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is what we greatly need in our efforts to reduce the incidence of these diseases.

Cole defines lobar pneumonia as follows: "Acute lobar pneumonia is an acute infectious disease, the characteristic feature of which is a uniformly diffuse exudative inflammation of entire portions of one or more lobes of the lung. It has long been a question of dispute, however, whether the definition of the disease shall be based on the pathologic, etiologic, or clinical features. In our opinion, so far as prevention and cure, of the disease are concerned, it is of the greatest importance that the chief stress should be laid on the etiologic agent. Lobar inflammation of the lung may undoubtedly be caused by a number of different bacteria. The vast majority of the lesions, however, are caused by varieties of diplococcus pneumoniae.”

The bacteriology of bronchopneumonia has not been so completely studied, but it is safe to say that the varieties of bacteria found in the exudate are more numerous, and, while the pneumococcus may be the sole causative agent, streptococci are more frequently present than in lobar pneumonia and may be the chief, if not the sole, causative agent. Careful observation and records in the laboratories of our base hospitals should give us most desirable information concerning the bacteriology of both forms of pneumonia, and there is opportunity in each of these laboratories to make useful contributions to the etiology and epidemiology of pneumonia.

The pneumococcus was first found by Pasteur in the saliva in a case of rabies, and about the same time by former Surgeon-General Sternberg in the normal saliva. The fact that many people in health carry these organisms in their saliva more or less constantly, led to the belief that pneumonia results, from the lowered resistance of the individual induced by unusual exposure to wet and cold, an attack of measles, etc., and that isolation and disinfection of sputum was unnecessary. Under this attitude toward the disease, it has not decreased and there is strong evidence that it has increased. The census of 1900 made it responsible for more than 10 per cent of all deaths.

The painstaking investigations of Cole and his associates at the hospital of the Rockefeller Institute have shown that pneumococci may be differentiated into several types and subtypes. This work is still incomplete, but it has progressed far enough to throw much light on the etiology of lobar pneumonia, and to justify us in taking quite a different view concerning the methods that should be followed in attempts to limit the spread of the disease. In a study of the mouth secretion of 297 individuals in health and without history of recent contact with a case of lobar pneumonia, 181 were found to be free from any form of the pneumococcus, while

161 showed some form of this organism. This indicates that more than half of normal individuals, without recent exposure, are free from pneumococci. In the 161, the types were distributed as follows:

Туре I 0.8 per cent
Type II - 0.0 per cent
Type IIa- 0.8 per cent.
Type IIb- 5.8 per cent
Type IIx-11.6 per cent
Type III -28.1 per cent
Type IV -59.9 per cent

In 458 cases of lobar pneumonia, the distribution of the type was quite in contrast with the above as shown by the following:

Type I -33.3 per cent
Type II -29.3 per cent
Type IIa- 1.3 per cent
Type IIb- 0.9 per cent
Type IIx- 2.0 per cent
Type III -13.0 per cent
Type IV 20.3 per cent

"Comparison of these two tables shows that the pneumococci most commonly found in the mouth secretions of normal individuals give rise to a minority of the cases of lobar pneumonia. The disease produced by these organisms, with the exception of Type III, is less severe in character, indicating a lower grade of pathogenicity of those types for man. On the other hand, Types I and II cause a majority of cases of lobar pneumonia, are of high virulence for human beings and are seldom or never found in the mouth secretions of normal individuals who have not been in intimate association with cases of lobar pneumonia. seems to indicate that lobar pneumonia due to Types I and II does not rise from infection with a pneumococcus which is habitually carried in the mouth, but that infection with these organisms occurs from without."

This

Men trained by Cole and familiar with his methods of differentiating the types of pneumococci have been placed in the laboratory of each camp in which pneumonia prevails, and we may expect much new information along this line. Cole has developed a serum which apparently gives good results in those pneumonias due to Type I. This serum is being used in cases shown to be due to this type. However, we are at present more deeply concerned with the prevention than the treatment of these diseases, and in our efforts at prevention we are proceeding on the assumption that pneumonia is a transmissible disease, and that the causative agent at least in a large percentage of cases comes from without. In doing this the probability that susceptibility may be increased by unaccustomed and untoward conditions of life must not be overlooked. Indeed,

the truth of this is indicated quite conclusively by observations extending back for centuries and recognized in many parts of the world.

