OFFICE OF NAVAL ADVISOR OFFICE OF MILITARY GOVERNMENT FOR GERMANY (US) Medical Section Room 124, EUCOM HDQTRS. NAVAL TECHNICAL UNIT, EUROPE FOREWORD TO THE TRANSLATION REPORT OF THE SECOND CONFERENCE OF THE MEDICAL CONSULTANTS TO THE GERM ARMED FORCES. In this report of the Second Conference of the Medical Consultants to the German Armed Forces, held in the fall of 1942 while their war ma- chine was still in its full vigor other than for one bad winter in Russia, we find them engaged largely with consideration of problems not commonly encountered in civilian practice. The necessity of indoctrination of their medical officers and troops in the treatment of these new problems is re- ferred to frequently. From the professional point of view it is interesting to note their attention to the problems of tuberculosis and psychiatric matters, and their probing into Hepatitis Epidemica and War Nephritis. From the historical point of view this was the second meeting of the Scientific Senate following the centralization of t e Medical Service which occurred as part of the general reorganization of t a Armed Forces subsequent to the disasterous campaign in Russia in the winter of 1941* Anyone interop ed in the historical aspects of the Medical Service of the German Armed For- ces is referred to the History Project of this section which will appear la- ter. ly 23 March 1948. HARRY J. ALVIS, Commander, Medical Corps, U. S. Navy. INDEX FOR REPORT OF THE SECOND CONFERENCE OF SPECIAL MEDICAL CONSULTANTS FROM 30th NOVEMBER TO 3rd DECEMBER 1942 AT THE MILITARY MEDICAL ACADEMY, BERLIN * ANNEX CONFERENCE ON PROBLEMS OF MOUNTAIN PHYSIOLOGY 4th TO 6th OCTOBER 1943 ST. JOHANN, TYROL. Translation prepared by: Office of Military Government for Germany (US) Office of Naval Advisor Medical Section, I TITUS PAGE, The lectures could be printed only in an abbrevi- ated form as short summaries. If the place of detailed publication is already fixed, this is given at the end of the respective article. Preface to the Report 2 Speech of the Chief of the Armed Forces Medical Service 4 I. Practical Problems of War Surgery. 9 1. Introductory report Directives on the treatment of cachexia due to sepsis and protein loss. Oberstarzt (Colonel, MC) Prof. WACHSMUTH 10 2. Special points on abdominal surgery and Directives on the treatment of gunshot wounds of the abdomen Oberstarzt (Colonel, MC) Prof. GOHRBRANDT 13 3. Treatment of fresh gunshot wounds of the lungs. Stabsarzt (Captain, MC.) Prof. KRA'AS 14 4. The late treatment of gunshot wounds of the lungs. Directives for the treatment of gunshot injuries of the lungs in hospitals at home. Oberfeldarzt (Lt. Col.,MC,) SCHINDLER 19 5. Primary treatment of gunshot wounds of the jaw. Directives. Oberstabsarzt (Major, MC.) Prof. WUSTROW 22 6. The late treatment of gunshot wounds of the jaw. Directives. Stabsarzt (Captain, MC) Prof. HAMMER 23 7. Primary treatment of gunshot wounds of the thigh. Directives. Oberstarzt (Colonel, MC) Prof. WACHSMUTH 25 8. Later treatment and reparative surgery in gunshot wounds of the thigh. Oberstabsarzt (Major, MC) Prof. BOEHLER 26 9. Treatment of gunshot wounds of joints. Directives. Oberfeldarzt (Lt. Col., MC) Prof. LAEWEN 29 10. Evacuation dressings Oberstabsarzt (Major, MC.) Prof. HELLNER 47 II TITLE PAGE II. Effect of Cold. 50 1. Heat regulation Oberfeldarzt (Lt.Col.,MC) Prof. fLiNKE 51 2. Prophylaxis and diagnosis. Oberfeldarzt (Lt.Col.,MC) Prof. LOEHE 51 3. Therapy of injuries caused by cold. Stabsarzt (Captain, MC.) Prof. ST.iRLINGER 54 4. Prevention and therapy of cooling effect. Stabsarzt (Captain, MC.) Prof. H0LZL0HNER 57 5. Pathology of the effects of cold. Oberfeldarzt (Lt.Col. MC) Prof. SCHULTZ 57 6. Pharmacological evaluation of the medicinal therapy of local injuries, caused by ef- fect of cold. Stabsarzt (Captain, MC.) Prof. LENDLE 58 7. Pharmacologic results in animal experiments concerning local injuries due to cold. Stabsarzt (Captain, MC.) Prof. LT1 jLE 60 III. Shock and Collapse 87 1. Clinical picture and experimental investi- gation of shock Oberarzt (1st Lieut., MC.) Prof. DUESBERG 68 2. New viewpoint concerning the pathogenesis and therapy of shock and collapse. Stabsarzt (Captain, MC) Dozent SCHWIEGR 71 3. Shock and the control of shock. SS-Standartenfuehrer (Colonel, Elite Guard) SCHLINCK 74 4. Pharmacological aspects. Oberarzt (1st Lieut. MC) Prof. KOLL 76 5. The pathological anatomy of shock Kriegsarzt (War Surgeon) Dozent SCRaLLOCK 78 IV. Malaria. 81 1 Maiaria Oberfeldarzt (Lt.Col. MC) Prof. ROSE 82 2. Malaria Oberstabsarzt (Major, MC*,) Prof* 83 3. Malaria v Oberstabsarzt (Major, MC.) Prof. MARTINI 83 III TITLE PAGE 4« Comments on the discussion on malaria and amebic dysentery. Oberstabsarzt (Major, MC) Prof. HAUER 87 5. Relationship between topography and malaria in Greece, Stabsarzt (Captain, MC,) Prof, HABS 89 6. Malaria in South Russia. SS-Standartenfuehrer (Colonel, Elite Guard) Dozent MRUGOWSKY 89 7. Control of Anopheles larva by aircraft Oberfeldarzt (Lt.Col.,MC.) Prof. ROSE 91 V, Bacillary and Amebic Dysentery. 94 A. Bacillary Dysentery 95 1. Bacillary dysentery 1942 Oberarzt (1st Lieut. MC.) Prof. SYLLA 95 2. Dysentery. Oberarzt (1st Lieut., MC) Dozent WALTER 96 3. The pathogenesis of dysentery. Oberstabsarzt (Major, MC.) Prof. 97 B. Amebic Dysentery 102 1. Experiences with amebiasis in Lybia Stabsarzt (Captain, MC.) Prof. HORSTER 102 2. Parasitology of amebic dysentery Sonderfuehrer (Special Consultant) WESTPHAL 105 VI. Typhus. 107 1. Early symptoms, problems of evacuation and treatment Oberstabsarzt (Major, MC.) Prof. DENECKE 108 2. Therapy for typhus. Oberstabsarzt (Major, MC.) Prof. v.FAL- KENHAUSEN 112 3. Thepsychic disturbances in typhus. Oberstabsarzt (Major, MC.) Prof. v.STOK- KERT 114 4. Pathological anatomy of typhus. Stabsarzt (Captain, MC.) Dozent BOEHNE 115 IV TITLE FA<1j VII* Paratyphoid C, Wound Diptheria, Scarlet Fever ana Hemolytic Streptococci 120 1. Paratyphoid C. Btabsarzt (Captain, MC.) Prof. HABS and Kriegsarzt (War Surgeon) BADER 121 2. wound diptheria Oberfeldarzt (Lt. Col.,MC) Prof. BUERGERS 122 3. Scarlet fever and hemolytic streptococci Oberarzt (1st Lieut., MC) Prof. v. BORMANN 124 VIII. Tuberculosis. 128 1. The effect of special types of climate on the treatment of soldiers suffering from tuber- culosis. Oberstabsarzt (Major, MC.) Dozent DEIST 129 2. Russian P. W.*s suffering from tuberculosis and their effect on the German population. Oberfeldarzt (Lt.Col.,MC.) Dozent NICOL 129 3. The different typos of tuberculosis in soldiers at the front. Oberfeldarzt (Lt.Col.,MC) 130 4. Tuberculosis diagnosed at the right time in the field Oberstarzt (Colonel, MC) Prof. SZERREIKS 133 5. The care of soldiers in the Field Army who suffer from tuberculosis. Oberfeldarzt (Lt.Col.,MC.) KREUSER 135 6. Tuberculosis occurring in foreign colonial troops. Oberstabsarzt (Major, MC.) ROLOFF 136 IX. Hepatitis Contagiosa (Epidemica). 13$ 1. Clinical considerations. Oberfeldarzt (Lt.Col.,MC.) Prof. GUTZEIT 139 2. Pathology of hepatitis epidemica Oberarzt (1st Lieut., MC.) Dozent BENECKE 142 X. War Nephritis 151 1. War nephritis Marine Oberstabsarzt (Lt.Comd.MC, Navy) Prof. VOLLHARD 152 2. Pathologic© * anatomical bases for the concept of ”War Nephritis”. Oberfeldarzt (Lt.Col.,MC) SPONKOLZ 15$ V P..GE TITLE XI. Influences of Climate and of Nutrition in Af f i o a; S cur vy 7 166 1. Influence of climate and kind of nutrition of German soldiers in North Africa. Stabsarzt (Captain, MC.) Prof. HORSIER 167 2* Cardiac findings among soldiers of the AfMca Corps Obefstabsarzt (Major, MC.) Prof. KXMMERER • l*v? 3> Scurvy. Stabsarzt (Captain, MC.) FAEHNDRICH 173 XII. Lues, Gonorrhea, Scabies. 173 1. Salvarsan poisoning Oberfeldarzt (Lt.Col., MC.) Prof. LOEHE 17? 2. Chemotherapy of gonorrhea in the Army Oberfeldarzt (Lt.Col., MC.) Prof. OOTTRON 175 3. A rapid form of treatment for scabiea. Marineoberstabsarzt (Lt.Comdr.,MC. Navy) Prof. BIRNBAUM 176 XIII. Proceedings of the Consultantsf Comml, ,oe on Psychiatry 177 A. Psychogenic Reactions. 176 1. Hysterical reactions in the Field Army. Oberarzt (1st Lieut., MC.) Dozent MIKOREY 176 2. Hysterical reactions in the Reserve Army. Oberkriegsarzt (Col., MC.) Prof. BUMKE 17? B. Differential diagnosis between schizo- phrenia and event-reactionsT 165 and event-reactions. Oberstabsarzt (Major, MC.) Prof. K.SCHNEIDER 165 C. Problems of encephalitis. 167 1. Problems of encephalitis Stabsarzt (Captain, MC.) Prof. C. SCHNEIDER 167 D. Causalgia. 188 1. Oberstarzt (Colonel, MC.) Prof. WUTH 166 2. Oberfeldarzt (Lt. Col.,MC.) FUCHS 169 3. Stabsarzt (Captain, Carl FOHNEIDER 19^ 4. Stabsarzt (Captain, MC.) Dozent ZENKER 191 VI TITLE P,xGA E. Punishable acts associated with drank- nessi ' 191 Military-medical expert opinion concerning alcoholism Oberstabsarzt (Major, MC.) Prof. MUELLER- HESS and Oberstabsarzt (Major, MC.) ROM- MENEY 191 XIV. Proceedings of the Consultants1 Committee on Pharmacology 194 1. Chemical warfare problems. Oberstabsarzt (Major, MC.) Prof. WIRTH 195 2* Cooperation of the consultant pharmacologist and the medical officers for chemical war- fare problems for the protection against enemy preparations for chemical warfare. Stabsarzt (Captain, MC.) Prof. GIRNDT 201 3* New experiences in air-raid defense medical service and the problems of the air-raid warden in case gas is used. Oberstabsarzt (Major, MC.of the Police) KRAEFFT 201 4. Poisoning in war. Oberstarzt (Colonel, MC.) Prof. FLURY 203 5. Accidents with fire-extinguishers. Flottenarzt (Captain, MC., Navy) PFLESSER 206 6. The pharmacological viewpoint on drug-therapy. Oberarzt (1st Lieut., MC.) Prof. KOLL 207 7. Problems of medical equipment from the pharma- cological aspect. Stabsarzt (Captain, MC.) Prof. LENDLE 209 XV. Proceedings of the Consultants1 Committee on Pharmacy and Food Chemistry." 210 1. Physical and chemical analysis and puri- fication of drinking water. ’Oberfeldapotheker (Lt. Col. Pharm.Corps.) Dr. GEMEINHARDT 211 2. Experiences with the supply of drinking water for the troops. SS-Sturmfuehrer (2nd Lieut.Elite Guard) GERSTEIN. 211 Water supply in North African theater of operation. ___ Stabsarzt (Captain, MC.) Dr. GOEPFERT 212 VII TITLE PAGL. Equipment for chemical water analysis Stabsapotheker (Captain, Pharm.Corps) Dr. LEHM4NN 213 The equipment for water purification Oberstabsapotheker (Major, Pharmacy Corps) Dr. WILLECKE 213 The acitivity of the chemical laboratories of the Field Army. Oberapotheker (1st Lieut., Pharm. Corps) Dr. HOFFMANN 213 The activity of the chemical stations in occupied and home territories. Stabsapotheker (Captain, Pharm.Corps) Dr. LINDNER 214 Examination of food. Oberfeldapotheker (Lt. Col., Pharm.Corps) Dr. DILLER 214 Peculiarities of the Russian sanitary equip- ment . Oberstabsapotheker (Major, Pharr . " e?ps) Prof. Dr. UNGERER 214 Winter hazards for medical supplies and preventive measures. Stabsapotheker (Captain, Pharm.Corps) Dr. KOCH, and Oberstabsapotheker (Major, Pharmacy Corps) Dr. PREUSS 215 Problems of medical equipment from the phar- maceutical point of view. Oberstabsapotheker (Major, Pharm.Corps) Dr. UNGER and Oberstabsapotheker (Major, Pharm.Corps) Dr. MAISS 2l6 XVI. Proceedings of the ConsultantsT Committee on Forensic Medicine. 21? Ammunition violating International Law. Oberfeldarzt (Lt.Col., MC.) Dozent PANNING 218 Self-inflicted mutilation by gunshot and other mechanical influence Oberstabsarzt (Major, MC.) Prof. MUELLER 220 The organization of the forensic-medical service in the theater of operations. Oberfeldarzt (Lt.Col., MC.) Dozent PLANNING 220 Experiences concerning forensic-medical service in frontlines. Stabsarzt (Captain, MC.) Prof. BUHTZ and Stabsarzt (Captain, MC.) Prof. SCHNEIDER 221 VIII TITLE Eh. Organization of the forensic-medical service in the homeland. Oberfeldarzt (It. Col*,MC.) Dozent PLANNING 221 The forensic-medical investigation on Soviet violations of International Law. Stabsarzt (Captain, MC.) Prof. Dr. BUHTZ 221 Search of evidence of Soviet violations of International Law. Dozent SPECHT 222 The problem of self-inflicted injuries. Oberfeldarzt (Lt. Col;, MC.) Dozent PLANNING 222 XVII. Various Lectures in the Field of Hygiene. 223 1. Geomorphological analysis as an element of fighting epidemics* Oberstarzt (Colonel* MC*) Prof. RODENVLJDT 224 2. practical results of predicting epidemics SS-Untersturflifuehrer (2nd Lieut.,Elite Guard) Dr* ZIEZOLD 225 3. New bioclimatic apparatuses and ox">r ience with them in Southern Russia. SS-Obersturmfuehrer (1st Lieut., Elite Guard) Dozent SCHARLAU 226 4. Medical cartography and control of epidemics. Oberstarzt (Colonel, MC.) Prof. ZEISS 22? 5. The sanitary situation in some regions of Africa, as seen from the point of view of the military hygienist. Flottenarzt (Captain, MC., Navy)Prof.ZSCHUKE 23C XVIII. Night-vision; Problems of Forensic Medicine. 234 1. Comparable experiments with different instru- ments for testing night-vision. Marineoberassistenzarzt (Lt.j.g.MC., Navy) F. A. HAMBURGER 235 2. Forensic medical questions. Oberfeldarzt (Lt. Col.,MC.) Prof. GUTZEZT 237 3. Forensic medical questions. Oberfeldarzt (Lt. Col., MC.) Prof. LOUCHE 238 ANNEX CONFERENCE OF THE CONSULTANTST COMMITTEE CON- CERNING PROBLEMS OF MOUNTAIN PHYSIOLOGY. (4 to 6 October 1$4£» St. Johann, TyroIT) 239 Foreword Oberfeldarzt (Lt. Col.,MC.) Prof. Dr. Dr. LANG 240 1. Sports and circulation. PARADE (Innsbruck) 241 IX TITLE IAGE 2. Heart and lack of oxygen. H. SCHWIEGK (Berlin) 242 3. Suitability for mountaineering. BilLKE (St • Johann) 243 4. Natural adaptation to high altitudes. LUFT (Berlin) 243 5* Exchange of gases at high altitudes. OPITZ,(Berlin) 246 6. Effect of cold. BREITNER, (Innsbruck) 246 7. Effects of cold. LOOS, (Innsbruck) 247 8. Chemical regulation of heat in extreme cold. KRAMER,(Berlin) 248 9. Clothing problems RANKE (Berlin) 248 10. Practical problems of the protection against cold. HILDMANN (St. Johann) 249 11. Problems of the metabolism in the high mountainsr LANG ( Berlin ) 230 12. Heat regulation in conditions of excessive heat. RANKE, (Berlin) 231 13. Physicochemical problems of respiration. FISOHBECK (Berlin) 14. The substances affecting blood formation. WESTPHAL (Berlin) 253 15. The measurement of physical efficiency. XEHM.NN (Dortmund) 25^ 16. The efficiency of the mountain soldier. CREMER (St. Johann) 253 REPORT , OF THE SECOND CONFERENCE OF SPECIAL MEDICAL CONSULTANTS FROM 30th NOVEMBER TO 3rd DECEMBER 1942 AT THE MILITARY MEDICAL ACADEMY. BERLIN ANNEX CONFERENCE ON PROBLEMS OF MOUNTAIN PHYSIOLOGY FROM 4th TO 6th OCTOBER 1943 ST. JOHANN, TYROL Translation prepared by; Office of Military Government for Germany (U* 8# ) Office of Naval Advisor Medical Section 2 PREFACE TO THE REPORT The second cdnference on the problems concerning the war in the East took place from 30 November to 3 December 1942 in Berlin. This conference for the first time met under the auspices of the entire Armed Forces and brought together Chief Medical Officers, Consultant Surgeons and Specialists of all branches of the Armed Forces, SS-troops (Elite Guard) and all the affiliated organizations* This second conference had the same purpose as the first conference, held in May 1942, namely to review critically all military regulations in the medico-scien- tific field. The prospect of the second winter of war offered new problems* As a master of course, the ex- perience ,gained-during the past winter served as a basis for the discussions of questions which had become urgent. The presence of experts of all branches of the Armed Forces promised that the results of this conference would be par- ticularly fruitful, especially in view of the fact that certain problems had been successfully attacked by different branches of the Armed Forces. The consultant internists in collaboration with the Physiologico-Chemical-Institute of the Military Medical Academy brought about many interesting discoveries con- cerning the soldiers’ diet, both in peace and war times with regard to scurvy. The results of this cooperation revealed that certain assumptions with regard to deficiency diseases, especially the so-called MhypovitaminosesM had to be revised in certain respects. The world wide extension of this war and the fact that important tactical operations have to be carried out under extremely varying climatic conditions, make necessary to include, more than ever before, geo-medical considerations in the scope of the discussions* Nowadays, diseases which are peculiar to tropical climates offer a problem to the field surgeon w'ho must be familiar with their importance, diagnosis and treatment; the consultant surgeon, on the other hand, has to Include these diseases in his research plans. The importance of this second conference is immediately acknowledged by the fact that such a wide variety of problems has been considered* The conference, in a certain respect, gives a picture of the events of the war during 1942 as they occurred in the areas in three parts of the world. The minutes of this meeting had to be condensed. They are herewith presented to the Chief Medical Officers as well as to all Consultants. In so far as the instructions compiled in connection with the different topics necessitate a modification of the current Medical Manual No. 209, this fact must be borne in mind in case of a reprint of the cor- responding chapters. It is not intended that those re- visions deemed necessary shall be published in label form to be pasted in over the original text* The medical personnel are supposed to adhere to these minutes, unless an extensive alteration of the existing medical arrangements are re- quired# The Army Group Surgeons, Chief Surgeons and Consultants ire especially advised to study the results carefully and to avail themselves of the practical applications# A limited lumber of copies of this report is placed at the disposal Df the important hospitals# /s/ Dr. HANDLOSEE Speech of the Chief of the Armed Forces Medical Service. Gentlemenl The demands due to the extension of this total war and the ratio between the requirements and the availabilities in regard to personnel and material necessitate the adoption of drastic measures towards simplification and centralization of authority* The military maxim "to ‘advance upon an Objec- tive separately and to fight as one unit” must, with regard to our present problems, be revised. The conditions which now face us, necessitate a complete change of this tactic: "wc must now march and fight as one unit". In accordance with this new concept, the post of Chief of the Armed Forces Medical Service has been created out of the former office of the Armed Forces Medical Service. Not only personnel and equipment but also all problems of medico- scientific training and research must be coordinated in a general plan. Therefore, the circle of the participants of the Second Conference (East) is wider thah that of the First Conference in May 1942, which was properly speaking a conference of the Army alone. Today representatives are present of the three branches of the Armed Forces, the SS-Troops, the Police, the Labor Service, and the Organization TODT. Gentlemen, you will allow me to extend to you a word of welcome and I wish to express the hope that our combined efforts may show favorable results. A special welcome is extended to Secretary of State, Chief of the National Health Service, Dr. CONTI, in whose responsibility lies the guidance of this project in the civilian sphere. I see in his presence not only an expression of interest but also an expression of concern towards the Armed Forces. I need not emphasize that we share the feeling of responsibility towards the fighting soldiers and give him the assurance that everything possible is being done in the medical field at home to keep up the highest level that can be attained under war conditions. In consideration of the new participants in today’s conference it seems necessary to review the scope of former medical conferences: January 194-0 Found-treatment, wound—infection, blood-transfusion under combat conditions, injuries by chemical weapons, dysentery, neurosis, psychopathia and organic diseases, evacuation of wounded soldiers; October 194-0 Gas-edema: prophylaxis and therapy; December 1940 Immunizations: typhoid-fever, dysentery, combined immunizations; May 1942 First Conference "East" The problems with which we have been confronted in the East, namely the boundless depth of the Russian territory, the condition of its inhabitants and the thinly distributed railroads in Eastern Europe, the ever present danger of an invasion of epidemics from the Asiatic countries and in particular the Russian winter, are reflected in the topics of the first con- ference dealing with: Technique of amputation; - brain injuries and their treatment, coordination of neurology and surgery; - chemotherapy of wound infections; - evacuation of the wounded. Typhus, Volhynia fever, recurrent fever, bacillary and amebic dysentery, typhoid fever, diphtheria, tularemia, war nephritis# Effects of cold, Reduction of the general resistance. Treatment of psychogenic reactions. Sulfonamide treatment of neurological diseases# It is particular interesting to observe how the topics of today’s conference mirror the developments of the severe war in the East* As far as surgery is concerned, the conference will deal in the first place with problems of abdominal surgery, injuries of the lungs, maxillary injuries, injuries of the joints, fractures of the thigh due to gunshots, surgical treatment of the injuries caused by cold. The internists are chiefly concerned with hepatitis epidemica and war nephritis* As a matter of course, special attention is de- voted to tuberculosis. Dermatologists and experts of foren- sic medicine participate for the first time. Fortunately, Ihe presence of the dermatologists has not been called forth by an increase of venereal diseases* Their cooperation has been assured in connection with the problems of the effects of cold* You will realize that also the experts of foren- sic medicine have an important task to fulfil in the fourth year of the war* Their activity is highly important for the proper administration of justice and a closer cooperation in line with the general objectives of the commanders of the Army Groups will be consiered. The work of the hygienists and specialists for tropical diseases will be concentrated 6 on wound diphtheria and malaria. Oberkriegsarzt (Lt. Col., MC.) Professor KLIEWE will acquaint you with pre- paratory measures of our enemies which have not been dis- closed so far. The pharmacologists who did not participate at the last conference have been invited again as it ap- peared timely to recall the essential points of the treat- ment of injuries caused by chemical weapons. Specialists for tuberculosis also are among the new guestsTThey work together in their pursuits with the pathologists and in- ternists. Examinations carried through in this war have thrown a light on the course of tuberculosis in colored people, who had never before come in contact with this disease. New findings concerning tuberculosis are relevant in connection with the evaluation of disabilities incurred in the service and arc important enough to be included in our considerations. This war has called for extensive operations in deserts and salt steppes which offer considerable problems with regard to a regular supply of potable water# The chemical analysis of water and devices for the chlorination and purification of water have, therefore, become major problems. The evaluation and examination of foodstuffs from the chemical point of view deserve special attention with regard to the critical supply situation, weather con- ditions, long transport distances etc? The examination of the nutritive value of the prepared meals, that is to say the value of the actual intake, and a simple classification of foodstuffs according to their caloric value is of special importance. The procedure of this conference will be much like the last one and the different problems will be discussed ac- cording to the present state of knowledge# Thereupon the measures and amendments deemed necessary will be determined. I would ask you to use your best endeavours to lay here the broad and reliable foundation and scientific basis for all military orders and directives in the medico-scientific sphere, but doing so you will contribute an important share to the combat efficiency of our valiant troops. Another Russian winter with all its hardships and perils lies ahead of us. We enter this winter with sub- stantially better preparation than the last one. We have taken ample advantage of all the experience gained and are- confident that the coming winter will find us well prepared in every respect. Our soldiers are well eouipped to defy all the hazards of the season. Extensive preparations were made to launch an efficient campaign against typhus. Aside from swiftly operating central delousing stations, we have established a great number of mobile units which enable us to decentralize the combat against lice# We succeeded in increasing the output of typhus vaccines of the existing plants and new plants will be added which promise a still greater supply. The prophylactic measures with atabrin against malaria proved satisfactory in every respect and the combat ef- ficiency of the troops could be maintained even in areas where malaria is most prevalent. Particularly successful work has been done in the field of general hygienic measures and terrain sanitation carried through during the summer in the respective areas* These measures have been pro- ceeded by thorough investigations not only of the topo- graphic but also of the ethnographic conditions* The dis- cover of the spleen index in children in these areas is a result of these investigations. The laboratory train of the High-Command of the Armed Forces as well as the motorized laboratory units of the Army and the malaria instructors have done an excellent job in cooperation with the consultant internists; their work will prove beneficial for the popu- lation of these areas for many yeais to come* The combat of epidemics has been entirely?” reorganized in the different theaters of war,, Medico-topographic in- vestigations furnished the necessary basis. The atlas of epidemiology which has now been published covers all areas which might possibly be of interest in this war and it will be placed at the disposal of all interested organizations as a source of fundamental information* Although this atlas for obvious reasons will not be on sale in the bookstores it will, however, be made available to the medical schools as a means of preparations of the students for their future military assignment. A soldier does not look back on past events and neither does the surgeon, who is a soldier of the Armed Forces. In this circle, however, an appreciative consideration of the work done in the past three years of war v/ill not be out of place. The medical chores and military necessities have to follow principles of their own and in the person of the medical officer lies the synthesis to make these principles compatible with one another. Although all the parties con- cerned quickly agree on the general route to follow, tbe practical application often conflicts with the actual con- ditions* The more often we find ourselves confronted with bottlenecks due to space and time, the more it will be nec- essary to resort to compromises which not infrequently con- stitute the only solution of a problem under given circum- stances • In this connection I wish to say a few words on the technicality of the reports of the consultant surgeons. They should be brief and concise and include definite proposals. Special consideration must be paid to the actual wartime conditions to ensure that the suggestions are practical* It will, therefore, be necessary to con- tact all Chief Medical Officers ahead of time who in some way are involved in a certain problem* If military commands are involved the responsible officers have to be informed in due time. The Chief Medical Officers should assume the liaison to military commands. Hand in hand with your advisory function goes the practical work whenever the opportunity arises. The long duration of the war makes your cooperation in this respect more necessary than ever before. Many or our medical students have had no connection with their alma mater for more than three years. Thousands of young physicians have been inducted as field surgeons and many of them stay on that post for years. It is, therefore, an important task of the consultant surgeons to acquaint their young colleagues with the progress in the medical field and above all to train their diagnostic capabilities. Special plans have been conceived for a perpetual rotation of the front line surgeons and surgeons at home, but the adverse conditions of war make a systematic and quick rotation impossible. hre must, therefore, aim at a de- centralization of medical training in order to avoid serious shortcomings. At our first conference "East11 in May we have paid tribute to two of our comrades who had-lost their lives for our country: Oberstabsarzt (Major, MC.) Prof, SEELIGER and Oberstabsarzt (Major, MC.) Prof, SOMMER. Since that time two more consultant surgeons have sacrificed their lives for their country. Oberkriegsarzt (Major, MC.) Prof. 6UBPFLE, consultant hygienist of the 6th Army died on 29 September 1942; Gbcrstabsabzt (Major, MC.) BASTEN, consultant hygienist of the 9th Army died in the field as a victim of typhus on 20 November 19421 Ober- feldarzt (Lt. Col., MC.) Prof. KIRCHNEH, Consultant Surgeon of Wehrkreis XII, died on 30 August 1942 at Heidelberg as a victim of an insidious disease. Three highly merit!torious men have passed away who served the medical cause in peace and wartime. They live in our memory together with the great number of surgeons and assistant surgeons who lost their lives in Soviet Russia and Africa and who set an example of loyalty and high sense of duty. You have risen in tribute to these soldiers* I thank you* And now I finally have at heart to thank you for your faithful cooperation in the past three years of war. This work bears its reward in itself and will stand as a magnificent monument of the achievements of the German physicians in this war which becomes visible in the lives saved and in restored health and working capacity. I wish your work all the success. All knowledge, research and advice is crowned by action and it is the objective of our conference today to pave the way for action to the benefit of our valiant German soldiers. 