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altogether, but we must reduce it so far as ceed as though we expect the war to continue possible. We must pay a penalty for the un- indefinitely. When it does stop, these camps prepared state into which we allowed ourselves and cantonments may be used for the universal to fall, notwithstanding the warning which came military training for which it is to be hoped we to us so plainly more than three years ago. The will be wise enough to provide. Some of the seasoned soldier learns to take care of himself, base hospitals would be excellent for tuberculosis and, if we are correctly informed, the infectious sanitoriums, if kept in repair. There is nothing diseases are infrequent among the French and more demoralizing to camp sanitation than the English veterans, but they have had long train- idea that the camp is soon to be abandoned. ing. At best, we are to pay dearly for our apathy.
With the restriction of the death rate from
tuberculosis, pneumonia is fast winning the rank When the new select men are called, each
of “Captain of the hosts of death.” There is should come to camp with a card from the
a general impression that it is most prevalent health officer of his home, giving a list of the
among children and the aged, but Cole states communicable diseases observed in that locality
that more than half the cases fall between 20 during the past month. These men should be
and 50 years—the period of greatest activity. housed in groups of not more than 30, and pre
It was the most serious disease met with by the ferably in much smaller groups, kept in quar
Surgeon-General in the Canal Zone and he was antine with daily medical inspection for at least
called to South Africa to advise concerning its two weeks. Their civilian clothes should be
restriction among the miners in the Rand region. disinfected and sent home. The men should
With the exception of dysentery and typhoid have thorough cleaning in supervised baths and
fever, pneumonia caused more deaths among the under the care of an officer. They should be
soldiers of the Civil War than any other disclothed in proper uniforms and supplied with
ease, and with the elimination of typhoid fever, an extra suit of underclothing. During the
pneumonia in all probability will claim more period of detention, the men should receive
deaths in our army than any other disease. Extheir vaccines and undergo all necessary special medical examinations. Each group, or squad,
perience shows that it is especially prevalent
among recruits. It levies a heavy tribute upon should be drilled or exercised by itself. At the
those who are passing through the transition end of two weeks, groups which have remained free from infection, might be brought together
from home life to that of the soldier. Many fall
its victims in the process of being adapted to —not more than two groups at first. After
the altered conditions of life. Especially is this shorter intervals, companies may be formed,
true when the period of this transition is acand finally regiments, but for two months the
companied by exposure to unusual cold and wet. groups should not be larger than companies.
The fact of this greater prevalence and fatality After this, regiments and larger masses may be
among the inhabitants of our southern states, organized. In the primary training camps, the
has already been mentioned, as has the special arrangement should be such that each company
susceptibility of those convalescent from meascould be isolated from every other part of the camp at short notice. Medical officers especially skilled in the recognition and effective manage- It is customary to speak of lobar and bronment of communicable diseases, should daily chopneumonia. This distinction is useful from examine every man, stripped and while in his the standpoint of the pathologist, but how usebath. Daily bathing should be a routine ex- ful it is from an etiologic or epidemiologic viewercise. Medical officers, during this prelimi- point remain to be seen. Both forms may be nary period, should live with the men, eat at primary and both may follow measles. It is the same mess, sleep in the same quarters, and generally believed that lobar pneumonia is more should, at the end of that time, have some voice frequently primary, while bronchopneumonia is in the selection of noncommissioned officers. the form most likely to follow measles. HowBesides, success in this work should be given ever, up to the present time there are no conweight in fixing the rank of medical officers. vincing statistics on this point. It is highly All the camps and cantonments now in this desirable that accurate observations should be country should be maintained at least as long made and recorded in our base hospitals as to as the war lasts. This is recommended in order the relation of the two forms of pneumonia to that overcrowdeing may not again be necessary, measles. The records should show in each case and, if the number now existent is not enough as to whether it was lobar or bronchopneumonia, to prevent overcrowding, more camps and can but what is of more importance, whether it was tonments should be provided. The barracks and primary or post measles pneumonia? With base hospitals now in existence should be paint accurate observations on these points, properly ed and kept in repair. This should include the recorded, we should soon have information oi water supply, sewerage, bath, etc. Let us pro- great value in an epidemiologic way, and this
is what we greatly need in our efforts to reduce 161 showed some form of this organism. This the incidence of these diseases.
