extent this is 
also true in time of peace, and as a general rule they are good 
friends. In my time there were two or three commanding offi- 
cers who always had difficulties with medical officers, unless they 
were sick, but so they did with all other officers. There were 
also two or three medical officers who always had difficulties with 
their commanding officers, although they might be on very 
friendly terms with other officers. These gentlemen were sensi- 
tive on questions of rank, and rights, not so much on their own 
account (as they explained), as because they felt it to be their 
duty to uphold the dignity of the Medical Department. Now 
the nature of either personal or Departmental dignity, and the 
desire to have all of one's rights, is such that the more attention 
you give to them the more they seem to require, and it becomes 
hard to spare the time necessary to preserve them spotless and 
II nf rayed. 

Your military rank may, on rare occasions, be an important 



356 LIEUTENANT COLONEL JOHN S, BILLINGS. 

matter in dealing with the rank and file, but your medical skill 
and tact are more important in the ordinary routine of army life. 

It is your duty to contribute your quota towards the social 
life of your post, and to try to make it cheerful and interesting. 
Of course, your personal likes and dislikes, strength or weakness, 
in such matters as athletics and games, shooting and whist, read- 
ing clubs and amateur theatricals, the nieces of the Major*s wife, 
and other sources of amusement, will have much influence on your 
actions, — but be ready to give some of your time to things you 
don't care much about, if it is for the general good and pleasure. 
You have got to take into consideration the opinions, feelings 
and desires of some women as well as the men, but the onlj- piece 
of advice I can give on this point is, — whenever you find your- 
self thinking that you thoroughly understand the ladies, — or a 
lady, — at your post, you had better not prophesy. 

You have also certain social duties in connection with the 
soldiers under your charge. You should know them by sight 
and name, and you should be interested in their individual pecu- 
liarities. And this should be a real interest, — the soldier is quick 
to detect perfunctory, patronizing forms of apparent interest. 
Why does Smith sulk or mope and get off by himself as much as 
possible? Why has Brown suddenly become quarrelsome? How 
is Jones the new recruit getting on? ' 'These matters are the bus- 
iness of the line officers," you will say. They are, but they 
should also interest the medical officer, who, without imperti- 
nent inquisitiveness, and with tactful sympathy, can often make 
the rough path smooth, and help his brother officer to form a 
wise judgment. , 

The medical officer may also have social and professional du- 
ties in connection with civilians in the vicinity of his post. At a 
few special places his medical services are in much demand hy 
civilians and are paid for, wherefore these places are desired by 
army surgeons. If there are other physicians in the vicinity, and 
there are few places where there are not, they may think that 
the army surgeon's work should be confined to the limits of his 
post, and professional jealousy with a little mixture of the Code of 
Ethics, has in bygone years, caused trouble to the medical ofl&cer. 



THE TWENTIETH CENTURY MEDICAL OFFICER, 357 

On the other hand you will find that such jealousy is the 
exception and not the rule, and that if ydu sympathize with what 
interests your professional brethren, wherever you may be. you 
will receive cordial sympathy and aid from them. • You are 
"members of a world-wide guild, the oldest one, and the only 
one. ' ' The medical ofi&cer has thus a double comradeship, and 
this is one of the specially attractive features of his position. 

Your attendance at this Army Medical school will have other 
results besides increase of professional knowledge. You have 
become more or less acquainted with each other's personality, 
more than you could otherwise have done in many years, and I 
hope you have formed some friendships which will endure. 

Probably you will never all come together again in this life, 
after you have taken your different routes over the iron lines that 
bind this country to its Capital, but your paths will cross each 
other many times and in unforeseen places. At each crossing may 
your memory of your Washington experience aid in making the 
meeting a happy one. 

As members of a great profession, as officers of the nation, 
as citizens of a great country, as men possessing special knowl- 
edge and selected from many candidates, you are coming on the 
stage of action to share the burden and responsibility of the world's 
work, to bring fresh blood and energy into the organism, to 
maintain and add to the dignity and honor of your corps and of 
your country. Enter upon your heritage modestly, but confident- 
ly. Be strong and of good courage. *'Nosmoriturisalutamus.'* 



» ^ 



^\0 



? 



THE OPPORTUNITIES OF THE YOUNG MEDICAL 
OFFICER OF THE ARMY.* 

By the honorable ELIHU ROOT, LL.D , 

SECRETARY OF WAR OF THE UNITED STATES OF AMERICA. 

THE formula to be applied to these occasions requires the 
officer delivering the diplomas to say something. It also 
requires that what he says shall be brief. 

I am glad of the opportunity to say to you that I hope the 
address which has just been delivered, when it is printed, as it 
will be, will be preserved by each one of you, and that on the 
14th of April every year during your connection with the Army 
you will read that address through from beginning to end and 
revive in your minds the wisdom enforced by the charming- humor 
and sentiment with which Dr. Billings has favored you. 

I will add to what he has said my congratulations to you on 
coming into a Corps which can produce such men as he; which 
has already a standard which you have to live up to and by which 
you can measure your own growth or decadence in intellectual 
and moral status. 

About the only recognition that the Congress of the United 
States has given to the American Army for all the labors and 
struggles of the past five years is to be found in the signal honor 
conferred upon a member of the Medical Corps of the Army by 
the statute making Dr. Gorgas a Colonel as a recognition of his 
distinguished ser\ace. That same honor would have been con- 
ferred upon Dr. Reed had it not been for his untimely and la- 
mented death. 

It is due to the untiring effort and the trained intelligence of 
the Medical Corps, that the Army of the United States has the 
extraordinary distinction of having in Cuba saved more lives than 

♦Address upon conferring diplomas upon the graduating class of the 
Army Medical School at Washington, April 14, 1903. 

(358 



THE YOUNG MEDICAL OFFICER OF THE ARMY. 359 

it destroyed; so that the saving department of this great agent 
of destruction has overbalanced, — preponderated over the de- 
structive element, and made a life-saving rather than a life-de- 
stroying Army. 

I congratulate you upon your opportunities, — the opportu- 
nities of science secured to you by your position in the Army. I 
hope the opportunities are more to you than the rank and pay 
and allowances, — the opportunitj'^ to pursue your science, to de- 
velop yourselves, to accomplish something for mankind, for your 
country, for your profession, free from the restraints and diffi- 
culties that the necessity of bread and butter throws before al- 
most evety scientific man. 

The opportunities of the Medical Corps of the Army are 
constantly widening. The policy which is now being pursued of 
taking care of the larger Army in larger posts instead of scatter- 
ing it in small posts will greatly increase your opportunities for 
practice and, for research and for individual growth. The large 
posts where there will be the attrition among many men, associ- 
ation with your seniors and the opportunities that come from a 
great collection of men will take the place for you of those little 
one and two company posts in which the isolation and the lack 
of occupation and of opportunity led so many a promising young 
man to dwindle and dry up before he reached maturity. 

Congress is continually broadening in its treatment of every 
scientific branch of the Army. It takes time and campaigns of 
education to secure the adoption of measures and the grants of 
money necessary for great steps in advance, but that kind of 
campaign is going on all the time, and I look with great confi- 
dence to see at an early date complete success following the ef- 
forts of your Chief, the Surgeon General, to secure ample endow- 
ments for a greater Army Medical School and more complete 
hospital facilities for the members of your Corps in the city of 
Washington. 

So you are entering a Corps which is ennobled by past achieve- 
ments and which has before it constantly broadening opportuni- 
ties for good, opportunities to do great things for mankind and to 
make a mark in tne history of j'our profession and history of the 



360 THE HONORABLE ELIHU ROOT, LL.D. 

Army. I congratulate you upon it. I hope that you will never 
allow the desire to be military men purely, — the desire to be sol- 
diers as distinct from doctors overcome you. I would rather 
hear a surgeon called a ''surgeon in charge of a hospital" than the 
* 'commanding officer of a hospital. ' * I believe I have sometimes ob- 
served a tendency to sink the "Doctor" in the "Captain" or the 
"Colonel." I think that this is doing injustice to a noble pro- 
fession, and that you will not become officers rather than re- 
remain doctors. You cannot climb any higher up in rank or in 
title than you are when you stand on the pedestal of the profes- 
sion to which you gave your first loyalty, your first adherence. 
But as members of two noble professions, both of which have high 
standards of ethics and of ambition, you ought to have every ca- 
pacity which you possess developed to the highest point and to 
have through life the happiness which comes not from making 
fortunes, not from holding great offices or wielding power, but 
which comes from well-employed, well-rounded and useful lives, 
—the happiness which comes from accomplishing things, from 
achievement, from results and from individual growth and indi- 
vidual worth attained by individual effort. 

In the belief that you will do honor to this institution and to 
the Army of the United States, it is with greatest pleasure that 
I now hand you these diplomas. 




"THE IDEAL RELATION FOR THE MEDICAL 
DEPARTMENT OF AN ARMY.". 

By major WILLIAM O. OWEN, 

SURGEON IN THE UNITED STATES ARMY. 

THE relation held by the Medical Department of an army 
to that army, should be that all sanitary dangers should 
be dealt with by the general in command, with the same 
care and detail that he would give to the information received 
from his trusted scouts as to an ambuscade or other danger pre- 
pared by the enemy to receive him. . 

What is the truth? General officers trained in the line of the 
army, without a knowledge of sanitary laws beyond that possessed 
by ordinarily well educated gentlemen, but highly trained in a 
knowledge of all dangers from a military standpoint. They do 
not appreciate the dangers in an encampment from a sanitary 
standpoint. 

The price which England paid in lives and money for not en- 
forcing a proper legal responsibility upon her line officers in the 
Crimean war is most graphically told in McLeod's history of this 
campaign, with the road from the landing place to the firing line 
marked out by the dead bodies of animals and the camps polluted 
in every possible way, with regiments showing a loss of 209f , 
30% and some 75%, of their average strength and one showing a 
death loss of even greater than its average strength. It was in 
this war that a general told the inspector for the medical depart- 
ment that he had better keep his strictures and criticisms to him- 
self until they were called for. 

In the Civil war in the United States the Union army lost 
from typhoid fever, diarrhea and dysentery some 80,000 men, 
while there were reported more than 1,800,000 cases of these 
three diseases. In the Spanish American war a General officer 

361 



362 MAJOR WILLIAM O. OWEN. 

testified that the opinion of the Chief Surgeon of his command 
had not been borne out by the analysis of the water supply, yet 
his command lost by typhoid fever, 714 men and had 9960 men 
taken sick with this disease in about four months, and he also 
testified that he did not act on the advice offered him but that he 
had continues to set the example of drinking from a well which 
he had been informed had been polluted. He, under the present 
absence of all law was perfectly within his own rights when he 
continued to do so; the cost to the United States of his example 
is excellently shown by the death of 714 men and the disabling 
of over 20 out of every one hundred (100) of his command. 
What would have been done to a general who had deliberately 
led his men into an ambuscade, of which his scouts had many 
times told him the exact location, and had lost 714 killed and had 
9960 wounded out of 44,000? All the world knows! Yet when 
a description of his camp which had been written by the sanitary 
inspector of the camp, was read tohini by the Dodge Commission, 
he requested that he be given a copy of the report in order that 
he might in his capacity as a General officer bring the young man 
to a trial before a General Court Martial for having dared to 
write such a report. He was informed that the report was on 
file in the Adjutant General's office. 

It has not been a century since a medical officer of the army 
of the United States was brought to trial before a Court Martial, 
(composed entirely of line officers,) and sentenced to dismissal from 
the army for malpractice of his profession, without the testimony 
of a medical man being given, if I read the books correctly. 
When the Army of the United States embarked from Mexico for 
the United States careful advice was given of how to avoid the 
yellow fever; to this advice no attention was paid — the penalty for 
failure to observe it was however in the loss of life from this dis- 
ease. No later than March 1902 I was informed by a medical of- 
ficer of the army that less than two years since he had given advice 
to a general officer that unless he housed his men in temporary 
quarters, it would result in loss of life and disability from pneu- 
monias, colds, etc. The answer he received was that his men would 
remain in tents as he had placed them, and that furthermore that 



RELA TIONFOR MEDICAL DEPARTMENT OFANARMY^ 363 

when his advice was wanted he would be sent for and told to offer 
it; until then he could keep it to himself. With such conditions 
as this staring us in the face, it does indeed seem time that steps 
were taken, looking to the correction of these evilsso plainly evident 
from a perusal of McLeod's History of the Crimean war, from * 
the proceedings of the Chelsea Board on the same war, and when 
the published records of the Surgeon GeneraPs office are consid- 
ered, such as the Medical and Surgical History of the War of the 
Rebellion, the report of Reed Vaughan, and Shakespeare upon the 
* * origin and spread of typhoid fever in the military camps of the 
assembly within the United States in 1898" together with the re- 
port of the commission appointed by the President to investigate 
the conduct of the War Department in the war with Spain, and 
the eight volumes of the testimony taken before it. 

THE REMEDY. 
The remedy for these conditions lies within the Medical De- 
partment of the Army itself. It is for them to comply with the 
executive orders and organize themselves and act through the 
Surgeon General, the constituted head of the Corps, he in his 
turn through the Secretary of War, the head of the Department. 
Show the Secretary of War the great loss of life, the number of men 
disabled by diseases; show to him that the greater part of these 
losses are from preventable disease, that proper sanitary care 
would result in a very large decrease from these diseases. Let 
him see that these disease losses have not been the fault of the 
medical men with the troops, but that they gave the advice which 
the generals refused to heed; that these losses do not occur on the 
active campaign but that they occur in the camps of assembly, 
Instruction, or of wintering at times when there is no other enemy 
to be feared than disease. Let him once understand that there is a 
definite chain of responsibility for diseases arising in camps an^ 
the losses resultiug therefrom, with the responsibility fixed by 
Statute Law and not by regulation — for with regulations the gen- 
eral in command is the executive, and there is no legal means to 
reach him for he only follows that which in his personal 
judgment is the best and proper course to follow; to under- 
take to control his action when he is about to meet an enemy, is 



364 MAJOR WILLIAM O, OWEN, 

to court disaster, equally so is it to allow him to pay no attention 
to the information given him by his sanitary scouts of dangers 
lurking along his road. In truth it is a matter of almost univer- 
sal knowledge that disease has in wars always killed and injured 
' more men than ever did the offensive weapons of the enemy 
called *'man." 

Show to the Congress that such a law would result ill the 
saving to a great extent, of money and lives, and that with the 
number of men thus placed on the firing line, the result on the 
moral and physical force of those on it will be better, — and you 
will at least receive a respectful hearing; for you are trying to 
accomplish a public good and not a personal advantage. 

Let the organization insist upon a law that will enforce upon 
the commander a direct legal personal responsibility for his re- 
fusal to allow proper sanitary precaution to be taken, leaving him 
always the absolute right to refuse all sanitary suggestion when- 
ever there is in his judgment a military necessity requiring it, 
and allow him to be the sole judge of when and under what con- 
dition it should be done, — hold him to a legal responsibility 
that his results are good ones, but do not leave him such a 
latitude as will allow him to go unpunished when he deliberately 
sets at defiance all the rules recognized the world over by sani- 
tarians, or when he by his deliberate personal example en- 
courages his men to violate them, allowing his men to .drink 
water which he has been advised is polluted, — he may be immune 
from the disease, it is certain some of his men will not be. 

As far as I have been able to obtain the history of the Boer 
war in South Africa and the camps of assembly and instruction 
in the U.S. in 1898, — they^re excellent examples of the result to 
flow from this lack of legal responsibility before the statute law 
of the land. Give the general in command the proper medical 
advisers and compel him to take the responsibility before the law. 
He will then have to stop and think of the cost of human life. 
Leave him always free in the face of the enemy with one 
thought alone, * 'What is the best way to defeat the purpose of the 
enemy of the country?" But in camps of assembly and instruc- 
tion he should have this added responsibility. Do this, and no 



RELATIONS OF MEDICAL DEPARTMENT OF AN ARMY. 365 

general will for a moment hesitate to insist upon the most abso- 
lute fulfillment of the rules of sanitation by the medical officers 
under his orders, nor on the other hand will he hesitate for a 
moment, when in his judgment it is necessary, to throw all san- 
itar>' precautions to the wind, for it is far better to lose 100 men 
to disease than to the battle for fear of results to flow from un- 
sanitary condition. He should then simply direct his medical 
officers to take such precautions as they may, under conditions 
over which he has no control. 

A search of the Statutes of the United States shows a 
very curious state of affairs, for of all the various laws passed by 
the Congress concerning the Medical Department of the United 
States Army almost all without exception show pay. rank, etc., 
but in no place do they in any way even indirectly tell what 
the law expects of this scientific body of men as duties, with two 
exceptions, one of which provides that they shall give medical at- 
tention to the families of the officers and enlisted men free of 
charge, and the other provides that the Secretary of War may 
assign its officers to such duties as he may deem for the best in- 
terests of the service. 




i^« ^ 



•W 



MAJOR OPERATIONS AT THE UNITED vSTATES NAVAL 
HOSPITAL IN BROOKLYN, N. Y., DURING 1901. 

By GEORGE ROTHGANGER, M.D., 

SURGEON IN THE UNITED STATES NAVY. 

PRIMARY union was secured in all cases not already in- 
fected with one exception. The infection in the one ex- 
ception must have been due to a ligature for it exploded 
on the sixth day after the operation. In the buried sutures cat- 
gut, plain or chromicized, was used. The subcuticular stitch was 
adopted in uniting the skin, and gave most satisfactory results. 

AMPUTATION. 

An amputation of the thigh at its middle was made for tu- 
berculous disease of the lower end of the femur. As there were 
fistulous openings on the outer and posterior surfaces of the 
thigh, a long antero-intemal flap was used, in order to make the 
amputation as low as possible. The resulting stump was a good 
one. 

APPENDECTOMIES. 

Two patients were operated on during the attack.* The 
others were interval cases. Each patient had a history of at 
least one previous attack. Except in one case of gangrenous ap- 
pendicitis the abdomen was opened by the intra-muscular method. 
In treating the stump the following method was used. A cuff of 
peritoneum was reflected from the appendix. A ligature of plain 
catgut was placed around the appendix at the highest point 
stripped of peritoneum and drawn upon gently. The appendix 
was divided, the stump cauterized by introducing the point of 
the cautery within the lumen and afterwards searing the surface. 
The ligature was then tightened, the reflected cuff of peritoneum 
drawn forward and stitched. Where no cuff could be reflected 
the ligature and cautery were found to be sufficient. 

(366) 



OPERA TIONS AT NAVAL HOSPITAL IN BROOK L VN 367 

Case I. Operated on during the attack. Cuff of peritoneum 
to cover the stump. Catarrhal type of disease. 

Case 2. Interval case. Cuff of peritoneum. The luijen of 
the appendix was obliterated and the distal portion distended 
with fluid. 