We may laud the advantages of free ventilation, out-of-door living and sleeping, the hardening and bracing effects of cold weather, cold bathing, etc., as much as we please, but we must admit that when men in masses suddenly change their residence from warm, unventilated or poorly ventilated homes, to the life of the tent and the open barrack, they need warmer clothing and heavier bedding, and if these are not furnished, pneumonia takes heavy toll from their ranks. Furthermore, it seems true that the more radical and sudden this change, the greater is the toll. The Michigan lad may have his snow bath or his plunge through the broken ice, and quickly get back into his heavy woolens with impunity, but when the South Carolina youth indulges in such an experience and goes back into his cottons, insurance on his life ceases to be a good risk. The French have found it absolutely necessary to provide warmer quarters and heavier clothing in the winter for their African contingents than is needed by the native Frenchman.

Hookworm infection among the southern select men has been suggested as an explanation of the lesser resistance they show toward respiratory diseases. It may be a fact, but so far this has not been demonstrated. These facts long known to medical men seem to have been without the ken of those who provided or failed to provide quarters and clothing for the recent recruits in the southern camps. It is for the future to determine whether the Cracker from Georgia will make as hardy a soldier as the Wolverine from Michigan. Both bore many privations in the Civil War and proved themselves worthy antagonists.

To the suggestion that lack of suitable clothing has been a factor in the prevalence of pneumonia in the camps, the reply is made that warm garments in sufficiency are now in the camps or on the way to them. To the man who died of pneumonia in the base hospital in Fort Worth last month, last week, or yesterday, this reply is of small comfort. However, this is no time to look backward, but it is the time to look forward and to see that mistakes are not continued. It is the duty of the medical officer to protest repeatedly and vigorously, if necessary, through official channels, if those under his care suffer from insufficient clothing or bedding. It is also his duty to see not only that they have proper clothing, but that they wear it.

That overcrowding favors the dissemination of pneumonia can not be questioned. It multiplies the number of those within the infection range, increases the contacts and makes segregation more difficult.

On entering an amusement or assembly hall in one of our cantonments and hearing many coughing and filling the air with germ-laden spray, one can not easily dismiss the impression that these places serve as distributors of the respiratory infections. A like impression has evidently been made upon those in authority, for in several camps places of assembly have been closed and similar extra cantonment picture shows have been barred to the soldier. This procedure is regrettable but nevertheless commendable. In the process of making soldiers, some pleasures must be curtailed.

The soldier sick with pneumonia, either primary or post measles, should be immediately carried to the base hospital, and, so far as protective measures are concerned, should be treated much the same as has been recommended for those with measles. Overcrowding in hospital and the screens between beds should be remembered, the one to be avoided and the other to be provided. An individual with Type I of the pneumococcus may distribute his more fatal infection to a neighbor originally infected with the less virulent Type IV, or a streptococcus infection may be engrafted on a pneumococcus growth. The fact that empyema frequently develops in both lobar pneumonia and bronchopneumonia suggests that the streptococcus is present, either as a primary or secondary factor. Moreover, in several hospitals pneumonia has developed in physicians and other attendants. Whether patients with pneumonia do better in a cold or in a warm, moist atmosphere seems to be an undecided question. While this is being determined, it is quite certain that whatever the temperature of the inhaled air may be, the body should be protected from chill. Among those most experienced in the treatment of pneumonia, the value of digitalis seems to be conceded, but there are differences in opinion as to the extent to which this drug should be administered, as to the indications for pushing or decreasing its administration, and as to the preparation of this drug most suitable.