indicates that more than half of normal indiCole defines lobar pneumonia as follows: viduals, without recent exposure, are free from “Acute lobar pneumonia is an acute infectious pneumococci. In the 161, the types were disdisease, the characteristic feature of which is tributed as follows: a uniformly diffuse exudative inflammation of "Type I -.0.8 per cent entire portions of one or more lobes of the lung. Type II – 0.0 per cent It has long been a question of dispute, however, Type IIa-- 0.8 per cent whether the definition of the disease shall be Type IIb— 5.8 per cent based on the pathologic, etiologic, or clinical Type IIx-11.6 per cent features. In our opinion, so far as prevention Type III –28.1 per cent and cure, of the disease are concerned, it is of
Type IV —59.9 per cent the greatest importance that the chief stress should be laid on the etiologic agent. Lobar
In 458 cases of lobar pneumonia, the disinflammation of the lung may undoubtedly be
tribution of the type was quite in contrast with caused by a number of different bacteria. The
the above as shown by the following: vast majority of the lesions, however, are caused
Type I -33.3 per cent by varieties of diplococcus pneumoniae.”
Type II --29.3 per cent The bacteriology of bronchopneumonia has
Type IIa- 1.3 per cent not been so completely studied, but it' is safe to Type IIb—- 0.9 per cent say that the varieties of bacteria found in the Type IIx- 2.0 per cent exudate are more numerous, and, while the pneu
Type III –13.0 per cent mococcus may be the sole causative agent, strep Type IV —20.3 per cent tococci are more frequently present than in lobar “Comparison of these two tables shows that pneumonia and may be the chief, if not the sole, the pneumococci most commonly found in the causative agent. Careful observation and rec- mouth secretions of normal individuals give ords in the laboratories of our base hospitals rise to a minority of the cases of lobar pneushould give us most desirable information con- monia. The disease produced by these organcerning the bacteriology of both forms of pneu- isms, with the exception of Type III, is less monia, and there is opportunity in each of these severe in character, indicating a lower grade of laboratories to make useful contributions to the pathogenicity of those types for man. On the etiology and epidemiology of pneumonia. other hand, Types I and II cause a majority of
The pneumococcus was first found by Pas- cases of lobar pneumonia, are of high virulence teur in the saliva in a case of rabies, and about for human beings and are seldom or never the same time by former Surgeon-General Stern- found in the mouth secretions of normal indiberg in the normal saliva. The fact that many viduals who have not been in intimate assopeople in health carry these organisms in their ciation with cases of lobar pneumonia. This saliva more or less constantly, led to the belief seems to indicate that lobar pneumonia due to that pneumonia results, from the lowered re- Types I and II does not rise from infection sistance of the individual induced by unusual ex- with a pneumococcus which is habitually carried posure to wet and cold, an attack of measles, in the mouth, but that infection with these oretc., and that isolation and disinfection of sputum ganisms occurs from without." was unnecessary. Under this attitude toward Men trained by Cole and familiar with his the disease, it has not decreased and there is methods of differentiating the types of pneustrong evidence that it has increased. The cen- mococci have been placed in the laboratory of sus of 1900 made it responsible for more than each camp in which pneumonia prevails, and 10 per cent of all deaths.