9 I. PRACTICAL PROBLEMS OF WAR - SURGERY Translation prepared by: Office of Military Government for Germany (U« S. ) Office of Naval Advisor Medical Section 10 Amputations in case of injuries due to cold TSee Section II, Article 3) 1» Introductory report. Directives on the treatment of cachexia due to sepsis and protein loss* Oberstarzt (Colonel, MC.) Prof. WACHSMUTH The demand for special hospitals for patients, who for personal or material reasons require certain con- ditions, seems to be justified. This refers first of all to severe injuries of the extremities, jaw and skull, due to gunshots. In addition to especially qualified personnel, these special hospitals ’rould have to offer all the tech- nical facilities necessary for the efficient treatment of the respective diseases. Whether the establishment of these special hospitals is practically possible, depends beside the difficulties of organization and transportation, general medical economy, etc., in the first place upon the number of patients concerned# On the basis of the statistics at hand concerning patients under treatment in the different military districts, the conclusion has been reached that the establishment of special hospitals or special wards for patients with injuries of the jaw, skull and lies within the realm of possibility. It would, however, be difficult to create a similar organi- zation at home for all severe injuries of the extremities which would have to include, in addition to fractures of the femur and injuries of knee joints due to gunshots, at least tho severe injuries of the leg and of the upper extremities. Even a considerable increase in the number of the already existing special hospitals would not be sufficient to meet the actual requirements. With the view of improving the results of the treatment of the patients now being admitted to small hospitals and who suffer from severe injuries of the extremities due to gunshots, only one solution seems possible, namely, the establishment of 1 or 2 hospitals for instructional pur- poses in every military district. In these hospitals, information and practical advice ought to be given in rotation to all surgeons at home entrusted with tho care of these severe injuries, in order to establish uniform treatment procedures. This endeavour, which can be directed centrally is, however, not intended to create a stereotyned pattern of treatment. We rather aim at disseminating the well established principles, many of which are frequently enough disregarded in many places. These courses ought to include the following topics; Theoretical and practical instruction; I# General surgery* 1. Treatment of combat injuries and their compli- cations; 2. Treatment of infections in general; 3* Secondary hemorrhages; 4. Blood transfusion* blood substitutest continuous intravenous drip. II. Surgery of the extremities. 1. Indication and technique of fixation by plaster of Paris bandages, free extension, combination of wire and plaster; 2. Technique and indication, for the perforated rod apparatus; 3. Indication and technique of sequestrotomy; 4. Indication and technique of the reduction of fractures (by extension, plaster of Paris casts, closed and open reductions, etc.); 5. Indication and technique of follow up treatment of injuries of the joints (conservative and active surgical intervention); 6. Indication and technique of amputation and cor- rection of stump; 7. Indication and tefchnique of treatment of pseudar- throsis; 8. Indication and technique of removal of foreign bodies; 9. Indication and technique of local and general treatment by movement exercises in the sick-bed and during the follow up treatment. One outstanding problem, namely the treatment of con- ditions which we night describe best as septic cachexia and cachexia due to loss of protein, is still of much con- cern to us- We observe these conditions in wounded patients, generally of youthful age, with severe bleeding or sup- purating injuries, who fade away in spite of all treatments. Numerous cases of this kind have been observed and studied in all details in the special hospitals for surgery and by the special group of surgeons. A continuing observation of the protein content (DUESBEHG and SCHROEDER) has been instituted on these patients. A report on the loss of plasma and protein during one month in a wounded patient and examinations at the special hospital for surgery concerning the average loss of protein and possibilities of replacement reveal that with an average daily loss of 12.6 grams of protein, it is only possible to maintain the protein balance by a daily serum infusion of 320 cc. or by a daily blood transfusion of 107 cc. Causes, clinical picture and treatment of cachexia ~~ciue to sepsis "and protein loss# I. Causes: High grade physical exhaustion, lack of food, per- sistent increase of metabolism (fever), protracted loss of protein of the body through hemorrhage and suppuration produce a general decrease of resistance and a consumption of the protein reserves of the body. A hynonroteinemia develops. Progressive toxic damages to vessels, heart, liver and kidneys render the initial conditions still w^rse. II* The clinical picture: The clinical picture is characterized by a seri ous emaciation, loss of appetite, profuse serous and purulent secretion from the wounds, diarrhea and edemas in the in- volved parts of the body. A conspicuous reduction of hemo- globin and leucocytes can be observed in the blood picture. The content of plasma and albumin is decreasing. The extra- vasation of blood and tissue is to be explained by a shifting of the osmotic relation of blood and tissue because of the hypoproteinenia. Disturbances of the functions of the heart, liver and kidneys are the clinical symptoms of a developing serous inflammation of one of these organs. Ill* Treatment; The treatment includes? 1. The removal of the cause of the protein loss by surgical measures such as incision, early amputation or disarticulation; 2. parenteral and enteral supply of protein by blood transfusion, serum infusion, by adequate food rich in protein (milk powder, eggs, meat): use of duodenal tube feeding in case of complete loss of appetite. The supply of liquid alone is of no avail; 3. administration of drugs, such as adrenalin de- rivatives, iron preparations, adrenol cortical hormones. Discussion; In order to avoid unnecessary loss of protein, GOETZE recommends the earliest possible closing of all important granulations by means of repeated graftings according to the method of BRAUN, in addition to blood and scrum in- fusions * 13 2» Special points on abdominal surgery and Directives on the treatment of gunshot wounds of* the abdomen Oberstarzt (Colonel, MC.) Prof* GOHRBRANDT Every patient with an injury of the abdomen caused by a projectile or with an injury of the abdominal organs should be operated as soon as the circumstances permit and as long as the operation promises success. A limitation of time for the operation (10 to 12 hours) does not actually etfist. The name of the medical unit is not decisive with regard to the place where the operation should be performed. Advantage should be taken of the first opportunity for operation which offers the possibility for a subsequent period of quiet. The operation has to be performed in the most simple manner. Large resections, especially resection of the large intestine, should be avoided in favor of a marsu- pialization. The surgical treatment stands in the foreground. Additional use of sulfonamides is recommended. For local application in case of partial peritonitis Prontalbin- Marfanil powder (up to 30 grams) is strewn over the in- fected area; in case of a diffuse peritonitis dissolved sulfonamides will be poured into the abdominal eavity. In addition to this local Prontalbin treatment the custom- ary treatment with sulfonamides in case of peritonitis will be instituted. Furthermore it is advised to use a peritonitis serum derived from several strains. An immediate effect is only produced by intravenous inoculation. No anaphylactic shock is to be feared if the serum is given slowly during a deep narcosis or otherwise by continuous intravenous drip. It is suggested that the poisonous substances due to a disintegration of body protein be referred to as nNoxinen, For their elimination parathyroid preparations are recommended. Discussion* In patients with a reduced power of resistance, GOETZE suggests sewing up the linea alba with a continuous buried suture with 0,3 mm. strong, extra soft and non-oxidizing wire of Krupp's V2A steel. In this manner an evisceration is avoided. For the closing of fistulas of the rectum draining to the back, GOETZE suggests mobilizing the rectum on both sides upwards and downwards by approach from the hollow of the sacrum and to cover the resulting hole with a large pedunculated flap of skin. KRUEGER: Suggests the use of sulfonamides for ab- dominal injuries; he believes that his good results (55 per cent of complete recoveries in nearly 1000 cases of abdominal injuries caused by gunshots, which percentage includes the fatalities occurring in base hospitals) could be obtained thanks to the use of sulfonamides# W. SCHULZE: Declared himself decidedly in favor of sulfonamides. SMIDT: Rejects the ihtraperitoneal use of sulfona- mides. As many as 7 surgeons obtained 50 percent recover- ies, although under peace time or similar conditions, with- out having recourse to sulfonamides. 3» Treatment of fresh gunshot wounds of the lungs. Stabsarzt (Captain. MC«) Prof» KRAUSS According to the experience gained by this consultant in cases at the Eastern Front, the treatment of newly inflicted lung injuries caused by projectiles must fulfil three conditions: 1. surgical treatment of the wound$ 2, the elimination of pathological pressure con- ditions ; 3* prompt restoration of normal pressure conditions within the thoracic cavity. The first condition is based on the general principles of war-surgery; chest wounds, however, for vital reasons call for the closing of the open pneumothorax by suture. The suture of the musculature should be used, if possible in two layers; the suture of the skin as the third layer may be delayed up to 12 hours and under particularly favor- able conditions up to 24 hours. Injuries caused by shell and mine splinters of bullet size frequently lead to severe phlegmons within the muscular parts of the pectoralis and shoulder area and in this case, the trimming and fixation of the wound according to the conservative procedures is to be preferred. The bleeding is to be_stopped by approxi- mation sutures which are to be placed with round needles. Particular care must be given to the intercostal and internal mammary arteries. The removal of a fragment of a missile from the lungs will be done only it it can be done easily and if the lungs have to be exposed anyhow. The second point, namely the elimination of pathological pressure conditions, includes the closing of the open pneumothorax in order to stop the shifting of the mediastinum. If the closure cannot be effected by suture even by shifting of the soft parts, tamponade of the pleural cavity is the method of choice* Artificial respiration is not an absolute necessity in this procedure, it contributes, however, to the allevia- tion of the oatientfs distress. Pressure and valvular pneumothorax are eliminated in the acute stage by aspiration. The closed drainage of the valvular cannula is superior for permanent relief. In case of a displacement by liquid a slowly applied aspiration in the acute stage aiming at establishing the equilibrium of the mediastinum, e#g. the pressure value of ± 0, must be considered as the method of choice. A mediastinal torsion in case of a partial collapse of the lungs will be removed immediately by.a therapeutic pneumothorax. Dorsal mediastinotomy is in- dicated in case of a mediastinal emphysema# The third step is the restoration of normal intrathoracic pressure conditions which help the body to remove blood and exudate along with the creation of conditions favorable to the respiration and the circulation as well as to the biologic function of the pleura. At the same time the lungs are expanded and this expansioh is particularly important for the healing of amr pleural disease, as the stress is taken off the suture of the open pneumothorax and a secondary extravasation as well as a thick callous coat of the lungs and the resulting residual cavities are avoided# This is synonymous with a shorter treatment aid protection against infections and their sequelae: amyloidosis and cachexia. Closed drainage is the method of choice to obtain these conditions and the intrathoracic physiology responds favorably to all types of punctures, from the single puncture to the permanent puncture performed as a closed drainage according to BUELAU. The practical conclusion which imposes itself is the early aspiration of the hemo- thorax under normal pressure conditions after 3 to 5 days. The duration of each aspiration depends primarily on the intensity of pain and cough irritation experienced by the patient. As a rule 3 to 4 aspirations within 2 to 3 weeks will be sufficient. In case of a continuous outpouring of exudate following a sterile hemothorax the application of closed drainage should not be delayed for more than 3 weeks# The infected hemothorax ought to be treated by closed drainage not later than 8 to 12 days after the injury# In case of a later application, the lungs fail to expand, unless auxiliary means are. employed# A second- ary open pneumothorax calls for a closed drainage after an approximation of the wound by bandages or suture# As a logical conclusion, the prophylactic application of closed drainage is to be advised in all those cases of larger in- juries of the thorax in which the closure of the open pneumothorax by suture could only be performed by the use of pressure or by the shifting of the soft parts. In case of an infected hemothorax a delayed application of closed drainage may prove hazardous, since the growth of the resorptive surface and quantity, as well as the formation of the pleural callosity, constitute additional hazardous factors# The particular advantage of closed c'rainage con- sists in the concomitant removal of the exudate and ex- pansion of the lungs vrhich promises a satisfactory result. The expansion of the lungs is secured only in case of an early use of closed drainage. The intercostal method for the initiation of closed drainage is always to be performed early# The leakage around the tube which begins around the 5th and 7th days, usually stops after 6 to 8 more days. In case of an early use, the expansion of the lungs usually requires 3 to 5 days. Empyemas due to injuries caused by projectiles are poor in fibrin. The occasional blockage of the drainage may be eliminated by rinsing with a boric solution. A renewal of the suction power of the negative pressure system is to be performed twice daily# The_ application of closed drainage under front line conditions is possible; it represents no obstacle to an evacuation. Discussion: KRUEGER: Also suggests the use of sulfonamides in case of fresh lung injuries due to gunshot# In about^ 1000 cases of injuries of the lungs caused by projectiles, the rate of mortality, including all cases which turned out fatal later on in hospitals at home, amounted to 12,6 per cent. W. SCHULZE: Proposes the use of silk thread for sutures of the open pneumothorax and warns expressly against the use of catgut. Good results with regard to the pressure conditions of the suture of open pneumothorax have been observed by the application of subperiosteal, pericostal loops of wire around the adjacent ribs. KHAUSS: Has not observed an essential influence of sulfonamides on lung injuries caused by projectiles# Directives for the treatment of newly inflicted injuries of the lungs due to gunshots# The treatment must fulfil three conditionss 1. the surgical treatment of the wound; 2# the elimination and removal of pathologic pressure conditions; 3# the restoration of normal pressure conditions within the thoracic cavity# 1. Wounds of bullet size, if impermeable to air, will be covered with a sterile dressing which will be held in place by airtight, adhesive bandage material overlapping by 3 to 5 cm. on all sides# All other injuries are to be taken care of according to the general principles of war surgery concerning soft parts and bone tissue# The same applies to bullet sized wounds of the pectoral muscle'and shoulder area caused by bomb and shell splinters# A possible developing pneumothorax will be closed by the application of a suture of two layers. The additional skin suture may as a safety measure be applied up to 12 hours and under especially favorable conditions even up to 24- hours later. An early removal of the skin suture at the onset of in- flammation is necessary due to the of phlegmons. The use of adhesive tape to ease the stress on the suture is indicated* Exposure of lung wounds will be undertaken only if the clinical picture of continual hemorrhage suggests a possible intra-pleural hemorrhage (rapidly increasing dullness). Bleeding lung wounds are to be approximated by deep stitches with round needles and catgut* Due regard must be given to the intercostal and internal mammary arteries. In case of a hemorrhage the suture is to be performed with silk and if necessary with resection of ribs. A foreign body (missile) in the lungs will be removed only if this can be easily done and if the lungs are ex- posed anyhow for another purpose. 2, Elimination of pathologic pressure conditions. a. Mediastinal flutter due to open pneumothorax is eliminated by the use of sutures in 2 to 3 layers (See #1)* In case of extensive disruptions with partial loss of two and more ribs, plastic shifting of the soft parts has to be undertaken in order to com- plete a closure with a minimum of tension. If the disruptions are so extensive that an approxima- tion suture is impossible, a tamponade of the pleura with the Mikulicz bag or the air-tight sewing in of the lungs into the fenestra of the thorax has to be performed* b* Positive pressure due to air in cases of pressure and valvular pneumothorax will be elimi- nated in the acute stage through aspiration in the 2nd or 3rd intercostal space about two fingers width from the sternum. For permanent relief, BUELAUts drainage is superior to a valvular cannula* c, Positive pressure due to blood or exudate is eliminated by aspiration to establish the equilibrium of the mediastanum, i*e* up to the pressure value of 1 0, Caution and slow per- formance of drainage is advised until liquid just drips from the cannula or just forms a drop in the needle lumen when the syringe is removed. 3* The restoration of normal intra-thoracic pressure conditions will be accomplished as follows? a• In all cases of injuries of the thorax in whi ch the closing~~of the open pneumot h or ax wa s possible only under tension br'TTir6ugF 'shafting °f soft parts, by the prophylactic application of BUELAU1s drainage in the same operation. b. In cases of hemothorax without pressure on the mediastinum by the use of closed aspiration, if possible by use of the two-way cock, on the 3rd to the 5th day. The aspiration must be inter- rupted as soon as the patient feels pain or cough irritation* As a principle no aspiration should be continued to the point of a complete drainage* The aspiration has to be repeated after a couple of days; in most cases 3 to 4 aspirations within 3 weeks are sufficient* In case of an uninfected hemothorax, filling itself very quickly with exudate and in which the exudative process does not come to a standstill by the end of the 3rd week, closed drainage, according to BUELAtJ, has to be unaertaken. c. In case of an infected hemothorax, the early establishment of closed drainage is indicated at the latest 8 to 10 days after the injury. d, In case of a secondary open pneumothorax, BUELAtJ*f s closed drainage and approximation of the wound either by airtight adhesive tape or by a secondary suture performed at the same time, will serve the purpose. Points of general interest about BUELAU*drainage• The patient assumes a sitting position* Local anes- thesia will be sufficient. The drainage will be performed with the standard equipment, preferably at the deepest point between the median and the posterior axillary line and with a small intercostal incision of 3 to 4 centimeters length (see directives). An open drainage will not bo performed; a rib resection is not necessary. After clamping the tube of BUELAU1s apparatus, the negative pressure system should be rinsed and freshly filled twice daily if possible, in order to restore the suction power. The leakage around the tube, occurring between the 5th and ?th day, usually stops in about 6 to 8 more days if the tube is allowed to remain in position, A stopped up drain, which is a rare occurrence in the early operation, will be taken care of by rinsing with a boric solution. If the patient is other- wise in a transportable condition, the BUELAU drainage, after a period of 3 weeks will not represent any obstacle to evacuation. 19 General remarks on the treatment. For general relief of pain and the normalization of the respiration in order to give,rest to the lungs and chest, the administration of a 0.01 dose of morphine or a morphine^derivative every 8 hours during the first 3 to 4 days is recommended. As long as a drainage has not been applied, the patient is at liberty to assume a con- venient position; after the drainage is performed a pros- tate position has to be avoided; elevation of the upper part of the body is necessary. In case of a loss of blood not too large amounts (up to 500 cubic centimeters) of blood, serum and saline solutions will be given. Evacuation. If possible, chest injured patients, after proper care lias been taken of the chest-wound, and after closing an open pneumothorax and eliminating the abnormal pressure conditions, ought to be brought as fast and carefully as possible, best by air, to that medical unit which is able to provide the final surgical and follow up treatment for at least 3 bo 4 weeks. The general condition of the patient, as a matter of course, must be such that the evacuation will not present special hazards. 4. The late treatment of gunshot wounds of the lungs* Directives for the treatment of gunshot in- juries of the lungs irTHospita 1 s at 'home. Oberfeldarzt (Lt, Col,, MC#) SCHINDLER The fate of severely injured patients with severe gun- shot wounds of the lungs depends to a great extent on the care given in dressing stations at the front. The patients should not be transferred too early to hospitals in the homeland. Also patients with hemothorax ought not to be evacuated for at least 3 weeks and then only to hospitals in which they may stay until completely cured# I. Missiles lodging in the body. The only indication for removal of missiles from the lungs is bleeding or suppuration. Missiles should only be removed after a most exact localization. IT* Lung abscesses due to missiles lod.glng in the body. Abscesses due to the missiles lodging in the lungs ought to be operated early if the missile is the cause of the suppuration. Ordinary lung abscesses should be treated by conservative procedures no longer than 8 weeks (single doses of Salvarsan starting with 0.15 up to 0.5 grams, entire amount not more than 3 grams and diathermy). 20 Abscesses due to gangrene of the lungs ought to be opened at an early opportunity, particularly if located close to the pleura# III* Empyema, 1* Late exudation with or without blood after gun- shot injuries of the lungs, when observed in hospitals at home, are to be examined carefully and be kept under observation; early aspiration, especially in case of an increase of temperature, is necessary# If the purpose is not achieved after a maximum of 2 weeks, BUELAU!s drainage will be employed.(see directives)# 2. BUELAU1s drainage *) is to be applied at the lowest point cf the empyema as determined by percussion# At the right time expansion exercises with overpressure, inflating air cushions etc* have to be instituted# The continuous careful supervision and the later X-ray ex- aminations as well as daily rinsings and fillings of the drainage tube system, in order to renew the suction power, are of primary importance* If in spite of satisfactory drainage no expansion occurs, the freezing (Vereisung) of the phrenic nerve is to be undertaken in order to put the diaphragm at rest* The suction apparatus should not be removed before the third or fourth week. After its removal, the insertion of a rubber tube which gradually and methodically is shortened and reduced in diameter, has to take place. If, owing to especially close position of the ribs, BUELAU1 s drainage cannot bo applied with safety or when congealed exudate obstructs drainage, which rarely happens in cases of empyema due to gunshot injury, the airtight insertion of a thick rubber tube to be followed by suction treatment is necessary# Only in very rare cases of extreme septic conditions is a wide cleavage and insertion of a Mikulicz bag indicated# *) Mistakes in the application of BUELAU1s drainage: 1# The inner end of the BUELAU1 s tube lies above the sur- face of the liquid, pus cannot drain off# Correction: fenestrated tubes and frequent observation. 2# If BUELAU1s drainage lies too far posteriorly, the tube is clamped* Lateral application, under no circum- stances behind the posterior axillary line* 3. When BUELAU1s drainage is placed in too low an inter- costal space, the pus is drained off, the diaphragm moves up, sticks to the wall of the chest, and the pus stays above it. 4# BUELAU1 s drainage is placed correctly in an encapsulated cavity and another coexistent empyema is overlooked* 5# BUELAU1s drainage is removed too early* IV. Residual cavities. 1. Residual cavities will be approached only after at least three months. If a residual cavity does not exist for longer than 4 to 5 months, the attempt of a treatment with a water-jet vacuum pump should be made. However, the suction power may be used only to the ex- tent tolerated by the patient without pain and dyafcnoea. 2. Surgical treatment of residual cavities. a. residual cavities should be treated first by extra-pleural, paravertebral plastic operations according to SAUERBRUCH*s technique. By this method it is possible to make the cupola space as well as the space in the paravertebral angle disappear which offer special difficulties to a plastic approach. b. Cavities which still persist will be treated best by HELLER's lattice-plastic technique in which case it must be considered that pieces of ribs toward the spinal column as well as toward the sternum have to be dissected 3 to 4 centi- meters beyond the margin of the hollow space. Also in an upper and lower direction 1 to 2 more ribs have to be taken out in order to accomplish a better adaptation of the costal and pulmonary callosities. 3. Persisting bronchial fistulas without residual cavities and "honey-comb" lungs are to be treated according to LEBSCHE* s or LETZIN* s method. 