Inspection of our camps and their hospitals leaves one with the impression that so far as their medical personnel is concerned, the greatest need is for men skilled in the early recognition and the handling of the acute respiratory diseases. Valuable as improvements in the determination of the types of the pneumococcus and the development of curative serums are, the prevention of infection and the limitation of its spread are far more important. The daily mail of the Surgeon-General's office brings suggestions, recipes and offers to sell to the government "sure cures" for pneumonia. We can leave the treatment of this disease to the wisely selected medical officers in the base hospitals. What is needed is knowledge whereby we can prevent this

disease. However, the mere possession of knowledge is of no value unless it be accompanied by the means necessary for its application. Insufficient clothing, overcrowding in tents, barracks. and hospitals, and lack of heat in the houses, have been potent factors in the development of the pneumonia among our soldiers, and for these deficiencies the medical corps is not responsible. This is not intended as a criticism on anyone, nor does it imply that the medical corps would have done better if it had been given authority in all these matters. It does mean that in the making of an army, the health of the soldier is of first importance and this can be secured only by the intelligent cooperation of all those who are responsible for the conditions under which he lives.

The Surgeon-General has asked:

(1) That deficiencies in clothing be made good.

(2) That additional tentage and housing be provided, sufficient to give each soldier at least 50 square feet of floor space.

(3) That a detention camp be established with each division, and in which all arrivals may be kept under medical observation for such time as may be necessary.

(4) That a quarantine camp be established in connection with each division and in which contacts, suspects, and carriers can be isolated and observed.

(5) That, where necessary, tents or other housing should be provided for convalescents.

(6) That unfinished hospitals be hastened to completion, including water, sewers and baths.

(7) Additional nurses, when necessary. (8) The enlargement and better equipment of the base hospital laboratories where desirable. (9) The selection and detail of medical officers specially qualified in epidemiology as assistants to the division sanitary inspector.

(10) Provision for laying the dust in certain

camps.

the request ofthe Ordnance Department Wilmer devised a protective steel eye shield which has a single horizontal stenopaeic slit in front of each eye which allows for good vision and is by far the best. Such a shield can be fastened to a helmet. Is it advisable to make the eye shield. tight enough to keep out lachrymatory gases, or to have the gas mask entirely separate.

The treatment for the action of war gases on the eye, a cocaine salve or collyrium seems more rational treatment at first, followed by an instillation of a medicated salve for a whole week, even in mild cases.

Ginseppe says the toxic gases which induce much lacrymation are far less dangerous for the eyes than the usual asphyxiating gases. If severe injury, the cornea develops small foci of necrosis with atrocious pain in the brow, back of the neck and the temples, the eye slowly dies, the eyeball becoming completely atrophied. In his experience 16 per cent of the war injuries of the eyes were from machine guns or shrapnel. 50 per cent from flying scraps of stone, 5 per cent from glaucoma, and 25 per cent from asphyxiating gases.

Greenwood is apparently partial to some form of implantation operation in enucleations.

Conjunctival keratoplasty is most useful in injuries of the cornea for protection and the prevention of infection.

Greenwood says he cannot agree with those who consider that military ophthalmology differs from civilian only in degree, but not in kind.

De Schweinitz says that up to the present time we are obliged to depend upon clinical sings in making a diagnosis of trachoma.

fited by peritomy or more properly peridectomy. Not infrequently pannus is materially bene

De Schweinitz says trachoma is curable if

properly managed. Trachoma is often intro

duced into the army from the outside.

While other injuries determine the disposal of the patient who also has an ocular lesion, 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.

WAR AND THE EYE

P. I. LEONARD, M. D., St. Joseph, Mo.

Napoleon used to say, "I do not believe in medicine, but I believe in Corvisart" (his physician). His definition of medicine has seldom been surpassed: "l'experience chez un homme superieur," the experience of a superior man.

The war has not yet given us the ideal antiseptic.

Eternal vigilance is the price of asepsis. Greenwood, in Medical War Manual No. 3, on Military Ophthalmic Surgery, tells us that at

diable.

Terrien remarks that the visual disturbances of shell shock are generally transient.

Vaccination against typhoid may bring on a relapse of iridocyditis.

Sympathetic reaction after injury is comparatively common, appearing early and disappearing after enucleation

The poisonous drift of gases may induce iritis or neuroretinitis, but the course has proved essentially mild.

The prevention and cure of infection constitute the greatest single problem of military surgery.