Case J. Interval operation. Cuff of peritoneum. The ap- 
pendix was obliterated near the tip and the distal extremity dis- 
tended with fecal matter. 

Case 4. Inter\'al operation. Mesentery very short, making 
the removal of the appendix difficult. Catarrhal type of disease. 

Case J. Interval operation. No lumen present for more 
than an inch from the caecum, to which the appendix was ad- 
herent. 

C^se 6. Interval operation. Stump covered with cuff,. 
Catarrhal type of disease. 

Case 7. Interval. The appendix was closely adherent to 
the iliac fo.ssa. No cuff of peritoneum could be formed. The 
pocket left by the removal of the appendix was closed by stitch- 
ing the free margin of the peritoneum to the mesocaecum. The 
appendix was found to be closed by stricture. Pus was in the 
lumen beyond the stricture. 

Case 8, Interval case. The appendix was 6 inches long, 
with a short mesentery, making its removal difficult. Peritoneal 
cuff. Catarrhal type of disease. 

Case 9. Patient was admitted with peritonitis present. Ab- 
domen opened by a long incision parallel to the outer margin of 
the rectus muscle. Pus escaped. The appendix had sloughed. 
No attempt was made to di.sturb the bowels. The pus was washed 
away, with peroxide and saline. Gauze drains were introduced 
and several wire sutures were inserted to prevent too wide gap- 
ing of the incision. He died seven days after the operation. 

Case 10. Interval case. The appendix was adherent to the 
caecum, coiled and twisted upon itself, and much thickened. Cuff 
of peritoneum reflected. 

Case II, Interval case. Appendix very adherent to the 
outer wall. In freeing it a small perforation close to the tip wa.s 
found. Through this a drop of pus escaped. Drainage with a 
strip of gauze. Wire sutures were inserted and were tightened 
two days later when the gauze was withdrawn. 

Case 12. Interval case. No cuff could be formed. Appen- 
dix was short, much thickened and adherent to the caecum. 

Case ij. Interval case. The mesocaecum was so short that 
the appendix could not be brought out through the incision. The 
termination of the appendix in the csefcum was conical, expand- 
ing to three quarters of an inch in diameter. 



368 SURGEON GEORGE ROTHG ANGER, U.S.N 

BRONCHOCELE. 

Case I. The right thyroid body was removed by an incision 
along 'the anterior border of the stemomastoid. It was the seat 
of a cyst filled with hemorrhagic fluid and of the size of a duck's 
egg. 

Case 2. The enlargement afiFected the whole gland. The 
right body was much the larger, and it and part of the isthmus 
were removed. It was in size equal to a fist and was closely ad- 
herent to the thyroid and cricoid cartilages and the surrounding 
connective tissue planes. The veins which emerged were nu- 
merous and large. The thyroidea ima were two in number, the 
larger having the diameter of a little finger, and the smaller that 
of a lead pencil. The hemorrhage was profuse. A middle thy- 
roid vein was torn at its union with the internal jugular. Mi- 
croscopic examination by Dr. E. H. Wilson showed an area car- 
cinomatous in appearance. The patient's age was only nineteen. 

CYSTOTOMY. 

The patient gave a history of gradually increasing vesical ir- 
ritability, pain and hematuria. With vesical distension and rec- 
tal colpeurynter the bladder was easily opened in the median line 
above the pubes. In the base of the viscus an irregular shaped 
ulcer was found, extending close to the opening of the right 
. ureter. The ulcer was scraped thoroughly. The local symp- 
toms improved much, but after some months the patient died of 
general tuberculosis, symptoms of which were present at the time 
of the operation. 

FEMORAL ANEURISM. 

The patient, a small Japanese, had an aneurism as large as 
an orange on the right thigh, extending a little above Poupart's 
ligament. The Cooper incision was used to uncover the external 
iliac which was tied with chromicised catgut one and one-half 
inches from Poupart's ligament. Pulsation in the tumor ceased 
immediately but reappeared very faintly within a minute. With- 
in 24 hours pulsation was reestablished in the posterior tibial. 
Examination one week later showed complete absence of pulsa- 
tion in the aneurism which had become firm. As the patient was 
unruly a plaster of Paris bandage about the extremity and pelvis 
was used to secure immobility. Three months after the opera- 



OPERA TIONS AT NAVAL HOSPITAL IN BROOK L YN 369 

tion the patient was discharged to duty. The tumor had shrunk 
so that it could not be seen, and could be felt only on careful pal- 
pation. The pulsation in the posterior tibial on the side of the 
ligature continued to be much feebler than on the sound side. 

HERNIAS. 

Sixteen inguinal hernias, one femoral and one ventral her- 
nia were operated on. In the inguinal cases the method of 
Bassini was used as described by that operator in his paper in the 
Archiv fur Klinische Chirurgie, In continuance of a plan begun 
the preceding year the suture material uniting the conjoined ten- 
don, etc., to Poupart's ligament was silver wire in the first three 
cases. In the remaining cases I returned to thick chromicized 
catgut. The usual number of sutures needed to effect this union 
was four. Occasionally five were required. The incision in the 
external oblique was united with a continuous fine chromicised 
catgut suture and the skin with the subcuticular stitch. Most of 
our cases were received within a few months after the production 
of the hernia, and therefore small. The peculiarities in each are 
as follows: 

Case I. A small left indirect inguinal hernia which was 
easily reducible. 

Case 2, A right indirect inguinal hernia was diagnosed. A 
sac was found in the cord, not communicating with the peritoneal 
cavity nor with the tunica. 

Case j. Right indirect inguinal, easily reducible. 

Case 4, A small right indirect, with a sac of moderate size. 

Case 5. Right indirect. Sac large. Four sutures between 
the internal ring and the pubes. As the region immediately ex- 
ternal to the deep ring appeared to be weak a fifth suture was in- 
serted there. 

Case 6. Left indirect inguinal. Sac long with a very nar- 
row neck. 

Case 7. Right indirect inguinal. Sac was of moderate size 
and contained a long string of adherent omentum which was dis- 
sected loose and removed. 

Case 8, Right indirect inguinal. Large sac which was very 
adherent and contained adherent small bowel. The bowel was 
freed from the sac. 

Case g. Right indirect inguinal, reducible with sac of mod- 
erate size. 



370 SURGEON GEORGE ROTHG ANGER, U.S.N 

Case lo. lycft indirect inguinal, associated with unde- 
scended testis. The sac was large. The testis was not fully de- 
veloped, could riot be brought down into the scrotum, and was 
therefore removed. 

Case II. Left indirect inguinal. The sac was so small that 
it was not considered necessary to remove it. 

Case 12. Right indirect inguinal. Patient had been oper- 
ated upon in 1891 according to McBumey's method. The ad- 
hesions of external oblique, conjoined tendon and peritoneum 
were separated. The sac was found at the internal ring and was 
ligated. The conjoined tendon was stitched as in the Bassini op- 
eration with five sutures, one of which was external to the inner 
ring. Only the outer portion of the external oblique covering of 
the cord could be brought together with sutures as the aponeuro- 
sis which constituted the inner portion of the upper margin of the 
incision had been destroyed by the former operation. 

Case ij. Right indirect inguinal. Small sac. 

Case i^. Right indirect inguinal. Sac long and narrow 
with a very narrow neck. Four sutures, one of which was placed 
at the outer margin of the internal ring. 

Case IJ), Femoral Hernia on the left side, partly reducible. 
Sac covered with a thick deposit of fat. It was freed from the 
surrounding tissues up into the femoral ring. It contained adhe- 
rent omentum which was dissected loose and cut off. The stump 
of the sac was pushed into the ring and stitched to the external 
oblique. 

Case i6. Ventral Hernia. A small hernia in the median 
line, mid way between the umbilicus and the xiphoid cartilage. 
The opening in the linea alba was enlarged above and below, the 
omentum had protruded through a tear in the peritoneum so that 
there was no sac. The incision in the linea alba was united with 
chromicized catgut sutures, that in the skin with silkworm gut. 

KNEE JOINT. 

Floating Cartilage. Two operations were performed for 
floating cartilage. In the first case two bodies were removed 
from the joint which was opened by the U incision. In the sec- 
ond case an incision was made along the inner border of the pa- 
tella where the body could be felt. The cartilage was found to 
fast by one extremity to the head of the tibia, and was cut off 
close to that bone. 

Dislocated Semilunar Cartilage. In a case where repeated 
dislocation of the left internal semilunar cartilage occurred that 



OPERA TIONS A T A A VAL HOSPITAL IN BROOK L YN. 371 

structure was anchored by passing three chromicized catgut su- 
tures through it and the fibrous tissue close to the head of the 
tibia. 

Fracture of the Patella. This case had been treated with 
conservative measures. When the patient attempted to walk the 
fragments pulled apart. A straight incision was made over the 
line of fracture. The newly formed fibrous tissue between the two 
fragments was dissected away, and the fragments united with two 
silver wire sutures. A good result was secured. 

WIRING OF RADIUS. 

Patient had received a fracture in the lower third of the left 
radius, which had united in bad position. There was three quar- 
ters of an inch shortening. The lower fragment was deflected in- 
ward and pushed toward the anterior surface of the forearm. The 
lower end of the upper fragment was thrust inward. An incision 
was made on the radical side of the forearm. Nerv'^es, vessels 
and tendons were pushed aside. The bone was sawed through. 
The deformity was corrected with difficulty. It was necessary to 
remove a small part of the upper fragment. The fragments were 
wired. Primary union was secured. The deformity was in great 
part corrected, and the function ofthe member excellent notwith- 
standing the great disturbance of tendons and muscles necessary 
to correct the deformity. 




THE EDUCATION OF THE MEDICAL OFFICER OF 

THE ARMY. 

Bv MAJOR WILLIAM C. BORDEN, 

SURGEON IN THE UNITED STATES ARMY ; PROFESSOR OF MILITARY 
SURGERY IN THE UNITED STATES ARMY MEDICAL SCHOOL. 

WHEN a man trained for the profession of medicine en- 
ters the Medical Department of the Army as a medi- 
cal officer, new responsibilities and duties of a highly 
technical character devolve upon him. Many of these duties, 
while Strictly connected with the responsibilities which he has to 
assume in relation to the care of the sick and wounded and the 
maintenance of the health of the army, are, at the same time, 
entirely unlike in character to the duties for which the civil prac- 
titioner of medicine is trained. In civil life, the practitioner of 
medicine has mainly to do with the practice of his profession in 
what might be considered its purely professional aspects. He 
visits the sick, prescribes for them, operates upon surgical cases 
and ordinarily has at his command all the facilities of hospitals 
which are often administered by others than himself. 

In the military service his duties are radically different. The 
medical officer of the army has not only to care for the sick and 
wounded, but he has to do all of the administrative duties which 
are connected not only with the profession of medicine but with 
the personal care of the men under his charge. The sick not 
only have to be cared for, but they have to be sheltered, fed, 
clothed and, in many instances, their pay has to be attended to. 

For the nursing of the sick and wounded the United States 
Army is provided with a Hospital Corps, composed of enlisted 
men. In most instances these men are untrained for the duties 
of nurses when they enter the service and the medical officer has 
to train these men for these duties. Throughout their service 
they stand in the same relation to him that enlisted men of the 
line do to line officers. In other words, it is the function of the 

- (»72) 



EDUCA TION OF THE MEDICAL OFFICER. 373 

medical officer to attend to matters of discipline, and to see that the 
members of the Hospital Corps are properly .sheltered, clothed 
and paid. Not only have the sick and the members of the Hos- 
pital Corps to be provided for, but all the necessary medicines, 
dressings, surgical appliances, &c., have to be obtained by the 
medical officer in order to meet the requirements of the sick. 

In considering these manifold duties of the medical officer, 
it must be remembered that the Medical Department of an Army 
has for its end apd aim, two objects : 

1. To care for the sick and wounded; 

2. To maintain the health of the army. • 

In other words, the medical officer must not only care for 
the sick and injured but must do ever>'thing in his power to pre- 
vent them from becoming sick, for the efficiency of the army de- 
pends not upon its strength in numbers alone, but upon the num- 
ber of men who are well and able to fight when the exigencies of 
the service demand. The medical officer has, therefore, in ad- 
dition to his other duties, to assume sanitary duties and must be 
the health officer and sanitary advisor of the line officer under 
whose command he serves. 

In view of these facts it becomes a self-evident proposition 
that unless a Doctor of Medicine has supplemented his training 
for the profession of medicine and surgery by studying the duties 
of a medical officer he will be unable to properly and efficiently 
perform these duties when he first enters the service and if he 
does not receive adequate training before or at the time of his en- 
trance into the service, it will be only by costly experience, often 
to the discredit of himself and the service and of incalculable in- 
jury to the army, that such training is obtained. 

In the United States the military ser\nce presents certain 
peculiar features. The standing army is small and, upon the 
outbreak of war, is only sufficiently large to form the nucleus of 
the fighting force. The United States has in the past and will in 
the future depend largely upon volunteer troops, drawn from the 
country generally and, in most instances, most largely from the 
militia of the several states. This being the case the National 
Guard should be fully organized and equipped to meet the 
emergencies of war. As the regular army forms the nucleus 
of the fighting force and as its officers are men who de- 



,^74 MAJOR WILLIAM C. BORDEN. 

vote their lives to the profession of arms, it is their aim to so per- 
fect the organization of the Regular Army that it can both in or- 
ganization and equipment meet the demands of war when they 
arise. As the volunteer forces must assimilate with and conform 
to the methods adopted by the regular service, it is evident that 
the National Guard should be organized and equipped on the 
same lines as is the Regular Army, so that the two forces can 
combine and work in unison when called into actual hostili- 
ties. To this end the last Congress passed an act to promote 
the efficiency of the militia, which states that "the organization, 
armament, and discipline of the organized militia in the 
several states and territories and in the District of Columbia shall 
be the same as that which is now or may hereafter be prescribed 
for the Regular and Volunteer Armies of the United States, 
within five years from the date of the approval of this Act. * ' 

This enactment covers all the departments of the militia in 
the different states and, of course, includes the Medical Depart- 
ment of the National Guard. In connection with this reorgani- 
zation of the militia the education of officers of the Regular Army 
and of the National Guard has in the same act received attention. 
The act provides; '*That whenever any officer of the organized 
militia shall, upon recommendation of the governor of any State, 
Territory, or general commanding the District of Columbia, and 
when authorized by the President, attend and pursue a regular 
course of study at any military school or college of the United 
States such officer shall receive from the annual appropriation for 
the support of the Army the same travel allowances, and quar- 
ters, or commutation of quarters, to which an officer of the Reg- 
ular Army would be entitled if attending such school or college 
under orders from proper military authority, and shall also re- 
ceive commutation of subsi.stence at the rate of one dollar per day 
while in actual attendance upon the course of instruction." 

There are now in the Ignited States, five service schools to 
which the paragraph of the act just quoted applies. These are: 

The Artillery School at Fort Monroe, Virginia. 

The Engineer School of Application, Washington Barracks, 
District of Columbia. 

The School of Submarine Defense, Fort Totten, New York. 

The School of Application for Cavalry and Field Artiller>' at 
Fort Riley, Kansas. 



EDUCATION OF THE MEDICAL OFFICER. 375 

The Army Medical School, Washington, District of Colum- 
bia. 

Up to the present time these schools have been used exclu- 
sively for the instructing of officers of the Regular Army, but 
under the provisions of the act above referred to, these schools 
are opened to selected officers of the National Guard. 

The Army Medical School, with which we are particularly 
concerned, was established in 1893, and since then has had an- 
nual sessions, with the exception of a four years interval, begin- 
ning with the War with Spain. This school is carried on in the 
Army Medical Museum Building in the City of Washington. In 
this school didactic lectures are given in military surgery, medi- 
cine, the duties of medical officers, military hygiene, tropical dis- 
eases, parasitic diseases, military law, etc. Laboratory instruc- 
tion is given in clinical microscopy, bacteriology and sanitary 
chemistry. A course in operative surgery is given upon the 
cadaver and in clinical surgery at the Army General Hospital, 
and the students are also instructed in litter drill and first aid, the 
Company of Instruction, Hospital Corps, which is connected with 
the Army General Hospital, being utilized for this purpose. The 
value, of army medical schools has been recognized by all civi- 
lized nations. Such schools are being carried on in France, Ger- 
many, England, Russia, Turkey, Switzerland, Greece, Mexico 
and Japan. In some of these schools the students are composed 
of graduate medical officers. The officers who attend these schools 
graduate in medicine at regular medical schools and receive 
their military medical education as a post graduate course at 
the army medical schools In some countries, namely, France, 
Germany, Russia, Turkey and Mexico, the entire training, both 
in medicine and the duties of medical officers, is given in gov- 
ernment schools. Of the two methods, that of graduation from 
a regular medical college and post graduate instruction in military 
medicine, surgery and administration at an army medical school, 
is in my opinion the most practical in the United States. This is 
the method adopted in England and the United States. The 
Britisn Army Medical School is directly under the control of the 
Secretary for War and is located at the Royal Victoria Hospital, 
Netley. All the medical service schools have hospital facilities 
and such facilities are necessary for training medical officers in 



376 MAJOR WILUAM C. BORDEN. 

hospital administration, military surgery, hospital corps drill and . 
allied subjects. 

During the War with Spain a general hospital was estab- 
lished in the City of Washington, the post hospital' at Washing- 
ton Barracks being utilized for the purpose. A company of in- 
struction of the Hospital Corps was attached to this hospital. 
This company of instruction subserves two purposes: to train 
Hospital Corps men and to instruct the medical officers at the 
Army Medical School in Hospital Corps Drill, the establishment 
of field hospitals and administrative work. At the company of 
instruction a regular curriculum of lectures, recitations and drill 
is carried out. To show the work done at this company of in- 
struction, it may be stated that for the four years ending June 
30th, 1902, 2449 enlisted men passed through the company and 
received the training which would fit them for their future du- 
ties in the Hospital Corps. The value of such a company of in- 
struction in connection with an army medical school cannot be 
overestimated; indeed, it is essential that such a compan}' should 
be available for the instruction of the student medical officers in 
the duties which would devolve upon them in the field and w^hich 
can only be practically shown by the work of a company of instruc- 
tion. The value of having a general hospital available for teach- 
ing in connection with the school is equally great. In .such hos- 
pitals the medical officers can be instructed in the methods of ad- 
ministering military hospitals and can be given practical training 
in hospital methods as adapted to the military service, while val- 
uable clinical instruction can be given in the medical and surgical 
diseases which are most commonly met with in military practice. 
In this connection, it may be .stated that for the four years end- 
ing June 30th, 1902, 3596 cases were treated at the Army Gen- 
eral Hospital in Washington, and this number could have been 
much increased had the capacity of the hospital been greater. 