4. Prior to the performance of any plastics, a careful examination and preparatory treatment is imperative. An improvement of the blood picture (transfusion), of the functions of kidneys and heart has to be striven for in every case, before an operation can be performed# In case of a reduced general physical condition the operation ought to be executed in several stages. If at all possible, operations should be performed under local anesthesia. In the event of serious disturbances in the after- treatment according to BUELAU, after removal of foreign bodies, abscesses of the lungs in case of remaining cavities, bronchial fistulas and "honey-comb" lungs, operations are to be undertaken only in hospitals (at home) which have been designated by the consultant surgeons* It is necessary to institute early active exercises of the corresponding shoulder joint. If there exists a suspicion of a combined injury of lung and diaphragm,^the possibility of a diaphragmatic heinia has to be kept in mind# 5. Primary treatment of gunshot wounds of the daw. Directives. Oberstabsnrzt (Major, MC») Prof» WIXSTROW Unnecessary sacrifices of facial tissue have more serious consequences in the future life of an injured patient than sacrifices of tissue on any other part of the body* Smashed soft parts of the face should be sewed up finally only after splinting the fracture or destroyed bones beneath them* If fractured bones have to be treated with emergency splints, the respective damaged soft parts will likewise be joined by emergency sutures only* In cases of urgent necessity, emergency splints, once in a while also permanent splints, should be employed even at the main dressing stations* For that reason, specially trained dentists should supervise the treatment of wounds of the jaw and decide immediately whether and which kind of splint (emergency or permanent splint) has to be used at the main dressing stations* This decides at the same time whether the soft parts are to receive a final or an emergency suture* Smashed soft parts in jaw injuries due to gunshot are sewed best with wire (e*g* aluminum bronze wire 0*1 to 0.5 millimeters thick). The use of a suture over buttons is advisable in case tensions in the adjacent round area pre- vail* Burrowed areas sometimes extending into the vicinity and lobulated skin shreds facilitate the closing of the wound. In such cases, the most careful and efficient drainage is of paramount necessity. If proper drainage (at least at the deepest spot) is provided, facial wounds will heal primarily on the application of a late suture even ten and more days after the injury* Such a suture must be preceded by a freshing of the wound* These sutures will be called "late sutures"* A primary suture, even though only in the form of a late suture, is for that reason advised not only for in- juries of thorax, joints and brain, but it represents also the proper procedure in cases of injuries of the face. 6. The late treatment of gunshot wounds of the .law. Directives. Stabsarzt (Captain. MC.) Prof. HAMMER The late treatment is intended to remove the damage inflicted upon the soft parts and the bone structure by the injury and the natural healing process. With regard to the soft parts, we distinguish two Winds of damage. The first kind includes injuries not involving a loss of tissue; the parts have only shifted and healed in the wrong position. In these cases scar plasty is required to correct the disfigurations. In the second kind, a larger loss of tissue is involved in addition to the shifting of soft parts. The affected areas will be re- stored to proper shape by defect plasty. The necessary replacement of bone defects of the upper jaw differs from those of the lower jaw. Upper jaw defects can only be taken care of by maxillofacial prosthesis which has to be performed early before disfiguring contraction of soft parts has taken place. Lower jaw defects have to be cor- rected by grafts. If, in order to perform plastics on the lower jaw, an opening of the cavity of the mouth cannot be avoided, transplantation of bone structures has to be undertaken. In particular, the following directives are to be observed: 1. A proper primary treatment of injuries facilitates and simplifies the later treatment. 2. In case of a late treatment of injuries which still are in an infected granulating stage, active measures are not suitable. The natural healing power is always to be given a chance. Special vigilance for possible complications is necessary. The position of fracture stumps is to be secured by prosthetic measures. 3* With regard to the late treatment of injured soft parts, a distinction must be made between scar plasty and defect plasty. 4. In the application of scar plasty, the scar tissue has to be removed radically, the edges of the shifted wounds made flexible, duly separated and then joined layer by layer in the right order. 5. The defect plasty has to be executed according to a well organized plan. The edges of the scars often afford valuable material for the inner layers. Grafts of hairless skin are always to be used for the inner lining. Lining of a simple flap by freely transplanted epidermis is unsuitable. Flaps from the immediate vicinity or from farther off are to serve as covers; flaps from the scalp are to be used only for replace- ment of hirsute face skin especially in case of symme- trical loss of tissue. The rolled flap9 produced in varous steps is of inestimable value. 6# In every case of defect plasty, the necessary support to flaps will be provided by prosthetic means. 7# If possible, the lip coloring will be obtained from the patient's own resources. Recourse..will be made to the upper lip for this purpose. 8. Shifted fractures will be adjusted by orthopedic measures as far as they are still movable# 9# Dislocated, healed jaw fractures have to undergo an osteotomy and appropriate correction. Distinction has to be made between fractures of parts with and without teeth. In fractures of a dental arch, the osteotomy has to be performed at the original site of the fracture. In case of fractures outside of the dental arch, osteotomy has to be undertaken at the ascending bone between the incisura and the mandibular foramen for the lower jaw and in Guerin*s line with approach from the fossa canina for fractures of the upper jaw. In the latter case, the nasal septum has to be severed by approach from a small median incision. 10. Bone defects of the upper jaw are subject to early prosthetic correction# 11# Bone defects of the lower jaw are subject to re- storation by grafts. The following principles apply to these cases: a. Excision of all scar tissue; provision of a suitable base. b. The simple insertion by superposition. No complicated measures; no dove-tailing of stumps for the purpose of insertion. No wire sutures. The position of the fragments is to be secured by dental implements. c. Sufficient freshening of stumps, stimulation of neoformation of bone through chiseling* Abundant covering of defect stumps. d. Fixation of the graft by layer sutures. If suture is necessary to keep joined bones in place, catgut is to be employed for suture# 12. A fixed (locked) jaw has to be worked against right from the start. Early employment of spreading devices is advised. 13. In case of a persistent locking of jaws on account of a formation of scars, an osteotomy has to be per- formed at the muscular appendix by an incision at the lower edge of the yoke bone. 14, If an ankylosis of a maxillary joint is the cause, the new formation of a joint by surgical measures is indicated* 15, For the surgical pseudarthrosis the retro-auricular approach, according to AXHAU3SN, is the most suitable procedure. 7* Primary treatment of gunshot wounds of the thigh. Directives. Oberstarzt (Colonel, MC.) Prof,. WACHSMUTH During the last two years, the staff of the special hospital for surges of the High Command of the Army has had the rare opportunity to treat a great many cases of serious fractures of the thigh, due to gunshot injuries, from the very beginning to the actual discharge from the hospital* Again, observations have been especially im- pressive and confirmed that the hazardous period of fractures of the thigh due to gunshots is not limited to the first weeksafter the injury but that complications may occur many months later which may result in late amputations, disarticulations or maty cfreti cost the life of the patient* To a large extent, the occurrence of these late complications can be prevented by a proper primary treatment of thigh fractures due to gunshots* The primary treatment has to be performed according to the following directives• The most important points of the primary treatment of thigh fractures due to gunshot injuries are the fixation for the duration of the transport, the surgical treatment itself and a suitable immobilization* A* The fixation. The emergency fixation prior to the surgical treatment must fit the purpose i*c# it must include not only the adjacent joints, and most important of all the pelvis* This will be accomplished by use of a splint which must extend up to the thorax* Field-trans- port splints (New Model). For the fixation after the surgical treatment, the applieao© of the large plaster bandage, reaching down to the knee-joint on the healthy side is generally indicated. No makeshift bandages ought to be employed after the surgic- al treatment. B* The surgical treatment aims at an approximate reduction of the fractures on the extension table, with a wide prophylactic separation in order to make possible a drainage of blood and pus from the septum intermuscular fibularis- (to avoid late dependent abscesses)* The pro- phylactic drainage is to be performed in all cases of bone destruction including injuries due to shell splinters of bullet size. Careful drainage of the wound is necessary. c. The most suitable immobilization must follow the surgical treatment. It is accomplished wEen the reduction of the fracture is secured in a recumbent position with a large pelvis plaster of Paris cast and held in place with the aid of the wire suspension apparatus. The free ex- tension and bandaging by means of BRAUN*s splint is, on account of difficulties encountered in taking care of the wound, the impossibility of evacuation and the increased danger of later complications due to dependent abscesses (under some circumstances subsequent suppurations of the hip joint) in general is not the method of choice for dressing stations at the front lines. In the large, padded and fenestrated pelvic plaster of Paris cast and wire suspension device, the patient is transportable, freed of pains as much as possible and he is the least endangered by infections; the reduced fracture and the drained wound are in the most restful position. 8» Later treatment and reparative surgery in gunshot wounds of the thigh. Oberstabsarzt (Major, MC.) Prof. B05HLER Patients with fractures of the thigh due to gunshots ought to be sent, if they are transportable at all, as soon as possible to hospitals in which a proper treatment can be provided (Extension apparatus, wire, tension hooks and Par- ticularly portable X-ray equipment are an absolute necessity). The aim of the treatment consists ins 1. combatting chronic infections, 2* the restoration of function* The best means for combatting infections :s the thorough exposure of all foci of inflammation and a continuous ef- ficient drainage at the deepest spots. In addition hereto, the fractured leg, after a proper reduction of the fractured parts, must be kept uninterruptedly at rest. Exposure of foci of suppurations. The suppurations proceed in pathways predetermined by anatomy, especially in insertions of the extensor and adductor muscles. For that reason, in all cases of suppurating fractures due to gunshot injuries in which the foci of suppurations have not been exposed yet, incisions must be made at the deepest places of the extensors and adductors in addition to the exposure of all other foci of infection. Large wounds in the area of the flexor do not provide a sufficient drain. Bone splinters will not be removed unless they are free in the wound because otherwise there develops the hazard of a defect-pseudarthrosis. Reduction and fixation* For these purposes, as a rule, the extension splint shall be employed and onljr in cases of severe infection the plaster of Paris cast. Permanent extension splint. Plateing of the leg In BRAUlTfs splints. Application of the wire at the tibial tubercle for the first 4 weeks, then attachment of the traction device at the thigh in order to avoid an over- extension of the knee-joint* As a rule, the weight em- ployed for the traction device should not exceed 7 kilo- grams as otherwise it would lead to a separation of the fractured parts of bones and to a delayed growth of callus. Theemployment of too much weight with the permanent ex- tension apparatus produces, besides infections, the most severe permanent damages. The support of the forefoot in order to avoid pes equinus and heel pressure ought not to be neglected. Elimination of angulation* The varus position will be eliminated bv abduction which, however, should not be too strong. In case of old fractures, the nail should be £ut crossways into the trochanter so as to cduse a level* effect in the sense of the adductor movement of the upper part of the fracturel The recurvation of fractures of the lower third dis* appears as soon as the lengthwise traction is arranged just above the toes thus being located lower than the axis of the thigh. Controls by X-rays. After 2 to 3 days, the first check by X-rays has to be made in order to ascertain whether the angulation has been eliminated and whether the traction is too strong or not strong enough. Movement exercises will begin the very first day. These will comprise unsupported movements of toes and ankle-joint to the full extent as well as movements of the hip by permitting the patient to assume a sitting position and active tensing of the thigh muscles. As a rule, the duration of the fixation in the extension splint should not exceed l6 weeks. If the Tracture is not sufficiently healed at that time, an unpadded plaster of Paris cast, which is to reach from the toes to the ribs, is to be made. Application of a plaster of Paris cast in case of severe infections. If in spite of adequate drainage and exposure of the foci of suppurations, the high fever is not reduced after about 2 to 3 weeks, a fenestrated plaster of Paris wire reinforced cast has to be made. Secondary septic hemorrhages. In case of a secondary hemorrhage from a large artery, an immediate amputation must be performed as otherwise the most severe infections possible developing into gangrene will set in. In case of hemorrhages, the profunda and other branches must be tied off. Tamponade and ligature at the place of choice are not sufficient. Amputations* If the fever cannot be reduced after 4 weeks in spite of sufficient exposure and drainage of the foci of suppurations and the general physical conditions deteriorate in spite of the use of the large plaster of Paris ttlro cast, amputation must be performed* Sequestrotomy* If there is a copious discharge of pus and if the roentgenogram reveals larger sequestra, their removal should be undertaken even during the first weeks; otherwise one had better wait until the fracture is firmly healed which will be the case in about 4 to 6 months* The operation is to be performed bloodlessly with complete exposure of all fistulas and elimination of bone hollows by chiseling in order that the soft parts can adjust themselves* The spaces are filled with vaseline, or unguentolan and loose skin sutures are placed* No tamponade, no rinsing. Older thigh fractures* The correction of shortening and angutation is frequently successfully counteracted during the first three months by the permanent extension apparatus. Otherwise angulation, with presence of only a little callus, are eliminated by manipulation or with the aid of PHELP* s belt, to be followed up later by the ex- tension splint. If the fracture is firmly healed up al- ready and if only minor infections are present, an osteo- tomy can be performed, possibly at the same time as the sequestrotomy. In cases of previous and more severe_in- fections one has to wait for one year after the opening of the fistula before performing an osteotomy. It is best performed on a healthy bone. In case of aseptic fractures, the osteotomy may be performed at any time* If a shorten- ing does not amount to more than 4 centimeters, KUENTSCHER's marrow nail can be employed. Peeudarthrosis. The marrow nailing according to KUENTSCHER produces better results and is easier to per- form than the bone grafting operation. In aseptic cases it can be performed at any time and in. case of pseudarthrosis as a rule only one year after the closing of the fistula. The extension stiffness of a knee-joint* It will be best removed through the quadriceps plasty according to BAYR. The after**treatment. Movement exercises of the whole body will be performed when etlll in the extension splint. Combined exercises and sports are undertaken when still in the pelvic cast* Thereby, not only the physical condition of the body will be improved but also the mental attitude. Discussion: A. W. FISCHER; Likewise recommends the marrow nailing according to KUENTSCHER although with a particularly critical selection of especially suitable patients* 29 ROSTOCK: Objects to the immediately performed amputation of a limb in case of an injury to the femoral artery as a hemorrhage of the femoral artery is not synonymous with an indication for amputation* SMIDT: Is of the opinion that KUENTSCHER1s nailing method in cases of pseudarthrosis is restricted to cases without defect* HAEBLER: Gives a report about his experiences with the KUENTSCHER nailing method. 9* Treatment of gunshot wounds of joints* Directives* Oberfeldarzt (Lt* Col** MC*) Prof* LAEWEN With regard to the treatment of gunshot wounds of joints the following remarks have to be made: 1* A distinction is to be made between the treatment of new gunshot wounds of joints and the treatment of sup- purations of joints due to gunshot. On purpose I avoid the expressions "infected gunshot wound of the joint" and "in- fection of joints". They are vague and give rise to mis- understandings* Also the expression "capsular phlegmons" docs not describe accurately the actual conditions. Sup- purations, originating in a joint, are no phlegmons of the capsular ligament. Only once, in surgery before the war. have I observed a real phlegmon of the capsular liga- ment in the knee-joint of a child, in other words, a sup- puration in the loose connective tissue between the synovial membrane and the fibrious capsule. That, which is usually described as a phlegmon of the capsular ligament, is in reality a suppurating inflammation of the synovial membrane combined with a severe hyperemia and the discharge of pus into the inner space of a joint, a subsynovial edema and a developing phlegmon which in some as for instance in the shoulder-joint, may be located all around the joint and in others, however, such as the elbow, hip and knee-joint, it might develop by extension from the inner part of a joint or from the canal of the missile into the connective tissue of the adjacent parts of the extremities. 2# In order to facilitate the choice of proper treat- ment X-ray pictures in two planes of new joint injuries and suppurating ones ought to be secured by medical units at the front, if at all possible. It can be ascertained that way$5 whether the injury of the joint is a perforating or penetrat- ing one, whether the injury is just a plain injury of the joint or a fracture .of the joint. With "regard to the proper treatment ot fractures of joints it is important to know, whether parts of the bone just split off or if we have to do with a cleavage of the bones reaching into the joint or even with the destruction of larger bone parts of the joint. 30 3* The treatment of a new joint injury presents more problems than the treatment of a joint suppuration. In case of a new joint injury it must be decided whether a Primary operative or a primary conservative treatment is the appropriate procedure’! This problem was not solved dur- ing World War I. Fundamentally it cannot be solved at all. During World War I in the trench warfare on the Western Front, i.e. under the most favorable conditions, PAYR, KLAPP, AX- HAUSEN, MEMNENGA among others suggested the radically per- formed primary operative method as the proper treatment for new gunshot injuries including also injuries of the inner parts of the joints with complete closing of the capsular ligament especially of the knee-joint. By contrast, con- ditions in the present war, a war of movement as well as a stationary war on large parts of the Eastern Front at the present time, have led more and more to the adoption of the primary conservative treatment method for new injuries of joints. These treatments, forced upon us through difficult external circumstances, frequently could not prevent the development of severe suppurations of the joints. In how far improvements might have been obtained in suitable cases by the primary operative procedure, such as the prevention of suppuration for instance, rill oe commented upon during the discussion of the various injuries of joints due to gunshot. The treatment of suppurating joints requires an early surgical opening of the inner joint continual ex- posure of phlegmons spreading from the joint. In field surgery, this principle stands unchanged even after the introduction of the Eubasin treatment by FH.U0BD. Phlegmons, originating from the joint, are symptoms of a disease by themselves which are not influenced at all just by the opening.-pf-the joint .“buf-which have to be suitably treated by operative procedures. One has to-know their stage of de- yelopnent, subject to the principles, of anatomy* in order to open them soon enough after discovery. Just as in the first World War, suppurations of the larger joints caused by gunshot injuries, especially of knee and hip-joints but also of tarsus-joints, raise again the serious problems of their treatment. Exhortations to save the functions of these joints, so frequently expressed in the literature, have to be disregarded many times in practice. With regard to these suppurating joints, the problems should rather be expressed by the following question How can I save the extremities without even taking into consideration the~ preservation of the functional suppurating joints? - or, regrettably not infrequently, which is the right time for amputation in order to^protect the joint- ing ured patibnt ftom a general infection, or to protect him from an exhaustion of his strength which must lead to his certain death? 4. How is a joint injury with the missile lodging in the joint to be treated? Should it” be treated by the primary conservative ir-the primary operative method? The most important thing for any decision as to treatment is the exact localization of the missile by an X-ray Picture in 31 two planes* More comments will be given on the subject during the discussion about injuries of the different joints* A relatively uniform treatment method can be applied to missiles lodged in the joints of a shoulc’er, elbow or knee* Undor the present conditions at the Eastern Front, I see no indication for a removal by operation in cases of fresh small entrance wounds occasioned by infantry missiles or shell-splinters which are lodged in a bone of the joint of in the inner parts of a joint* The same is true for multiple small splinters lodged in a joint* The danger of a suppuration of a joint and the possibility of an infection due to an operative intervention must always be kept in mind. Under the conditions prevailing on the Eastern Front as observed by me, I advise the removal of lodged missiles with small wound of entrance. Only with an exceptionally good possibility to^operate under aseptic conditions if there is no rush, a primary removal of missiles from joints with small entrance wounds is td> be ad. vised. The situation is different if a large entrance wound and de- struction of bone parts of the joint make the primary operatior a necessity. In these cases? the missiles, localized by X-rays, shall always be removed from the articular space or the cleft of a joint. If a. case of suppurating joint injury due to a lodged missile arrives for treatment, an arthrotomy and the removal of the foreign body is always indicated. 5. Of importance for the treatment of injuries of joints due to gunshot is furthermore the question whether the joint injury is the sole injury or wrhether other in- juries exist. Simultaneous injuries of parts of the body surrounding the injured joint as well as injuries farther remote from the injured joint, which of themselves reduce the power of resistance of the entire organism and which make it doubtful whether the patient will overcome a sup- puration of a joint, must be taken into consideration. In such cases e.g. the suppuration of a knee-joint the healing of which requires the best possible general constitution of the whole body? one would be more readily inclined to perform an amputation of the thigh than in those cases where the suppurating injury of a knee-joint represents the only injury. 6* The particular importance of an early and proper fixation of the injured .joint by plaster of Paris cast in its various forms lies in the fact that it is likely to prevent the suppuration of an injured joint as has already been tought by BERGMANN* Even in cases of fever due.to an injured joint, a correct fixation which is best obtained with a plaster cast may help to get rid of the fever with- out the use of any other measures.One has to keep that fact in mind when judging the chemotherapeutic treatment of gunshot injuries of the joint. This fixation is of equal significance in cases of injuries of joints due to gunshot and treated by the primary operative method as in operated cases of suppurations of joints* ?• Premature evacuation of patients with injuries of joints is very hazardous• After the unavoidable transport to a field or any other forward hospital and an interval of about 3 weeks, results will show whether a suppuration of the joint is developing. If this is not the case tolth regard to small injuries due to smoothly penetrating or perforating missiles, the evacuation is a possibility after those three weeks, provided the wounds are in satisfactory condition. However, an absolute guarantee that a suppuration of these wounds will not develop later on does not exist. Patients with operated suppurative injuries of the joints due to gunshots are transportable only if local examinations indicate a gradual subsidence of the infection and when the joint injured patients have been free from fever for several weeks. KINGREEN has made the sensible suggestion to carry these patients, prior to transfer, up- and downstairs several times within the hospital in order to ascertain whether they react with renewed increases of temperature* As a rule, the general power of resistance of the body!han.'suffered during the protracted treatment of the joint suppuration so that reserves do not exist to counteract a renewed development of suppurations. We had many opportunities to observe wounded patients, especially with injuries of joints of the shoulders and knees, arriving at reserve hospitals in serious conditions with high temperatures who were supposed to be well enough to stand transportation, but who actually developed severe suppurating inflammations of joints during the transport. I shall do my best to give you a rough outline of the treatment of the different injuries of joints due to gun- shot in due consideration of the prevailing conditions on the Eastern Front* 1. Treatment of injuries of the shoulder-jotnt due to gunshot. a* The treatment of a new injury of the shoulder-!loint Hue to gunshot. With regard to injuries with small entrance wounds no operative treatment is necessary. Extensive damage to soft parts caused by shell splinters should be treated in accord- ance with the general principles of war-surgery including excision of the entire wound and not of the skin alone. The joint is not subjected to treatment* A suture of the capsu- lar ligament is usually an impossibility solely for the reason that the wounds, especially those at the back, are too far remote from the capsular ligament. The wounds are kept open. A drainage of the joint will not be undertaken. The primary treatment with regard to the joint is, therefore, a conservative one. Also in cases of fractures caused by gunshot, and. even in larger injuries of the head of the humerus due so destructive shots, the primary conservative treatment is the treatment of choice; a resection should be avoided* Even fractures of the head may heal up vithout suppurations of the joints and without sequestra. A lodged missile is no indication for an opening of a shoulder-joint 33 during the primary surgical treatment. Of imperative necessity is the properly performed fixation of the in- jured shoulder-joint with the abduction splint which is to be fastened onto the thorax by a plaster of Paris cast. In suitable cases, the transport difficulties of^patients with abduction splints can be facilitated b3r a firm fixation cf the arm to the thorax in a forward position at about 45 degrees to the horizontal line by wire splints and a plaster of Paris cast around the thorax. b* The treatment of suppurations of shoulder-joint in- juries due to gunshotI In contrast to the treatment of new injuries of shoulder joints due to gunshot with regard to the joint itself which is conservative, the treatment of suppurating joint Injuries must be operative. The operation of the suppurating shoulder- joint is done in two steps, the opening of the connective tissue spaces surrounding the shoulder-joint, frequently suppurating, which have to be kept open, and the actual operation on the joint itself. The roentgenogram which can- not be dispensed with shows whether the fracture site is at the head of the humerus or in the articular cavity and furthermore the exact location the missile is seen if the X-ray picture is taken in two planes# The missile, lodged in the joint space or the cleft, is to be removed, In case of comminuted fractures .at the head of the humerus, its severance from the shaft or its complete destruction. Ihe the~Tiead is performed by approach through the anterior resection incision with a counter-incision on the frontally inserted dressing forceps and drainage toward the posterior aspect. It is advisable, in order to prevent a flail joint, to fix the shaft^of the humerus to the acromion in a slightly opened angle in a forward direction by one or two wire sutures while in ab- duction. In case the head of the humerus is not damaged or if only splinters came off at its axillary part or at the edge of the articular cavity, I suggest the partial, re- section of the head of the humerus, resembling my condyle resection method on the knee-joint, the technique of which has been developed by my assistant WUETHRICH. WUETHRICH makes the posterior resection incision and chisels off the lower calotte with the upper arm held in abduction (Epicondylus lateralis humeri in upper This makes an efficient drainage of the shoulder—joint in the backward direction possible without the sacrifice of the entire head of the humerus. I used to perform^the operation by approach with the anterior resection incision. I take off the lower calotte of the head of the humerus from the front, insert dressing forceps^in a backward direction, make upon it a counter incision and pull a drain from the rear into the open joint of _ tie shoulder. I have observed really favorable results with this simnle operation at the front. 