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ASSOCIATE EDITORS

P. I. LEONARD, St. Joseph.
J. M. BELL, St. Joseph.
JNO. E. SUMMERS, Omaha.

CONTRIBUTING EDITORS
H. ELLIOTT BATES, New York.
JOE BECTON, Greenville, Texas.
HERMAN J. BOLDT, New York.
A. L. BLESH, Oklahoma City.
G. HENRI BOGART, Paris, Ill.

ST. CLOUD COOPER, Fort Smith, Ark.
W. T. ELAM, St. Joseph.

JACOB GEIGER, St. Joseph.

S. S. GLASSCOCK, Kansas City, Kan.
H. R. HARROWER, Los Angeles, Cal.
JAS. W. HEDDENS, St. Joseph.
VIRGINIA B. LE ROY, Streator, I.
DONALD MACRAE, Council Bluffs.
L. HARRISON METTLER, Chicago.
DANIEL MORTON, St. Joseph.
D. A. MYERS, Lawton, Okla.
JOHN PUNTON, Kansas City.
W. T. WOOTTON, Hot Springs, Ark.
HUGH H. YOUNG, Baltimore.

"Our country; its need is our need, its honor our honor, its responsibility our responsibility. To support it is a duty, to defend it a privilege, to serve it a joy. In its hour of trial we must be steadfast, in its hour of danger we must be strong, in its hour of triumph we must be generous. Though all else depart, and all we own be taken away, there will still remain the foundation of our fortunes, the bulwark of our hopes, a rock on which to build anew-our country, our homeland, America."-From American Medicine, May, 1917 (National Number.)

The Editors' Forum

The Health Officer and Patriotism

The health officer who remains at his post, faithfully and intelligently performing his duties, is serving his country in no less measure than he who goes to the front.

At the meeting of the American Public Health Association in October great emphasis was laid on the country's need for active cooperation on the part of all health officials. A resolution was adopted urging upon all public health workers "the importance of unusual solicitude and activity in conserving and promoting the health of the civilian population during and after the present war.

War conditions are adding stress and strain in all walks of life. Overwork, overcrowding of public conveyances, insufficient food and fuel and many other unusual circumstances brought about

by the war are all having their influence in rendering the individual more liable to disease. The result will inevitably be much higher morbidity and mortality unless these conditions are met by a corresponding activity on the part of the local health authorities.

Any health officer, who, by his neglect or lack of proper oversight, allows a communicable disease to become epidemic, especially in a community contiguous to an army camp or in a city manufacturing supplies used by the Allies, is assuredly "furnishing aid and comfort to the enemy." Vigilance in maintaining sanitary conditions, in preventing the transmission of infection by prompt and intelligent application of modern health measures, always of importance, is especially so at the present time.

Nearly one-half the health officers of the state accepted service as examining physicians on draft exemption boards-a remarkable exhibition of active patriotism. Less spectacular, perhaps, but fully as important, is the patriotism that causes a man to put his last ounce of energy into protecting the health of his community.Health News.

The Mastoid Operation

Aurists have a great deal to say about the conservation of hearing. The ear is usually affected in measles, diphtheria, grip, pneumonia, scarlet fever, tuberculosis and other infectious conditions. During the winter the writer has seen a large number of cases of suppurative inflammation of the ear and of mastoditis. The general practitioner still relies in many cases upon the external application of heat to the ear 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 appendicitis or calls in a surgeon. The practice is just as detrimental, even if not much more so, in mastoditis than in appendicitis. If the tympanic membrane is bulging and notwithstanding antiphlogistic and other measures with indications that perforation is likely to occur, a paracentesis membrane tympani should be performed. Or if there be an insufficient opening, this should be enlarged. It is not wise to make three or four incisions during three or four weeks or months duration, in the presence of a persistent discharge and some pain. A posterior operation becomes imperative. There is no better means of making a diagnosis in these cases than by taking the history in connection with the otascopic appearances. After a paracentesis or after free drainage from a ruptured ear drum with ostoscopic and general symptoms greatly improved, with the mastoid process greatly swollen, a large number of cases recover without mastoidectomy.