With this general survey of the field, the conditions as 
they obtain at present may be seen. We now have an army 
medical school in the city of W^ashington and have connected 
with it a general hospital and a company of instruction. At the 
present time, only approved candidates for the medical depart- 
ments are given instruction in this school and it is desirable that 



EDUCA TION OF THE MEDICAL OFFICER. 377 

the school and the facilities of the school be sufficiently enlarged 
to admit of carrying out the provisions of the act of Congress 
above referred to, so that not only medical officers of the regular 
establishment, but officers of the National Guard may be in- 
structed at this school. It is believed that great benefit would 
be derived from so extending the scope of the institution, for 
not only would the student officers both of the regular and state 
ser\'ices be instructed in the technical duties of medical officers, 
but by association of the medical officers of the Regular Army 
and National Guard, the interests of the public service would be 
greatly furthered. 

One of the greatest benefits which has followed the organi- 
zation of the Association of Military Surgeons of the United 
States has been the mutual acquaintanceship and association to 
which it has given rise. If now the advantages of the army med- 
ical school, can be extended to include instruction of selected of- 
ficers of the National Guard and so disseminate knowledge of the 
methods of adifiinistration. organization and supply of the regu- 
lar medical department, it will follow that when the militia of 
the different states is called upon to act with the Regular Army 
it will be better able to conform to and carry out the methods by 
which the regular army works so furthering that preparedness 
for war without which military efficiency is impossible. 

At the last session of Congress an effort was made toward 
the beginning for an extension of the Army Medical School such 
as outlined above and it is the desire of the Secretary of War and 
the present Surgeon General of the Army, General O'Reilly, to 
establish in the city of Washington a large general hospital, to 
have connected with it a company of instruction aud to erect an 
' academic building of suitable size for the future and extended re- 
quirements of the Army Medical School. The establishment of 
such a complete institution where officers of the Medical Depart- 
ment of the Array and of the militia of the different states can be 
instructed together in the peculiar and highly technical duties re- 
quired of medical officers, would, it is believed, be a great step in 
advance and would be of inestimable value in preparing medical 
officers for the great responsibilities and duties which will surely 
be thrust upon them in time of war. 



THE INSTRUCTION OF THE HOSPITAL CORPS IN 
COMPANIES AND DETACHMENTS. 

By captain P^REDERICK P. REYNOLDS, 

MEDICAL DEPARTMENT, UNITED STATES ARMY. 

THU Hospital Corps 170W numbers 3000 men, being about 
5% of the minimum or present (peace) strength of the 
Army. It consists of sergeants first class, sergeants, 
corporals, privates first class, and privates, and in garrison is or- 
ganized into detachments and companies of instruttion. The al- 
lowance for post service in the United States is 3% of the troops 
and on foreign service 5 % . About 600 men are needed for duty 
at independent posts, arsenals, general hospitals, and with the 
transport service, and about 100 are in companies and detach- 
ments of instruction. (May 1st, 1903). 

The field organization at the front consists of regimental de- 
tachments and detachments with smaller line units, ambulance 
companies, and field hospital detachments. On the lines of com- 
munication and at the base detachments are provided for duty 
with advance and base medical supply depots, rest stations, sta- 
tionary and base hospitals, hospital trains, and hospital ships. 
F'or the categories at the front the allowance (according to recent 
Medical Department regulations) is about 3^^/( Hospital Corps 
for a brigade of infantry at war strength, together with a total of 
17 medical officers or 3.4 per 1000 troops of the line. This pro- 
portion of sanitary personnel is considerably below that provided 
for European armies, in which for service the front an average of 
4.S77r is allowed. 

It can readily be seen that as the field organization provides 
for about 3^% and that the present allowance for post service in 
the United States is but 3^/,, by taking every man the Medical 
Department is incapable of supplying the enlisted personnel of 
the field units, without considering the personnel required for 

<378) 



INSTRUCTION OF THE HOSPITAL CORPS. 379 

duty with stationary hospitals, supply depots, etc., at the base. 
It may, therefore, be stated that the Medical Department is un- 
prepared to furnish the quota of Hospital Corps for any consider- 
able body of troops which may take the field, and have the nec- 
essary number of men for garrison or home duty. 

As defined by Army Regulations the duties of the Medical 
Department are: (1) Sanitary Duties. The investigation of the 
sanitary condition of the Army and making recommendations in 
reference thereto. (2) The care of the sick and wounded of the 
Army (including their transportation), and the management and 
control of military hospitals. (3) Furnishing all medical and 
hospital supplies. (4) The recruiting, instruction, and control of 
the Hospital Corps and of the Army (female ) Nurse Corps. Un- 
der (4) come also the duties of maintaining discipline; of provid- 
ing clothing, equipment and rations; of "keeping the accounts of 
pay and clothing; and of preparing records, reports, and returns 
required by regulations and orders. 

The duties of the Hospital Corps relate almost entirely to the 
care of the sick and wounded. We may define these duties to be 
as follows: In garrison, — (1) The nursing of the sick and 
wounded; (2) cooking, including the preparation of sick diets; 
(3) dispensary work — the use and care of appliances and the 
compounding of prescriptions; (4) clerical work — keeping records 
and the preparation of reports and returns: (5) outside and in- 
side police; In the field, — (in addition to the duties in garrison) 
— (1) first aid to the wounded; (2) transportation of the sick and 
wounded; (3) care of animals, ambulance driving, and equita- 
tion, (4) the use and care of the articles of field hospital equip- 
ment including packing, unpacking, and pitching of field hos- 
pitals. 

The instruction of the Hospital Corps should be of a charac- 
ter to enable it intelligently to perform its duties, and a well in- 
structed detachment should not only be proficient in the work of 
the post hospital, but its members should be able to take the field 
in any capacity which the work of the Medical Department re- 
quires. 

The amount of instruction required to make a Hospital Corps 



380 CAPTAIN FREDERICK P. REYNOLDS. 

man competent in his duties is large and covers many subjects. 
The time necessary to complete is consequently considerable. 
After completion of instruction, drills and practical work are nec- 
essary to maintain efficiency. His duties require superior mental 
qualifications and the instruction demands pains-taking effort on 
the part of medical officers. 

The responsibility of medical officers for the discipline and 
instruction and consequent efficiency of the Hospital Corps is di- 
rect and positive and a proper understanding of this responsibil- 
ity is essential to our success in meeting the arduous work 
which devolves upon the Medical Department in time of war. As 
in the line, active service in the field requires familiarity with all 
duties and conditions liable to be encountered, and to meet these 
conditions and perform the duties are demanded the same great 
essentials — discipline and training. 

The regulations governing Hospital Corps instruction in the 
Army require that one hour's instruction be given daily, except 
Saturday and vSunday, in the duties of litter bearers and method.s 
of rendering first aid to the sick and wounded, and "in the vari- 
ous subjects pertaining to the sanitary soldier." These subjects 
being (besides the duties of litter bearers and of rendering first 
aid), nursing, materia medica and pharmacy, clerical work, and 
cooking. Considering the nature and amount of instruction to 
be given, it would seem that one hour a day, in addition to actual 
work in the hospital, is not excessive and that at least that 
amount of instruction should be given in all detachments. It is 
contemplated that a well instructed private of the Hospital Corps 
should have a thorough knowledge of all the duties which he may 
be required to perform in garrison and in the field. 

As it is evident that all recruits for the Hospital Corps have 
not the intelligence to profit by the instruction in every subject, 
nor have all the moral qualities required to satisfactorily perform 
the important duties of nurse, clerk, or dispensary attendant, the 
grading of privates has long been desired. By recent legislation, 
the Medical Department is now able to make a distinction be- 
tween those qualified for these higher duties and those who for 
any reason are not capable of performing duties requiring intelli- 



INSTRUCTION OF THE HOSPITAL CORPS. 381 

gence and special training. The former are now graded as pri- 
vates first class with paj- of $18 per month, and the latter as pri- 
vates with pay of $16 per month. This classification gives every 
prospect of enabling medical officers to place upon a rational basis 
the work of training Hospital Corps men in the duties which are 
required of them. The general effect of the law will be to place 
in the first class Hospital Corps privates of excellent character, 
whose service is honest and faithful, and who are proficient in 
any special qualification, as nursing, dispensary work, clerical 
work, cooking and diet cooking, carpentry, or laboratory work. 
It is not reasonable to suppose that the intention of the law is to 
qhalify a man in one branch of work and end the man's instruc- 
tion at that point: rather its object seems to be to provide that a 
first class private is a well instructed Hospital Corps man, capa- 
ble of performing any of his duties, and in addition, having 
special qualifications in^me lines in which he has shown marked 
aptitude and has had considerable experience 

Men in the grade of private should be instructed in all duties 
which they are capable of performing and to the limit of their in- 
telligence. 

From a consideration of the duties of the Hospital Corps we 
may now state the subjects to be included in the course of in- 
struction. These are as follows: For privates and first class pri- 
vates, — (1) Discipline and the duties of a soldier. (2) Bearer 
drill. (3) First aid. (4) Field work. (5) Care of animals. 
(6) Anatomy and physiology. (7) Cooking and diet cooking. 
(8) Nursing. (9) Materia medica and pharmacy. (10) Clerical 
work. For noncommissioned officers: (in addition to the above) 
(11) Elementary hygiene. (12) Minor surgery. (13) Army 
Regulations. (14) Mess management. Of these subjects, all 
members of the Hospital Corps should be proficient in the first 
five subjects, which are the essentials for field' service. 

Instruction is given in all detachments at military stations 
and in detachments and companies of instruction. There exist 
at present two companies of instruction, and regulations direct 
the establishment of a detachment of instruction in each military 
department **to provide an emergency reserve under the imme- 



382 CAPTAIA FREDERICK P. REYNOLDS. 

diate control of the department commander and the chief sur- 
geon.*' **The curriculum shall consist of theoretical and practi- 
cal courses prescribed by the Surgeon General." The personnel, 
organization, and administration of companies of instruction are 
now defined by regulations, but no curriculum has as yet been 
prescribed. 

Instruction in Companies. Under date of August 7, 
1891, the Surgeon General was authorized to station, for purposes 
of instruction, ten additional Hospital Corps privates at Fort 
Riley, at Fort D. A. Russell, and at Fort Keogh. In October 
of the same year it was decided that the detachment of instruc- 
tion at Fort Keogh be discontinued and that those at Forts 
Riley and D. A. Russell be increased to 30 men each and that 
they be designated as companies of instruction. Two years later 
the company at Fort D. A. Russell was given up and a new one 
organized at the post of Washington Barracks. On the recom- 
mendation of the Surgeon General, the company at Fort Riley 
was discontinued, July 22, 1896. 

A '*school of instruction" was established at Fort McDowell 
in September 1899, but was "considered as a receiving and dis- 
tributing depot rather than an educational institution.*' It was 
organized as Company of Instruction No. 2 by authority of the 
Secretary of War, dated November 8, 1902. 

A company of instruction was organized in Manila in Janu- 
ary, 1900, and was given a definite status by the commanding 
general in May 1900. After attaining **a high degree of pro- 
ficiency," it was disbanded August 13, 1901. 

The Work of a Company of Instruction. Company of In- 
struction Number One was organized by authority of the Secre- 
tary of War, dated August 16, 1893. Until the beginning of the 
Spanish- American war it consisted of about 25 men, under in- 
struction from 4 to 6 months. From May until December 1898, 
it acted as a casual camp where recruits were received, clothed 
and equipped, and sent to the front with practically no instruc- 
tion. From about September 1899 until July 1902, the period of 
instruction varied from a few weeks to five months and many men 
were transferred without instruction. Only for the past few 
months has it been possible to adhere to a fixed period of instruction. 



INSTRUCTION OF THE HOSPITAL CORPS. 383 

ORGANIZATION OF COMPANY OF INSTRUCTION NO. i, HOS- 
PITAL CORPS, U.S. ARMY, MARCH i, 1903. 

OFFICERS. 

Captain Frederick P. Reynolds, Assistant Surgeon, U.S. A. 
ist Lieutenant James R. Church, Assistant Surgeon, U.S.A. 
ist Lieutenant Frederick A. Dale, Assistant Surgeon, U.S.A. 
noncommissioned officers. 

I 1st Sergeant. i Quartermaster Sergeant. 

1 Mess Sergeant. i Company Clerk. 

1 Police and Stable Sergeant. 9 Instructors and Assistant Instructors. 

Total, 14 

PRIVATES on special DUTY. (PERMANENT CADRE). 

2 Cooks. 2 Kitchen Police. 

I Dining room attendant. i Property attendant. 

1 Ambulance driver. i Night Watchman. 

2 Clerks. 2 Musicians. 

I Artificer. 

Total, 13 

DUTIES OF OFFICERS. 

Company Commander. General Supervision. Company fund and mess. 
Instructor in first aid and field work. 

Lieutenant Church. Instructor in first aid and noncommissioned officers' 
class. Clothing and personal equipment of the company, and records 
elurns relating to. 

Lieutenant Dale. Instructor in anatomy and physiology, care of animals, 
and drill. Condition and completeness of company property, includ- 
ing field equipment. 

duties of NONCOMMISSIONED OFFICERS. 

First Sergeant, In general charge. 

Quartermaster Sergeant. In charge of field and Ho^ital Corps personal 
equipment, including medical, quartermaster and ordnance property. 

Mess Sergeant. In charge of the ration and mess, kitchen and mess hall 
Assistant instructor in mess management. 

Company Clerk. In charge of company office, records and papers. Assist- 
ant instructor in clerical work. 

Police and Stable Sergeant, In charge of stable, public animals, and trans- 
portation. Assistant instructor in care of animals. 

/ Assistant Instructor. In charge of class books, instruction rosters and 
other instruction records. In charge of indoor instruction and sec- 
tion rooms. Assistant instructor in first aid. 



384 CAPTAIN FREDERICK P. REYNOLDS, 

I Assistant Instructor. In charge of outside instruction, setting-up drill, 
bearer drill and field work. 

y Assistant Instructors, Outside instruction, 4; materia medica and phar- 
macy, i; anatomy and physiology, i; first aid and bandaging, i. 
COURSE OF INSTRUCTION. 

FIRST MONTH. 

Daily, except Saturday and Sunday. 
Anatomy and Physiology. Bandaging. 

Diet Cooking. Bearer Drill. 

Calisthenics and Company Drill. 

SKCOND MONTH. 

Nursing. First Aid, 

Care of Animals. Bearer Drill. 

Calisthenics and Company Drill. 

THIRD MONTH. 

First Aid. Nursing. 

Clerical Work. Materia Medica. 

Bearer Drill. Practical Field Work. Calisthenics and Company Drill. 

FOURTH MONTH. 

Clerical Work. Pharmacy. 

Materia Medica. Field Exercises. 

Calisthenics and Company Drill. 

SATURDAY. 

Inspection. Articles of War. Company Regulations. 

Complete outlines of the instruction to be given in each sub- 
ject have been prepared and printed and are used by instruc- 
tors and members of the classes. In accordance with paragraph 
49, Manual for the Medical Department, the discipline and in- 
terior economy of the company conform as nearly as possible to 
those of a company of infantry. Company routine is strictly ad- 
hered to. Recruits on joining are assigned to squads, equipped 
and clothed, and join the classes to at once take up the routine. 

The Personal Equipment is required to be kept complete 
and in order at all times. Each man is given an "equipment 
sheet," (see below) which shows of what articles his equipment 
consists and the regulations relating to damage, loss or sale. 

PERSONAL EQUIPMENT OF A PRIVATE OF THE HOSPITAL 
CORPS, IN COMPANY OF INSTRUCTION NO. i. 
I. Clothing List, Issued to the soldier by the Quartermaster on "Cloth- 
ng Schedule" and money value charged against the soldier's clothing allow- 



INSTRUCTION OF THE HOSPITAL CORPS, 



385 



ance. Clothing thus issued becomes the property of the soldier, but it must 
not be sold. Loss or damage of clothing by neglect is also a court martial 
offense under the 1.7th Article ol War. 



2 Blankets. 


I pr Leggins. 


I Waist Belt 


I Overcoat (in winter). 


2 Blouses. 


1 Poncho. 


I Forage cap. 


2 Blue shirts. 


2 Cap ornaments. 


3 Muslin Shirts. 


4 pr Hospital Corps insignia. 


3 Undershirts. 


I Canvas coat. 


I pr Black shoes. 


2 Summer coats (in summer). 


I pr Tan *shoes. 


I Field coat. 


6 pr Socks. 


6 Collars. 


I pr Suspenders. 


I Cravat. 


\ pr Canvas trousers. 


4 pr Drawers. 


I pr Field trousers. 


I Campaign hat. 


2 pr Summer trousers. 


I Hat cord. 


2 pr Blue trousers. 


2 pr Gloves, Berlin. 


2 pr Trouser stripes. 


2. Medical Department Property. 




I Hospital Corps Pouch. 


I Litter Sling. 


I Weeks' "Nursing." 


I Smart's "Handbook." 


1 Pilcher's "First Aid." 


1 Hospital Corps Drill Regulation.s, 


3. Ordnance Property. 




1 Canteen and strap. 


! Haversack and strap. 


r Waist belt and plate. 


I Meat can. 


I Tin cup. 


I Knife. 


I Fork. 


I Spoon. 


4. Quartermaster Property . 




1 Shelter tent half. 


2 Shelter tent poles. 


5 Shelter tent pins. 


I Barrack bag. 


4 Sheets. 


2 Pillow cases. 



1 Box locker. 

The articles supplied by the Medical, Ordnance, and Quartermaster's 
Departments do not become the property of the soldier but remain Govern- 
ment property. The soldier is held responsible for the proper use and care 
of these articles, and in case of loss or damage due to his own carelessness 
or neglect, he is required to pay for the loss or damage, and may also be 
tried by court martial. 

COMPANY ROUTINE. 
Company regulations and the Articles of War are read to the 
company once a month. Besides this, the chief of squads take 
up the military instruction of recruits by carefully explaining 



386 CAPTAIN FREDERICK P. REYNOLDS. 

company regulations and the duties of soldiers. During the first 
month two hours' instruction in the latter subject is given by a 
medical officer. A printed sheet is given each recruit and he is 
frequently questioned on the subjects covered until he thoroughly 
understands them. Th^s sheet in plain language explains the 
regulations and customs of the service to which all soldiers are 
required to conform. A synopsis is here given. 

INSTRUCTION TO RECRUITS. 

(i) Military Honors. •When the salute is to be rendered. When soldiers 
stand at attention, — indoors, out of doors. Honors to the Colors and to 
National Anthem. 

(2) Afilitary titles. Manner of addressing officers and noncommissioned 
officers. 

(3) Uniform. Civilian Clothing. 

(4) Manner of approaching a sentry or guard. 

(5) Military rank. How indicated. Grades. 

(6) Duties of an orderly, dismounted and mounted. Manner of receiv- 
ing and transmitting messages. Obedience to orders of officers and noncom- 
missioned officers. 