we may expect much new information along The painstaking investigations of Cole and this line. Cole has developed a serum which his associates at the hospital of the Rockefeller apparently gives good results in those pneuInstitute have shown that pneumococci may be monias due to Type I. This serum is being differentiated into several types and subtypes. used in cases shown to be due to this type. This work is still incomplete, but it has prog- However, we are at present more deeply conressed far enough to throw much light on the cerned with the prevention than the treatment etiology of lobar pneumonia, and to justify us in of these diseases, and in our efforts at pretaking quite a different view concerning the vention we are proceeding on the assumption methods that should be followed in attempts to that pneumonia is a transmissible disease, and limit the spread of the disease. In a study of that the causative agent at least in a large perthe mouth secretion of 297 individuals in health centage of cases comes from without. In doing and without history of recent contact with a this the probability that susceptibility may be case of lobar pneumonia, 181 were found to be increased by unaccustomed and untoward confree from any form of the pneumococcus, while ditions of life must not be overlooked. Indeed. the truth of this is indicated quite conclusively On entering an amusement or assembly hall by observations extending back for centuries in one of our cantonments and hearing many and recognized in many parts of the world. coughing and filling the air with germ-laden
We may laud the advantages of free venti- spray, one can not easily dismiss the impression lation, out-of-door living and sleeping, the hard that these places serve as distributors of the ening and bracing effects of cold weather, cold respiratory infections. A like impression has bathing, etc., as much as we please, but we must evidently been made upon those in authority, admit that when men in masses suddenly change for in several camps places of assembly have their residence from warm, unventilated or been closed and similar extra cantonment picpoorly ventilated homes, to the life of the tent ture shows have been barred to the soldier. This and the open barrack, they need warmer cloth- procedure is regrettable but nevertheless coming and heavier bedding, and if these are not mendable. In the process of making soldiers, furnished, pneumonia takes heavy toll from some pleasures must be curtailed. their ranks. Furthermore, it seems true that The soldier sick with pneumonia, either prithe more radical and sudden this change, the mary or post measles, should be immediately greater is the toll. The Michigan lad may have carried to the base hospital, and, so far as prohis snow bath or his plunge through the broken tective measures are concerned, should be treatice, and quickly get back into his heavy woolens ed much the same as has been recommended for with impunity, but when the South Carolina those with measles. Overcrowding in hospital youth indulges in such an experience and goes and the screens between beds should be rememback into his cottons, insurance on his life ceases bered, the one to be avoided and the other to be to be a good risk. The French have found it provided. An individual with Type I of the absolutely necessary to provide warmer quarters pneumococcus may distribute his more fatal inand heavier clothing in the winter for their fection to a neighbor originally infected with the African contingents than is needed by the na- less virulent Type IV, or a streptococcus infective Frenchman.
tion may be engrafted on a pneumococcus Hookworm infection among the southern growth. The fact that empyema frequently select men has been suggested as an explana- develops in both lobar pneumonia and bronchotion of the lesser resistance they show toward pneumonia suggests that the streptococcus is respiratory diseases. It may be a fact, but so present, either as a primary or secondary factor. far this has not been demonstrated. These facts Moreover, in several hospitals pneumonia has long known to medical men seem to have been developed in physicians and other attendants. without the ken of those who provided or failed Whether patients with pneumonia do better in to provide quarters and clothing for the recent a cold or in a warm, moist atmosphere seems recruits in the southern camps. It is for the to be an undecided question. While this is being future to determine whether the Cracker from determined, it is quite certain that whatever the Georgia will make as hardy a soldier as the temperature of the inhaled air may be, the body Wolverine from Michigan. Both bore many should be protected from chill. Among those privations in the Civil War and proved them- most experienced in the treatment of pneumonia, selves worthy antagonists.
the value of digitalis seems to be conceded, but To the suggestion that lack of suitable cloth- there are differences in opinion as to the extent ing has been a factor in the prevalence of pneu- to which this drug should be administered, as monia in the camps, the reply is made that warm to the indications for pushing or decreasing its garments in sufficiency are now in the camps administration, and as to the preparation of this or on the way to them. To the man who died of drug most suitable. pneumonia in the base hospital in Fort Worth Inspection of our camps and their hospitals last month, last week, or yesterday, this reply leaves one with the impression that so far as is of small comfort. However, this is no time their medical personnel is concerned, the greatto look backward, but it is the time to look for- est need is for men skilled in the early recogniward and to see that mistakes are not continued. tion and the handling of the acute respiratory It is the duty of the medical officer to protest diseases. Valuable as improvements in the derepeatedly and vigorously, if necessary, through termination of the types of the pneumococcus and official channels, if those under his care suffer the development of curative serums are, the prefrom insufficient clothing or bedding. It is also vention of infection and the limitation of its his duty to see not only that they have proper spread are far more important. The daily mail clothing, but that they wear it.
of the Surgeon-General's office brings suggestThat overcrowding favors the dissemina- ions, recipes and offers to sell to the government tion of pneumonia can not be questioned. It “sure cures" for pneumonia. We can leave the multiplies the number of those within the in- treatment of this disease to the wisely selected fection range, increases the contacts and makes medical officers in the base hospitals. What is segregation more difficult.