34 Pertaining to suppurating injuries of the shoulder- joint due to gunshot, dangerous phlegmons develop from the subdeltoid space in the musculature of chest and back and also occasionally in the wall of the thorax which have to be opened. ihere are suppurations of shoulder-joints which have developed secondarily after an injury by gunshot and suppuration of the subdeltoid space. For those suppurations also, I recommend the calotte resection of the head of the humerus with drainage toward the back. Cases of suppurating injuries of shoulder-joints due to gunshot are not transportable for a long period of time. In field hospitals, I have observed patients transported too early arriving in such serious condition that even the resection of the head of the humerus could not improve the situation and the outcome was fatal. The fact that in case of a suppuration of a shoulder- joint, a fixation of the arm on the abduction splint lasting for months is a necessity until a firm ankylosis of the horizontally abducted humerus with the acromion has been formed in the articular cavity needs hardly to be mentioned here. 2• The treatment of an injury of the elbow-joint dUfe- to gunshots» a* The treatment of a new injury of the el boy;-.joint due to gunshots* In case of lodged missiles causing only small entrance rounds and not attended by fractures, the primary treatment is conservative and consists of the fixation of the elbow- joint at a right angle to the upper arm and semi-pronation of the forearm (position assumed in writing). In case of more extensive disruptions of the joint and fractures due to gunshot, all detached or destroyed bone fragments ¥7ill be removed conservatively. A closure of the capsular ligament is usually not possible. A drainage of the joint must be avoided. The surgically freshened wounds will be subject to open treatment. The typical total resection of the joint is to be performed only in case of comminutod gun- shot fractures. Also in this case it is recommended to freshen the surfaces of the joint conservatively and to pay special attention to the triceps insertion. The total resection is hazardous and may cause flail-joints and should be replaced whenever possible, by the more conservative atypical resection. The early amputation is to be under- taken only in case of serious splitting of bone with simultaneous injury of the cubitalis artery, the inter- ruption of which is frequently followed by gangrene. A splitting of the bone itself does not necessarily imply primary amputation. b. The treatment of a suppurating elbow-joint due to gunshot. A suppuration of the elbow-joint due to gunshot may he,ve an outlet to the exterior particularly in case of large wounds with attendant destruction of posteriorly located 35 parts of bone to such an extent that an outflow of pus from the anterior articular pocket becomes possible. At times, inspissations of these wounds cause an empyema which develops especially in the anterior pocket of the joint. In the back, phlegmons spread subcutaneously towards the upper arm and forearm and have to be opened there. Under pressure of the M, brachialis a break-through occurs in front into the space below this muscle and continues distally from here by way of the interosseous membrane below the extensor tendon and the flexor muscle# In case of injuries due to destructive shots, bone fragments, very often in the stage of osteomyelitis, must be removed. Through this intervention, sufficiently wide openings will be created to permit a drainage# In case of the presence of an empyema on the anterior part of the elbow-joint, be it without an injury of the bone or with small splittings or with destruction of parts of the posterior bones, the arthrotomy of the elbow-joint and its drainage is a necessity. The lateral or medial incisions are suitable for this purpose. jn the performance of these incisions one comes easily into undesired contact with nerves, however, especially the radial nerve, the median nerve or the ulnar nerve, particularly, when the anatomy of these parts is disfigured by large wounds. For such cases and for empyemas of the elbow-joint in general, I recommend the anterior longitudinal incision through the biceps tendon and the brachialis muscle# In order to make sure whether pus is present it is suggested to puncture first the tendon with a thick, hollow needle to reach the anterbr articular pocket and the space below the M. brachialis. Occasionally, in case of severe suppuration of the synovial membrane, the pus has disappeared from the wound, but the inflammation of the wound continues. In all such cases, I recommend the following procedure: One splits the biceps tendon in a longitudinal direction and the M# brachialis in front of the elbow-joint and opens in this manner the anterior articular pocket. After this, one inserts the dressing forceps from the front, permits it to slide upon the anterior surface of the lower end of the humerus inside and outside and lateral incisions upon the tip of^the dressing forceps are made, through each one of which a drain is pulled into the anterior articular pocket# In this manner, every hazard to any of the nerves will be avoided. The drainage tubes lie below the muscles and do not come in contact with the nerve trunks. For the first four days, I insert a T-drain through the anterior incision which I remove later, in order hot to overstrain the tendon. An excellent rinsing of the suppurating joint is possible through these three or two drainage tubes# The phlegmon in front of the joint is alsi drained in this way# If necessary, the lateral phlegmons can be opened and drained by approach from the lateral incisions. The first fixation of the joint is performed for the time being at a right angle to the upper arm in semi-pronation of the forearm. If there exists a chance of restoration of the function of the 36 joint, I perform careful movements of the joint during anesthesia of the plexus after a few days and fix the joint in a more obtuse angle. This procedure will be re- peated sevdtal times during the after-treatment with fix- ation in different positions. 3• The treatment of injuries of the wrist».1oint and carpus due to gunshots* ~ The injuries of wrist joint and carpus due to gunshots are usually accompanied by fractures, the extent of which can only be ascertained by X-ray. a• The treatment of a fresh injury of the wrist-joint due to gunshot. The treatment of many of the injuries of wrist-joints due to gunshot, particularly perforations by infantry missiles but also many with lodged missiles, is a conservative one. There are only few possibilities for use of the primary operative method. It consists of the excision of bruised or dirty edges of wounds as well as the removal of bone splinters and foreign bodies. A suture of the capsular ligament is usually impossible. The fixation is performed with the hand in slight dorsal flexion. Suitable plaster of Paris casts and banjo splints with finger extensions. a rule lodged missiles are to be removed by secondary oper- ation only when located in the radio-carpal joint. The total crushing of the hand makes the amputation of the forearm a necessity. b. The treatment of suppurating gunshot wounds of the wrist-joint. Only the radio-carpal joint can be drained which is opened best by the dorsal resection incision between the tendons of the M. extensor pollicis longus and the M* ex- tensor digitorum communis according to LANGEFBECK. If the- seat of the suppuration is between the bones of'the carpus, one or the other, sometimes a whole row of them, must be sacrificed in order to accomplish an adequate drainage. Likewise, attendant phlegmons of the tendon sheath, para- articular abscesses and the deep forearm phlegmons have to be opened by operative intervention. With regard to a threatening ankylosis of the wrist-joint, the fixation of the hand should be undertaken in slight dorsal flexion. 4• The treatment gf gunshot wounds of the hip-joint• a. The treatment of a new injury of the hip-.joint due To gunshot. The participation of the hip-joint in an injury of the pelvis or the trochanter by gunshot can sometimes, especially in an injury of recent origin, not be ascertained even with the aifl of X-ray An injury of the hip-joint is suggested by an increased pulse-beat of the arteria femoral below Poupartfs ligament displaced in an anterior direction due to a hemorrhage within the capsular ligament of the hip- 37 joint as has been described by BERNHARD v. LANGENBECK as a certain indication of an injury to the hip-joint. In all doubtful cases the injury has to be treated as if an Injury of the hip-joint injury were a certainty.- The treatment of a hip-joint is entirely conservative, omali wounds are also treated conservatively, larger ones arc excised. Of utmost importance is the immediate proper fixation of the supposedly injured hip-joint; first by use of the field- transport splints, by wire or any other emergency splints " which must extend along the side up to the axilla. This has to be replaced however, as soon as possible, with a pelvic plaster cast which must extend on the injured side of the body from the ribs to the vicinity of the ankle-joint and which must also fix the healthy hip-joint. Even in the First Wotld War, the early resection of the hip-joint was not used and in the present war it is of no importance in the primary treatment. b. The treatment of a suppuration of the hip-joint due to a gunshot injury. The treatment of a suppuration of the hip-joint and of phlegmons caused by the suppuration is operative. The possible methods are arthrotomy with a drainage of the joint, partial resection of the hip-joint and resection of the head of the femur. For the drainage of the joint in backward direction KOCHERfs incision may be used which has been recommended also by PAYR and KLAPP* Starting with a skin incision which ex- tends from the posterior edge of the trochanter major in an upward direction toward the crista iliaca, one continues deeper between the M* gluteus maximus and the M. gluteus nedius to reach the joint capsule between the M. pirjformis and the M, gluteus minimus* The capsule is then severed transversely* If the head is not smashed or if there afe only damages at its lower calotte or fissures which extend to the inside of the head or if only the margin of the aceta- bulum is damaged, I advise the partial resection of the head through the removal of a lower calotte* The incision must reach the lower part of the capsular ligament* It is best performed by a large diagonal incision through the lower part of the M. gluteus maximus, pulling the N* ischiadicUs in- ward to reach the joint capsule, if one continues farther into the depth along the edge of the M* quadratus femoris. After the latter has been severed in the direction of the neck of the femur, the lower calotte is chiseled off* In this manner, a sufficiently large opening of the hip-joint has been created into which a drainage tube can be inserted. In a field hospital, I have witnessed a partial resection of the head of a femur, performed by MARQUARDT according to my incision method, in the case of a suppuration of the hip-joint, "which was not influenced by massive doses of Eubasin and which was nearly healed after the fever subsided. In case of a total destruction of the head, LANGENBECK’s resection should be considered which may be replaced, ac- cording to FRANZ, by a subtrochanteric resection directly below the neck of the femur. If possible, the trochanter minor should be preserved on account of its being the muscu- lar insertion of the M. ileopsoas. In the hospitals at the fronts I have observed onlT’ a few resections of the head and no subtrochanteric resection of the hip-joint at all. As satisfying as the treatment results of the terribly sup- purating wounds by the resection of the head of the femur have been, thatconsequences of the permanent loss of the head of the femur are just as regret&ble* With Reference to the arthrotomy of the hip-joint, the most suitable type of bandage is the fenestrated pelvic plaster cast or the extension bandage. Simultaneous in- juries of urinary bladder, rectum or ilium sometimes render the arrangement of a plaster cast more difficult and at times make it impossible altogether. These cases generally rate a very serious prognosis. After the surgical treat- ment of these combined injuries, the patients are usually so weakened that they cannot withstand further intervention on the suppurating hip-joint. The phlegmons which develop from the suppurating hip-joint in a posterior direction in the muscle compartments of the buttocks, and at times also extend in an anterior direction below the muscle iliacus are difficult to treat* For the drainage of anterior phlegmons the exposure of the retro- peritoneal space is necessary. Posterior phlegmons are opened best by an oblique incision through the lower gluteus maximus. By this manner I have been able to open a phlegmon Ytfhich even extends behind the deep muscle plane behind the knee-joint. Phlegmons, spreading from the hip-joint into the musculature of the thigh, can extend themselves to the bursa suprapatellaris below the quadriceps and thus may even cause a secondary suppuration of the knee-joint. These phlegmons are to be opened and drained by long incisions on the outside and the front of the thigh or are to be kept open by wornd spreader. 5 • The treatment of injuries of the knee-.joint due to gunshot. a. The treatment of new injuries of the knee-.joint due to 'gunshot! The primary treatment of injuries of the knee-joint dusgt© ghnshot, not considering the surgical treatment of larger wounds and the performing of surtures of the capsular ligament, has usually been a conservative one during the present war. Excellent experiences, made with the early surgical treatment during World War I. have not any influence with regard to the treatment of new injuries of the knee-joint in the present war. The early treatment is a preventive measure, which, through a mechanical excision of the contaminated canal of the missile up to the capsular ligament, the chiseling off of bone surface and the removal of foreign bodies and other carriers of infections, attempts to rid the joint of intruding germs and by a complete suture of the capsular ligament or a suture of adhering soft parts tries to prevent a secondary infection* In view of the present type of war on the Eastern Front we are con- fronted with the problem of whether an operative treatment of new injuries of the knee-joint due to gunshot is to be recommended on principle, if it is objectionable, or whether special directives regarding the indications * for operative treatment sho ild be prepared. In ray opinion, the latter point of view should be adopted. The prevailing local con- ditions, the possibility of an entirely aseptic operation, the number of wounded arriving at the same time and last but not least the technical skill of the surgeon determine the advisability of the primary operative treatment of fresh gunshot wounds of the knee-joint* Pertaining to the present campaign in the East I estab- lished the following principles for the primary surgical treatment of new injuries of the knee-joint due to gunshot: 1* Absolute certainty about the kind of injury of the knee-joint due to runshot is to be established through X-ray pictures# If an X-ray picture cannot be taken, the clinical examination must suffice* 2* With regard to smooth perforations, especially those caused by infantry missiles, or in case of lodged missiles with samll entrance wounds or with small splinter- ings of the femur condyles, the patella or of the edges of the tibial joint surface, the primary treatment is the con- servative one* Of particular importance is the reliable fixation of tne best performed by a fenestrated plaster of Baris cast or by a wire splint which is to be fastened onto the thigh, the lower leg and the foot by plaster bandages* 3. With reference to gross damage to joints, splintered fracture of the femur and tibia or large wounds caused by destructive shots in the area of the lower end of the femur and tibia and at the head of the tibia, the primary surgical treatment would be the correct one, especially when the prevailing conditions permit an aseptic operation* The term primary operative treatment means an intervention performed within about two days* Therefore it can usually be performed in field hospitals* The early operation, however, does not consist alone in the excision of the wound and the suture of the capsular ligament but it includes also the revision of the inside of the joint* The excised canal of the missile itself will be most useful for the arthrotomy incision as it permits an approach to the joint and the damaged bone of the joint. Completely detached bone fragments are to be re- moved and new surfaces of bones have to be attained through chiseling. Lodged missiles, deeply imbedded in the bone, are to be left alone, splinters of fractures and splinters within the joint cavity, however, are to be removed* The capsular ligament is to be closed. At the discretion of the surgeon the joint may be filled with an antiseptic liquid* Objection is raised to the drainage of a primarily operatively treated and closed knee-joint. Wounds of soft parts are to be kept open* For that purpose I advise the use of improvised wound- spreaders. 40 As a matter of fact, the primary operative treatment of injuries of the knee-joint due to gunshot, successfully employed during the last years of the First World War, is only rarely used in the present war* That fact is proved by the numerous cases of suppurations under treatment in the field and reserve hospitals. There are cases among them which give the impression that a properly performed early operation especially the removal of bone fragments, might have prevented a serious infection* 4. The typical resection of the joint is to be per- formed in cases of severe intra-articular damages due to destructive shots. It can be combined with the joining of femur and tibia by a wire suture* Experiences made during the First World War teach that the primary resection of the knee-joint is superior to the secondary treatment method with regard to the certainty of accomplishing satis- factory results. However, the primary resection of severely damaged knee-joints is rarely performed in the present war. 5* The primary amputation is to be undertaken in case of extensive damage in the hollow of the knee-joint with attendant perforations of vessels in the popliteal space* Conservative attempts usually fail as in addition to the original severe injury of the joint, gangrene of the foot and the lower leg set in very soon* The primary amputation is also necessary in case of extended smashing of joint bones and of soft parts which do not permit a re- section* I want to emphasize, however, that extensive wounds of the soft parts on the side and above the knee- joint, in other words belonging rather to the thigh, with attendant tearings of the knee-joint but with only minor or no injuries of the knee-joint itself, do not constitute an indication for the amputation in the thigh as these injuries may be cured by adequate excision of the wound and the suture of the capsular ligament* b* The treatment of suppurating knee-joint injurdue ■ ■ to gunshot* In my opinion, one should not lose valuable time with rinsings or massive doses of Eubasin in case of empyemas of the knee-joint after an injury by gunshot. One should rather open the knee-joint and then perform appropriate rinsings. The rinsing of closed joints with phenol-camphor, rivanol or other antiseptic solutions is so unreliable in accomplishing the desired results that I object in principle to its employment in case of suppuration of the knee-joint. It has to be admitted that also after less severe injuries by gunshot suppurating synovitis does occur which at times may react favorably to a treatment of rinsings of the closed knee-joint. However, especially with regard to the medical units at the front where one can observe newly developed suppurations of knee-joints, one can never estimate the consequences of this kind of treatment, particularly after transports, in spite of seemingly favorable reactions at the beginning of the treatment. The experiences made in reserve hospitals with these protracted cases of empyemas of knee- joints speak eloquently for themselves* Opinions differ with regard to the most advantageous type of arthrotomy performed on knee-joints* On the basis of valuable experience gained in hospitals including reserve hospitals, I am taking the following positions 1* If an X-ray picture has not been made, an X-ray picture in two planes should be taken by all means* 2* Pertinent to plain suppurations of the joint without the presence of gross damage to bones, I drain the suprapatellar bursa starting with the customary two para-patellar incisions. Even during an anterior arthoromy, the upper end of the suprapatellar bursa is to be explored with the dressing forceps in order to ascertain whether an opening, reaching into a tube phlegmon of the thigh is present; If so, the thigh phlegmon is then to be opened immediately by long incisions laterally or anteriorally. After this, I flex the knee-joint slightly, proceed from the lower point of the patella in downwards and a little distal in order to find that place where I always perform the deep lateral incisions on both sides over the lower condyles of the femur and the articular space. In this manner, I am able to open both of the posterior joint pockets and remove from the front on either side a thick posterior calotte from the femur condyles. The preservation of the crucial liga- ments is of importance as they prevent a subluxation of the tibia. I disc do not remove the meniscus articularis. It is not necessary. I drain the posterior articular spaces from both sides. To accomplish this purpose, I employed wound-spreaders from birchwood at the front which were made according to my instructions and which ga’fee me valuable service. In reserve hospitals, wound spreaders of metal of better design and even elastic ones could, be produced. With regard to a posterior operation it has always to be ascertained whether a deep or subcutaneous phlegmon of the calf is present which also would have to be opened. Other surgeons are content to perform the arthrotomy of the knee-joint from the front and to remove the posterior parts from the side. Anyone who ever has performed a condyle resection from the front according to my system and who has convinced himself by probing with the finger the wide ex*- posure of the posterior pockets will recognize the great advantage of this small bone operation as compared to the plain posterior approach. Other surgeons again add another arthrotomy from the front accross the quadriceps tendon above the patella. I cannot ascribe particular importance to this method of opening of a jofnt, because the knee-joint is sufficiently widely exposed on all sides through the four arthrotomy incisions and the removal of condyles and it is easily ac- cessible for a treatment by rinsing* Repeatedly I have been shown infected knee-joints at hospitals which were supposedly drained toward the rear. Starting with an anterior parapatellar incision dressing forceps had been inserted in a downward direction and an incision had been performed upon it through which a drain was later inserted into the knee-joint, A corresponding illustration with the inscription "Drainage of Knee in backward Direction" has even been published in literature. This procedure arises from erroneous anatomical concepts. Through an incision performed in this manner, the dangerous posterior articular pockets cannot be opened because the whole region of the epicondyles is situated extracapsularly between suprapatellar bursa and the posterior articular pocket* Such a drainage drains in a backward direction only with regard to the suprapatellar bursa which, however,' is already sufficiently opened by the parapatellar incision. Were one to drain the posterior articular pocket from a frontal arthrotomy incision with the aid of dressing forceps, then one would have to force the dressing forceps through the articular space between femur and tibia an undertaking which is scarcely a possibility. I consider also as danger- ous the opening of the posterior articular pockets in a backward direction into the popliteal fossa as the pus may sink into this region and lead to a hemorrhage of the popliteal artery. 3, TRAUBE (D.m.W. 1942, 982) as well as WESTHUES and RUED (M.m.W. 1942, 736) open the joint wide from the arch of Textorfs incision, saw off a flat slice from the lower end of the femur and in addition perform a removal of the condyle by saw according to my system. This is an un- necessarily large operation. The removal of the cartilageous bone at the lower end of the femur is superfluous because there is no danger of a flail joint. In most cases a firm ankylosis of femur and tibia develops which, without any sequestra, in a few of the cases even at^ains a certain amount of flexibility. If the crucial ligaments with the eminentia intercondrdLoidea of the tibia are smashed, which happens rarely, I advise a limiting wire suture through the femur and tibia from both of the deep lateral without any sawing off of bone ends as a means of avoiding subluxation of the tibia. 4. With regard to splintered fractures at the lower end of the femur or at the edges of the tibia joint surface, also in case of not too extensive splintering attended by infection of the knee-joint, I perform the anterior and deep lateral arthrotomy, remove bone fragments, and always chisel off the posterior femoral condyles. These cases also, even though accompanied by phlegmons of the thigh and the lower segment of the leg below the knee, can be cured by this operation and the leg can be preserved. According to data submitted by E. PLAAS at the reserve hospital of the Surgical Clinic of the University in Koenigsberg, among 33 cases of unnecessarily prolonged suppurations of knee-joints after injuries by gunshot, 24 cases had fractures of the joints with phlegmons most of which extendedt*thigh and the lower leg. Of these 24 cases, 16 had been cured with the preservation of the leg, 4 were cured by amputations and 4 had a fatal outcome. 3 cases showed only fractures with attendant suppurations of the joint without phlegmons* All of them had been cured with preservation of the leg. 6 cases had phlegmons of the thigh and lower leg with infected knee-joints but with- out fractures* 3 had been cured with preservation of the leg, 3 ended fatally. In all these cases, the operations performed corresponded to the one described by me. In case of fractures of the patella due to destructive shots with infection of the knee-joint, the entire patella has to be removed. 5, I object to the performance of the typical secondary resection of the knee-joint in case of suppuration of the knee-joint after an injury by gunshot* If both of the bones are joined by a wire suture, the posterior drainage is not sufficient unless the condyles have been chiseled off too. If the two bones are not joined by suture, the sawed off ends of the femur and tibia extend into the sunnurating cavity of the joint. Also by this procedure, a reliable drainage of secretion, especially from the posterior parts of the knee-joint, is not a certainty. For these reasons, I con- sider the rypical resection of the knee-joint an unnecessary procedure as it does not offer any advantages when compared with the fourfold arthrotomy combined with the removal of condyles• 6* I do not perform the exposure of the knee-joint as recommended by SCHLOSSER, which always makes a later re» section of the knee-joint and frequently even an amputation necessary, because it does not offer any advantages over the type of arthrotomy recommended by me. According to my observations, it is rarely performed in the present war. 7, Foreign bodies in the articular space and also those in fracture clefts are removed during the arthrotomy of the suppurating knee-joint. On the other hand, with regard to missiles deeply embedded in bones, I do not ad- vise their removal by chiseling as they, as a rule, do not support the suppuration of the knee-joint and the removal of them leaves unnecessary deep cavities which are difficult to cure. 8. I have already referred to the great importance of phlegmons in the thigh and the lower leg. Frequently they are difficult to recognize as they are located deeply and do not produce any inflammatory changes of the skin. One has to be on the alert for their presence curing the arthrotomy as already mentioned. In order to keep-these sufficiently opened phlegmons in an open condition, I re- commend the use of wound-spreaders. Rubber tubes are fre- quently not sufficient for drainage. 