Company Regulations cover the following: 

Smoking. Boisterous behavior and indecent or profane language. 

Lights Talking or noise after tattoo. 

Inspection and check roll-call at taps. 

Use of civilian clothing. 

Uniforms authorized. 

Baths. Change of bed and personal linen. 

Care of hair. 

Intoxicating liquors. 

Leaving garrison. Passes. 

Respect to Colors during playing of National Anthem. 

Arrangement and care of equipment in barracks. Use of barracks bags 
and care of soiled clothing. 

Caution regarding .sale of clothing. 

Fire Regulations. 

"^ Noncommissioned Officer in Charge of Barracks will be detailed by 
roster from noncommissioned officers on duty with the company. He will go 
on duty at 9.15 A. M. and will be relieved by his succes.sor at the same time 
the following day. He will report to the commanding officer of the company 
when going on duty and when relieved. When on duty he will sleep in the 
guard room, and between the hours of 9.00 A. M. and 6.00 P. M. will be habit- 
ually in the guard room, except when attending to his duties as herein pre- 
scribed. 

His duties are as follows: 



INSTRUCTION OF THE HOSPITAL CORPS. 387 

**To lake the roll calls from noncommissioned officers in charge of squad 
rooms at the taps and reveille. 

"To receive reports from the watchman and noncommissioned officers in 
charge of squad rooms. 

"In case of fire to give the alarm and proceed as ordered in fire regula- 
tions. 

. "He will make an inspection of quarters at i i.oo p. m. reporting all ab- 
sentees of the company not on pass and see that all unauthorized lights are 
extinguished. 

"Members of the company returning between the hours of u.oo P.'M. 
and 6.00 A. M. will report to him. 

*'The watchman will be under his immediate orders and he will be re- 
sponsible for the efficient performance of the latter's duties." 

^^Th€ Duties of Noncommissioned Officers in Charge of Squad Rooms 
are as follows: 

"Responsible for the order and discipline and cleanliness of the quarters 
under their control; instruction of chiefs of squads; supervision of the work 
of room orderlies; prompt report of needed repairs; the publishing of orders 
pertaining to the company; the proper instruction of all men under their con- 
trol in the Articles of War and in company regulations; the assignment of 
men to squads; the provision of material necessary for the police of bar- 
racks; the arbitration of trivial differences between men; and the perform, 
ance of such other duties as are assigned to them." 

DUTIES OF CHIEF.S OF SQUADS. 

"The instruction of all members of their squads in their strictly military 
duties as laid down in "Instruction to Recruits." The enforcement of dis- 
cipline at all times and places. They will be responsible for the proper care 
of personal equipment, for the police around and under the bunks of mem- 
bers of their squads; for the packing of lockers and arrangement of cloth- 
ing and equipment; for the collection of, and preservation by the room or- 
derly of property belonging to men absent from the company; and for the 
proper appearances of all men leaving the quarters for any purpose." 

DUTIES OF ROOM ORDERLIES. 

"Room Orderlies will be responsible for the proper police of squad 
rooms, porches and surrounding grounds; of the closets, bathrooms, wash- 
rooms, stoves, and furnace rooms; for the extinguishing of lights as required 
by company regulations; for the heating and ventilation of the squad rooms; 
for the safety of property turned over to them by chiefs of squads; and for 
the filtering of drinking water. They will report needed repairs to the non- 
commissioned officer in charge; apply for necessary articles for policing: re- 
port delinquencies and irregularities of police or arrangement of equipment, 
and will remain in quarters during meal hours." 

DUTIES OF INDIVIDUALS. 

"The routine duties of the day will start as provided in paragraph 15, 



388 CAPTAIN FREDERICK P, REYNOLDS. 

company regulations. After beds are made down, each man will police 
around and under his bunk, sweeping the dirt into the aisles. Shoes must 
be polished, free from dirt at all times, and aligned under the foot of the 
bunks. Articles of equipment must be properly arranged above the head of 
each bunk. Lockers will be packed according to diagram on the bulletin 
board. Hair will be worn short, and should be cut at least once a month." 

DAILY SERVICE. (APRIL, I903). 

Reveille, first call 6.00 A. M. 

^ " a.ssembly 6.20 " 

Breakfast 6.25 " 

Police 6.45 " 

Recall 7.30 " 

Calisthenics 7.45 " 

Recall .8.15 " 

Drill Call ••• 8.15 " 

" " assembly 8.30 " 

Recall 9.30 " 

School Call 9.40 " 

Recall 10.40 " 

School Call 10.50 " 

Recall 11.50 " 

Dinner 12.00 M. 

Sick Call 12.30 P. M. 

School Call 12.45 " 

Recall 1.45 " 

School Call f .55 " 

Recall 2,55 " 

Drill Call 2.55 " 

" " assembly 3.05 " 

Recall 4.05 •* 

Supper 5.30 " 

Retreat, first call 6.00 " 

" assembly 6.15 " 

Tattoo 9.00 " 

Call to quarters 10.45 *' 

Taps 11.00 " 

RECORDS, REPORTS, AND RETURNS RELATING TO HOS- 
PITAL CORPS COMPANY OF INSTRUCTION NUMBER i. 

Dally: — Morning Report. 

Sick Report. 

Delinquency Report. (To company commander). 
Report of N.C.O. in charge of quarters. (To company com- 
mander). 



INSTRUCTION OF THE HOSPITAL CORPS. 389 

Weekly:— Report of Detachment of the Hospital Corps. (To the 

Surgeon General). 
Tri-Monthly: — Ration Returns. 
Monthly:— Pay Rolls. 

Examination of Recruits. 

Return of the Hospital Corps. 

Report of deposits. 

Personal Report of Medical Officers. (To Surgeon Gen- 
eral). 

Grade Average. (To company commander). 

Changes in Special Duty Details and Classes. (To com- 
pany commander). 

Schedule of Calls. 

Requisition for fuel, forage, and straw. (To the Quarter- 
master). 
Bi-Monthly:— Muster Rolls. 
Quarterly:— • Requisition for crockery, etc. (To the Quartermaster). 

Statement of charges on muster and pay rolls. 

Estimate for Clothing and Equipage. (To the Quarter- 
master). 
Semi-Annually: — Ordnance Returns. 
Annually: — Return of Medical Property. 

Occasionally: — Clothing Schedules. 

Detached Orders. 

Change of Status, Hospital Corps. 

Record of Summary Courts Martial. 

Charges and Specifications. 

Discharges and Final Statements. 

Certificates of Disability. 

Enlistment papers. 

Descriptive Lists. 

Efficiency Reports. 

Notification of Transfer of Property (Issued and received). 
Record Books: — Descriptive Book. 

Clothing Book. 

Letters sent. 

Letters. Received. 

Company Fund Book. 

Company Order Book. 

Special Qualification Book. 

Class Books and Instruction Records. 

Record of Delinquencies. 

Duty Roster. 

The company has the usual company equipment of quarter- 



390 CAPTAIN FREDERICK P. REYNOLDS 

master property. — bunks, mattresses, pillows, bed linen, etc. It 
also has the complete equipment (excepting transportation) for a 
field hospital, a regimental hospital, and an ambulance company. 
The Rations, Mess and Company Fund are managed as pre- 
scribed by regulations for companies of the line. A certain num- 
ber of noncommissioned officers and privates are on temporary- 
duty in the mess under instruction in cooking and mess manage- 

ijient. 

COMPANY INSTRUCTION. 

Instruction is given daily except Saturday and Sunday. 
There are three hours of inside instruction and two and one-half 
of outside work, including one-half hour of calisthenic exercises. 

Records of class work are kept and the daily work of each 
man is entered in the class books, the record being based on a 
scale of ten. Instructors turn in to the company ofiice the class 
standing at the end of each week, and at the end of the month 
the weekly marks are consolidated and the relative standing of 
all men under instruction is published. 

The experience of this company has been that classes should 
be limited to 20 men each. With larger classes the same results 
have not been obtained for the reason that instructors cannot 
handle more men and give the necessary time to individuals. The 
maximum number of privates under instruction in classes should, 
therefore, be fixed at 80 if the course is of four months, twenty 
graduate men being turned out each month. 

The rivalry of class standing has a beneficial effect on the 
men in stimulating ambition. It seldom becomes necessary to 
resort to punishment for neglect of duty in classes; with but few 
exceptions all men work earnestly and up to their capabilities. 
To those who qualify the opportunity to become first class pri- 
vates (with increased pay) is offered at the end of the course. 

I. Discipline, The necessity for willing and prompt obedi- 
ence to orders is at once impressed upon the recruit. It is the 
aim of the officers attached to maintain the same standard of dis- 
cipline as in the best companies of the line, and the methods 
of the line in imparting discipline are followed as far as practica- 
ble. Respect for Anny traditions and customs of the service is 
encouraged. 



INSTRUCTION OF THE HOSPITAL CORPS, 391 

In a report to the Surgeon General on this subject the fol- 
lowing aids were mentioned: **A most useful incentive to this 
end is to encourage in the men a feeling of pride in their corps; 
to guard its honor and reputation at all times, teaching them that 
the delinquencies of any one reflect on the organization and on 
each member of it, and consequently it is the duty of each man 
to aid in bringing offenders to justice. An esprit de corps thus 
established has caused privates to report their comrades for un- 
tidiness and boisterous conduct while on pass, for appearing in 
public places with disorderly women, etc. For the establishment 
of this feeling the influence of noncommissioned officers is most 
important and it is through it that the result is to be attained.** 

* 'The greater the individualitj' you give to the soldier him- 
self and to his company the moie he feels that his 

individual conduct is of importance. " 

"It is of course to be understood that a satisfactory state of 
discipline can only be imparted by inspiring the men*s respect 
and confidence in their officers, the result of conscientious and 
pains-taking interest in everything that concerns a soldier's wel- 
fare. In the Army the bestowal of praise is the greatest of all 
moral levers. A knowledge that the duty a soldier performs is 
observed by his officers, and that duty of any character conscien- 
tiously performed and meriting approval will receive it, has never 
failed to stimulate men in their efforts to accomplish the highest 
results. ' * 

''For minor breaches of discipline several methods of punish- 
ment have been in use in this company. For a first offense it has 
been customary to inflict no punishment but the man has been 
admonished and made to understand the position he has placed 
himself in, the danger he is taking of permanently injuring his 
record, etc. An appeal to a man's reason and sense of honor has 
seldom failed of good result. Confinement to quarters, denial of 
pass privileges, and extra (squad) drill have been the usual minor 
punishments. When summary court martial trials are necessary 
the sentence of confinement is avoided where there have been no 
previous convictions. ' ' 

The advantages of the company routine and the association 



392 CAPTAIN FREDERICK P, REYNOLDS, 

with intelligent, self-respecting and well disciplined men are great 
aids in rapidly imparting to recruits the spirit of military disci- 
pline. The recruit soon learns the meaning of discipline and 
what is expected of him. It is important that there be in a com- 
pany of instruction a considerable number of men of some service 
who are thoroughly trained in all Hospital Corps duties. These 
with the noncommissioned oflBcers constitute the backbone of the 
company. By their example they furnish an ever present object 
lesson to the recruit and by their pride in their organization con- 
tribute greatly to its esprit de corps and efi&ciency. 

II. The Course in Bearer Drill covers sixty hours, as fol- 
lows: 

12 School of the Soldier Infantry Drill Regulations. 

Par. 10 — 43. 
( The Detachment Hospital Corps Drill Regu- 

3 < latioDS. Par. 1 — 6. 
( Alignments Par. 7 

5 Marchings Par. 8 — 22. 

4 Turnings Par. 23 — 49. 

8 Litter Drill Par. 50— 92. 

5 The Loaded Litter Par. 93 — 1 26. 

3 Improvisation of Litters Par. 127 — 132. 

5 RemovingWounded without Litter Par. 133 — isO. 

5 The Ambulance Par. 151 — 164. 

8 Tent Drill and Packing Par. 173—187. 

1 Inspection and Muster Par. 165 — 172. 

To continue proficient after the course, it is believed that the 
recruit should have at least one hour's drill per week, which 
should be given as part of practical field exercises. 

Litter drill is frequently criticised, particularly by officers of 
the line and occasionally by medical officers. This criticism has 
never in my experience been accompanied by suggestions which 
would improve or remedy the conditioils criticised, and it has 
usually been based upon an imperfect knowledge of the objects of 
the drill or upon defective instruction or execution. Imperfectly 
trained men will fail in an emergency and bring discredit upon 
their organization, but this is no more to be considered a fair trial 
of the system than would be the demoralization and rout of a 
hastily organized and imperfectly drilled regiment of recruits. 

Our present drill is the result of the experience of civilized 
nations in transporting wounded in battle and embodies the best 
features of the systems in use in European armies. Its simplicity 



24 . 
Hours 



36 
Hours"* 



INSTRUCTION OF THE HOSPITAL CORPS. 393 

as compared with others, uotably that of the British army, is no- 
ticeable. It is always to be considered as a means to an end, and 
is of value only in so far as it provides rapid and safe transporta- 
tion of the disabled on the field of battle. The principle upon 
which it is based is that trained men will care for and transport 
wounded better than untrained men, and that this training can 
best be attained by systematic drill with the use of the equipment 
provided and under conditions simulating as nearly as possible 
those which exist during an engagement. 

III. Anatomy and Physiology, Instruction in anatomy and 
physiology is limited to one month, and comprises twenty hours 
of lectures and recitations. 

No attempt is made to consider the minutiae of anatomy or 
the details of physiological action, but each man who passes in 
this course has a sufficient groundwork to serve as a basis for sub- 
sequent study, and to enable him to understand the subjects 
which come later in his course of instruction. Technical terms 
are eliminated so far as is practicable, and the course is arranged 
for the comprehension of the dullest man. Particular stress is 
laid upon the circulatory system, and the accurate location of all 
of the most important blood-vessels. Each man locates the prin- 
ciple arteries in the living subject, and by practice learns the 
amount of force necessary to effect complete compression. 

The lectures are illustrated by means of a skeleton, a mani- 
kin, and large drawings. A portion of each hour is spent in an- 
swering questions on previous lectures and one day each week is 
devoted to review. 

The location and relations of the various organs are illus- 
trated by the manikin, and in addition, the men are taught to de- 
scribe these locations as accurately as their elementary knowl- 
edge of anatomy permits. 

It has been found that 80% of the me|i make a passing mdrk 
in this subject. At least 5% of the class is incapable of profiting 
by the course. 

The Instruction in Diet Cooking and Nursiii^ is given by 
Miss Elizabeth Stack, a trained nurse and dietist, who has been 
in charge of this work since 1898. 



394 CA P TA IN FREDERICK P- RE YNOLDS. 

IV. l^he Course in Viet Cookings aims to give the private of 
the Hospital Corps instruction in the preparation of the various 
articles of diet furnished for the use of the sick in military hospi- 
tals. Each man actually prepares the various diets and also re- 
ceives practical teaching in the care of kitchen utensils and of 
those contained in the field mess and food chests. Effort is made 
to give the man an understanding of the particular uses of differ- 
ent diets and also how to make use of the components of the field 
and garrison rations as food for the sick. With but few excep- 
tions all the men profit by the instruction and the majority are 
qualified to prepare the articles taken up in the course. It has 
been found that about 10% of those instructed become proficient 
and are capable of preparing and serving the usual hospital sick 
diets. A liking for cooking and work in the kitchen is not to be 
expected of the majority of men who enlist. Proficiency in this 
line also requires a considerable degree of intelligence. 

COURSE IN DIET COOKING. 

(I Months. 

1. On Foods: The five food principles. Use in care of sick. Hospital 

dietaries. 

2. Milk Diets: Sterilization and care of milk. Preparing milk in various 

forms; punch, junket, whey, koumyss. 

3. Liquid Diets: Meat juices, beef juice, beef tea, etc. Chicken broth, 

mutton broth. 

4. Liquid Diets: Cereals. Gruels, — barley, rice, arrow root, oatmeal, toast 

water, hard bread gruel. 

5. Fruit Juices: Lemonade, limeade, orangeade. 
Beverages: Tea, coffee, cocoa, chocolate. 

6. Eggs: Eggnog, sherry and egg, t^'g lemonade, egg broth, 

7. Practical review of milk and liquid diets. 

8. Gelatine: In combination with beef juice, wine, coffee. Fruit juices 

as jellies. 

9. Eggs: Poached, soft cooked, omelet, custards, — ^soft, baked. 

10. Bread: Toast, — milk, dry. 

Cereals: Porridges,!— oatmeal, farina, rice. 

11. Puddings: Bread, rice, tapioca. 

Fruits: Fresh and dried, stewed and baked. 

12. Beef: Broiled, scraped on toast, beef sandwiches. 

13. Serving of Food: Preparing tray, care of utensils, etc. 

14. Review of milk, liquid and semi-liquid diets prepared and served by 

class. 



INSTRUCTION OF THE HOSPITAL CORPS. 395 

15. Potatoes: Boiled, baked/mashed, creamed. 

16. The Field Ration: General instruction in preparation of field ration 

17. Contents of Field Food Chest. 

.0 t( (i (( (I it 

JQ 41 l( t( <t <i 

20. Review. 

V. Instruction in Nursing" covers two months. The class 
work is made as practical as possible. All members of the class 
make beds, take temperatures, make out charts, give baths, and 
prepare enemata, solutions, dressings, etc. Particular attention 
is given to instruction in the care of helpless and unconscious 
patients. 

COURSE IN NURSING AND WARD MANAGEMENT. — FIRST MONTH. 

1. The hospital ward: its contents, furniture, utensils, supplies, etc. Care 

of ward; 

2. Bedmaking. 

3. Admission of patient; care of effects. 

4. Observation of symptoms. 

5. Clinical thermometer. Temperature taking. 

6. Pulse and respiration. 

7. Charting and recording temperature, pulse and respiration. 

8. Baths, — bed, basin, foot. Cleansing bath. 

9. Preparation of simple enemata; instruction in the use of the various in- 

struments and care of same. 

10. Review. 

11. Use of disinfectants in general ward work. 

12. Medicines and their administration. 

13. Treatment of inflammation (simple cases). 

14. Preparation of patient for operation. 

15. Preparation of surgical bed. 

16. Asepsis and antisepsis. Sterilization. 

17. Mode of preparing simple dressings; cotton and gauze, sponges, wipes,etc. 

18. Simple dressings. Instruments, surgeon's table. 

19. Disposition of soiled dressings, infected bedding, patient's clothingi 

Necessity for disinfectants in care of above. 

20. Review. 

second month. . 

1. Daily routine of ward work, medical and surgical. 

2. Bed making for special cases,— surgical, medical, fracture. 

3. Bedside notes for special cases. 

4. Treatment for special cases. 

5. Special diet and feeding. 

6. Bathing in special cases. 



3 96 CAPTAIN FREDERICK P, RE YNOLDS. 