The aurist is frequently called into these cases when the patient or the parents of children become alarmed and they desire a technical opinion. The writer was called into a house on account of a twelve year old girl's ear "failing to break." There were four children convalescing from measles. Two boys had mastoditis with discharges, one of them had a second large swelling of the mastoid process, the first swelling had completely disappeared and now the second swelling was much reduced in size. One boy was in bed with a discharging ear, while the girl had a bulging ear drum and paracentesis was performed. It is nothing unusual for an aurist to meet such cases in practice and he wonders if the mastoid disease is so dangerous to the mechanism of hearing and to the life of the patient.

At any rate, the cases of otitis media suppurativa should be properly examined, by one competent to do so, and handled accordingly. All these cases invade the mastoid antrum, and this fact alone is not sufficient explanation for the commercial enterprise of an over ambitious operator. With the history of the case, ostoscopic appearances previous incisions into the ear drum, a persistent profound impairment of the function of hearing, involvement of the static labyrinth, or the persistent discharge of weeks or months, some or all of these symptoms guide to a proper procedure. P. I. L.

The Kansas City Medical
and Surgical Club

The February meeting, held at the General Hospital and the German Hospital on the 11th and 12th was well up to its usual degree of interest. The attendance was not as large as former meetings, due to the attractions offered by the Automobile Show. Some men, no doubt, went home because of lack of hotel accommodations. Everything was full to overflowing. The writer finally found a bed in a private family through the aid of Dr. Fassett. After all is said of clinics, the pleasure and profit does not all accrue from the lectures and operations. We had a little visit at the General Hospital with Dr. Ernest Robinson and discussed abdominal ptosis; then a chat over some bed cases with Dr. Skoog, on nervous work; and a talk with Dr. Knear at the German looking over x-ray pictures, all enjoyable and helpful. Medical advancement comes most profitably and pleasantly from such association, a point here, one there, from one who is well informed. It pays any doctor to run in to such a class of men as compose the Kansas City club, and the most benefit most often comes from the little talks upon the subject in mind, and the touch among men who lead. J. M. B.

A Volunteer Medical Service Corps.

The Council of National Defense on Feb. 27th, authorized the following statement:

For the purpose of completing the mobilization of the entire medical and surgical resources of the country, the Council of National Defense has authorized and directed the organization of a "Volunteer Medical Service Corps," which is aimed to enlist in the general war-winning program all reputable physicians and surgeons who are not eligible to membership in the Medical Officers' Reserve Corps.

It has been recognized always that the medical profesion is made up of men whose patriotism is unquestioned and who are eager to serve their country in every way. Slight physical infirmities or the fact that one is beyond the age limit, fifty-five years, or the fact that one is needed for essential public or institutional service, while precluding active work in camp or field or hospital in the war zone, should not prevent these patriotic physicians from close relation with governmental needs at this time.

It was in Philadelphia that the idea of such an organization was first put forward, Dr. William Duffield Robinson having initiated the movement resulting in the formation last summer of the Senior Military Medical Association with Dr. W. W. Keen as president-a society which now has 271 members.

Through the Committee on States Activities of the General Medical Board the matter of forming such a nation-wide organization was taken up last October in Chicago at a meeting attended by delegates from forty-six states and the District of Columbia. This committee, of which Dr. Edward Martin and Dr. John D. McLean-both Philadelphians-are respectively chairman and secretary, unanimously endorsed the project. A smaller committee, with Dr. Edward P. Davis, of Philadelphia as chairman, was appointed to draft conditions of membership, the General Medical Board unanimously endorsed the committee's report, the executive committee-including Surgeons General Gorgas of the army, Braisted of the navy, and Blue of the Public Health Service-heartily approved and passed it to the Council of National Defense for final action, and the machinery of the new body has been started by the sending of a letter to the state and county committees urging interest and the enrollment of eligible physicians.

It is intended that this new corps shall be an instrument able directly to meet such civil and military needs as are not already provided for. The General Medical Board holds it as axiomatic that the health of the people at home must be maintained as efficiently as in times of peace. The medical service in hospitals, medical colleges and laboratories must be up to stand

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