9. A very difficult task is the fixation of the operated knee-joint. Usually, one certain type of fixation does not accomplish the purpose. Special splints for knee- joints are not available in the hospitals. For field surgery, difficult to produce splints can hardly be con- sidered. If one makes a large, firm plaster cast exposing 44 only the actual region of the knee-joint, one cannot ob- serve the development of nhlegmons in the thigh and the lower segment of the leg. In order to investigate, the thick plaster cast has to be cut open which frequently is a very trying experience. After the phlegmons have been opened, the fixation again produces difficulties because there is not sufficient space for the plaster cast. These ex- periences have led me to the construction of the simple graduated splint, the latest type of which I have described in the Zentralblatt fuer Chirurgie (Zbl. Chir* 1942, 1569). It must be heavily padded especially in the region of the thigh. Only thin plaster of Paris casts which can be easily cut again, are applied on the thigh, the lower leg and also above the opened phlegmon, •‘■he foot also is kept in firm fixation by the plaster of Paris cast*. This splint, per- mitting the exposure of the knee-joint for the purpose of rinsings, is supposed to be employed only for the critical time immediately after the operation. This splint is not a suitable transport bandage. When the knee-joint becomes quiescent, and the healing process of the phlegmons is progressing well, a fenestrated plaster cast should be put on again. 9* Of utmost importance is a careful after-treatment. One may dpply bandages around the joint or just cover the wounds with dressing material, otherwise the method of treat- ment is the open one. I usually perform several rinsings daily of the open joint with Dakin or Hivanol solutions. A careful after-treatment and continual re-examinations for the purpose of discovering possible developing phlegmons is of decisive importance for the fate of these severely injured patients. Evacuation may be undertaken only after the patients have been without fever for several weeks. 10* must an operated, suppurating knee-joint be amputated? With considerations of actual war conditions, an operation which accomplishes regularly the cure of a com- pletely infected knee-joint is an impossibility. Of de- cisive importance with regard to thigh amputation, is not the fact that phlegmons are present or that fractures into the joint exist or the fact that a fever does not set in immediately after the operation but rather the observation of the patient and the judgement about his physical conditons in general. If one gains the conviction that blood trans- fusions are futile, that the physical conditions in general are deteriorating more and more without the discovery of new phlegmons or abscesses which would have to be opened, then the thigh must be amputated. Of particularly unfavor- able portent are long, gross splintered fractures of the femur which extend into the joint, especially when a large piece of bone is completely detached as well as more ex- tensive smashings of the head of the tibia. With reference to this kind of fractures with attendant severe infection of the knee-joint, rise in temperature and high pulse and a poor general condition, one would better waste no time •with conservative operations on the knee-joint, but ampu- tate immediately. The treatment of ankle-.joint injuries due to gUnehot* Injuries of ankle-joints due to gunshot, shell splinters and particularly by urines, are especially frequent in the present war. They are usually combination injuries with more or less destruction of the posterior tarsal bones with large woi nds of the ankle-joints. Often they are bilateral. a» The treatment of a new injurycof the ankle-joint due To gunshot^ Injuries of the posterior part of the foot due to mines consist mostly in the destruction of calcaneus and talus with the simultaneous opening of both ankle-joints. The primary treatment is in principle a conservative one. The excision .of the wound does not accomplish much. A primary removal of bone fragment is to be objected to as one never knows how man}' of these fragments might heal in eventually. Sutures of capsular ligaments are not possible. Wounds of the sole of the foot are to be kept open. The san© principle must be applied to wounds of the metatarsus caused by destructive shots. Also in this case the treat- ment is fundamentally conservative. X-ray pictures are in- dispensable. Of utmost importance is the proper fixation of the foot in a vertical position in relation to the lower leg in slight supination. As injuries of the posterior part of the foot due to gunshot usually heal up with ankylosis of both of the ankle-joints, one has to be on the alert even during the primary treatment in order to avoid pes equlnus. The ankylosis of the joints, with reference to the MGehoofn is later replaced by a certain flexibility of the tarsometatarsal, joint. The proper fixation of the foot using a fenestrated cast or plaster bandages is often a very trying job as there is little space for the application of the plaster of Paris cast on the injured foot. b. The treatment of suppurating; injuries of ankle-.joints due to gunshot. The course of treatment of injuries of ankle-joints with long protracted suppurations of ankle-joints, osteomyelitic processes and phlegmons is usually attended by fever which at times causes just as much anxiety to the surgeon as an empyema of the knee-joint. The operative opening and^drain- age of the suppurating ankle is usually to be accomplished only by the removal of the frequently also osteomyelitically diseased bone fragments or the sacrifice of one or more bones of the tarsus. One has to remove for instance the talus or one or more of the sphenoid bones or perform a resection at the bases of the metatarsal bones. The removal of bones at the inner or outer edge of the foot is to be avoided on account of the consequent occurrence of a wrong position of the foot in adduction or abduction. The talo- crural joint is opened at both sides of the extensor ten- doni Phlegmons of the sole are to be drained through lateral incisions. Not infrequently edema with multiple 46 small abscesses^are encountered which have to be opened by multiple incisions, I have never had the opportunity to witness the dorsal opening of the entire metatarsus and the tarsus by saw according to KLAPP-KIRSCHNER, but it has to be kept in consideration# The course of the fever is usually a very protracted one and places strong demands upon the power of resistance of the body# Unfortunately, in case of a threatening general infection, the amputation of one or both of the lower segments of the legs concludes the local treatment. At times, chills occur during the course of treatment which have their origin in suppurating thrombophlebitis in the veins of the leg in the region of the tarsus# In the case of an ankle injury of a young medical officer due to multiple shell-splinters with attendant multiple sup- purations, even the amputation of the lower segment of the leg, performed by me, did not eliminate the chills so that the general physical condition of the patient was endangered. Only the ligature of the femoral vein belovr Poupart’s liga- ment brought about the sudden ceasing of the chills and was conducive'to the complete restoration of the patient. 7* The Eubasin treatment of joint injuries due to gunshotI With regard to the Eubasin treatment of injured joints due to gunshot I take the following position: The group of new injuries of joints due to gunshot with sterile hemorrhages and the ones with turbid hemorrhagic or serous contents in the joint must be separated from the group of pure suppurations of joints# With regard to poly- arthritis we know that the synovial inflammation can be favorably influenced by large doses of aspirin# Therefore, a treatment of new inflammatory reaction of the inner tissue of a joint in the early stage with effective sulfonamide preparations, as Eubasin for instance, is worth the trial and might even obtain good results. FRUEND has applied that treatment» Through a massive dose of Eubasin he has performed, so to speak, a prophylactic treatment of these new inflammations of joints. But, as he claims, he has submitted to a Eubasin treatment also severe suppurations of joints and phlegmons of the capsular ligament with disregard of operations. He has removed only bone fragments and opened secondary abscesses and phlegmons# With reference to these methods the following comments have to be made: 1. Pertaining to the prophylactic Eubasin treatment of still sterile joint hematoma or new infections, FRUEND has not onlv administered strong doses of Eubasin but he has also used aspiration and rinsing with rivanol and. he has also taken care of a proper fixation, especially by unpadded plaster of Paris casts. The favorable reactions to these procedures he ascribes to the Eubasin treatment# We know, however, that the proper fixation as well as the aspiration and rinsing have soothing effects upon joints with new in- fections# For these reasons, I do not agree that the results obtained by this combination treatment are solely due to the Eubasin treatment. 2. With reference to suppurations of joints due to injuries by gunshot, I reject the pure Eubasin treatment even with high doses of Eubasin without a previous surgical treatment expertly performed. Of course, one can observe a subsiding of temperatures after the administration of high doses of Eubasin, the decline of temperatures, however, hides the real conditions of the joints. The process of suppurations of joints will not be influenced by it. The wasting of the body continues. It comes to the formation of abscesses and phlegmons and frequently, as I have observed, the proper time for an operative treatment has passed on account of this type of treatment and an amputation must be performed. If trials with sulfonamide treatments of totally suppurating joints due to injuries by gunshot are to be undertaken at all, they should follow only expertly performed surgical exposure. If effective sulfonamides do give a good account of themselves in this respect, one will gladly consider the employment of them as a valuable additional method for the complicated after-treatment of suppurating joints. Within these limits, the continuation of these trial of suppurations of joints, due to actions of war, and initiated by FRUEND is to be desired. Inasmuch as the sulfonamide treatment of suppurating joints and wounds will always re- main a kind of an additional treatment procedure the opinions, at all appearances, will always remain divided about its effectiveness. 10. Evacuation dres?tings• (Major, MC») Prof» HELLNBH The evacuation ‘dressing has to serve the following pur- poses: 1. Protectjon of the wound from secondary infection; 2. Fixation to counter any danger of pyogenic or anaerobic infection threatening any wound; 3. To render conditions as painless as possible. Fulfillment of points 2 and 3 also counteract shock. Pertinent to point 1; The pro- tection of the wound is taken care of by a special covering of the wound with ntastisol or adhesive tape as otherwise the actual bandage of the wound beneath the padded and more bulky bandage is frequently shifted. The consequence is favorable to a secondary infection. With reference to point 2: The necessity of fixation can never be emphasized too much. The fixation Is accomplished by KRAMER’s, PAPPfs, VOLK- MANN!s splints eto. The fundamental principle of any fix- ation that it be extended over two adjoining joints is fre- quently being violated. With reference to fractures due to gunshots, the fixation by splints is also of primary im- portance since for reasons of limited time and saving of plaster of Paris material, plaster of Paris casts alone can hardly ever be made use of. At the front, evacuation dressing without padding, especially the unpadded plaster of Paris cast, are prohicited even for the experienced physician. If a transport unit is being delayed for a longer period 48 of time, the bandage must be fenestrated at the wound site. The fixation, so important for the wound, will be disturbed by the unnecessary unrolling of the entire bandage. The bandage of the wound must be so arranged that an examination of the wound during transport is a possibility (phlegmons, danger of gangrene, hemorrhages). Eight from the start, the fenestra must be so large that also the area surround- ing the wound can be examined. The evacuation dressing, to serve its purpose as a medium for rest and fixation, should always be arranged with the idea in mind that ii can be left undisturbed for as long a time as possible. The restful position and the painlessness of seriously injured patients during the first transport are effectively sup- ported by medicines. During transport in v/inter time, the possibility of damages by cold has to be kept in mind. In general, prior to a transport, one should first carefully consider: a# whether the injured patient is transportable in the first place, b. how long a time the transport will probably take, c. what means of transportation are to be employed (sleds, autos, railroads, aeroplanes). Disastrous damages due to transport are more frequently occasioned by careless selection of patients for evacuation than through the inefficiency of transport units. A rehl danger is the too hasty evacuation. Patients with conservatively treated injuries of chest or abdomen should be held back for at least 14 days, patients with infected injuries of joints or fractures due to gunshots should be evacuated only after overcoming the infections. Directives. The longer the distance to be covered, the more time to be consumed by the transport, the more careful the arrangement of the bandage has "co be. In general, the following directives with regard to evacuations have to be observed: 1. A special closing of the wound by a mastisol bandage. For longer transports, no circular windings of dressings because of the danger of hemostasis. The wound must be accessible by a fenestra whose location is clearly apparent and which is to be bandaged separately# 2. The fixation by splints. Any kind of material, suitable for splints, is to be employed. Always fix the two adjacent joints on either sides at least, as other- wise an insufficient fixation and &bshifting of the splints may take place. Improper fixation mdans a danger of in- fection, a reduction of the power of resistance of the wound itself in its flight against an infection and even the possibility of shock during the period of transport. Always good paddings in order to avoid pressure and hemostasis. No unpadded plaster of Paris casts. Always physiological relaxation positions* Particularly careful selection of patients for evacuations. If possible, evacuation only after overcoming the infection. No evacuation of operated patients with injuries to brain, chest or abdomen due to gunshot for at least three weeks after an operation. Special suggestions. With regard to new injuries of the tipper extremities with attendant damage of bones and joints, DESAULTfs bandage, reinforflfld by a half splint of plaster, is to be recommended. Pertinent to operated fractures of shoulder joints or upper arms due to gunshot, is the use of thorax plaster casts on abduction splints. With reference to new injuries of soft parts of the lower extremities, splint bandages are suitable. Pertaining to new fractures of the thigh due to gunshot injuries, splints of boards or WACHSMUTHrs splints should be used for the un- injured leg. Surgically treated fractures of the femur as well as injuries of hip and knee-joints due to gunshot require the large, fenestrated evacuation dressings of plaster which have to extend from the line of the breast down to the toes and in case an extension bandage cannot be provided immediately. BOEHLERTs sheet plaster will best serve this purpose. Injuries of lower legs are best taken care of by VOLKMAMNfs splints. Every stump, the result of an amputation, requires a splint bandage extending above the next higher joint with a special protection of the stump from mechanical irritations. Concerning injuries of the floor of the mouth, the tongue or the jaws, special precautionary measures have to be applied for evacuation dressings through the use of a traction thread in the tongue,fila- ments. Tracheal cannulas are to be fastened carefully. Inserted permanent catheters must have large diameters. 50 II. EFFECT OF COLD Translation prepared by: Office of Military Government for Germany (U. 3. ) Office of Naval Advisor Medical Section 1. Heat regulation, Oberfeldarzt (Lt. Col., MC.) Prof. RAMKE In addition to the known heat regulation (physical regulation of the delivery of heat, chemical regulation of the development of heat) it was explained that up to 300 calories are available in those parts of the human body which are exposed to a cooling-6ff due to an inter- ruption of the blood circulation (KOENIG) before any harm- ful effects will arise. The same quantity of heat is required to restore the normal temperature again: Re- gulation of the distribution of heat. We do not yet know much about metabolism in parts of the body subjected to such treatment. However, we can say that serious in- flammations will go hand in hand with injuries of the blood circulation. While, according to HOLZLOEHMER, the quickest possible rewarming of the entire body is re- quired in cases of a cooling-off of the body, the circu- lation has to be stimulated and restored to function first in cases of local injury due to cold and only then should the affected part be re-warmed. Furthermore the adapt- ability to cold was discussed: Change of metabolism af- fected by the thyroid gland, capillary exercises* Human beings can better stand a short period of intense cold than a long lasting but less intense cold. Full par- ticulars of this lecture may be read in the MKlinische Fochenschrift” 1943, page 113* 2. Prophylaxis and diagnosis. Oberfeldarzt (Lt« Col», MC») Prof# LOSHE Prophylaxis is as important as the therapy of in- juries due to cold. It requires the early procurement and efficacious use of the protector against cold by troop leaders and the physician, VTiere ever the troops - according to the tactical situation - had the opportunity to dig trenches in time, there were almost no signs of in- jury due to cold, A regular supervision and training, par- ticularly of the inexperienced recruits, is essential. General hygienic precautions are to be met, hygiene as a whole is to be practised as well as the hardening of the body at the beginning of winter time. This proved to be especially useful as the body becomes accustomed by and by to low temperatures without suffering any injury. For instance, the rapid fall of temperature in December 1941 had only a partly unfavorable effect; only some of the soldiers suffered injuries due to cold although all were living in the same circumstances, especially those who were not used to cold and those with a poor blood cir- culation such as those who had previously been office- workers, while soldiers of peasant extraction were con- siderably less endangered. It appeared again and. again that the troops should have been hardened against the influence of bad weather during their training period in the homeland or behind the front and thus be prepared for winter battles. Only thus will the soldier be ac- customed to protect himself against cold and be able, better able to face, mentally as well, the possibility of a combat during periods of extreme cold. This psycho- logical preparation is rather important. Officers and non-commissioned officers should be informed by the physician about the development of apathy in the cold, which refers to the increasing indifference of the soldier caused by cold as regards the protection of his own person from cold and from danger of the enemy. During Y/inter battle, which requires higher qualities of the individual many cases of injuries due to cold may be attributed to apathy, and are in that way self-inflicted. On the other hand it was frequently observed that good officers and N.C*0.!s much more rarely experienced injuries due to cold though living under the same conditions, because they were aware of the danger. Hunger should be avoided and the internal protection against low temperatures should be increased by higher food rations. In this connection special consideration should be given to the value of rich vitamin food, the supply of cod liver oil and providing at least one hot meal daily. Alcohol added to tea has proven itself use- ful during periods of intense cold and moisture. An excessive use of alcohol should be forbitten because of the drowsy effect produced which may obscure an early injury due to cold. First consideration should be given to the early issue of winter clothing. It should be adapted as well as possible to the style of the Finnish clothing accord- ing to the experiences of the past winter. Blouses and trousers, lined with cotton pads, fur waist coats and knee-protectors, head-protectors, still better fur-caps, comprise the really necessary equipment of the rifle-man. Fur coats, though reducing too much the agility in combat action are indispensable for guards on duty. Shortening the period of guard duty should not be overlooked. Most particular attention should be paid towards a good and well fitting equipment for the feet that should include for every soldier, felt boots, provided with leather soles to facilitate walking. The fitting should be made carefully so that no moisture or wet snow can enter the upper part even when two pairs of woolen socks or foot-wrappings are worn. The ability to move the feet and toes must be guaranteed. The supply of a riding-type of trousers lace-up legs, similar to the camouflage-trousers, is to be recommended. Instead of woolen gloves that quickly become wet by snow and moisture, coverings of fur or linen texture or canvas are urgently required and must be provided with three separate compartments for the thumb, index finger and the other fingers, so that any weapon can be handled with- out hinderance. One should also be able to pull them over the sleeves so that no snow can enter the sleeve while lying down. In addition to a sufficient outfit of under- wear, ear-protectors and protective head gear with sewn in layers of cotton providing slits for the eyes, nose and mouth are indispensable. Although it is admitted that the opinions regarding the value of the ointment for frost protection are divided, it is nevertheless true that this^ointment is offering an effective protection against high degrees of cold. Even a regular * application of cold cream, containing a little water, often enough to just keep the skin soft, affords protection. Special care is necessary in the evacuation of wounded soldiers, to protect them against effects of cold. Snow-drifts and impracticable terrains often made it impossible to send the ambulances right to the first aid stations which had to be installed near the front- lines, because first aid in the lines was jeopardized by the extreme cold and was limited to inoculations against tetanus. The Russian flat sledges proved to be very use- ful if protected against cold and wind by a suitable cover. At greater distances, the transportation should be relayed and hot drinks in insulated bottles should be served. To ocver the absolute requirements of warmth for the wounded soldiers, caused by loss of blood and shock, a sufficient quantity of woolen and fur blankets should be available. Further evacuation to the main-dress- ing station is to continue by motor vehicles that should be heated before and during the trip by medium sized chemical stoves. Small, fixed iron-stoves heated by char- coal proved to be even more advantageous. The smoke pipe is led through the side panel. The thermo pads,1 used by the Russian Army, which develop heat during 8 to 9 hours when moistened, have proved satisfactory on the whole. As to the diagnosis of the effects of cold the picture is so characteristic by its outer appearance and by the history that errors are hardly possible. It should be realized, however, that a strict classification into the traditional and customary three degrees is almost im- possible, as there exist many intermediate cases and it is often not possible to make sure at the first examination, whether or not deeper located structures of the tissue are involved. Chilblains may at first sight be confused with Lupus pernio, particularly when localized to ears, hands and feet, and furthermore with Erythema which is, however, easily distinguished from the regular resorptions, and chilblains by its tendency to cicatricial atrophy, central cicatrization, hyperemia at the edge as well as by the small scales. Ulcerated frostbite can always be differ- entiated from syphilitic lesions by the anamnesis, the itching, the localization in areas where pressure is ex- erted, as well as the co-existence of persistent chilblains. Therapy of injuries caused by cold* Stabsarzt (Captain* MC.) Prof. STABLINGER The evaluation of injuries caused by cold should be adapted and coordinated to the tactical situation and should consider the physical and mental condition. Effect of cold in general: Quick outer and inner heat supply (5 per cent solution of dextrose, 45°C, in- jected intravenously; fever therapj^-; if necessary arti- ficial respiration with increased oxygen; slight rhythmical massage; elevation of will power. Local effect of cold: The severity is often not recognizable at first sight; position at rest* Papaverin- Cardiazol tablets. Effects of cold; 1st degree? Ointment dressing, pro- tection against cold, alternating hot and cold baths. 2nd degree: Marfanil-Prontalbin powder; chemical and sero-prophylaxis (tetanus and gas-edema) drainage of the edema by salyrgan and by various incisions into the edematic parts; position at rest. degree: Shifting of the demarcation toward the periphery by intra-arterial, percutaneous injection of Eupaverin, continuous intravenous drip infusion of Padutin or Priscol, blocking of the lumbar portion of the spinal cord, sympathetic nerve, plexus or peri-arterial; fever therapy if increase of temperature fails to appear, zinc- gelatin cast up to the probable limit of theinjuries caused by cold; contractures. Prophylaxis against infections, ligation of veins, local decompression incisions, elevated resting position, massive doses of sulf (jO grams within three days, added to soup); in case of threatening infection an early amputation is generally advised in the immediate proximity of the frost-injury; small transfusions of blood, care and support of the blood circulation, psychic guidance and obtaining permission prior to any amputation. As soon as a clear cut demarcation of the in- jury is established and if not otherwise contra-indicated, the demarcation amputation slightly above the necrosis will take place and will be followed up by an injection of TAT, gas-edema serum (desensitization) and sulfonamide-prophy- laxis. After the operation, if the necessity arises: Delayed suture, active exercises, immediate prosthesis: Attainment-sport games and attainment-gymnastics; en- couragement. In case of a ubad,f stump and failure of all plastic or other means of cure, including surgical^operations of the sympathicus, a delayed amputation with consideration of the professional requirements and according to the scheme of ZTTR VERTH should be made. The medical objective con- cerning the treatment of frost injuries is the individual treatment of the patient avoiding any stereotyped measures in consideration of the interest of the community according to uniform regulations. It must finally be said that the best way to prevent injuries by cold is an energetic pro- phylaxis by the military command and the medical service. Discussion: LAEWEN; Pleads for the early removal of the dead tissue (after about 3 weeks) so as to shorten the healing process. BOEHLER is of the same opinion. • General instructions for amputation in cases of effects ' of cold (fexcerpt). 1. The early amputation. (Approximately 1*55 per cent of all reported cases of 2nd and 3rd degree injuries, equalling 8*97 per cent of the total}. of 3rd degree injuries, for the Army only*) Indication for operation: Anaerobic infections; tetanus, also when spore elimination is only partly achieved (PIERINGER); general infection developing (deterioration of circulation, repeated chills, toxic diarrheas); severe} secondary^injuries of the same limns (destruction of bones or joints), injury of a main vessel ahd avulsion of the principal nerves* Indication for anaesthesia: General anaesthesia (Ether, Evlpan)"* Indication as to the height of amputation; In case of gas edema the amputation should be made b3r cutting deep enough in the sound part, in all other cases as deep as possible and as high as necessary (LEXER). The scheme of ZUH VERTH will be disregarded. Object of the operation: Freeing of the body from sources of spreading infection and poison by a single emergency oper- ation, when in critical state and in shortest possible time with the view of creating wound conditions as propitious as possible with the least possible mutilation. Yet, life has to be considered first of all, before thinking of the limbs in particular or even of an especially desirable formation of the stump, which in most cases is not achieved finally. Technique of the operation: Conservative incision in the sense of WACHSMUTH without double-esmarch (KIRCHNER) by means of a single circular incision without nerve shortening, bone- marrow scraping, shifting of muscles, or formation of loops. Fixation of an extension apparatus without any sutures but with exposure of all still possibly infiltrated muscular and vascular layers, as well as tubular abscesses by an^appropriate splitting of the stump; in cases of thrombo-phlebitic veins, high ligature; Marfanil-Prontalbin powder; fixation in a posi- tion of rest. Repeated circular incisions are more injurious and more dangerous than the formation of sufficiently large and well-nourished lobules. 