7. Enemata and medication in special cases. 

8. Nursing in typhoid fever. 

9. Use of disinfectants in special cases. 
ID. Review. 

1 1. Nursing a surgical patient following an operation. 

12. Treatment of inflammation in special cases. 

13. Nursing in contagious diseases. 

14. Nursing in convalescence. 

15. Ward emergencies. 

16. Dissolution; care of body, autopsy. 

17. Wardmaster's table: its contents, records, charts, requisition slips. 

18. Field furniture and bedding; setting up of field furniture. 

IQ i( ii if 11 t( II (I U II 

20. General review. 

VI. Care of Animals. — This course is entirely practical, and 
extends over a period of one month. 

CARE OF ANIMALS. 

1. Nomenclature of equipments; their uses; taking apart and putting to- 

gether; care and cleaning. Care of horse equipment in the field. 

2. Anatomy of the horse. 

3. Grooming, handling, feeding, watering, care after exercise. 

4. The halter and watering bridle. Blanket and surcingle. 

5. To mount and dismount wfthout saddle. Position of trooper mounted. 

6. Aids to horsemanship. The gaits of the horse. To walk, trot, and 

gallop without saddle. 

7. The curb bridle. The saddle and saddle blanket. To mount and dis- 

mount with saddle. The spur. 

8. To roll bed blanket, overcoat, and shelter half. To pack saddle. 

9. The ambulance. The army wagon and escort wagon. Wagon and 

ambulance harness. To harness horses and hitch to wagon or am- 
bulance. The picket line. 
10. To pack saddle. To load and unload cargoes. 

The men are first instructed in the nomenclature of the horse 
and of the mounted equipment, and are then shown how to put 
on properly the folded blanket and watering bridle. A considerable 
portion of the month is then devoted to the position of the troop- 
er mounted, with and without the saddle, and the various aids to 
horsemanship are carefully explained. A portion of each hour 
is given to the mounted exercises, which seem to allay the fear 
many recruits show for the horse. Instruction is given in the 
use of the pack saddle, though few men show aptitude for this 



INSTRUCTION OF THE HOSPITAL CORPS. 397 

work. Every mau is given practice in hitching up an ambulance 
team, and in driving the ambulance. The proper packing of a 
saddle for field service is taught and the use of the various parts 
of the field equipment is shown. 

Under the direction of the stable sergeant, each recruit has 
practical instruction in grooming, feeding, watering, and stable 
management, together wdth the actual care and cleaning of har- 
ness and horse equipment. 

About 70% of the men show proficiency in the course. 

VII. The Instruction in First Aid covers two months. The 
work of the first month consists of lectures and recitations and 
that of the second month is devoted to the practical application 
of the first month's instruction. The subject is considered under 
the following heads: — 

FIRST AID. 

I. Wounds. Definition. Varieties. Characteristics of each variety. 
Characteristics of gun.shot wounds. Poisoned and infected wounds. Heal, 
ing of wounds. Causes of death from gunshot wounds. Indications to be 
met in treatment. Means at hand for treatment. Methods of exposing and 
examining wounds, Diemer's rules. Burns and bruises. Freezing. Sprains. 

Shock Causes. Symptoms. Diagnosis. Treatment. Treatment in 
the field. 

Wounds of Regions. Symptoms peculiar to wounds of the various 
organs. 

II. /^j^/j/j, or surgical cleanliness. Infection or sepsis. Suppuration. 
Disinfection and antiseptics. 

\\\. pyactures. Definition. Varieties. The symptoms or signs. How 
fractures unite. Compound fractures. Gunshot fractures. Principles of 
first aid treatment. Method of exposing fractures. Possible dangers in 
handling. Reduction. Splinting. Use of garments for support. Treat- 
ment of special fractures. 

Dislocations. Definition. Characteristics of. Diagnosis. First aid 
treatment. 

IV. Foreign Bodies. Eye. Ear. Nose. Throat. Symptoms. Dan 
gers. Treatment. 

V. Asphyxia. Smothering by gases. Smothering' by hanging. By 
pressure on the chest and other obstructions to breathing. Drowning. 
Principles of treatment of asphyxia. Rescuing. To restore breathing. 
Artificial respiration and other means. 

VI. Hemorrhage. The heart, arteries, and veins. Lines of the arter- 
ies. Outlines traced on the skin. Points for pressure. General symptoms. 
Internal hemorrhage. Control of hemorrhage. Natural means. Necessity 



398 CAPTAIN FREDERICK P. REYNOLDS, 

for artificial assistance. First aid methods. Stopping hemorrhage by 
patient himself. . 

VII. Emergencies in General. Symptoms. Diagnosis. What to look 
for. Indications and symptoms. General rules for emergencies. Uncon- 
sciousness. Most common causes: — injury, fainting, heat, alcohol. Princi- 
ples of diagnosis in the different cases. Treatment of each. 

Poisons. General classes. Symptoms of each case. Treatment. 
Usual means at hand for first aid treatment. Special poisons. Most com- 
mon poisons. 

VIII. The Instruct ion in Field Work is entirely practical in 
character and covers all duties of the Hospital Corps in the field. 
Effort is made to simulate field conditions whenever practicable. 

COURSE IN FIELD WORK. 

1. Uses of the First Aid Packet. 

(a) Application to wounds of all regions. 

(b) Slings. 

2. Uses of other articles in the Hospital Corps and Orderly pouches. 

3. First aid treatment of fractures in all regions of the body. 

4. The methods of transporting wounded in war. Positions on the litter. 

Improvised litters. Without litters. Use of ordinary wagons. 

5. Search for wounded. Patients tagged. Wounded cared for as indicated, 

using first aid equipment and extemporized materials. 

6. Use and care of articles of field hospital equipment. 

7. Organization of the regimental and of the field hospital. 

8. Pitching, striking, and packing field hospitals. 

9. Organization of the ambulance company. Work of the ambulance com. 

pany during an action. Establishment of aid stations. Collection and 
care of the wounded from the firing line to the field hospital. 

IX. The Course in Clerical Work, covers two months and is 
taken by all men who can profit by it. About 20% of the re- 
cruits received are not capable of understanding the subject. Of 
those instructed it is estimated that about 15% are prepared to 
do the routine work in a hospital office under the direction of a 
noncommissioned officer. The work of the course consists in 
taking up each of the usual reports and record books connected 
with medical department administration by first explaining the 
object of the paper, then the method of preparation, and finally 
requiring each man to make out a complete copy for examination 
and criticism. 

X. Materia Medica and Pharmacy. Inasmuch as a large 
percentage of the men have a common school education only, it 



INSTRUCTION OF THE HOSPITAL CORPS, 399 

is obvious that the method of instruction in these branches must 
be simple in order to be understood. The class room is fitted up 
with charts and illustrations explaining the fundamental princi- 
ples in practical pharmacy, while apparatus and specimens of 
crude as well as prepared drugs are used for purposes of in- 
struction. 

During the first month 20 hours are devoted to materia med- 
ica and 20 hours to pharmacy. 

The student is supplied with a brief outline on the subjects 
of materia medica and pharmacy, compiled in accoi dance with 
the Army Medical Supply Table, which treats all preparations in 
a short, concise manner, not beyond the average man's compre- 
hension. The drugs are taken up in alphabetical order and as 
each drug is discussed, mention is made of the official name, the 
English name, the synonym, source, character, tests, action and 
dose. Specimens in crude and pure form are shown. Official 
names, dosage, and the metric system are the chief stumbling 
blocks. 

In teaching practical pharmacy, the student is familiarized 
with the processes and apparatus in common use, and the manip- 
ulations behind the prescription counter. 

During the past two years 415 members of the Hospital Corps 
have received this instruction; 110 graduated with a class stand- 
ing of 90%, 96 with an average of 80%, and 102 with an aver- 
age of 70%, and the remainder below 70%. In examinations for 
promotion to the grades of hospital steward and acting hospital 
steward, 29 of those who have taken the course have passed with 
high averages. Seven men have been assigned to duty as dis- 
pensing clerks in the di.spensary of the general hospital and have 
performed their duties satisfactorily without other knowledge of 
the art than that obtained in this course. 37 men have been 
transferred from the classes on account of lack of aptitude. It 
has been the experience that about 80% of recruits of the Hos- 
pital Corps can be given this instruction with satisfactory results, 
and that about 20% of those instructed can be made into com- 
petent Army dispensing clerks by their course of instruction in 
the company. 



400 CA P TA IN FREDERICK P. RE VNOLDS. 

Aoncommissioned Officers' Instruction. All noncommiss- 
ioned officers of the company, in addition to their other duties, 
attend one hour's instruction daily. In this noncommissioned 
officers' class are included certain privates who have completed 
the course in the company and are candidates for promotion to 
the grades of sergeant and sergeant first class. 

1. Hospital Corps Drill Regulations. Recitations and drill with company. 

2. Army Regulations. Recitations. 

3. Materia medica and pharmacy. Lectures and practical work. 

4. I 'roperty responsibility and accountability. Recitations. 

5. Minor surgery and first aid. Lectures, recitations and practical work. 

6. Clerical work. Practical in company office. 

7. Mess management and cooking. Practical. With noncommissionsd 

officer in charge of mess. 

8. Elementary hygiene. Lectures. 

9. Nursing and ward management. Practical in hospital. 

In most of the courses printed outlines are followed. 
USEFULNESS OF COMPANIES OF INSTRUCTION. 

I think it can with confidence be stated that Hospital Corps 
companies of instruction have demonstrated their usefulness and 
are no longer an experiment, and that a well regulated company 
affords the best and quickest means of imparting uniform instruc- 
tion to recruits. It is hardly reasonable to expect that a man on 
completing four months of instruction in a company is well in- 
structed in all his duties. Many duties, such as nursing and 
dispensary work, require months of practical training to reach 
proficiency. In other branches of the service a man is hardlj" 
out of the recruit class in four months and is not considered well 
instructed in less than a year. It is to be expected, however, 
that four months in a company should make an average recruit a 
soldier who has a knowledge of discipline and understands what is 
expected of him, and who is capable of performing with some 
degree of skill, most of the duties of the Hospital Corps in gar- 
rison or in the field. 

The principles upon which company work should be based 
appear to be; (1) to at once impart a thorough knowledge of 
discipline in the same way and by much the saime methods as is 
imparted in the line of the Army, with which the Hospital Corps 



INSTRUCTION OF THE HOSPITAL CORPS. 401 

is always serving. (2) To teach men the principles of order and 
neatness, both as regards themselves and their personal equip- 
ment and also to familiarize them with the departments of a hos- 
pital and the articles with which they work. (3) After this, to 
impart to each man a knowledge, as far as his mental capacit)^ 
will permit, of practical nursing, of preparation of diets for the 
sick, of first aid and transportation of the wounded, and of am- 
bulance driving and care of animals, (4) To teach them to care 
for themselves and the equipment entrusted to them in field ser- 
vice, and to be familiar with the usual duties of Hospital Corps 
men on the march, in camp, and during an engagement. (5) To 
instruct in clerical work, materia medica and pharmacy, those 
who have aptitude for such work. 

The training of non-commissioned officers is an important 
duty of a company of instruction. In companies a uniformly high 
standard of noncommis.sioned officers is maintained, the result of 
which would be of great good to the service. Noncommissioned 
officers trained in companies could do much toward disseminating 
throughout the service uniformity in Hospital Corps instruction, 
discipline, and esprit de corps. To any one who has considered 
the subject, the advantages of such a system of training must, 
I think, be obvious. 

The company now stationed in Washington is of especial im- 
portance to the Medical Department for the reason that it is 
available for the instruction of student officers in the Army Med- 
ical School in field exercises and in Hospital Corps administration, 
instruction, and discipline. It also provides opportunity to 
make practical tests of articles of field equipment and is prepared 
to demonstrate at any time the organization and work of a field 
hospital or an ambulance company, having at hand the specified 
equipment and men trained in their duties. Thje company, there- 
fore, can at once take the field, either as an ambulance company 
or a field hospital. The company has represented the Medical 
Department of the army in numerous public ceremonies, which 
during the past two years have included the inauguration of 
President McKinley, his funeral ceremonies, ceremonies connect- 
ed with the dedication of the Rochambeau monument, and of the 



402 CAPTAIN FREDERICK P. REYNOLDS. 

Army War College. Numerous public exhibitions have been 
given which have been largely attended and have excited consid- 
erable interest in Hospital Corps instruction and in the new field 
organization and equipment of the Medical Department. The 
company attended the encampment of the National Guard of 
Pennsylvania at Gettysburg, Pa., going and. returning by march- 
ing, at which point it established a regimental hospital: at the Army 
maneuvers at Fort Riley, Kansas, during the past autumn, the 
company organized and largely manned both Field Hospital No. 
3 and Ambulance Company No. 3. It also manned the field hos- 
pital provided for the use of the Grand Army of the Republic 
at its recent encampment in this city. 
ADVANTAGES OF COMPANY DUTY FOR MEDICAL OFFICERS. 

The duties of the medical ofl5cers attached to Company of 
Instruction No. 1, have previously been stated. 

The advantages, both to the medical officer *and the Gov- 
ernment, to be derived from such a tour of duty are many and 
important. First, is the opportunity to learn thoroughly th-: 
routine work of the c<^mpany in order that there may be availa- 
ble medical officers to take charge of similar companies. The 
work is of a special character and a medical officer cannot take 
up such work and achieve satisfactory results until he has by 
experience learned the routine and methods employed. To gain 
this experience requires many months of application. Second, 
the medical officer can learn to the best advantage the methods 
of teaching Hospital Corps men and of imparting and maintain- 
ing discipline. Third, valuable practical experience is to be 
gained in the use of the field equipment and in the organization 
and work of ambulance companies and field hospitals. There are 
also unusual opportunities for medical officers to investigate and 
make trials of nevy articles of field equipment and to suggest im- 
provements to those now supplied. 

UNIFORM INSTRUCTION TO RECRUITS. 

I take the liberty to repeat the following suggestions which 
were contained in a report to the Surgeon General, dated August 
31, 1901. "With a view to uniformity and as the most effective 
and satisfactory method of training Hospital Corps men, I would 



INSTRUCTION OF THE HOSPITAL CORPS. 403 

suggest that companies of instruction be attached to general or 
post hospitals having a capacity of 30 beds or more, — all Hospi- 
tal Corps men on duty at the post to belong to the company or 
companies, those on duty in the hospital to be considered as on 
special duty. The number of men detached from the company 
for special duty in the hospital should not exceed one-third of the 
company. A company having a maximum quota of say 150 men, 
could ordinarily furnish the necessary detail for a hospital of 150 
beds and have 100 men for company duty. At hospitals having 
a capacity of over 150 beds, more than one company might be at- 
tached; for hospitals of, say 160 to 300 beds, two companies; over 
300 to 400 beds, three companies; over 400 to 500 beds, four com- 
panies, etc. 

* 'Suppose, for example, there were attached to a 150 bed gen- 
eral hospital a company of instruction of 150 men. Fifty men 
could be on special duty in the hospital, one-third of whom, (say 
17,) constituting the permanent force and two-thirds, (say 23,) 
making up the temporary force under instruction. After a few 
months this hospital would turn out about twenty trained Hos- 
pital Corps men each month including the necessary quota of 
noncommissioned officers, who had had four months company 
instruction and had passed through the different departments of 
the hospital, without in any way interfering with the latter's 
most economical and efficient administration. Two or three such 
companies attached to large hospitals could supply the Army and 
could keep it supplied with uniformly trained Hospital Corps 
men, a result well worthy of consideration. 

"In time of war the uniform training of all recruits might 
be begun at once by organizing as many companies of instruc- 
tion as were necessary and attaching them to base hospitals. Should 
the conditions necessitate the mobilization for field service with 
the least possible delay, the recruits might be passed through the 
company, equipped, and sent to the field without hospital in- 
struction. Also, the length of the period of instruction in the 
company might be reduced. Hospital training being the least 
necessary in the personnel of ambulance companies and regi- 
mental detachments, men without such training should prefera- 



404 CAPTAIN FREDERICK I\ REYNOLDS. 

bly be supplied to these field units and men with haspital expe- 
rience reserved for service at the base or permanent hospit£ils and 
field (brigade) hospitals.'* 

HOvSPITAL CORPS INSTRUCTION AT POSTS. 
The instruction of detachments at posts, in order to be sys- 
tematic should cover the prescribed subjects in a manner so that 
the work will be begun and completed in a given time, similar to 
the method pursued in the instruction of troops of the line. Such 
a course might be outlined as follows: 

1. Anatomy and physiology, 20 hours, (one month). 

2. Nursing. 40 hours, (two months). 

3. Materia medica and pharmacy, 20 hours. For selected men only. 

4. Elementary hygeine, 20 hours, (one month). 

5. First aid, 40 hours, (two months). 

6. Bearer Drill, '40 hours, (two months). 

7. Field work, including use of field equipment, 20 hours, (one month). 
Instruction in cooking, clerical work, and care of animals 

should be given while the men are on duty in the kitchen, office 
and stables. 

The "school year" by concluding with bearer drill and field 
work would thus be preparatory to the annual practice march or 
field maneuvers of the troops of the post. The practice of clos- 
ing the post hospital and going into camp at the post by estab- 
lishing a small (regimental) hospital where the post sick may be 
transferred and treated, is to be commended. 

To complete a man's training a system of rotation of duties 
in hospital is necessary. It is hardly necessary to .state that 
such rotation should never be allowed to interfere wiith the effic- 
ient administration of the hospital or the welfare of the sick. 
Some men will never be cooks, and some will never be nurses.but 
such facts do not obscure our duty of making the Hospital Corps 
men under our charge as proficient in all their duties as their ca- 
pabilities will allow. 



IReprints anb XTransIatlons. 

THE MILITARY MEDICAL JOURNALS OF SPAIN 

FOR 1902. 

By lieutenant CHARLES NORTON BARNEY, 

MEDICAI, DEPARTMENT, UNITED STATES ARMY. 

LA MEDICINA MILITAR ESPAiVOLA, {Concluded). 

THE Workings of the Sanitary Service on the Bat- 
tle-Field. Isidro Garcia Julidn. — Since the sani- 
tary service and the other services of an army are as 
vitally related and interdependent as are the various organs 
of a livings being, field and staff officers should familiarize 
themselves with the tactics of the sanitarj^ service and medi- 
cal officers should acquire some knowledge of the tactics of 
the other services, in order that there may be secured that 
close collaboration which is so necessary to good results. 