· needed is knowledge whereby we can prevent this
disease. However, the mere possession of knowl- the request ofthe Ordnance Department Wilmer edge is of no value unless it be accompanied by devised a protective steel eye shield which has the means necessary for its application. Insuffi- a single horizontal stenopaeic slit in front of each cient clothing, overcrowding in tents, barracks eye which allows for good vision and is by far and hospitals, and lack of heat in the houses, the best. Such a shield can be fastened to a have been potent factors in the development of helmet. Is it advisable to make the eye shield the pneumonia among our soldiers, and for these tight enough to keep out lachrymatory gases, or deficiencies the medical corps is not responsible. to have the gas mask entirely separate. This is not intended as a criticism on anyone, The treatment for the action of war gases nor does it imply that the medical corps would on the eye, a cocaine salve or collyrium seems have done better if it had been given authority more rational treatment at first, followed by an in all these matters. It does mean that in the instillation of a medicated salve for a whole making of an army, the health of the soldier is week, even in mild cases. of first importance and this can be secured only Ginseppe says the toxic gases which induce by the intelligent cooperation of all those who
much lacrymation are far less dangerous for the are responsible for the conditions under which
eyes than the usual asphyxiating gases. If sehe lives.
vere injury, the cornea develops small foci of The Surgeon-General has asked:
necrosis with atrocious pain in the brow, back (1) That deficiencies in clothing be made of the neck and the temples, the eye slowly, dies,
the eyeball becoming completely atrophied. In (2) That additional tentage and housing be his experience 16 per cent of the war injuries of provided, sufficient to give each soldier at least the eyes were from machine guns or shrapnel, 50 square feet of floor space.
50 per cent from flying scraps of stone, 5 per (3) That a detention camp be established
blished cent from glaucoma, and 25 per cent from as
C with each division, and in which all arrivals may phyxiating gases. be kept under medical observation for such time Greenwood is apparently partial to some form as may be necessary.
of implantation operation in enucleations. (4) That a quarantine camp be established Conjunctival keratoplasty is most useful in in connection with each division and in which injuries of the cornea for protection and the contacts, suspects, and carriers can be isolated prevention of infection. and observed.
Greenwood says he cannot agree with those (5) That, where necessary, tents or other who consider that military ophthalmology difhousing should be provided for convalescents. fers from civilian only in degree, but not in kind.
(6) That unfinished hospitals be hastened to De Schweinitz says that up to the present completion, including water, sewers and baths. time we are obliged to depend upon clinical sings (7) Additional nurses, when necessary.
in making a diagnosis of trachoma. (8) The enlargement and better equipment
Not infrequently pannus is materially beneof the base hospital laboratories where desirable fited by peritomy or more properly peridectomy.
De Schweinitz says trachoma is curable if (9) The selection and detail of medical offi
properly managed. Trachoma is often introcers specially qualified in epidemiology as assistants to the division sanitary inspector.
duced into the army from the outside.
While other injuries determine the disposal (10) Provision for laying the dust in certain
of the patient who also has an ocular lesion, camps.
proper attention is not given the eyes sometimes (11) Special recommendation indicated by for weeks and then the condition becomes irremethe local conditions at certain camps.
Terrien remarks that the visual disturbances WAR AND THE EYE
of shell shock are generally transient. P. I. LEONARD, M. D., St. Joseph, Mo.
Vaccination against typhoid may bring on a Napoleon used to say, "I do not believe in
relapse of iridocyditis. medicine, but I believe in Corvisart” (his physi
Sympathetic reaction after injury is comcian). His definition of medicine has seldom
paratively common, appearing early and disap
parat been surpassed: “l'experience chez un homme pearing arter
homme pearing after enucleation superieur," the experience of a superior man.
The poisonous drift of gases may induce The war has not yet given us the ideal anti- iritis or neuroretinitis, but the course has proved septic.
essentially mild. Eternal vigilance is the price of asepsis. The prevention and cure of infection consti
Greenwood, in Medical War Manual No. 3, tute the greatest single problem of military suron Military Ophthalmic Surgery, tells us that at gery.