2. The amputation of demarcation. Indication for operation: Clear demarcation; satis- factory defense and general condition and absence of contra- indications, especially healthy vascular S3rstem and good blood circulation; no diabetes; blood count and sedimentation rate should not show considerable deviation from normal; operation will be practicable in about three or four weeks. Indication for anaesthesia: General anaethesia (Ether, Evipan), or blocking of nerves• Indication as to the height of amputations Close above to the upper par/t of the demarcated area; arterio- graphical clarification of the functional state of the vascular system before and after intra-arterial injection of Eupaverin is desirable, trial-incisions as decay of tissue is often only superficial; only dead tissue is to be removed. Roentgenogram reveals the demarcation level of the bones. Objective of the operation? By removal of all dead tissue, prevention of possible ascending vascular damage and of still possible generalization or at least spreading of the infection (late tetanus, late gas-edema) with a view of shortening the healing period (LAEWEN, BOEHLER). The extension of the curative treatment, the extent of the permanent damage, respectively the remaining working capacity and a maximum usefulness of the stump and its configuration are at stake. Technique of the operation: Separation of the skin in the healthy area and of the bone as well only as high as necessary at the upper part to assure a reliable covering by the anterior and posterior lobes and to avoid a second operation; change of instruments after perforation of the parts near the demarcation; exact evaluation of the con- dition of the deeper situated tissues (connective tissue of the muscular and vascular layers, of the sheaths, nerves and jointsi In the area of the foot preference should be given to the joint-lines, the cartilaginous surfaces will be removed, but the small bones will not be sawn through; special caution is necessary when closing the wound; Marfanil-Prontalbin powder; approximation-wire-sutures to be used at first, no knotting, over-rubber-tubing on both sides, position at rest. In case foreign matters or ex- tensive infiltrations are still encountered operation should be finished in the sense of an early amputation. 3. The late amputation. Indication to operation: Bad stump-formation after early or demarcation-amputation. Failure of all curative measures because of vascular diseases and its after-effects, trophic disturbances, diabetes, sympathalgias. abscesses caused by pressure of the prosthesis, contractures etc. if visible lobe plastic operation, double pedunculated skin lobes or skin transplantation according to RAVARDINO or 8RAUN do not suffice to overcome the damage* Indication as to anaesthesias As for the amputation of demarcation. Indication as to the height of amputations BIER’s test to ascertain anaemia of the tissue,scheme of ZUR VERTH, pro- fessional requirements to be considered first of all. Object of the operation: Good final formation of the stump and the increase of working capacity of the patient. Technique of the operation: Almost the same as in case of the demarcation-amputation, if necessary tenotomies, dislodging of the tendon channels, respectively shortening of sinews. The wound-closing by suture may be more com- plete. Further details concerning formation and evaluation of the stump are contained in the leaflet entitled f,C Kaelte- schaedigungen" (cold injuries) dated September 1942. 4. Prevention and therapy of cooling effect* Stabsarzt (Captain. MC.) Prof. HOLZLOEHNER When exposed to cold water below 15 degrees Celsius, biologic counter-regulations become almost ineffective in animals and humans. The reflex rigidity, increase of blood sugar and acidosis is developed earlier and stronger in humans than in test-animals. In case of rectal-temperatures below 30 degrees Celsius, auricular fibrillation 1s re- gularly observed under these distressing sea-emergency conditions. Below 28 degrees Celsius, the human heart will often stop beating (Stress by dislocation of blood, increased resistance and viscosity). Medical therapy is senseless and useless in that case. Best results in humans will be obtained by hot baths. As a protection against cooling in cold water below 15 degrees Celsius a foam suit has been developed. 5, Pathology of the effects of cold. Oberfeldarzt (Lt* Col,, MC.) Prof* SCHULTZ Reference is made of the detailed report of SIEGMUND (first conference "East1’ and Muenchn* Med* Wchschr., 1942 No. 39)* The complications immediately following the effects of cold are of special interest to the field- pathologist, namely: suppurative thrombo-phlebitis, metastatic, articular suppuration, extensive phlegmons, frequent endocarditis (according to BOEHNE in 10 per cent) and as a general, but not clearly established sequela: nephroses in 50 per cent of all 3rd degree cold injuries according to BOEHMIG. No specific anatomical findings can be said to be generally prevailing in case of death due to cold. The displacement of the greater part of the blood into the internal organs, the absence of glycogen in the liver and the muscular tissue (LUCKE) but in spite of this an increase of weight of the liver (by cloudy swelling, according to BOEHMIG) is characteristic. SCHULTZ discovered waxlike degeneration of the muscles in 37 per cent of all autopsies in the cold season as compared with only 4 per cent in the warmer season. The exact examination of the suprarenal glands as described by REIN and KILLIAN was then considered as the important future problem. 58 6a Pharmacological evaluation, of the medicinal therapy of 3.6cal Injuries# caused .fey, effects, of' cold. Stabsarzt (Captain* MC.) Prof# LENDLE Medicinal measures intended to ward off local injuries dtie to cold must exclude the spastic stenosis of the ar- terioles and paralysis of the capillaries with a simultaneous increase of permeability* Remedies with a specific effect on the capillaries are not available* For the counteraction of the spasms of the vascular muscles quite a number of so-called spasmolytics are available* which are predominantly effective by way of direct paralysis of the smooth vascular musles themselves or by way of an excitation of the paralysing elements. Any influence on the vascular width by blocking the central vasomotoric-tonus (narcotics) or by peripheral elimination of the nervus symnathicus (type of ergotamine) is not possible. Acetylcholine and Dory! are para-sympathetically effective drugs which should be avoided because of their transient effect and because of their side effect on other organs; while on the other hand Prostigrnin seems to answer well either by way of paralysing the esterase which splits the Acetylcholin, or by direct-parasympathetic muscle-effect increasing the blood circulation of the skin and muscles. Prostigrnin has even when perorally administered an effect which lasts for several hours* Among those spasmolytics which directly paralyze the vascular muscles* Papaverin is too evanescent arid of an insufficiently reliable effect when perorally administered. Among the analogous synthetically produced isochinolin de- rivations* Eupaverin proved most satisfactory* A com- bination of "Eupaco" with Atropin which is in the trade is not essential for the therapy of vascular spasms, be- cause Atropin has - when given in therapeutic doses - no effect on vascular dilatation. Priscol (Ciba) has been recently recommended as a spasmolytic. It is a synthetic derivative of Imidazolin, which is a substance similar to Histamin# According to hitherto available reports Priscol does not have the capillary-injuring property of Histamin. It is said that it paralyzes only the arterioles and produces only an arterial hyperemia* Also when perorally administered, it is sufficiently effective. This effect when measured by the temperature of the skin lasts for several hours. The range of the effect is satisfactory. Increase of the secretion of gastric juice and the intestinal peristalsis have been observed as side-effects; these symptoms relate to a persistent effect of Histamin. Finally the so-called circulatory hormones and various Adenyl-acid preparations which are also contained in organic extracts* such as Lecarnol* Eutonon. Myotrat etc* must be mentioned in this group of spasmolytics acting on the system of arterioles* The chemically not yet clarified Callicrein (Kallikrein) or Padutin which are said to be derived from the pancreas# belong to this group too# All these compounds have only a transient effect when parenterally administered and have no reliable effect when perorally given# Their side effects, when highly dosed, are insignificant and harm- less# No preference should be given to them over Eupaverin or Priscol. The supply of great quantities would encounter certain difficulties. The sexual hormons are the last pharmacological group to be named, the effect of these hormones in preventing vascular spasm has likewise been proven by experiments on animals in the prevention of rat's tail-gangrene after administration of Ergotamin. There is no explanation of how this therapeutic effect comes about# The synthetically produced Cyren has exactly the same effect as the sexual hormones# This is a preparation of Stilben which has the same hormone-effect in other respects. These efficacious remedies may also be applied percutaneously as an oint- ment • Other local measures of therapy were not dis~ cussed. The remedies, likewise recommended for this, are chiefly aiming at securing an improved blood circulation (e#g# camphor, ichtyol). All these remedies named above have to be applied at the earliest stage of any frost-injury, in order to maintain the blood circulation. Whenever there exist serious capillary-injuries or whenever the insufficiently nourished tissue is frozen throughout, the prognosis is unfavorable and all spasmolytics have only relative value, in that they might reduce the extent of necrosis# It should, therefore, be required that the field dispensary equipment, also set A, contain a sufficient quantity of in- jectable spasmolytics and that in case of longer trans- portations a sufficient supply.for tho injured patients must be provided. Remarks on this subject bv Oberstabsarzt (Ma.ior. MC.) Prof. ZIPF 1. With regard to vascular spasms in case of in- juries by cold the question is important, whether, besided the re-heating to normal tissue temperature a therapy with spasmolytics is indicated after all. For there exists the possibility that the vascular spasm continuing after the temperature restoration must be interpreted as a physiologic counter-reaction in the sense of a vascular contraction (subsidence of serous inflammation) and pro- tection of the body against infiltration of cell decom- position products into the general circulation# Wherever a spasmolysis by pharmaceuticals is indicated, prostigmin as the strongest remedy to interrupt the cholin esterase and possibly sympathicolytics of the type 933 P (piperi-domethyl-benzo-dioxan and others) may be used, all of which are not attended with the disadvantageous side- effect of the alkaloids of the ergot of rye# 60 2• For the local therapy of effects of cold the treatment with CO2 gas seems to be suitable*' According to out experience with CO2 gas baths a local, sharply limited hyperemia of the skin and the subcutaneous con- nective tissue may be caused thereby* 7.i Pharmacologic results in animal experiments con- cerning local injuries due to cold* Stabsarzt (Captain, MC,) Prof, LENDLE It was the object of our experiments to prove the correlation between the time and degree of exposure to cold and the severity of the injuries of the rat!s tail* This did not prove successful. The investigation of the influence of medicinal therapeutics on the rat*s tail and the rabbit’s ear did not bring any convincing results* These experiments led only to a certain insight into the patho-physiological processes in case of an intense effect of cold. The capillary system must be considered as the principal site of injuries. This fact explains the oc- currence of stasis, formation of edema, insufficient blood supply to the tissue, formation of blisters etc* It was authenticated by way of vascular biopsy, while thawing off frozen ears, that the blood, contained therein is hemolyzed and that vessel-dilating substances (FLEISCH) result from the hemolysis; besides a histaminlike substance was bio- logically proven. On circulating tellurit solutions (direction by WELS) through the frozen ear preparations, an injury, in the sense of the elimination of the reduction capacity within certain layers of the skin was observed, even when the susceptibility of the arterioles to adrenalin Still existed* Concerning the possibilities of influencing the capillary permeability in the sense of a contraction, it may be stated that no specific remedy having this effect is known. Discussion: HANDLOSER: Pointed out the extraordinary importance of instructions to fight the effects of cold and addressed an urgent appeal to all officers of the medical corps and asked them to fulfil also in this field their mission as vigilant guardians of the health and to see to it that every soldier is kept well informed on all the possible preventive measures* BREMER: The signification of the status dysraphicus is pointed out, which often represents a constitutional pre- disposition for injuries of the ends of the extremities by cold. Nearly all patients suffering from pronounced dysraphla, with cold hands and feet even before real damage occurred, contracted the most severe injuries* 30 per cent of all soldiers with frozen hands or feet were subjects of "status dysraphicus"* HIPPKE; In case of general Injuries caused by cold the massage of the body following a hot bath is very im- portant in restoring the normal function of the skin. Cardiac remedies as well as others are unreliable. Short wave therapy offers difficulties with respect to proper dosage* JARISCHs Reactive hyperemia of the arm following ligature of the upper arm at 15 to 20 degrees Celsius room temperature and concomitant observation of the tem- perature of the fingers provides a means to establish objectively the individual differences of vascular re- action. There are three types of human beings; 1. Tem- perature will rise above the starting point* 2. Tem- perature will rise as high as the starting point. 3* Temperature will not rise at all* The latter type is peculiarly susceptible to low temperatures* (State of dysraphia.) BERG: Criticized the recommendation of alcohol as a protection against cold. It is generally known that the consumption of alcohol affords an agreeable sensation of warmth in case of short exposures to cold* As set forth, however, in reports on mountain physiology the danger of injuries by cold increased appreciably after the con- sumption of alcohol, as the peripheral radiation of heat will be increased and the warning signals of the human body will be depressed and the drowsiness, preceding death by cold will be even more intense. Sentries on duty during snowstorms are praticularly endangered by intense cold. When I - after having been detailed to another unit - rejoined my former battalion, fighting at altitudes of 1700 meters at the crest of the Carpathian Mountains, I found 19 cases of injuries due to cold. I then taught all non-commissioned officers of this unit a special mountaineer's technique for preventing in- juries by cold and have succeeded in shortening the period of duty to 12 and even 8 minutes, so that, after being 8 minutes on duty the men actually has 16 minutes for warming up and rubbing the extremities. In spite of the continuation of the cold, the injuries by cold within that battalion stopped abruptly. SCHOERCHER: A distinction must be made between a general cooling effect and local injuries due to cold. According to the directions by HOLZLOEHNER. it is quite allright to re-warm those men by a hot bath who are seriously cooled off and who are in danger of life; subsequent drops of temperature will also be avoided thereby. In case of local effects of cold that exist simultaneous- ly with the cooling off in general, such a hot full-bath seems to be a risk regarding the local injury of the tissue. In that case the frozen parts of the tissue would be ex- posed to a difference of temperature of 4-0 to 60 degrees Celsius. It, therefore, seems to be logical to leave those frozen parts of the body as for instance hahds and feet out, and to protect them by a bandage. There is, certainly, no danger to be expected from the slowly increasing general temperature of body and blood as a result of the hot bath, as a dilatation of the peripheral vessels is desired and encouraged by the ad- ministration of Pjpostigmln and Eupaverin. Directions should* therefore specify a auick re-heating with adequate protection of the frozen parts. VOLHARD: Was of the same opinion as SCHOERCKER. A difference must be made between a general cooling down of the body and cooling of extremities. Whenever the body has been exposed to intense cold a quick repeating by a hot bath may be helpful, whereas a quick re-heating of the extremities in that condition may lead to severe damage. The common remedy is the rubbing with snow. The idea is to keep the tissue cool the oxygen requirement of which in the cold is minimal until the circulation of blood becomes normal again by continuous rubbing and massaging. The requirement of oxygen for the tissue is increased too early by quick heating and considerable damage would be produced by lack of oxygen in case of a still insuf- ficient circulation of the blood. BEUCHNER: We have examined the morphology of the adaptability to cold and the pathology of the cooling down in general in 20 cases of injury due only to cold with fatal outcome as well as in a great many experiments on animals and therefore are able to state the following: In case cf a continuous influence of cold with the heat regulation intact, the thyroid gland changes from a state rich in colloids into a highly active and a Base- dowian state# In fatal cases, however, no changes of the thyroid gland have been observed but in most of these cases an atrophy of the lipoids of the suprarenal cortex is found which can also be observed in animals following an acute cooling off. In case of a long exposure to in- tense cold the suprarenal cortex dilates and becomes rich in lipoids. In case of an acute cooling off the glycogen of the liver, the skeletal muscle and the heart muscle is considerably reduced. Whereas the glycogen values of the liver and of the skeletal muscle after a long exposure to intense cold under normal conditions of heat regulation show almost normal values; an almost complete absence of glycogen will, be found in this case in the heart muscle# A vacuolar degeneration of various organs, an adiposity of the heart muscle, the kidney and the skeletal muscle reveal a general lack of oxygen as the cause of death due to chilling. The kidney never reveals a glomerulo- nephritis but an excretion of protein as well as storage of protein. Multiple erosions of the mucous membrane are very frequently observed in the stomachs of humans and animals which probably do not develop into chronic peptic ulcers. Directions for injuries due to cold* (Cover for the leaflet concerning prophylaxis, rec- ognition and therapy of effects of cold5 Army Manual 209/1. From B 4 (page 19) the leaflet is still in force.) In case of an exposure to cold the peripheral cir- culation is decreased by the regulating mechanism and the formation of heat is increased simultaneously' in order to maintain the necessary temperature for the vital organs. The reduced blood circulation of the peripheral parts of the limbs, causes in these parts a considerable drop of the temperature giving rise to injuries (local effects). In case of a severe or continuous exposure to cold, these reg- ulations will be disturbed so that the nucleus of the oody with its vitally important organs will be cooled off (general chilling). At the same ratio as the temperature goes down, the metabolism and the consumption of oxygen is reduced as well, which increase again when the temperature rises. A disproportion between the requirement of oxygen and the blood circulation when warming up the body therefore leads to injuries quicker than the cooling off in itself. That is the reason why only the very quickest re-heating or, this being impossible, the old-fashioned method of slowest re-heating should be used. Constitutional disposition: Vagotnnlc soldiers are particularly susceptible to all injuries of cold because of an abnormal condition of the capillaries and a specific humidity of the skin. External conditions: State of exhaustion, lack of food and loss of blood, toxic infectious diseases, such as, first of all, typhus. It is distinguished between cooling off in general (chilling) and local effects of cold. Prophylaxiss Containing instruction to troops as to'the general principles of hygiene, and use of equipment, care of the body and clothing. No abuse of alcohol and nicotin. Supply of food rich in carbohydrates and fat is desired. A power of resistance of the body is obtained by regular training. The best means for vascular training at present is some kind of sport, gymnastics such as Finnish Sauna baths, alternating hot and cold baths etc. Constant hygienic care is very important, daily wash of the entire body. In cold climates the soldier is constantly to be instructed to watch his body; soldiers should observe each otherfs nose, cheeks and ears. Attention to drowsiness and indifference. Intense muscle training in the calm, open air, whereas when exposed to wind, it would be better to seek protection by huddling together at a place protected from the wind. No coddling of the body with regard to clothing. Several layers of thin clothing are better than a few thick ones, because of the air-isolating space between them* Layers of paper and straw insulate well* Any pro- tection against cold loses its effect, when the clothing is drenched throughout. Clothing should, therefore, be carefully dried as often as there is an opportunity to do so. Wind and moisture are particularly hazardous. In- juries by intense cold arise not only during solid freezing, but still more during the transition period of thawing. Preventive measures consist in digging gutters to drain the trenches in making wooden grates to stand on. Evacuation of wounded soldiers? In case of intense cold only absolutely indispensable transportations should be carried through and then under constant supervision. In each rnaneuvre of the transportation the wounded soldier is seriously endangered as the period of transportation and therefore the exposure to cold cannot be determined ahead of time* Relay-stations for warming up and re- freshments must be provided. Bedding on sufficiently isolated layers (paper and straw). Protection of bandages by blankets and paper, hot water bottles. Any drenched bandage means an increased danger. En route, only dry plaster dressings should be applied. No narcotics and no adrenalin derivations to be administered. The vehicles should be heated before use and be provided with heating devices. A. Cooling off in general (chilling). A distinction will be made between a quick cooling effect, for instance cold water, and the slow coding effect v/ith subsequent disturbance of the heart regulations of the body. The chief symptoms besides the timinuation of the rectal-temperature are: Slow cooling off Quick cooling off: Feeble, accelerated pulse or slowing down with si- multaneously strong sink- ing blood pressure, breath- ing slowed down; pale, sometimes blue-gray, spot- like marbled, cold skin, blueish lips and cheeks\ After an early acceleration of the pulse, the rate slows down and changes into an arythmia perpetua if the temperature of the body drops below 30 degrees; the surfaces of the skin, grown cool are white, the face often looks cyanotic; Question to the surgeons Symptoms of slow cooling off: Apathy extending into unconsciousness and rigidity of muscles, disturbed sensitivity of the skin. Even the completely unconscious patient may still be saved as long as the muscle rigor exists. Therapy; Quick supply of heat inside and outside, until normal temperature of the body is obtained, is decisive. A danger of collapse, particularly in case of severe, local injuries, still exists for many haul's. a. Immediate measures; If the respective facilities are available; Hot bath at 40 degrees Celsius until normal temperature of the body is attained* Less effective are electrical radiation and hot air. If no facilities are available; Supply of heat by all means, yet, avoid burns (hot water bottles, etc., not hotter than about 60 degrees Celsius; temperature that can be tolerated by the fingers). No analeptics. No adrenalin-derivations in particular. Hot drinks when consciousness has returned* b. Further therapy. Artificial respiration on drowned men, friction is favorable if skin is previously warmed* In case of ex- haustion, glucose will be useful. A persistent control of the circulation of the blood and rest are essential. In case cf more intense, localized effect of cold, danger of collapse particularly still exists for many hours* This collapse will be treated in the usual way. * B* Local effects of cold. 1. Prophylaxis. As shown under A. 1*: Prevention of peripheral dis- turbances of the circulation of the blood*• All tight clothing, such as too tight boots, gloves, socks, garters and shoe-laces must be loosened. In case of temperatures below 15 degrees Celsius, steel-helmets should not be worn; this is particularly true with chauffers* There must be space enough for two pairs of socks inside the boot. The upper ends of the boots should be made tight against snow and water by short gaiters etc. Rubber boots should be lined with fur, felt, straw or canvas. 90 per cent of all injuries by cold effect the lower extremities* Attention should be paid in particular to a good care of the feet and the boots. Boots should be dried daily and greased once weekly. Daily foot-baths in cool water followed up by careful drying is especially important* In case of sweaty feet, formalin powder should be used after the drying and be sprinkled also inside the socks. Frequent change of socks. Medical instructions with the view of interesting the soldiers in this problem and of keeping an eye on their comrades should be undertaken by the troop physician. 2. Symptomatology. The injury by cold develops in most cases unnoticed by a diminution of mobility, deafness and a reddening of the skin at the particularly effected spots* This redden- ing changes, while the injury progresses, into a wax-like paleness or a blue-gray color. Low temperatures and dis- turbances of sensitivity of the affected areas which feel doughy and rigid are characteristic. The peripheral pulse especially at the back of the ankle and on the inside of the ankle is very feeble or not palpable. The affected limb may even freeze finally. 