This idea is not a new one, but its most enthusiastic ad- 
vocate, M. Benech*, Chief Surgeon in the French Army, who 
for the past four years in his lectures to the medical officers 
stationed in Paris and to the students at the War College, has 
been insisting upon its importance, renders homage to the 
Prussian General and Minister of War Verdy du Vernois, who 
advocated it more than 20 years ago, to Colonel Bischer, Chief 
Surgeon of the 2nd Corps of the Swiss Army, who wrote on 
this subject in 1893, to Pelzer, Division Surgeon in the Ger- 
man Army, and to Lieut. Colonels Hausamblas and Kiisma- 
nick. The idea has been put into practice not only in France, 
but in Germany as well, where tactical instruction has been 
given medical officers since 1898. 

•Author of the very original, suggestive and valuable "Le service de 
sant^ en campagne; donn^es pratiques a Tusage d'^tat-major et des m^de- 
cins chefs," 2 vols., 12°, Paris, 1901-1902. — C.N.B. 

(405) 



406 LIEUTENANT CHARLES NOR TON BARNE Y. 

The author of this article, after showing how dependent 
are the disposition and workings of the sanitary units — par- 
ticularly on the firing line and at the regimental aid and dress- 
ing stations — upon th« dispositions and workings of the troops 
to which they are attached and upon the various contingencies 
of battle, and after noting that even with the greatest pre- 
vision and preparation the sanitary materiel and personnel 
must be insufficient at once to dispose of the veritable ''epi- 
demic of traumatisms" (Pirogoff) which accumulate within 
the space of a very few hours, describes in detail the sanitary 
service of the first line, treating of it under two headings: 
(1) On the firing line, and (2) At the dressing station. 

(I) Service on the firing line has for its objects the search 
for the wounded on the battlefield, the application of first aid 
to them, and their protection from the fire of the enemy until 
it be possible to transfer them to the dressing station. By 
Spanish regulations this work is placed under the charge of 
the medical officer youngest in commission among those serv- 
ing with each body of troops. He has under his control a sani- 
tary personnel consisting of four dressers or nurses, eight lit- 
ter bearers and a corporal of the Hospital Corps to each bat- 
talion, and the sanitary materiel represented by the first aid 
packet (which every officer and soldier must, by regulation, 
carry upon his person) , litters, medical and surgical chests, 
and occasionally carts and wagons. 

The probable number of casualties may be estimated, ac- 
cording to statistics of modern wars, as follows: 
10 to 15% of the total effective of an army, 
20 to 25% " " " " " " ** corps, 

25 to 30% '* " " " " a division, 

40 to 60% •' " " •" " a regiment. 

These percentages represent the ordinary maxima in the 
larger battles. Of these casualties one quarter will be killed, 
and a second quarter will be able to walk to the dressing sta- 
tion. On the other hand, in case of victory it is necessary to 
remember that the enemy has approximately an equal number 
of casualties, and that when he is being driven back from his 



THE MILITARY MEDICAL JOURNALS OF SPAIN. 407 

position he has to abandon two-thirds of them to the sanitary 
service of the conqueror. These figures are to be considered 
in connection with the area of the ground over which the 
wounded are scattered and the amount of time necessary to 
transport each one. 

From his experience of three years' campaigning in Cuba, 
where four medical ofl&cers were killed and three were perma- 
nently disabled while assisting wounded on the battlefield, 
and one gained the cross of San Fernando for dressing the 
wounded of his battalion under fire before attending to his 
own wounds, the author concludes that it is ordinarily im- 
practicable for the medical officer under the conditions of mod- 
ern warfare to carry out literally the Spanish regulations for 
field service, which provide that he shall take his sanitary de- 
tachment into the m^l^e, perhaps at the decisive moment of 
an attack when the troops are advancing from position to 
position under such cover as the terrain affords to shield them 
from the hail of bullets, and then and there direct the collec- 
tion and transportation of the wounded, prevent malingerers 
and the slightly wounded from leaving the ranks, determine 
which men need attention first, what dressings should be ap- 
plied to others, etc. Unless there is reasonable probability 
that his mission will succeed, because of conditions of the ter- 
rain or contingencies of the fight, or because an advance of 
the line leaves the zone where the wounded lie in greatest 
number less battered by the enemy's fire, or because of the oc- 
currence of a period of truce or calm, the medical officer can 
accomplish nothing by thus exposing the lives of his subordi- 
nates, the life of the wounded man whom he is trying to as- 
sist, and his own life. Sanitary soldiers on the firing line are 
especially exposed, and their services are so important to their 
comrades and so beneficial to the morale of the troops that 
their lives should be endangered as little as practicable. 

Beaunis, from his experience in the Franco-Prussian war, 
says, '*By the force of facts I am brought to this conclusion: 
the wounded ought not to be carried off the field while the 
fighting is in progress. Collecting them under the enemy's 



408 LIEUTENANT CHARLES NOR TON BARNE V. 

fire is extremely dang-erous, unnecessar}', and usually imprac- 
ticable." Beaunis also states that leaving* the wounded on 
the battlefield is not cruel, as might appear at first sig-ht, 
since the active part of an engfag-ement does not last longer 
than five or six hours as a rule, thoug-h the battle as a whole 
may last a longer time, and the wounded who cannot wait as 
longf as this without dang-er are few, with the exception of 
those cases which present hemorrhag-e. 

The first aid packet was adopted so that the wounded 
mig-ht assist themselves with it, pending such time as they 
could be attended later by the sanitary service. The author 
(Julidn) thinks that the wounded are hardly ever able to ap- 
ply the first aid packet themselves; in one case because the 
wounded man has fallen unconscious, in another because the 
lesion is in the arm, in a third because it is in such a position 
that the patient cannot see it, and in a fourth because the dis- 
covery of the wound necessitates removal of blouse or trousers 
— an impossibility for the patient to accomplish by himself in 
case of fracture or joint lesion. The author further states 
that duringf the campaign in Cuba he saw only one person, a 
captain, who knew how and was able to apply the packet to 
himself; and is of the opinion that the sanitary soldiers, in 
gathering- up the wounded under the direction of the medical 
officer, taking advantag-e of all the contingencies of the fight, 
advances of the line, and conditions of terrain, are the only 
ones able to render first aid. [This is decidedly not the ex- 
perience of American military surgeons. C.N.B.] 

At first the sanitary soldiers devote their efforts to sup- 
plying the wounded with water to drink and dressing those 
only who present hemorrhage or fracture. Severe primary 
hemorrhage from a large vessel causes the death of the pa- 
tient before he can be attended; and the greater part of the 
hemorrhages which come under the surgeon's care are those 
in which syncope has delayed the outpour of blood. [Synop- 
sis has already been given of an article published by thissame 
author in the **Revista" on this subject.] Dressers should 
not attempt to make complete diagnoses of fractures, but 



THE MIUTARY MEDICAL JOURNALS OF SPAIN, 409 

should merely try to recognize them as best they can, and to 
immobilize them. Doing up a sprain as a fracture would be 
erring on the safe side. 

(2) Service at the dressing station lias two objects, putting 
the severely wounded into such condition that they can stand 
transportation to hospital, and returning to their respective 
commands such of the slightly wounded as are able to do duty 
after having their wounds dressed, — excepting in the latter 
case, of course such as may belong to the enemy. 

The efficiency of modern fire-arms at long range makes 
it necessary that the troops shall take battle formation while 
they are still at a considerable distance from the enemy (2000 
yards or more). The battle is usually opened by artillery fire, 
under cover of which the infantry advance to take their posi- 
tions. As the advance progresses infantry fire is soon added. 
Though at first the firing is not accurate, it is sufficient to 
cause some casualties. At a distance of 700 to 800 yards from 
the enemy the firing line ceases to advance so openly, and, de- 
ployed as skirmishers, but still under the control of the section 
commander, halts temporarily for the purpose and fires by volley. 

If, merely because there are casualties occurring, the 
dressingstation should be established at this stage, which is 
hardly more than a preparatory one, it would soon be too far 
from the troops it is intended to care for, as these keep march- 
ing on toward their positions. Transportation of the wounded 
by litter from firing line to dressing station would be over 
such a long distance as to be impracticable, and as a result 
the dressing station so prematurely established would soon 
cease to carry out its function. At this stage of the fight the 
wounded should be given first aid from such resources as are 
comprised in the first aid packet and hospital corps pouch. 
The senior medical officer on duty with the regiment, who 
should have full knowledge of the part which the regiment is 
called upon to play in the tactics of the battle, should estab- 
lish the dressing station after the troops have stopped advanc- 
ing, the firing has become general, and the losses are nu- 
merous. 



410 LIEUTENANT CHARLES NORTON BARNEY, 

When the units of a brigade are together it may be con- 
venient to establish one dressing station early, leaving the es- 
tablishment of others until it is demanded by the advance of 
the troops and the necessities of the fight. 

According to Spanish regulations the dressing station 
should be placed near the center of the rear guard of the com- 
mand to which it belongs, a little outside the line of retreat 
(which implies a knowledge of what this will be), in a place 
easily accessible to litters, and to ambulance wagons also if 
possible, and at any rate where there can be direct communi- 
cation between it and the ambulance station or field hospital. 

Because of the increasing range of modern fire-arms it is 
getting more and more difficult to protect dressing stations 
from the enemy's fire. The projectiles of both small arms and 
cannon sweep the space in which dressing stations are in- 
stalled; and many of the larger projectiles, charged with ex- 
plosives and provided with time fuses, wound forces which 
formerly would have been considered out of danger. 

As the brigade reserves are likely to be the objective of 
the enemy's artilery fire the dressing stations should not be 
placed in line with them nor too close to them. Buildings 
should not be occupied as dressing stations, since they offer 
excellent targets for the enemy's cannon; and, should they be 
ignited or demolished by a shell while they are crowded by an 
accumulation of wounded, the catastrophe would be horrible. 
On the other hand, it is well to have the dressing stations 
reasonably near dwelling houses; not only because hay, straw 
and other materials for bedding, water, shade trees and wag- 
on roads will usually be found in the vicinity, but also be- 
cause such houses would later serve as nuclei for the forma- 
tion of temporary field hospitals, which after the battle are 
charged with the care of such of the wounded as cannot be 
transported to the rear. 

But the dressing station should be protected to such an 
extent as is possible; by the utilization of depressions of ter- 
rain, obstacles of all sorts, and a soft soil where bullets will 
not ricochet. Fortunately, as the trajectory of modern fire- 



THE MILITARY MEDICAL JOURNALS OF SPAIN. 411 

arras is more nearly rectilinear than that of the older arms, 
obstacles need not be so high as formerly in order to give con- 
siderable protection. An obstacle six feet in height will pro- 
tect against infantry fire, and an obstacle nine feet in height 
will give reasonable security against direct fire from light 
artillery. Within the zone of effective fire the greater the 
range at which the enemy is shooting the closer one must 
keep to these obstacles in order to secure protection. But no 
place within this zone can be considered really safe, and con- 
sequently such of the wounded as are able to bear transporta- 
tion should be evacuated to the field hospitals as rapidly as 
possible. 

Spanish regulations describe in detail the improvisation 
at dressing stations of small field stoves by which water can 
be boiled for the sterilization of instruments and dressings 
and the preparation of antiseptic solutions, surgical serum, 
and drinks for the sick. Though it is true enough that a 
crude stove can be set up in a few minutes, yet it is unlikely 
that the commanding general would tolerate during a battle 
the cloud of smoke which would be produced by such fuel as 
is ordinarily obtainable at such a time; and it is certain that 
an hour or more would be needed to get the water boiling, 
and almost another hour would elapse before the water could 
be considered sterile. The latter difficulty has been solved 
by Tarel, who has found that if a. little common salt be added 
the water can be thoroughly sterilized by only a few minutes 
boiling. 

The wounded accumulate very rapidly at a dressing sta- 
tion, and the personnel, the time, and even the water required, 
for such a period of sterilization as is described in the Span- 
ish regulations referred to are usually lacking. Nimier and 
Laval advise that water which has been boiled the night be- 
fore be carried in the regulation reservoirs, and that it be 
not wasted in sterilization of instruments, as these can be 
sterilized quite as thoroughly and much more quickly by 
passing them through an alcohol flame. It is of course not 
necessary to have a lamp for this purpose; the alcohol may oe 



412 LIEUTENANT CHARLES NORTON BARNEY, 

poured out on a meat can' or other flat surface and ignited. 
The instruments should not be held in the flame so long that 
they acquire a blue color. Wolbrecht has devised a method 
of **drj sterilization" for the hands of the surgeon and his 
assistants and for the surroundings of the wound, bj means 
of the tincture of soap. This method is now under investi- 
gation. When water is abundant instruments may be steril- 
ized by putting them in boiling water provided the water has 
been boiled so long that all the air contained has been ex- 
pelled. If the contained air has not been expelled by boiling, 
black specks are produced on the steel. These can be pre- 
vented by adding to the water sodium carbonate in the pro- 
portion of one part in a hundred. If sodium carbonate be not 
at hand, sodium borate may be used. 

As a general rule modern bullet wounds may be consid- 
asceptic, and the less disinfection attempted the better. Dis- 
infection when unnecessary is positively harmful as it dam- 
ages the tissues to some extent and makes them less resistant 
to any infection which may get into the wound at a later pe- 
riod. As Tarel puts it, '*Moins on fait, mieux on fait*'; and 
Nimier and Laval are of the same opinion as to the results of 
attempting to disenfect these wounds. On the other hand, 
the experience of Watson Cheyne in the South African War 
and of Spanish surgeons in recent colonial wars shows that 
suppuration rarely results when these wounds are not subject 
to disinfection as a routine, even though conditions for se- 
curing aseptic treatment be very imperfect. The -reason is 
that the modern bullet is of small calibre: it does not ordina- 
rily carry in with it other foreign bodies, such as pieces of 
clothing, etc., it tends to separate rather than destroy tissues, 
and leaves a track of very small calibre, which is quickly ob- 
literated by apposition of the tissues, and in which as a con- 
sequence there is little opportunity for exudates to accumu- 
late and afford culture media for germs. 

The difficulty of doing dressings and performing opera- 
tions in a kneeling or squatting position, and the necessity of 
improvising an operating table are recognized by the Spanish 



THE MILITARY MEDICAL JOURNALS OF SPAIN. 413 

regulations, but the author thinks that some apparatus should 
be adopted which could easily be attached to the litter, such 
as the Dujardin-Strauss litter-support used in the French 
army. 

Too little attention has been paid by military surgeons 
iQ general to means of illumination at the dressing station. 
But this is a subject of some moment on account of the im- 
portant part which the sanitary formations of the first line 
have to play on the night following a battle, in the search 
for, collection, and dressing of the wounded. Mention is made 
of Dr. Nikolai*s exhaustive studies in this field, and of the 
acetylene apparatus which he devised. Reh's modification of 
Nikolai's acetylene lantern shQuld be supplied to every litter 
bearer, ambulance wagon, dispensarj', and dressing station. 

The progressive increase in the weight and volume of 
the material which is considered necessary for the proper 
equipment of a dressing station calls for the adoption of -wag- 
ons specially designed for the transportation of this material; 
except of course, in such commands as are intended to be most 
mobile — cavalry for example, and in these pack animals must 
be relied lipon. Surgical wagons are already employed in 
several armies. [Apparently not in Spain. The slowness of 
Spain to make any extensive use of drugs in tablet form has 
already been commented upon in a previous article by this 
author, an abstract of which has been given above. C. N. B.] 

The operations of the dressing station is very intimately 
connected with that of the litter bearers, in spite of the fact 
that at least a quarter of the wounded are able to walk. When 
the time consumed in applying first aid to the wounded indi- 
vidual, in carrying him and his equipment to the dressing 
station, and in returning the empty litter, are all considered, 
it is calculated that under average conditions a litter squad 
travels at the rate of two kilometers an hour: and, as the 
distance from the point at which the soldier falls wounded 
and the station at which his wound is dressed averages ap- 
proximately one kilometer, [five eights of a mile], it is calcu- 
lated that each litter will transport only one patient an hour. 



414 LIEUTENANT CHARLES NORTON BARNE Y. 

Benech * gives algebraic formulae for calculating the number of 
wounded which will probabi y have to be provided for, the time 
which will be consumed in attending and transporting them, 
etc., but these formulae are not easily retained in the memory. 

The medical officer in charge of the dressing station and 
his assistants rapidly examine the wounded as these arrive, 
divide them into groups according to the disposition which is 
to be made of them — whether to be returned to the firing line 
at once, dressed or operated upon at once, transported to the 
field hospital, or left at the dressing station on account of not 
being able to endure transportation — and fill out diagnosis 
cards for all. 

The manner in which the wounded should be evacuated 
to the field hospital and the nature of such urgent operations 
as should alone be performed at the dressing station are well 
indicated in regulations. Attention should be paid especially 
to hemostasis, the treatmentofpost-hemorrhagic syncope, and 
the reduction and immobilization of fractures. At this sta- 
tion vessels should not ordinarily be ligated above the wound, 
but in the wound. Hypodermic injections of morphia should 
l;ere be rather freely used for the relief of pain add nervous 
excitation. 

The medical officer should always remember that the 
principal object of the dressing station is merely to put the 
wounded into such condition that they may be transported to 
the field hospital as soon as possible, and should never forget 
What Sarazin, Inspector in the Sanitary Corps of the French 
Army, said after the Battle of Froschweilerf: *'Good surgery 
requires more calm and less distraction than exist on the bat- 
tle field." 

Experiments on Cadavers as Tests of the Effects of 
Fire-Arms. Abudemio Ruiz Lozano ridicules the supposi- 
tion that by ''firing at dead people" we can learn the effects 

♦In his "Service de Santd en Campagne." 

tThe battle of Worth or Reichsnofen, in Alsace, where the Germans 
under the Crown Prince of Prussia were victorious over the French under 
MacMahon, Aug. 6, 1870. The Germans lost 10,000; the French 8,000, with 
9,000 taken prisoners. C.N.B. 



THE MILITARY MEDICAL JOURNALS OF SPAIN. 415 

of fire-arms in the living-, and incidentally gives a whack at 
the various theories advanced to explain the so-called "explo- 
sive effect" of bullets. 

Medical Teaching and the Sanitaky Corps. The ed- 
itor (Angfel de Larra j Cerezo) points out two instances of 
apparent injustice to the medical officers of the army. 

First: That at every new station to which a medical of- 
ficer is sent, perhaps just after he has paid for license to prac- 
tice in the vicinity of his previous station, he must pay for a 
new license, at the same rate as is charged local physicians, 
before he can practice among* the civil population. 

Second: That in the scheme of Public Instruction the 
military hospitals, which are the best equipped hospitals in 
Spain, are never constituted as nor utilized in connection with 
medical colleges for the instruction of civilians, and medical 
officers are not given an opportunity to hold civil professor- 
ships. As one example of the relationship which should ob- 
tain between the Army Sanitary Corps and Public Medical 
Instruction is cited the case of the Inspector in the Sanitary 
Corps of the Army of the Argentine Republic who is Profes- 
sor of Clinical Medicine in the Faculty of Buenos Aires and 
is authorized to give his instruction in the military hospital 
at that city. 