MEDICAL HERALD ADVERTISERS
The Medical Herald
by the war are all having their influence in ren
dering the individual more liable to disease. The Incorporating the
result will inevitably be much higher morbidity kansas City Medical Inder-Lancet
and mortality unless these conditions are met by Vol. XXXVII. MARCH, 1918 . No. 3
a corresponding activity on the part of the local
health authorities. CHAS. WOOD FASSETT, Managing Editor
Any health officer, who, by his neglect or 613 Lathrop Building, Kansas City, Mo.
lack of proper oversight, allows a communicable
disease to become epidemic, especially in a comASSOCIATE EDITORS
munity contiguous to an army camp or in a city P. I. LEONARD, St. Joseph.
manufacturing supplies used by the Allies, is asJ. M. BELL, St. Joseph.
suredly “furnishing aid and comfort to the JNO. E. SUMMERS, Omaha.
enemy.” Vigilance in maintaining sanitary conCONTRIBUTING EDITORS
ditions, in preventing the transmission of infecH. ELLIOTT BATES, New York.
tion by prompt and intelligent application of JOE BECTON, Greenville, Texas. HERMAN J. BOLDT, New York.
modern health measures, always of importance, A. L. BLESH, Oklahoma City.
is especially so at the present time.
Nearly one-half the health officers of the
state accepted service as examining physicians JACOB GEIGER, St. Joseph. S. S. GLASSCOCK, Kansas City, Kan.
on draft exemption boards—a remarkable exhibiH. R. HARROWER, Los Angeles, Cal.
tion of active patriotism. Less spectacular, perJAS. W. HEDDENS, St. Joseph. VIRGINIA B. LE ROY. Streator. ni.
haps, but fully as important, is the patriotism DONALD MACRAE, Council Bluffs.
that causes a man to put his last ounce of energy L. HARRISON METTLER, Chicago. DANIEL MORTON, St. Joseph.
into protecting the health of his community.D. A. MYERS, Lawton, Okla.
Operation honor our honor, its responsibility our responsibility. To support it is a duty, to Aurists have a great deal to say about the defend it a privilege, to serve it a joy. In its hour of trial we must be steadfast, in conservation of hearing. The ear is usually afits hour of danger we must be strong, in
? fected in measles, diphtheria, grip, pneumonia, its hour of triumph we must be generous. Though all else depart, and all we own be scarlet fever, tuberculosis and other infectious
taken away, there will still remain the foundation of our fortunes, the bulwark of our hopes, a
conditions. During the winter the writer has rock on which to build anew-our country, our homeland,
seen a large number of cases of suppurative inAmerica."-From American Medicine, May, 1917 (National Number.)
flammation of the ear and of mastoditis. The general practitioner still relies in many cases up
on the external application of heat to the ear The Editors' Forum
and assures that the "ear will break" and all will be well. The same practitioner who does this
either operates himself upon his cases of appenThe Health Officer
dicitis or calls in a surgeon. The practice is just and Patriotism
as detrimental, even if not much more so, in
mastoditis than in appendicitis. If the tympanic The health officer who remains at his post,
membrane is bulging and notwithstanding antifaithfully and intelligently performing his du
phlogistic and other measures with indications ties, is serving his country in no less measure that perforation is likely to occur. a paracenthan he who goes to the front.
tesis membrane tympani should be performed. At the meeting of the American Public Or if there be an insufficient opening, this should Health Association in October great emphasis be enlarged. It is not wise to make three or four was laid on the country's need for active co- incisions during three or four weeks or months operation on the part of all health officials. A duration, in the presence of a persistent disresolution was adopted urging upon all public charge and some pain. A posterior operation health workers “the importance of unusual so- becomes imperative. There is no better means licitude and activity in conserving and promoting of making a diagnosis in these cases than by takthe health of the civilian population during and ing the history in connection with the otascopic after the present war.
appearances. After a paracentesis or after free War conditions are adding stress and strain drainage from a ruptured ear drum with ostosin all walks of life. Overwork, overcrowding of copic and general symptoms greatly improved, public conveyances, insufficient food and fuel and with the mastoid process greatly swollen, a large many other unusual circumstances brought about number of cases recover without mastoidectomy.