3• First aid in cases of local injuries. In recent local injuries the grade and the demarcation of the injury is not clearly recognizable for several hours. The blood circulation must be restored to function as quick as possible. This will be achieved no sooner than the cooling process has come to a climax, that is the reason why the therapy of the cooling down in general should be considered first. Then, the frozen areas up to their demarcations will be thawed by baths of 25 to 30 degrees Celsius increasing little by little up to 40 degrees Celsius, considering how the patient concerned can tolerate it. Under certain circumstances antiseptics should be added. Hereafter the limb will be kept in an elevated position and gentle exercises of movement should be instituted. As an after-effect of severe local injuries by cold a collapse may develop. Analeptics, except coffee, may be only con- sidered after a general reheating. The danger of collapse may last for several hours. III. SHOCK AND COLLAPSE Translation prepared bys Office of Military Government for Germany (U, S« ) Office of Naval Advisor Medical Section 1, Clinical picture and experimental investigation of shock. Oberarzt (1st Lieut., MC.) Prof* DUESBERG Many surgeons are of the opinion that shock and collapse must be considered as two different conditions. These colleagues used to call the condition shock if the reaction in general, especially the changes caused in the circulatory system, had no correlation to the severity of the wounding, i.e. if on account of its insignificance the wounding itself could not be made responsible for such a large implication of the whole svstem. As often described in the literature such shock-like conditions may bccur even without physical trauma, e.g. if the respective person had merely been in a dangerous, or supposedly dangerous situation. The physiological bases of these reactions will be better understood if one remembers the most harmless and everyday forms of shock. People used to speak of a nervous shock, meaning thereby that the person in question turns as pale as death, with cold sweat appearing on the forehead. The patient himself states, that he felt as if paralyzed with terror, and that he thought his heart for the moment was at a standstill. This condition varies individually as to duration, until the patient has overcome the fright. Then the body takes refuge in counter-measures, i*e. it combats the danger by offering resistance, or it retires to safety. Anyway, he gets free of the stupor, which is another name for shock, and passes over into a state of excitation and activity, i.e* into an irritable defense position* In forensic medicine this condition is known as ''momentary fright reaction" during which the person is not in command of all his mental powers, and for this reason one is in- clined to attribute extenuating circumstances to it* In the course of our lifetime, everyone on some oc- casion or other happens to be frightened deeply, or has to pass through a danger or to face it* What are the Particular kinds of feeling? The person holds the breath, thinks the heart to be at a standstill for a moment, feels the pulse beat in the throat, the face becomes pale, the vision fades, intestinal troubles arise and in the end faintness may be an additional feature* In short, a sudden neurovegetative change of regulation takes place* Quite the same process, yet with a stronger and more lasting effect, follows immediately after a trauma and is called a true -wound shock* It is due to the change in the autonomous regulation that the human organism shows in a frightened condition, a behavior as if it had been exposed to a physical trauma• The decreased speed of the pulse waves points to an increased tonus of the vagus during the shock condition. It is associated with the cutting off of^the peripheral vascular regions and a decrease in the circulating blood. Due to the narrowing of the arterioles the peripheral tonus of the vessels (W) is increased and the elastic tonus (E) (tests according to the method WEZLER/BOEGER) is caused to rise, the minute volume decreases and the blood pressure is reduced due to a diminution of the amplitude of the pulse wave. From the evaluation of the figures obtained through the method referred to, and from experimental and clinical findings it results, that in the case of vagotonic changes in the circulatory system the supply of blood to the vital organs, which are in direct association with the lungs, is ensured, whereas more distally situated vessel regions, especially the skin and extremities, may be cut off to such an extent that the peripheral pulse is imper- ceptible. 4 centralization of the circulatory system appears to have taken place. As it is worded in the clinical language there is a peripheral collapse in the circulatory system during the condition of shock* The general symptoms of a collapse are the decline of the blood pressure, feeling of cold with the skin turning pale, decrease of the output of the heart, and the blood in circulation. From some hundreds of clinical as well as surgical cases in wartime it would be ascertained that at least four groups of collapse can be clearly de- fined from one another, each of which in comparison with the other one shows distinct deviations as to the function- ing of the separate vessel regions (lungs, arterioles, cap- illaries), Similarly, as in the weakness of the heart muscle, the diagnosis can only be called perfect if the cause of the weakness is ascertained (myocarditis, coronary stenosis, insufficiency in the case of cardiac defects or hypertonia). It will be necessary in the future to see in the word collapse wider clinical concept which requires further subdivision. Anyhow, as far as this lecture is concerned it may suffice to say that collapse as it enters into appearance in the condition of shock deviates considerably from the other types of collapse. The collapse observed in the main dressing stations and field hospitals usually shows the circulatory system to be changed in its functions# A thorough analysis, watching the further progress and lastly postmortem ex- aminations, reveal that the changes can never have been brought about by the action of shock, but must be due to some other causes (loss of blood, fat-embolism, fulminating infection, mechanically caused injuries etc#) (see Dtsch. Mil# Arzt 1942. page 69, H. DUESBERG and page 76, G, SCHALLOCK). it must be strictly rejected to give such conditions the name '’secondary wound shock" since the poor functioning of the circulation is intrinsically different from that in shock; moreover it is caused by an indirect effect of the traumatic event, and by no means directly as in shock# Cell disintegration products such as Histamine can never be considered as the cause of a true shock picture, since terror in no connection whatever with physical injury may cause parasympathetic changes of the regulation as well# The change in the circulatory system which is caused by acetylcholine, the vehicle agent of the vagus, differs in essential points from the collapse asso- ciated with Histamine intoxication# 70 Slight horror, momentary fright reaction, street ac- cidents, air raids at night and also wounding at the front are stimuli varying in strength. They all may lead to neurovegetative changes, varying from a slightly increased tonus of the vagus to a full shock with fainting and eventual death. i.e. shock with sudden heart failure (e.g. GOLTZ's experiment)• The intensity of the reaction depends on the con- stitution of the individual and its autonomous nervous system, or it is dictated by the severity of the irritation, which, as in wounding, may reach a highly unphysiological degree. The irritation passes centripetally over to the senses of feeling and impression, mostly implicating pain, hearing, sense of equilibrium, and then reflexly jumps over to the neurovegetative system without having beached the consciousness. If the centripetal irritations are impeded or excluded, as in narcosis, the shock reaction does not make an appearance, or at least only in a very mild form. Now the question may be raised whether a change in the vagotonic regulation, such as occurs in shock, may be regarded genuinely as an advantageous reaction. The explanations given above were to show that in the case of an increased tonus of the vagus the peripheral vessels are blocked off and a centralization results. A sufficient supply of blood to the vital organs is secured while the areas in the periph- ery, dhiefly the organs of motidn, are put to rest, the metabolism is reduced, consciousness and the senses of feeling ate dulled* due apparently to an insufficient supply of blbod to the cerebrum while the with its vital Centers Remains in good supplyk As a, rule* the clinical picture of a freshly wounded man. or the aspect of a wounded ahimali exhibits a slight form or degree of *«uch a general Vegetative change* exhaustion, desire for rest, drowsiness* apathy towards the environment* lazinessi If such dohfcefving measures do not appear automatically upon the act of wounding, bb ohly in an insufficient way, the physiciail, in accordance with skilled practice, will ad- minister morphine and thus nabcotize not only the pain but caUSe the Vegetative functions to subside as well. The expedience of an increase of the excitability of the para- sympthetics is thoroughly described in connection with the stoppage of blood by R. DUESBERG and rf. 3CHH0EDER (Kli. W. 1942, page 981). Therefore the change of regulation as a consequence of physical trauma must be regarded as a very clever measure, one can say it is provided for physiologically. The fact that this protective reaction may on the other hand lead to exaggerations, such as shock and death due to shock, must be ascribed, as already mentioned, to many absolutely unphysiological stimuli which may impinge upon the human body, and also to the respective individual disposition which in its turn may be additionally influenced in a de- trimental way by existing latent defects in the circulation (coronary Insufficiency, toxic-infectious damage of cap- illaries) • Summary* By an abrupt intensive stimulation of centri- petal regions, as occurs in woundings, the tonus of the vagus is increased* In its mild form this change of the neur©vegetative tonus may be regarded as a reaction of utility and protection for the human organism* Shock represents an extreme condition of excitement of the vagus, which may lead to sudden death. The collapse of the circulatory system, as in shock, is basically dif- ferent from the other forms of collapse. These, as to frequency, play a far more important part in practical field surgery. 2« New viewpoint concerning the pathogenesis and therapy of shock and collapse. Stabsarzt (Captain, MC.) Dozent SCHWIEGK It would go far beyond the scope of these discussions to touch on the details of the definition and general problems of shock and collapse. The widely varying dif- ference of opinion on the subject is due to the lack of uniformity of the definition of both manifestations* Par- ticularly in the foreign literature a distinction is made between primary and secondary traumatic shock* Primary shock is considered to be a condition following immediately upon an insignificant injury of highly sensitive innervated regions, as following a detonation or in terror impressions, and it is associated with circulatory disturbances* From a clinical aspect it deviates from collapse in its general form. Second- ary shock, the form which occurs most frequently in wartime, develops in a few hours after the injury has been inflicted and shows the true picture of a collapse* If only primary shock was called a true skock, as many surgeons do, and secondary shock was considered as one form of collapse, a clear-cut definition of both conditions might be possible. If, however, as is commonly done in surgical practice, secondary shock is considered as nothing other than ordinary shock - and this is in agreement with the general concept * in the world literature - one cannot make any distinction between shock and collapse from a clinical point of view. The fatal issue of both primary shock and collapse must be attributed to a disproportion between the volume of blood in circulation and the full capacity of the vascular system. I have called this condition a relative oligemia* This dis- proportion is due to an insufficient flow of blood back to the heart, a decrease of the minute volume, a decline of the blood pressure and finally it leads, in a steadily increasing vicious circle to the break-down of the circulatory system. The disproportion may be compensated to a certain^extent, the decrease of the blood pressure and the insufficient supply of blood to the cerebrum inhibited for some time by placing some strain on the regulation i.e. by causing the blood to discharge from its reservoirs, by prompting the peripheral vascular system to contract in the regions not absolutely of vital importance and lastly by forcing the influx of fluid from the tissue# But there will remain only two possibilities finally: either the volume of blood in circulation becomes too small, or the capacity of the vascular system too vast. The most obvious reason for the reduced volume of blood in circulation is the loss of blood* But apart from this in almost all kinds of secondary shock and of collapse the loss of plasma from the blood vessels and infiltration into the tissue plays a predominant part* This is stressed particularly in the Anglo-Saxon literature* In traumata, burns, injuries due to cold, intoxications and infections severe damage is done to the capillary system of the re- spective regions* As a consequence plasma protein leaks out of the capillaries. In this way the volume of blood may be diminished by one half due to this loss of plasma. Clinically it is to be noticed by a thickening of the the increase of hemoglobin and erythrocytes in the blood; besides the formation of edema following trauma, burns or effects of cold. This loss of plasma is added to the loss of blood commonly associated with war injuries and woundings. A reduction or the volume of blood, in circulation by one half, however, will usually be a danger to life.- • Some details of practical importance may be cited here. WILSON, ROOMS, ALLEN made reference to the fact, that in the use of the Esmarch-bandage, owing to a deficiency of O2, severe damage is done to the capillaries in the blood- less region. When the blocking is lifted by removing the bandage plasma protein will ooze through the walls of the capillaries from the blood vessels, the result being a fatal collapse due to the reduced volume of blood in cir- culation. If an Esmarch-bandage is applied to a dog’s hind extremities for 5-6 hours to cause bloodlessness and then released, there will be a decline of the blood pressure and the volume of blood in circulation is proportionally more reduced, the hemoglobin and erythrocyte levels will rise and all this together will lead to death due to the efflux of plasma from the vascular channels into the areas previously rendered bloodless. I make reference to this experiment because usually one thinks only of a possible danger to the bloodless limbs when applying the Esmarch- bandage, and not of the severe danger the whole circulation is threatened with on releasing the bandage again, especially if applied for too long a time and unless the bloodless ex- tremity is to be amputated immediately afterwards. A disproportion between the volume of blood in cir- culation and the vascular capacity may also be caused by dilated capillaries or veins in a large vascular region. In this respect two points of view of former times require some modification. Firstly, that in shock and collapse a ’’hemorrhage” .into the splanchic region occurs* With the exception of damage done directly to the abdominal organs by peritonitis or intoxications, no congestion of blood in the abdominal vessels takes place, especially not in traumatic shock. Secondly, the idea of a paralysis of the vasometer center being the cause of a collapse cannot be supported. Quite on the contrary active regulatory processes are ob- served in most cases of shock and collapse indicating an ex- cellent functioning of the circulatory centers. An insuf- ficient cerebral circulation takes place only in the last phases, due to the decline of the blood pressure and the failure of the heavily strained central regulatory mechanism which causes a complete breakdown of the circulatory system. No doubt, from the periphery and some single organs depressor reflexes arise* As examples one may remember the collapse due to the tearing of the mesentery, contusion of the testes or pleural shock* Such reflexes are felt not only as sensitive pain stimuli, but they also remain active in narcosis. Such reflexes have been under consideration also in connection with traumatic shock* Unobjectionable proof by experiment, however, has not been furnished so far. An experiment which can be made any time may be mentioned here. If both hind extremities of a dog are injured by pounding, thus producing a traumatic shock, the blood pressure can be made to decline considerably by applying slight massage to one of the extremities, or by moving it* A similar pro- cess begins within 3-4 seconds after the application of a tourniquet* There is no doubt that this is a nerve reflex reaction. These experiments prove that reflexes reducing the blood pressure are active within the region affected by trauma, and they explain why a fatal collapse may occur, during evacuation of inadequately splinted fractures. As to the relatively rare forms of primary traumatic shock, which occur with trauma implicating more sensitive regions such as the abdomen, testicles, etc., the nerve reflex factor doubtless plays a predominant part* However, secondary traum- atic shock is the most frequent form of shock and collapse in wartime and in this case the escape of plasma into the tissue in addition to the common loss of blood is decisive. As has become evident in the treatment of shock and collapse the remedies acting in a central or peripheral vasoconstrictive manner cannot alone achieve success* This is easily understood as the counter-regulation of the or- ganism has caused the maximum contraction of the peripheral vessels already* A second possibility would be to increase the volume of blood in circulation by infusion, and this procedure has in fact become the rule in almost all cases of shock and collapse, provided that the fluid to be in- fused contains colloids which will retain water in the vas- cular channels, as is the case with preserved serum. The excellent effect which is achieved by blood transfusions is to be attributed likewise to a refilling of the vascular channels with a fluid containing colloids, and not to the erythrocyte content. Three factors shoula be considered in using the infusion of serum: Infusion of a considerable quantity of fluid, repeated infusion when the effect of in- fusion decreases, and using the infusion as early as possible. The results of such treatment so far observed have been statistically compiled by front-line medical units: At the top ranks exsanguinetion with 86 per cent favorable results; serious injuries to the limbs and the thorax region associated with severe shock follow with 72 per cent; gunshot wound of the abdomen with 66 per cent; dehydration and collapse in dysentery with 65 per cent; even in gas gangrene the figure was 67 per cent* Out of 1059 infusions given because of exsanguination, shock and collapse 74 per cent favorable results were re- ported. These figures do not require any further comment. Now there is also currently available a certain number of types of dry preserved serum* They offer the advantage of not being effected by cold in wintertime, and in addition they inhibit the escape of fluid from the blood channels into the tissues, due to the hygroscopic power of the con- centrated serum preparation* Undoubtedly, in very serious cases of shock both the treatment with serum and the transfusion of blooc" may fail since the infused fluid vrill escape as well through the damaged capillaries# Experiments made in conjunction with SCHOETTLER showed an improvement in this process when adding some hormone of the posterior lobe of the hypophysis to the serum, hypophysin having a specific constricting and "tighten- ing” effect on the capillaries. In my opinion the addition of a hypophysis extract to the dry serum will improve results even in the most serious cases. 3« Shock and the control of shock, SS-£tandartenfuehrer (Colonel, Elite Guard) smTiwK Shock is regarded as a condition to which the human body is exposed abruptly and unprepared, as occurs par- ticularly frequently in wartime. As to the possible cause there are fnainly two points of view. Some support the idea that the trauma acts via the neurovegetative system in a detrimental way upon the organs of the body which it controls* Others believe that the efflux of toxic matter from the Wound into the body must be made responsible for the genesis of shock* There is also no uniformity in the description of the clinical picture* The main reason is that the predominant factob in the manifestation of shock is the impairment of the circulatory system clue to collapse. This may lead onQ to assume that no difference exists between shock and collapse. However* there is a basic recognizable difference in the symptomatology of both conditions and therefore there must also be a basic difference between the two. In shock the wounded person is absolutely quiet, even indifferent, the face looks worn and shows inflexible features, the eyes, under half-closed lids, are indifferent and stare at a far off place, the pupillary reflex is usually depressed. Frequently the lips turn blueish. The skin is pale and moist. The whole body feels cool. The pulse is not high or only insignificantly accelerated, as observed at the radial artery. Sensitivity is reduced. Only after repeated and energetic requests or irritant ef- fects will a slow but absolutely logical reaction set in. Therefore there is no doubt a distinct difference as com- pared to the picture in a severe injury associated with ex- tensive hemorrhage or to the disorder of the circulatory system in toxinaemia. It has been shown repeatedly by two factors that both kinds of circulatory disturbances must be kept strictly separated from each other; 75 1. Any therapy of the circulatory system, especially the refilling of the vascular system by infusion or trans- fusion may be considered as a good means of differential diagnosis* The more promptly and favorably these measures influence the circulatory system, particularly in case of large hemorrhage, the less Is the chance that one is dealing with a state of true shock. 2. Macroscopically, it could never be determined in postmortems following shock that death was due to pathologico-anatomical changes. Rather there is the im- pression - although the impairment of the circulatory mechanism is the principal feature in the clinical picture of shock - that the real cause must be due to a disorder or injury of a central or superordinated organic system, that is the autonomic nervous system* Moreover, it could be noticed - and this is typical for shock - that the latter needs some time to develop the picture as described before. It was in these particular instances of shock which ended fatally and where the injury was in no correlation to the seriousness of the case, that the physician attending the wounded first gave a distressingly misleading report. And also just in such instances one was always "astonished” about the fatal issue of so "slight” an injury, especially as the general condition of the wounded person was considered so satisfactory before he had been removed to the main dress- ing station. The only method of treatment which we believe may be able to influence the development of shock is to supply heat externally and internally by administering hot drinks. In addition the wounded have to be kept under super- vision in separate rooms in order to keep any stimuli away from them. As to the therapy two observations may give some hint i 1. Only in late autumn of 1941 and. increasingly in the winter-time the fatal cases of severe shock increased in frequency. This was in a period where by preceding and current hardships the units were to a large degree exhausted and, due to the shortage of vitamins in the food, were out of nutrition equilibrium. This was evidenced by the in- creasing number of hemorrhages, due to gingivitis and para- dentosis. 2. It was observed frequently at that time that the question was raised by members of the units to their medical officers concerning the decrease in their sexual power, which they noticed# This observation along with the knowledge recently gained as to the coupled relations between the vitamins and the hormones and the effect on the vital functions via the autonomic nervous system are apparently in a direct relationship with the increased incidence of shock. Due to the lability of the autonomic nervous system, in conseauence of vitamin and hormone deficiency, even an apparently minor incident or trauma, such as slight wounding, or the trans- portation on Russian roads may be sufficient to cause the lability to turn the situation into a total failure. In order to clarify this matter it will be necessary to investi- gate it in an unobjectionable and exact scientific way, as has been started with the formation of the Special Group of Surgeons of the High Command, The viewpoints being basic- ally different as to the definition of shock and collapse and also regarding the interpretation of the causes, the method of investigation requires a uniform course. It is of no use to have the problem undertaken by medical officers of the units and main dressing stations according to their own liking, and based upon varying presuppositions. It should rather be transferred to especially instituted "shock committees" and these be directed to the various sectors of fighting. These committees should be assisted by a pathologist and, if possible, also by a physiologist. The experience and clinical observations dealt with above were made by a medical company on active service in the East out of a number of more than 9000 transient cases, a good 2/3 of which were wounded. 4. Pharmacological aspects. Oberarzt (1st Lieut.. MC.) Prof. KOLL The pathologico-physiological conditions of the cir- culatory and nervous system, which are basis of the various, and sometimes rather contradictory, clinical symptom com- plexes of "traumatic shock" are very heterogeneous in character. Therefore it is impossible to develop the therapeutic measures with a uniform point of view. Diag- nostic differentiation depends on very complicatied methods; for this reason the adaptation of the therapy to the individual case also meets with difficulties. In addition it will be difficult to judge the suitability of a distinct pharmaceutical preparation, since so far only some of the conditions known as traumatic shock can be re- produced in experiments on animals. This refers in the first place to those conditions of shock that are due to most in- tense sensitive and sensory impulses, designated by SCHWIEGK as "primary wound shock". Their number is relatively small and they are least susceptible to therapy by medicines, as they either lead rapidly to death or soon show a spontaneous improvement. Only as far as they are associated with very severe pain do they last for a prolonged period and eventually change to collapse. It is an important and advantageous field of use for morphine, as this drug dulls the vasomotor effects of severe pain impulses and inhibits any possible existing pain hyperpnea, which via hypocapnia might open the way for collapse. Whether or not a combination of morphine and pervitin will show bettur results than mor- phine alone cannot be decided as yet. At present the matter is under examination from other aspects. The characteristic feature of the so-called "secondary shock" which may either be associated with loss of blood or without it, is a progressive, more or less prolonged stage showing increasing diminution of the circulating blood volume compensated by a rising neurovegetative counter-re- gulation until the latter reaches its climax. The process ends in severe collapse, due to a failure of the vasomotor centers. Apart from the significance of a refilling of the circulatory system with blood or some blood substitute, as demonstrated by SCHWIEGK, some pharmacological therapeutic measures appear to be possible. In addition to the seriousness of the trauma which causes the shock the functional power of the central vaso- motor regulation will determine the moment that secondary shock turns into severe collapse. In this respect consider- able individual variations are noticed on human beings. It will be possible and necessary, especially in vasomotor labile people, to prolong the interval of the counter-re- gulation considerably by administering central circulatory analeptics acting upon the circulation in the center in order to gain time for other measures. The increase of the vasomotor regulation under the influence of the ordinary analeptics stimulating the circulation such as cardiazol, corned or strychnine, does not reach its full height by considerable, ‘though strychnine is efficient. As I could demonstrate on the reflexes of the spinal cord, a considerable increase increase of the central regulation can be attained by combining remedies such as cardiazol or corned with strychnine. The stimulating effect of both remedies acts upon quite different elements of the central nervous system and this explains the considerable increase of the reflex power also seen at the vasomotor centers. Considering the prolonged period in the development from secondary shock into collapse, the relatively short effica- ciousness of the watery solutions of these preparations is a disadvantage, more so as the advantage inherent to them to act quickly under the circumstances is not absolutely necessary. A good and long lasting effect was observed by providing subcutaneous or intramuscular depots cf strychnine dissolved in oil. I think it advisable therefore, to use- such depot preparations also when administering strychnine and cardiazol - or corned - in combination. Pharmaceutical experiments on this effect are being made at present in the Institute for Pharmacology and Army Toxicology of the Military Medical Academy. There is practically no prospect of success for medicinal measures if the traumatic shock has entered the stage of collapse. Analeptics acting upon the center will fail com- pletely * Sympathicotrope vascular remedies, such as sympatol, will have hardly any effect on the damaged vessels. Pre- parations of the posterior lobe of the hypophysis,•as sug- gested by SCHWIEGK, should be used with great care, other- wise serious spasms of the coronary vessels may be the consequence.. 