The Great Hygienic and Social Problems in Rela- 
tion TO Armies. This is the title of a long article by Angel 
Fernandez Caro written in answer to the thesis which was 
presented by Dr. Angel de Larra y Cerezo on his admission to 
the Royal Academy of Medicine. Only the introduction is 
published in the volume of '*La Medicina Militar" for 1902, 
and the remainder of the article will occupy several succeed- 
ing numbers in 1903. 



fll>ebtco-fllMlttari2 1 nbei. 



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MEDICO-MIUTAR Y INDEX, 417 

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New (The) royal warrant for the army medical service. Med. Mag.^ 
Lond., 1902, xi, 273-280. 

Batidet (G.) [The surgeon dentist in the army.] Progrh dent.. Par. 
1902, xxix, 378-381. 

Be^manm [First aid on the field of battle; asepsis and antisepsis in 
field.] Arch de med. et pharm, mil., Par. 1902, xl, 429; 514. 

Bothooskl (V.) [Hours for instruction in the Army Medical Academy.] 
Vrach. Gas., St. Petersb., 1902, ix, 371-375. 

OdI (G») [Military dentists in the army.] Odonto-stomatoL, Napoli, 
1902,1,3-7. 

Call (G.) [The military service and surgeon dentists.] Odonto-stomatol., 
Napoli, 1902, i, 105-109. 

Dobroslavin (V.) [Articles 31 and 35, letter A of the table of diseases, 
supplementary to the Instruction to the military recruiting offices (Order of 
the Ministry of War of Oct. 31, 1897.)] Voyenno-med. J., St. Petersb., 1902, 
ixxx, med.-spec. pt., 2310-2329. 

Duchlne* Le service de sant^ de la brigade de Tarm^e (2d brigade) 
au cours de Texp^dition de Chine en 1900-1901. Arch, de med. et pharm. 
mil., Par. 1902, xxxix, 359-409. 

H« [The Dental Station of the Royal Garrison Hospital at Dresden.] 
Zahntech. Rundschau. ^ Berl., 1902, 9592. 

Nimier. [The medical corps during battle.] Caduch, Par., 1902, ii, 
291-293. 

Romeyn (D») Le service sanitaire dans les armies et la Croix-Rouge. 
MiL-geneesk. Tijdschr., Haarlem, 1902, vi, 177-181. 

Russia. Ministry of War. [Report of the Chief Army Sanitary Com- 
mittee for 1900]. Voyenno-med. J., St. Petersb., 1902, Ixxx, off. pt., 353-374. 

Stapleton (H«) Amalgamation of bearer company and field hospital as a 
military unit. J. Roy. U. Service Inst., Lond., 1902, xlvi, 1 501-1523. 



iBbttortal Department- 

THE STATUS OF THE ASSOCIATION OF MILITARY * 
SURGEONS OF THE UNITED STATES AT ITS 
TWELFTH ANNUAL MEETING. 

THE full report of the proceedings of the twelfth annual 
meeting, held last month in Boston, will form the bulk 
of the July number of the Journal but it may not be 
out of place to indicate here a few of the principal items of the 
work. The most important action taken was of course the reor- 
ganization of the Association in accordance with the Act of Con- 
gress creating it an official corporation under the laws of the 
United States. The Constitution and By-Laws, — as may be seen 
upon examination of the revised version presented in this issue of 
the Journal, — were revised so as to conform to the act of incor- 
poration and to embody such improvements as the experience of 
twelve years had shown to be necessary and desirable. 

The official status of the Association was established by that 
provision of the act attaching three cabinet officers and the three 
chiefs of government bureaux officially to the Association in the 
capacity of an advisory board, a fact which was di/ly recognized. 
The enlargement of the work of the Association and the 
greater responsibility attaching to its work had so much increased 
the importance of what had hitherto been known as the Execu- 
tive Committee, that it was very properly erected into an Execu- 
tive Council with added powers by which it was enabled to per- 
form the functions of a board of directors of a corporation and to 
conduct all the work of the Association during the period elaps- 
ing between the meetings of the Association. 

The more active participation in the work of the Association 
by the Public Health and Marine Hospital Service received rec- 
ognition by the creation of a third vice-presidency, so that a rep- 
resentative of each of the four elements comprising the Associa- 
. tion may be represented in the presidential and vice-presidential 

(418) 



EDITORIAL DEPARTMENT. 419 

chairs. It is hoped that in this way the principle of rotation in 
the presidency of the Association may hereafter be fully estab- 
lished, each of the vice-presidents succeeding to the presidency in 
turn. Much care was shown by the nominating committee at 
this meeting in selecting incumbents for these offices who should 
reflect honor upon the Association when they should arrive at its 
head. 

As foreshadowed in the Journal some months ago, the de- 
signs of the badge and button of the Association were made offi- 
cial by detailed description in the Constitution. A coat of arms 
was also created by which the documents of the Association may 
hereafter be properly' authenticated. 

Certain of the special committees, which by prolonged usage 
had practically become standing committees were definitely es- 
tablished in that class. This applied to the Necrology Commit- 
tee, the Transportation Committee and to the Committee of Ar- 
rangements. 

Prize competitions which have been held for a number of 
years without definite official recognition are now established 
upot) a fixed basis, and boards of award are now constitutional 
bodies. Although heretofore these competitions have been con- 
fined to essays upon subjects announced, the field was left open 
for competition in other directions if it should be desired at any 
time. This leaves the field open in future for competition in mat- 
ters of sanitary apparatus, material, or maneuvers, as well as in 
theory. 

A source of much misunderstanding hitherto has been the 
statement of the constitution that there was no admission fee but 
that the first year's dues included that fee. The expression * 'first 
year' ' signified the first calendar year of membership extending 
from the first of January to the last of December, but so many 
new members construed it to mean twelve months from the date 
of election to membership, that the By-Laws have now been 
changed to provide for an admission fee to accompany the appli- 
cation for membership, and remitting the dues for the remainder 
of the year in which the application is made. There has thus 
been no change in the amount paid but the statement regarding 
it has been made more definite. 



Constitution anb Bi^-Xaws. 

Adopted May 1% S903. 

PREAMBLE. 

TAg Medical Officers of the Army^ of the Navy^ of the Public Health 
and Marine Hospital Service of the United States ^ and of the Militia of the 
different States^ under the provisions of an act of Congress approved fanu- 
ary jo, igoj, have associated themselves together under the name of ''^ The 
Association of Military Surgeons of the United S tales. ^^ Now, therefore, 
pursuant to the laws of the United States, the members of said Association 
do hereby ordain and enact the following: 

CONSTITUTION. 

ARTICLE /. 

NAME. 
The Association shall be known as "The Association of Military 
Surgeons of the United States." 

ARTICLE 11, 

OBJECT. 

The object of the Association shall be to increase the efficiency of the 
medical services of the Army, the Navy, the Public Healtli & Marine Hos- 
pital Service, and of the Militia of the different States by mutual association 
and the consideration of matters pertaining to the medico-military service of 
the United States both in peace and in war. 

ARTICLE III 

MEMBERS. 

CLASSIFICATION OF MEMBERSHIP. 

Section i. 'There shall be Active, Life, Associate, Ex-Officio, Corre- 
sponding and Honorary Members. 

members eligible to office and entitled to vote. 
Section 2. Active and Life members only are eligible to office or en- 
titled to vote. 

active members. 
Section 3. Active membership is limited to commissioned medical 
officers of — 

(420) 



CONSTITUTION AND B VLA IVS. 421 

1. The United States Army; 

2. The United States Navy; 

3. The United States Public Health & Marine Hospital Service; 

4. The United States Volunteers; 

5. The National Guard and other state troops; and 

6. Contract or acting assistant surgeons of the United States Army, 
Navy and Public Health & Marine Hospital Service. 

Active members may retain their membership, should they be honorably 
discharged from the service in which they have been commissioned. 

LIFE MEMBERS. 

Section 4. Life membership and exemption from the payment of an- 
nual dues is conferred upon — 

1. Members who obtain first honorable mention in the prize compe- 
titions of the Association. 

2. Any active member upon the payment of fifty dollars at one time. 

ASSOCIATE MEMBERS. 

Section 5. Associate membership is open to — 

1. Ex-medical officers and 

2. Other officers of the aforementioned services, 

3. Ex-medical officers of the Confederate Army and Navy, and 

4. Medical officers of foreign services. 

EX-OFFICIO MEMBERS. 

Section 6. The Secretary of the Treasury, the Secretary of War, the 
Secretary of the Navy, the Surgeon General of the Army, the Surgeon Gen- 
eral of the Navy, the Surgeon General of the Public Health & Marine Hos- 
pital Service, in conformity with the Act under which this Constitution is 
adopted, shall be ex-officio members of the Association. 
corresponding members. 

Section 7. Corresponding membership is open to military surgeons, 
not resident in the United States, but prominent in military medicine, sur- 
gery, and hygiene. 

honorary members. 

Section 8. The President of the United States, the senior General 
officer of the Army, and the senior flag officer of the Navy for the time being, 
shall be honorary members. Other persons who have rendered distinguished 
services to the .'Vssociation, or who have otherwise attained distinction de- 
serving of recognition by the Association, are eligible to honorary member- 
ship. 

ARTICLE IV, 

GOVERNMENT OF THE ASSOCIATION. 

advisory board. 
Section i. There shall be an Advisory Board consisting of the Secre- 



422 CONSTITUTION AND B YLA WS. 

tary of the Treasury, the Secretary of War, the Secretary of the Navy, the 
Surgeon General of the Army, the Surgeon General of the Navy, the Sur- 
geon General of the Public Health & Marine Hospital Service and the Pres- 
ident of the Association. 

OFFICERS. 

Section 2. The officers shall be a President, three Vice-Presidents, a 
Secretary and a Treasurer, who shall hold their respective offices until their 
successors are elected and qualified. 

EXECUTIVE COUNCIL. 

Section 3. There shall be an Executive Council, to consist of the of- 
ficers, the ex-presidents and six (6) members, who shall be appointed by the 
President each year 

standing committees. 

Section 4. There shall be the following Standing Committees, to be 
appointed annually by the President, except as hereinafter specified: 

A Literary Committee, to consist of seven (7) members, — four (4) mem- 
bers from the National Guard, State Troops or Milkia, andone (i)each from 
the Army, Navy and the Public Health & Marine Hospital Service. 

A Publication Committee, to consist of three (3) members, one of whom 
shall be the Secretary as ex-officio Chairman, 

A Necrology Committee to consist of three (3) members. 

A Transportation Committee to consist of one (i) or more members. 

A Committee of Arrangements for the next ensuing meeting, to consist 
of one member, who shall be the chairman, with power to associate with 
him.self such other persons, members of the Association or not, as he may 
see fit. 

A Nominating Committee, based upon a representative or one vote for 
each State, Territory, the Army, the Navy and the Public Health & Marine 
Hospital Service, and for every additional ten (10) members or major frac. 
tion thereof an extra representative or vote; said vote or votes to be cast by 
a member or members, present from each State, Territory, Army, Navy and 
Public Health & Marine Hospital Service, to be designated by the members 
present from each State, Territory, Army, Navy and Public Health & Marine 
Hospital Service at the lime of meeting. 

BOARDS of award. 

Se( tion 5. Boards of Award shall be appointed by the President for 
the consideration of such prize competitions, as may from time to time be in- 
stituted ])y the Association. Membership in the Associationshallnot be re- 
quired of members of the Boards of Award, which shall be selected in each 
instance from men consi)icuous for knowledge of the subject of the compe- 
tition. 



CONSTITUTION AND BY-LA \VS, 



423 




ThcSeal* 



ARTICLE V. 
SEAL, INSIGNIA AND ARMS. 
SEAL. 

Section i. The seal of the Association 
shall consist of a circle, two and three-eighths 
(2 2) of an inch in diameter, charged with the 
cross of the insignia with the words '^Organized 
1891, Incorporated by Congress, 1903" within 
a circumferential band bearing the words 
"Association Military Surgeons United States." 

INSIGNIA. 



Section 2. The insignia 
of the Association shall com- 
prise (i) a Cross; (2) a Button. 

(i). The Cross shall be of 
gold, the obverse, enameled 
with red and bordered with gold, 
upon which shall be superim- 
posed, a white shield, enclosing 
a shield of the United States 
in its proper colors, — red, white 
and blue, with stars of gold, sur- 
rounded by the motto ''''Omnia 
pro Patriae Caritate'''', the re- 
verse, plain gold and bearing 
its number. Upon the reverse 
may also be engraved the name 
and address of the owner. The 
cross suspended by a ribbon, 
consisting of two bands of crim- 
son enclosing a band of white, 
may be worn by any member of 
the Association on ceremonial 
occasioi^,-*and shall be carried 
on ,the left breast,— or at the 
collar, if the wearer be an officer 
of the Association. 




The Insignia. 




utton, 

OILT LINE» OMITTED. 



(2) The Button shall consist of a red enameled cross, 
outlined in gold, upon a field of white enamel surrounded by 
a blue band, three-fourths ( ]) of an inch in diameter outlined 
on either side by circles of gold, and bearing the legend also 
in gold, '•''Omnia pro Patriae Caritatt'^ It may be worn 
by all members at their discretion in the upper left-hand 
button-hole of the civilian coat. 



424 



CONSTITUTION AND BYLAWS, 




coat of arms. 

Section 3 



The Goat of Arms. 



The Coat of Arms shall 
consist of a shield, bearing in the 
center the cross of the insignia of the 
Association and, quartered about it, 
the caduceus, the acorn, the crossed 
anchor and caduceus and a crossed 
saber and rifle, surmounted by a red- 
cross guidon, — emblematic of the Med- 
ical Departments of the Army, the 
Navy, the Public Health & Marine 
Hospital Service and the State forces, 
- with a crest consisting of an eagle 
with outspread wings, bearing a Ge- 
neva Cross upon i»is breast, — emble- 
matic of the patriotic and altruistic 
character of the Association. 



ARTICLE VL 



QUORUM. 
Thirty-five (35) members shall constitute a quorum for the transaction 
of business, but a less number may adjourn 

ARTICLE VII. 

AMENDMENTS. 

All amendments to this Constitution and By-Laws shall be proposed in 

writing at one annual meeting, and voted on at the next. A three fourths 

vote of all the members present at the annual meeting shall be necessary for 

adoption. 

BY-LAWS. 

ARTICLE I. 

ELECTION TO MEMBERSHIP. 

ACTIVE OR ASSOCIATE MEMnERSHIP. 

Section i. Election to active or associate membership shall be by the 
Executive Council, to whom the Secretary shall refer all applications, 
together with such credentials as may be presented. 

corresponding or honorary membership. 
Section 2 Election to corresponding or honorary membership shall 
be by a two-thirds vote of the Association, after the unanimous recommen- 
dation of the Executive Council. 

ARTICLE 11 
EXPULSION KKOM MEMBERSHIP. 
Any member who may be dismissed from the service for conduct unbe- 



CONSTITUTION AND B Y-LA WS. 435 

coming an officer and a gentleman shall be expelled and debarred from any 
further rights or privileges when proper proof has been furnished the Sec- 
retary. 

ARTICLE III 

MEETINGS. 
The Association shall meet annually, the time and place to be fixed at 
each meeting for the one ensuing. Special meetings may be called by the 
President at any time. At the annual meeting the President, Vice-Presidents, 
and the Treasurer shall be elected for the term of one year, the standing 
committees appointed, and the annual reports received. 

ARTICLE IV, 

DUES AND DELINQUENTS. 
ADMISSION FEE. 

Section i. The admission fee to be paid by Active and Associate 
members shall be three dollars, ($3.00), which shall accompany the applica- 
tion for membership. ^ 

ANNUAL DUES. 

Section 2. The annual dues shall be three dollars, ($3.00), due on the 
first of January of each year. No annual dues shall be required of new mem- 
bers for the remaining portion of the calendar year in which their admission 
fees have been paid. 

DELINQUENTS. 

Section 3. Delinquents in the paym'^.nt of dues will not be entitled to 
the Journal or other publications of the Association. Delinquency for two 
years shall terminate membership, after due notice by the Treasurer. 

MEMBERS exempt FROM DUES. 

Section 4. Honorary, Corresponding, Ex-Officio, and Life members 
shall be exempt from the payment of dues. 

ARTICLE V. 
DUTIES OF THE ADVISORY BOARD. 
The Advisory Board shall meet at such times as the interests of the pub- 
lic service may demand. Meetings may be called by one or more members 
of the Board and three members shall constitute a quorum. Any action 
taken by the Board shall be reported to the Association through the Presi- 
dent of the Association. 

ARTICLE VL 

DUTIES OF OFFICERS. 
THE PRESIDENT. 

Section i. The President shall preside at all meetings, appoint all 
committees, unless otherwise provided for, approve all proper bills, and per- 
form such other duties as are usually incumbent upon such an officer. 

THE vice-presidents. 

Section 2. The Vice-Presidents in order of seniority, shall perform 
the duties of President in the absence or inability of that officer. 



426 CONSTITUTION AND B Y-LA IVS. 

THE SECRETARY. 

Section 3. The Secretary shall keep the records and archives of the 
Association; receive all applications for membership and refer them to the 
Executive Council; notify the Treasurer of the election of active and asso- 
ciate members; issue certificates of membership to active, associate, corre- 
sponding and honorary members on election, and to life members when ad- 
vised by the Treasurer that the necessary fee has been paid; and shall hold 
office until his tenure is terminated by resignation or death, or by the elec- 
tion of his successor after due and timely notice. 

He shall be a member and ex-officio chairman of the Publication Com- 
mittee. 

He shall appoint an Assistant Secretary each year, and shall present an 
annual report. 

the treasurer. 

Section 4. The Treasurer shall receive all moneys due the Associa- 
tion, collect all assessments, and pay all bills which have been properly ap- 
proved. 

The accounts of the Treasurer shall be audited by a committee ap- 
pointed for that purpose on or before the annual meeting. He shall present 
an annual report. 

He shall execute such bond of ;?2,ooo as may be approved by the Ex- 
ecutive Council for the faithful performance of his duties, the Associa- 
tion to bear the cost of this insurance. 

ARTICLE VII, 

THE EXECUTIVK COU14CIL. 

DUTIES. 

Section i. The Executive Council shall be charged with the conduct 
of the affairs of the Association during the intervals between the annual 
meetings, shall elect active and associate members, and perform such other 
duties as may be assigned to it by the Constitution and By-Laws or by vote 
of the Association at any stated or special meeting. 
conduct of business. 

Section 2. The business of the Executive Council may be conducted 
by correspondence or at such meetings as may be called b> the chairman 
upon his own initiative or at the request of any three members. 

officers. 

Section 3. The president, the secretary and the treasurer of the Asso- 
ciation respectively shall be ex-officio chairman, secretary, and treasurer of 
the Executive Council. 

quorum. 

Section 3 Five members of the Executive Council shall constitute a 
quorum for the transaction of business. 



CONSTITUTION AND B Y-LA WS. 427 

ARTICLE VIII. 

DUTIES OP STANDING COMMITTIES. 

THE LITERARY COMMITTEE. 

Section i. The Literary Committee shall outline the literary work for 
the annual meeting in advance, making the necessary arrangements for the 
reading and discussion of papers. 

The Chairman shall be responsible for the program for the ensuing 
meeting. 

The Committee shall assist the Publication Committee in the prompt 
publication of the Proceedings. 

THE PUBLICATION COMMITTEE. 

Section 2. The Publication Committee shall have charge of the pub- 
lications of the Association. 

It shall determine what portions of the proceedings are of sufficient 
general interest to be printed, and decide upon the advisability of publishing 
the several papers, presented at the annual meetings, and such other matter 
as may be of value to the Association. 

It shall prepare for publication, contract for printing, and see through 
the press all the publications of the Association; but all contracts for print- 
ing must first have the approval of the President and the Treasurer. 

THE NECROLOGY COMMITTEE. 

Secyion 3. The Necrology Committee shall report to the Association 
at each annual meeting, the deaths that have occurred during the preceding 
year among the members of the Association, with a suitable memoir in each 
case. 

THE TRANSPORTATION COMMITTEE. 

Section 4. The Transportation Committee shall have charge of the ar- 
rangements for the transportation of members to and from the meetings of 
the Association. 

THE COMMITTEE OF ARRANGEMENTS. 

Section 5. The Committee of Arrangements shall have charge of all 
local arrangements for the annual meetings of the Association. 

THE NOMINATING COMMITTEE. 

Section 6. The Nominating Committee shall, at the annual meeting 
present a list of candidates for the various offices for the ensuing year. 

The vote or votfes, of the Nominating Committee shall be cast by a 
member or members present from each State or Territory, the Army, the 
Navy, and the Public Health & Marine Hospital Service. 

ARTICLE IX. 
DUTIES OF BOARDS OF AWARD. 

Boards of Award shall be charged with the selection of the person or 
persons to whom prizes shall be awarded, in accordance with the regulations 
of such prize competitions as may, from time to time, be instituted, and shall 
report the results thereof at such time as may be designated by the Asso. 
ciation. 



Inbei* 



A BSCESS of the liver, 156. 
/^\ Africa, British army in South, 

Alaska, Army sanitary work in, 
108. 
Allen, Dr. A. R , Review of Heath's 
practical anatomy, 195. 
Review of Ochsner's Clinical Surgery, 

65. 
Review of Saunders' American Year- 

Book, 196. 
Review of Scudder on Fractures, 66. 
Ambulance, Canadian, 2S5. 
Motor, 72. 

Work in South African War, 12. 
Ambulances, British army, 18. 
Amendments proposed to Constitution 

and By-Laws, 187. 
Amoebic dysentery, 156. 
Ames, Major Azel, Remarks on the Ex- 
ecutive Element in the Army Sur- 
geon, 218. 
The Vaccination of Porto Rico — A 
Lesson to the World, 293. 
Appel, Major Daniel M., Remarks on 
the Executive Element in the Army 
Surgeon, 213 
Association of Military Surgeons, Cana- 
dian view of, 40. 
Incorporation of, 125, 418. 
Preliminary program of twelfth annual 
meeting, 271, 342. 
Associations of Military Surgeons, Ger- 
man, 343. 
Austro- Hungarian View of the Medical 
Organization of the U.S Army in 
Active Service, 57. 



Automobile ambulance, 72. 
Automobiles in the army, 263. 

BADGE of Boston meeting, 276. 
of the Association, 423. 
Barney, Lieutenant Charles 
Norton, The Military Medi- 
cal Journals of Spain for 1902,262, 332. 
Battlefield, First aid on the, 405. 
Post-hemorrhagic syncope and anemia 
on the, 265. 
Bearer work in South African War, 12, 
Beri beri, 54. 

Billings, Lieut. Col. John S., The Mili- 
tary Medical Officer at the Opening 
of the Twentieth Century, 349. 
Birmingham, Major Henry P., Some 
Practical Suggestions on Tropical 
Hygiene, 45. 
Boer War, British army in, 12. 
Bolo wounds, 41. 

Borden, Major William C, The Edu- 
cation of the Medical Officer of the 
Army, 372. 
Boston meeting. Badge of, 276. 
Program of, 271, 342. 
Sketch of the city of, 256. 
Brain (see also cerebral) localization, 29. 
Briggs, Major Albert H., Remarks on 
the Executive Element in the Army 
Surgeon, 218. 
British Army in South Africa, 12. 
Brooklyn naval hospital. Operations at, 

in 1901, 366. 
Bubonic plague, 54. 
Bullet wounds in the Cuban campaign,322. 

of cadavers, 414. 
Bullets, Lodgment and deflection of, 67, 

(429) 



430 



INDEX, 



CADAVERS,Experimental wounds 
of, 414. 
Calef, Brig. Gen. J. Francis, 
How can Medical Officers 
promote Expert Marksmanship in 
the Army, 181, 
Camps, Avoidance of soil pollution in, 

107. 
Canada, Ambulance and transport ve- 
hicles of, 285. 
Canadian view of the Association of Mil- 
iary Surgeons, 40. 
Carroll, Lieutenant James, The Treat- 
ment of Yellow Fever, 232. 
Cerebral concussion. Pathological anato- 
my of, 24, 
Localization, 29. 
Chancre and chancroid at Vera Cruz, 177, 
Clothing for tropical service, 48. 
Compressed medicines, Spanish note on, 

336. 

Constitution and By-Laws, 420. 
Constitutional amendments, 187. 
Crawford, P. A. Surgeon C. Al^xan- 
DER, A New Field and Navy Litter, 

ISO- 
Cuba, First aid in, 319. 
Hospitals and Chanties in, 140. 
Mosquito work in Havana, 133. 
Service in, 317. 

Work of American Army in, 149. 
Curry, Captain Joseph J., Tuberculosis 
in the Tropics, 117. 

DENGUE in the tropics, 54. 
Dennis, P. A. Surgeon J. Ben- 
jamin, Ringworm cases at 
the Naval Academy, 1901- 
1902,81. 
Diet for tropical service, 52. 
Dressing station, Aid at the, 407. 
Dysentery, Amoebic, 156. 
Tropical, 53. 



EBERT, Major Rudolph G., The 
Sanitary Work of the United 
States Army Medical Depart- 
ment in Alaska, 108. 
Education of Hospital Corps, 378. 
Medical Officers, 372. 
Military Medical. Spanish, 415. 
English army in South Africa, 12. 
Enno Sander. Prize Notice, 128. 
Evans, Surgeon Sheldon G., Favus 
and its Treatment, 314. 
Gonorrhoea from the standpoint of the 
Naval Surgeon, 171. 
Executive Element in army surgeon, 206. 
ExHAM, Colonel Richard, Experiences 
of the British Army Medical Ser- 
vices in the War in South Africa, 12. 

FACTORS in Spanish soldiers' 
health, 
Favus and its treatment, 314. 
Feet, Soldiers', 63. 
Field, Lines of aid on battle, 405^. 
Filter in Boer war, 21, 
First aid on the battlefield, 405. 

work in Cuban campaign, 319. 
Fisher, Captain Henry Clay, Report 

of Cases of Bolo Wounds, 41. 
Forage Wagon, Canadian, "290. 
Ford, Lieutenant Clyde Sinclair, The 

Military Motor Ambulance, 72. 
Fractures, Review of Scudder on, 66. 
France, Politics and military hygiene in 

339. 
French and German armies, Comparative 
mortality of, 83. 

GALL, Cerebral theories of, 29. 
Geneva cross. Abuses of, 1%, 
German and French armies* 
Comparative mortality of, 83. 
Associations of Military Surgeons, 343. 
GiRARD, Colonel Alfred C, Abscess of 
the Liver, 156. 



INDEX. 



431 



GoLTRA, Contract Surgeon John Nel- 
son, The Executive Element in the 
Training and Skill of the Army Sur- 
geon, 206. 

Gonorrhoea at Vera Cruz, 176! 
from the standpoint of the naval sur- 
geon, 171. 

GoRGAS, Colonel William Crawford, 
A Short Account of the Results of 
Mosquito Work in Havana, Cuba, 

'33. 
Groff, Major George G., Relation of 
Volunteer Relief Associations to the 
Government, 277. 
Gunshot, Lodgement and deflection of,67. 
Wounds of cadavers, 414. 
Wounds in the Cuban campaign, 322. 



Hygiene, Index of Military, 186, 270, 341. 

Military in France, 339. 

Tropical, 45. ^ 

Hygienic and Social problems in relation 
to armies. 



I 
J 



NCORPORATION pf the Associa- 
tion of Military Surgeons, 125. 
Index, Medico-military, 55, 123, 18$, 
269,340,416. 

ARRETT, Captain Arthur R., 
Remarks on the Executive Ele- 
ment in the Army Surgeon, 217. 
Jarvis, Lieut. Col. Nathan S., 

Remarks on the Executive Element 

in the Army Surgeon, 217. 



HAVANA, Mosquito work in, 133. 
Havard, Lieut. Col. Valery, 
Remarks on the Executive 
Element in the Army Sur 
geon, 213. 
Translation of Note upon the Patho- 
logical Anatomy of Cerebral Concus- 
sion, 24. 
Headgear for tropical service, 5 1 . 
Health factors in Spanish soldiers, 337. 
Heart affections unfavorably affected by 

tropical service, 331. 
Hemorrhagic syncope and anemia on the 

battlefield, 265. 
Hollander on the mental functions of the 

brain, 29, 
Hospital Corps Company, The first, 193. 
Instruction, 378. 
On battlefield, 405. 
Reorganization of Army, 129. 
Training of, 220. 
Hospital on transport "Meade," 5. 
Ship "Missouri," 7. 
Ships in Boer War, 17. 
Steward, Abolition of title, 129. 
Tents, British army, 19. 



KEAN, Major Jefferson Ran- 
dolph, Hospitals and Char- 
ities in Cuba, 140. 
KiLBOURNE, Major Henry 
Sayles, Medical Department of the 
U.S. Army Transport Service, i. 
KuLP, Captain John Stewart, Review 
of Manual for the Medical Depart- 
ment of the United States Army, 
1902, 131. 

IADIES, Special arrangements for, at 
the twelfth annual meeting, 
^ 27S. 

Langsdorf, H. H., Review of 
the Adrenal Theories of Sajous, 344. 

Lines of aid on the battlefield, 405. 

Litter, A new field and navy, 150. 
Wheeled, 20. 

Liver abscess, 1 56. 

Ludlow, C. S., Classification, Geograph. 
ical Distribution and Seasonal Flight 
of the Mosquitoes of the Philippine 
Islands, 84. 

Lung troubles unfavorably affected by 
tropical service, 33 1 . 



432 



INDEX. 



MALARIAL FEVER, Control of 
in Havana, 133. 
Tropical, 5.H. 

Marksmanship and the medical 
officer, 181. 
Medical Department, The Ideal relation 
of the, 361. 
Officer, Education of, 372. 
Officer, Executive Element in, 206. 
Officer, Twentieth Century, 349, 358. 
Medicine, Index to military, 56, 341. 
Medicines, Compressed, Spanish note on, 

336. 
Medico-military administration. Index of, 

55» 123, 185,269,340,417. 
Medico-military history 'and biography. 

Index of, 56, 186,416. 
Medico-military Index, 55, 123, 185, 269, 

340,416. 
Military Hygiene, Index of, 186, 270,341. 
Medicine, Index of, 56, 341. 
Surgeon, Education of, 372,415. 
Surgery, Index of, 56, 124, 186, 270, 341. 
Training of medical officer — British 
view, 22. 
Molina, Lieut. Col. Zacarias Rojos 
DE, Practical Observations upon the 
Treatment of the Venereal Diseases 
most common among the Soldiers of 
the Garrison of Vera Cruz, 176. 
Mortality in the Spanish army. Disre- 
garded Causes of, 263. 
of French and German Armies, Com. 
parative, 83. 
Mosquito work in Havana, 133. 
Mosquitoes of the Philippines, 84. 
Motor ambulance, 72. 
MUNSON, Captain Edward L., Remarks 
on the Executive Element in the 
Army Surgeon, 216. 



NANCREDE, Major Charles 
Beylard, The Laws of Phys- 
ics and Ballistics the True Ex- 
planation of the Lodgement 
and Deflection of the Majority of 
Small Arm Projectiles, — not the 
Ricochet Hypothesis, 67. 
Naval medical officer during action, 44. 
Surgeon, Gonorrhoea from the stand- 
point of the, 171. 
Navy litter, 150. 

Neilson, Colonel J. L. Hubert, Ambu- 
lance and Transport Vehicles of the 
Tenth Field Hospital of the Canadian 
Army Medical Services, 285. 
Remarks on the Executive Element in 
the Army Surgeon, 215. 
Nerves, Wounds of, 197. 
Nimier, M., Note upon the Pathological 
Anatomy of Cerebral Concussion, 24. 



O 



RGANIZATION, Medical, of 
the Army in Active Service, 

57. 

Owen, Major William O., 
"The Ideal Relation for the Medical 
Department of an Army," 361. 

PHILIPPINES, Mosquitoes of the, 
84. 
Phrenology in the Examination 
of recruits, 29. 
Pilcher, Major James Evelyn, Ger- 
man Associations of Military Sur- 
geons, 343. 
Pension for widow of Major Walter 

Reed, 62. 
Review of Brubaker on Physiology and 

LeiiFman on Poisons, 195. 
Review of Havard's Venereal Peril, 
195. 

Keview of Imperial Yeomanry Hos- 
pitals in South Africa, 194. 



INDEX, 



433 



Review of Military and Naval Surgery 
in the American Textbook of Sur- 
gery, 64. 
Review of Oertel's Medical Micro- 
scopy, 194. 
The New Epoch in the History of the 
Association of Military Surgeons of 
the United States, 125. 
The Reorganization of the United 

States Army Hospital Corps, 129. 
The Status of the Association of Mili 
tary Surgeons at Its Twelfth Annual 
Meeting, 418. 
Porto Rico, Vaccination of, 293. 
Powder explosion, Wounds by, 332. 
Prize, Enno Sander, Notice, 128. 
Program of twelfth annual meeting, 271, 

342. 
Projectiles, Small arm. Lodgement and 
Deflection of, 67. 

RECRUITS, Character study in 
examining, 27. 
for tropical service, 45. 
Reed, Pension for the Widow of 
Major Walter, 62. 
Relief associations, Volunteer, 277. 
Reprints and Translations, 262, 332, 405. 
Review of the Adrenal Theories of 
Sajous, 344. 
Beyer on Naval Surgery, 64. 
Brubaker's quiz compend of physiol- 
ogy, 195- 
Forwood on Military Surgery, 64. 
Havard*s Venereal Peril, 195. 
Heath's practical anatomy, 195. 
Imperial Yeomanry Hospitals in South 

Africa, 194. 
Leffmau on Poisons, 195. 
Manual for the Medical Department, 

U.S. Army, 1902, 131. 
Ochsner's Clinical Surgery, 65. 
Oertel's Medical Microscopy, 194. 



Saunder's American Year-Book, 196. 
Scudder on fractures, 66. 

Reynolds, Captain Frederick P., The 
Instruction of the Hospital Corps in 
Companies and Detachments, 378. 

Ringworm epidemic, 81. 

Roentgen's ray in the sanitary service, 
267. 

Root, Honorable Elihu, The Opportu- 
nities of the Young Medical Officer 
of the Army, 358. 

RoTHGANGER, Surgeon George, Major 
Operations at the United States 
Naval Hospital in Brooklyn during 

1901, 366. 

SCHOOL, Army Medical, Annual 
Addresses before the, 349, 358. 
Schools, Military medical, 372. 
Skinner, Lieut. Col. B., On Sol- 
diers' Feet, 63. 
Small pox in Porto Rico, Suppression of, 

293. 
Soil pollution in camps, 107. 
Spain, Military Medical Journals of, for 

1902, 262, 332, 405. 

Steiner, Johann, An Austro-Hungarian 
View of the Medical Organization of 
the United States Army in Active 
Service, 57. 

Stephenson, Medical Inspector Frank- 
LIN Bache, Character Study in the 
Examination of Persons for Military 
Service, 27. 

Sterilizers, Unsafe water, 121. 

Stomatitis epidemic in South Africa, 175. 

Stone, Captain John Hamilton, Re- 
marks suggested by Three Years 
Service in Cuba, 317. 

Stretcher (see also litter). Wheeled, 20. 

Suicide among European soldiers, 139. 

Surgery, Index of military, 56, 124, 186, 
270, 341. 



4 34 



INDEX, 



Surgical Operations at Brooklyn Naval 

Hospital, 366. 
Surgery, Clinical, Review of Ochsner on, 
65. 
Military, Review of Forwood on, 64. 
Naval, Review of Beyer on, 64. 
Syphilid at Vera Cruz, 177. 

TINEA circinata at the Naval 
Academy, 81. 
Transport "Logan," 3, 
"Meade," s- 
**Sumner," 4. 

Service, Medical Department of the 
United States Army, i. 
Tropical diseases in Cuba, 329. 
Hygiene, 45- 
Service, Limit of, 331. 
Tropics, Tuberculosis in the, 117, 329. 
Tuberculosis in Cuba, 329. 
in the Tropics, 117. 
Military sanatoria for, 338. 
X-ray in, 268. 
Typhoid fever in its Earliest Stages, Dif- 
ferential Diagnosis of,— the prize es- 
say subject for 1903, 128. 



V 



Gonorrhoea) at Vera Cruz, 176. 
Volunteer relief associations, 277. 

WAGON, Forage or runabout, 
Canadian, 290. 
Warbasse, Captain James 
Peter, Observations on 
Wounds of Nerves, 197. 
Water Cart, Canadian, 290. 
Filter in Boer war, 21. 
Sterilizers, Unsafe, 121. 
WiEBER, Surgeon F. W. F., Note on the 
Unsafe Construction of Water Steri- 
lizers, 121. 
Winter, Major Francis A^ Some 
Points in the Training of Hospital 
Corps Soldiers, 220. 
Wounded in the Explosion of the Cara- 

banchel Powder Magazine, 332. 
Wounds, Bolo, 41. 
Incised, 41. 

in the Cuban campaign, 322. 
of nerves, 197. 



ACCINATION of Porto Rico, 

293- 
Spanish note on, 336. 
Venereal diseases (see aldO 



Y 



ELLOW FEVER, Extermina- 
tion of, in Havana, 133. 
in Cuba, 324. 
Treatment of, 232. 



l/j(L //^1t .