5. The pathological anatomy of shock* Kriegsarzt (War Surgeon) Dozent SCHALLOCK Shock and collapse are clinical conceptions for distinct and, principally, functional conditions# As already men- tioned before there is no uniformity in opinion as to these concepts. It is difficult therefore for the pathologist to choose a viewpoint concerning the problem of shock and collapse. The only possibility may be to investigate close- ly from a pathological aspect the details of such events as can be determined with absolute certainty from fatal cases of shock and collapse. From these cases, conclusions a posteriori may then be drawn to mildly progressing forms which do not end fatally, and to those showing a doubtful clinical picture. Sudden deaths, the classical type of shock, are well known to the forensic medical scientists and pathologists. In peace, as well as in wartime, their incidence is anything but rare; in fact, there may hardly be a pathologist who has not had similar experiences. Following quite a number of traumas of various kinds (blunt impact upon the thorax, head, neck, abdomen, sexual apparatus, cauterization of the trachea, sudden effect of cold and here one should think of death in cold water) death occurs suddenly to people in apparent good health. Postmortem examinations of such cases were made in this war after the explosion of mines and of various explosives detonating in the immediate vicinity of the persons in question* The external Injuries incurred thereby could not be considered the cause of the sudden death. From the literature on the subject as well as from various reports submitted by SCHUERMANN, who is a very experienced man in this field, it can be gathered that special importance in the development of the condition must be attributed to concussions inflicted either on the whole body or cn parts of it* The pathologist can only take shock as the cause of death if he has made absolutely certain by autopsy that another - I might say "natural” - cause of death is quite out of question. As has been discovered frequently in post- mortems, where according to clinical records people had died of shock following trauma, they had been suffering from other severe diseases which just as well might have been responsible for their sudden death. In these cases the pathologist can- not take the condition of shock as being the cause of the death, since the presence of an anatomically recognizable disease is sufficient evidence to him to make death explain- able. Quite the sane remarks apply to woundings. Also in this case the definition "death in shock" can only be ac- cepted if the nature and seriousness of the wounding ex- cludes with absolute certainty that the wounding itself or its sequelae did not cause death. Considering the natter from this point of view, deaths due to shock after wounding are extremely rare. As described in the literature (PONSOLD), and as con- firmed by ny own material, the anatomical aspect of shock is anything but characteristic. Neither macroscipically nor microscopically are there marked features allowing any conclusion* It is only on the basis of circumstantial evidence that the pathologist may assume shock. The latter can only be concluded from the circumstances, and not diagnosed from the findings in the organs. Also the disper- sion of the blood (designated by ROES3LE as the geography of the blood) in contrast to that in collapse is anything but regular or in accordance with ordinary rules* Rather one obtains the impression (as expressed rightly by ORTH) that the flow of the blood was abruptly stopped* Thus the organs are filled with the quantity of blood they held at the moment shock occurred. Any redistribution of the blood, perhaps as a measure of regulation, had not occurred* One might straight away speak of a Cataleptic standstill of the blood. Taking these anatomical findings as a base, shock may be presumed to be caused by a sudden, unknown as to its real nature, disturbance of the autonomic nervous system and its sequelae. The pathologist obtains knowledge only of the fatal cases. It stands to reason, however, that all kinds of conditions between the acute fatal standstill of the blood due to serious life-threatening events down to the really trivial cases must be considered* There have been reports that the condition of shock is due to the wounding of limbs. As regards the fatal case's of shock this opinion must be absolutely refused* Two times on service in Russia the Special Group of Surgeons of the German Army High Command observed about 1500 gunshot wounds of the limbs, partly in frontline medical units. A number of them, who showed clinical symptoms of shock had a fatal issue* However, anatomically in none of them could a condition typical of shock be found. 6 of those 14 cases showed the picture of fat-embolism, 8 of severe hemorrhage. Similar statements are known from World War I (SIEGMUND) and were confirmed by several pathologists who also had the opportunity of performing autopsies at front-line medical units* The anatomical picture of these cases described above can be differentiated from that of shock and collapse. A characteristic feature is the dispersion of the blood as seen in the state of hemorrhage, and, xvhat is not so well knovm, now and then also with fat-embolism; the blood is concentrated in the lungs, the heart, the spleen and the brain, the skin is bloodless, and so is the mesentery, the kidneys and sometimes also the liver* Experiments on animals have shown that this condition, which must be re- garded as a regulating process, may change to the picture of collapse, i.e. the peripheral vessels are dilated, asso- ciated with or without the efflux of a portion of the blood into the surrounding tissue. The collapse is marked by a regularly present cyanosis of all organs including the mesen- tery and muscular apparatus, with the spleen simultaneously in a contracted condition. The anatomical aspect of collapse and its sequelae on the organs is known by the work of EPPINGER and especially that of and co- • workers* Conditions of collapse are due to various reasons. 80 In experiments on animals they may easily be reproduced. Without going more closely into the problem of collapse it may be stated that the genesis of a severe collapse may be due to a physical-chemical action upon the periph- eral vascular system. We know that the tonus of the capillaries is not controlled directly in a neurological but rather in a physical-chemical way, and it is com- prehensible that dilatations of the capillaries associated with or even without capillary damage Till occur if par- ticular substances are formed in the organism or'are intro- duced into it from outside# As a matter of fact, such sub- stances are found in greater or smaller quantities in every wound and it is clear therefore that collapse is observed particularly frequently dfter wounding. It is also true, that such substances may be produced as well in severe irritations of the autonomic nervous system, as is seen in shock* This explains the change from shock to collapse. If this idea on the native gf shock is correct the occurrence of shock and collapse at the iane time in one and the same person is understandable* Varying opinions on the subject may in many cases be due to this circumstance* Discussion: STABLINGEH: It is absolutely possible, imperative and justified to make a distinction between shock and collapse. In order to treat the depletion of the circulatory system as occurring in collapse, continuous drop infusions should be used principally. In static warfare it can be performed in the main dressing stations* in mobile warfare usually no sooner than after arrival in the field hospital* It offers advantages as follows: The circulatory system is gradually refilled in a process extending over hours and days, a change of the infusion fluid is possible (citrate blood, preserved serum, periston, sugar or salt solutions), chemo-therapeutic remedies, sera or medicaments can be administered currently and besides the recovering heart along with the whole patient are treated in a cautious way and the demands on the attending personnel are less. MUNCK: According to observations made in World War I patients suffering from dysentery coiild not endure trans- portation after large quantities of bolus alba have been administered to them# The bolus mass formed stones thick as oneTs fist and thus caused collapse en route just as is known from G0LTZrs experiment# IV. malaria Translation prepared by: Office of Military Government for Germany (U. S. ) Office of Naval Advisor Medical Section 82 1. Malaria. Oberfeldarzt (Lt« Col», MC») Prof* ROSE 1♦ The effect of Atabrln prophylaxis During the period of malaria epidemics in 1941 - 42 a daily prophylactic administration of tablets was intro- duced, on my suggestion, in the Airforce and in the Army* The fact that a daily repeated measure can be carried through more completely under the adverse conditions of combat, was decisive for the choice of the method. As far as the dosage is concerned, it was taken into con- sideration that the alleged advantage of a massive atabrine prophylaxis over a daily dose was not due to the method but to the difference in quantity of the weekly dosage. In previous experiments of daily prophylaxis 15 per cent less was given than in the massive dose. This difference is important if the additional quantity surpasses the critical threshold of efficiency. Only in highly dangerous areas, where at least 2 per cent of the persons under prophylactic treatment became infected, was the daily dosage increased to 0.1 gram atabrine in the Airforce. Critical situations were therefore quickly cleared up in the summer of 1942. A higher daily dosage should not be introduced generally as atabrine is very scarce and has a serious after-effect in that it stains the skin and causes unfavorable psycho- logical reactions. It is of great importance to confine the prophylactic administration of drugs to cases where the danger of malaria infection is imminent* The in* convenience caused must be in a reasonable ratio to the risk. 2. Treatment. In the few positively determined cases in which the relapses exceeded 50 per cent in tertian malaria treated according to tie scheme (7 days 0.3 grans atabrine, the following 3 days 0.03 grams Plasmochin) it must be borne in mind that this percentage refers to patients under prophylactic treatment in a period of latency (Spring disease). The "spring disease" of a patient under pro- phylactic treatment is rather a relapse than a primary attack, the onset of malaria probably having been sup- pressed the year before by prophylactic and definitive treatment. Patients relapsing for the first and second time do not recover parasitologically at the same high percentage under the normal treatment as is usually ob- served in primary attacks and late relapses* A pro- nounced tendency to relapses cannot be counteracted by an increased atabrine dose. It is unnecessary to repeat experiments to that effect as this has positively proved inefficient* An increase of the atabrine dose is likely to affect the central nervous system. A larger dose of Plasmochin, however, will probably cut down the number of relapses. i simultaneous treatment with 0.3 grams atabrine and 0.03 grams plasmochin is recommended. In order to avoid abdominal colic, the plasmochin must be administered parenterally during the 7 days of treatment. We refer to the chinoplasmin treatment which in former times has proved satisfactory in that it reduced the number of re- lapses considerably. It is not advisable to treat malaria with pure quinine, or to treat tertian malaria with Neo- Salvarsan, which only holds the vivax infection down but will never cure it parasitologically* 3* Provocative treatment is prohibited in the Air- force, as this is considered worthless from the diagnostic and ineffective from the therapeutic point of view. Soldiers prone to relapses will be employed in such places where they can be hospitalized at any time. 4* Malaria and blood preservation. Examinations carried out by WOLPEHT have shown that the malaria parasites are active in the preserved blood as long as the latter is useable. (Successful self-in- jection carried out by WOLPEHT with preserved blood kept for 90 days). Persons who might be suspected of latent malarial infection, because of previous infection, are unsuitable as blood donors. 5. The malaria disinfection has to be carried out in those places where infected Anopheles are expected. Such areas have to be treated regularly with pyrethrum pre- parations such as ’’Detmoli" and "Flit”. The use of hand spray guns is not advisable as they wear out too quickly, the pressure is too low and the equipment is tiresome to handle* A new device for destroying Anopheles was designed by the Airforce, it consists of a motor-pump and a spray gun and is much more effective. A longer pressure tube is necessary in case of gasoline engines (about 15 meters) being used in order to prevent the exhaust gas of the engine from interfering with the spray. 2. Malaria. Oberstabsarzt (Major. MG.) Prof. MEYTHALEH The essential content of this report is found in booklet 6 (1942), Directives on Tropical Hygiene. 3* Malaria* Oberstabsarzt (Major, MC.) Prof. MARTINI This war has afforded us the opportunity of examining the Efficiency of the synthetic malaria remedies in a mass-experiment, which was based on the experiments made in peace-time. But it did not bring anything new to those who fought in the malaria infected districts in World War I. The period of relapses and latent infections started in March and reached its peak in May and June* In central Greece, on Crete and other places it started somewhat earlier^ The spring epidemic is almost exclusively caused by tertian malaria* This did not surprise us. Very few fatal cases due to tertian were reported* The tropical cases, which occurred very rarely, were much more dangerous# Some physicians are inclined to ward off the high percentage of relapses by more intensive therapy, but that way they get in the old wrong rut of the last century. It is the progress of the 20th century that it was recognized after numerous experiments that larger doses might prove harmful rather than increase the efficiency. The smaller doses were then given preference and NOCHT was one of the most fervent advocates of this therapy* Before World War I the results obtained with 3 x 0.5 hydrochloride of quinine were excellent* In my opinion, the sometimes high percentage of relapses observed after the administration of quinine were unduly emphasized* Under war conditions the per- centage of relapses due to the administration of atabrine may also be relatively high. It is, however, not worthwhile to enter into a debate about the differences. We refrain from using quinine in any case, as we only have a sufficient supply of atabrine* Even the follow-up massive dose of plosmochin does not prevent relapses entirely but according to the opinion of most physicians it is effective enough that it should not be omitted* An improvement of the general condition of health during the treatment seems to be very important. Whether the mentioned 50 per cent of relapses occurring with the old quinine therapy compared to 25 - 3$ per cent of relapses occurring with atabrine-plasmochin therapy are based on comparable figures or not is of no avail in this connection. There is no treatment for malaria that could in any way be called a therapy magna sterilisans. It is also known that malaria which occurred during World War I sub- sided after some time. How long it remains in the body is not certain* It is important to note that malaria in Germany does not essentially reduce the ability to earn a living after some years have elapsed and that the dangerous tropical malaria showed much less tendency to relapses. There is no reason to be pessimistic about the curability of malaria. We know that in contrast to the Italian and French, the English do not think much of prophylaxis* Lately, how- ever, the English seem to have changed their opinion. Even in Germany there are many physicians, who are quite pessi- mistic about prophylaxis because of the great number of in- fections which occur all the same* These cases were ex- pected, but they are not exclusively due to errors in the prophylaxis, although suspicion is well founded in this respect. During World War I the French had their flying malaria commissions, which quickly were at hand, wherever numerous malaria cases occurred and they examined the urine for quinine. If many negative results occurred, the leader of the unit was punished* The French considered this very useful* As pro- phylaxis does not counteract the infection itself, but only the clinical symptoms of malaria, there is the risk that malaria stifled by prophylaxis, remains untreated in the troops and breaks out on special occasions, for instance at home where the patient is sometimes erroneously diag- nosed. Therefore it is necessary to send the patient to military or even special hospitals as soon as malaria is suspected. The numerous latent infections endanger the new arriving troops* Latent malaria is not only found in persons who have been taking prophylaxis, but also in such persons who often are not aware of any malaria symptoms* These Plasmodium carriers are the most difficult problem in com- batting malaria. They will neither be discovered completely nor can they be eliminated by prophylaxis or treatment while free from symptoms. Such healing attempts called ’’final treatment” were perfectly useless, as far as the reshits have become known and it only means a waste of drugs* This result was not surprising, especially if the atabrine resistant E-forms are considered as a transitional stage. If we expect that something between 25 per cent and 75 per cent of the infected soldiers are protected from disease by taking prophylaxis and thus able to do their duty, this result has in any case to be taken into con- sideration and it may sometimes even be decisive* It would be desirable to increase the prophylaxis, although the opinions in this matter are divided. A second deficiency, characterizing all prophylactic administrations of drugs is the difficulty of carrying these measureas out consistently. Therefore, the danger of infection must be eliminated wherever possible. The control of the disease is based on the destruction of mosquitoes. The instruction for these control measures will be issued by the proper author- ities* The efforts of entomologists and technical experts in this direction cannot be dispensed with* The importance and ramifications of the task which often makes it necessary to amend and reorganize the malaria service of the occupied countries may require more experts in the near future than have been trained thus far. It is an important task to attach the fullest attention to the sanitation of terrain and gauze protection of the billets, The ’’spleen-index” and the condition of fever- gnats must be investigated in those places, which are of strategic importance, in order to get correct statistics concerning the incidence of malaria. The incidence of malaria was low among our troops, where control measures were effectively employed* The spread of malaria in the Greek population has increased this year* Everybody must be firmly convinced that these preventive measures, which cause great trouble, are an absolute duty for the soldiers from the viewpoint of comradeship, of responsibility and of discipline. It is most important to convince the troops of the necessity of these measures* Malaria was on the whole not so wide spread during this year in comparison to the last war. Naturally failures could not entirely be eliminated but no serious injuries among troops occurred. In spring, it seemed to me that during the malaria epidemic in Greece, consisting exclusively of tertian cases, the soldiers were hospitalized too long, half of the time used for treatment would have been sufficient on the average. Some of the soldiers suffered from a latent tertian infection due to their bad general condition of health, and others showed a bad condition of health because of being hospitalized only after their 4th and 5th attack of malaria# In such cases a supportive treatment for some weeks is advisable# On the whole, the patient suffering from tertiana is able to resume duty soon after he is freed from fever and vivax# In some reports the opinion was expressed that relapses will be the more rare the longer the patient is hospitalized# The small number of cases serving as a basis for this assumption can- not be considered as sufficient evidence# The fact that the diet in hospitals should exercise a favorable influence on the general condition of health, which represents an important fact in the final healing process, does speak in favor of the above mentioned assumption# The real question is if the same degree of convalescence can be obtained in the lines or in reserve formations, which are located closely behind the lines# Malaria and especially tertiana were, if possible, treated right in the front lines during the World War I in Macedonia# If the treatment of malaria would only take half of the time on the average, there would be only half as many soldiers on sick call# A strict isolation of patients in hospitals is ob- served because of the danger of unrecognized tropica.. The key to progress lies in the ability of the surgeons in the front line and in the presence of a sufficient number of facilities for differential diagnosis in reach of the troops, which make it possible to distinguish the different cases and so to keep the patients suffering from tertiana in the front line. It is a great pity that among 100 cases of tertiana probably one case of unrecognized tropica ad exitum may occur. But this fact does not justify permanent military measures# Hence it follows that the question whether the patient is to be evacuated or kept in the front line, depends on the type of malaria and on the military situation# On account of the experiences gained in three war years regarding malaria it seems advisable to decentralize the personnel capable of deciding on the treatment of malaria patients. For this purpose, a thorough training of the medical officers for judging and treating malaria in the malaria districts should be instituted in the same way as is the rule in other medical fields. The malaria instruction unit is indefatigably working in this direction# This point will be of special importance because of the extension of the theater of war in the South and Southeast so that an in- crease of personnel and a strengthening of the whole organiza- tion will be necessary. The prevention of malaria will at any time be backed up by military authorities who are fully aware of the fact that epidemics can become enemy No.l and many wars have been lost through epidemics. The Army has, on the whole, dealt satisfactorily with malaria# In some ways fortune smiled upon them and on the other hand careful preparations applied at the right time kept this enemy under control. 4. Comments on the discussion on malaria and amebic dysentery. Oberstabsarzt (Major, MC.) Prof. HAUER In contrast to the expectations of ROSE that the ten- dency to relapses of certain well treated malaria cases are probably due to bad atabrine prophylaxis, I would like to present the following observations The malaria relapses are on the increase in the hospitals, under my command. On a certain day, 25 per cent of malaria cases were relapses. Among them were a great number of patients who were thoroughly treated once or several times partly with alternating methods* This case material, as a matter of fact, is particularly suitable for a critical retrospective examination* Since the be- ginning of the war, we make one or several serological examinations on each malaria admission. Impressive ob- servations have shown that almost 92 per cent of our malaria relapses showed negative Wassermann, Meinicke and Kahn reactions. A simultaneous control of these examinations in two different laboratories corroborate this result, which we observed for months, as a remarkable symptom of tertiana relapses. Inversely, a negative T'Tassernann reaction in cases of a primary infection, permits the prediction of relapses. We periodically follow up the course of each malaria admission. First of all the following questions arose: Is this obvious anergy due to constitutional factors? Does it partly disappear with the end of malaria and is this due to the growing protection of the organism or to the weakening of the parasite strain? How does the Wassermann reaction act during the incubation period, that is to say during the latent period? Examinations in connection with a suitable follow-up control on a large scale would probably throw light on this matter if made in the Spring when the tertiana epidemic rages. Do the specific malaria drugs destroy the specific antigens in some of the relapsing patients? How would it be possible to break or modify the assumed anergy? We have examined the similarly mentioned question con- cerning the incompatibility of plasmochin and atabrine administered simultaneously for quite a long time* I feel sure that plasmochin and atabrine can very well be ad- ministered for 5 consecutive days without any trouble worth mentioning, if a certain care is observed* Two new ideas regarding the reduction of the curative treatment of malaria and the use of new remedies for the treatment of amebic dysentery were briefly discussed. The malaria curative treatment with quinine took about 6 weeks in World War I. The plasmochin-atabrine standard cure now in use requires 10 - 12 days* Such a considerable reduction of the period of treatment with the same effect and good tolerability will without doubt be highly welcome to the Armed Forces, and given preference over the older method of treatment. At least we have discovered a 5 day cure, Which seems to fulfil the necessary requirements. The chosen schizout-compound is administered concurrently with plasmochin and may be giveh fot 5 consecutive days, with a somewhat larger dose on the first and second day* So far this method has been used on 160 malaria infected patients as well as on patients for prophylactic purposes and the result has been satisfactory. The advantages are so apparent that this kind of treatment has been recommended as the method of choice* Nothing can be said as yet regarding the percent- age of relapses* At present this first test serves as a basis for the recommended simultaneous 5 day atabrine-plas- mochin treatment* Instead of using Yatren, a preparation which is very scarce*, we have examined the Wismut-Arsenic- acid preparation of I.G. Farben (9659a), which was given against amebic dysentery with the following briefly described results Excellent compatability, no symptoms of intoxication, in no case acting as a laxative, on the contrary having a constipating effect. So far, at least the same healing effect as with Yatren was obtained in the infections of the lumen of the intestines and also in ambulatory treatment. Two courses are advisable in order tc be sure of the result, finally two tablets must be given three times a day for the following 7 days* No effect has been observed on the active dysenteric amoebae or on clinical amebic dysentery. So far 60 cases ivere checked up, including an examination of the stool on 20 - 25 different days in each case* This remedy seems to be suitable for treatment of an infection of the lumen of the intestines as well as for prophylactic purposes. The preparation can so far be produced only in laboratories on a small scale* Mass-production will not be possible very soon. The roughly described test-results will be published. An examination concerning the matter is herewith suggested* 5« Relationship between topography and malaria in Greece» Stabsarzt (Captain* MC«) Prof, HABS The conditions concerning malaria in a given country are partly due to its climate and partly to the formation of the soil, Greece can he characterized as a country with a conglomerated geological formation, called detritus. This favored the formation of table shaped basins, which often hardly allow the water to drain off. In the lake and swampy districts the conditions favor the breeding of the Anopheles maculipennis. Irrigation works and artificial drainage afford additional breeding places. The masses of rain falling in a short period of the year cause extensive erosion in the upper course of the brooks and rivers and huge deposits in the lower course. Due to the reciprocal play of forces of land and sea, the most different geo- logical formations come into existence in the delta region, such as dams and lagoons, which are favorable breeding places for Anopheles elutus. which are particularly fond of brackish water* If small troughs are cut in the dry river beds of the upper courses, which are often deeply excavated, the breeding of Anopheles superpietus can also be developed in running water. There are three different groups of malaria infected areas according to the different character of the country# Most mosquitoes exhibit a pre- ference for a certain type of breeding place such as swamps, brackish water and river beds. For instance in the plain of the river Wardar it is shown how the different geological factors contribute to develop serious malaria infection in this district. 6• Malaria in South Russia. Sd-Standartenfuehrer (Colonel, Elite Guard,) Dozent toUGOWSfcY !• General spread. Malaria is endemic in the river valley of the Ukraine, the Don and Wolga-plain and in the Caucasus. Especially in the years of famine and civil war, namely in 1921 - 23 and - 35 malaria increased extraordinarily# Today malaria occurs mainly in swampy districts of the river Bug# Dnieper, Inguel, Unguletz, Don, Donez and Volga, in hilly districts of the Crimea, along the coasts and in the lowlands of the Caucasus. The highest number of malaria cases were reported in Azerbeidjan, Armenia and Grusinia. The distribution in the different periods shows that the curve of malaria generally reaches only one peak, al- though curves with two peaks have been observed. A rapid change has to be expected in the South of Russia in con- nection with the total casas of all diseases'in regard to their usual forms • 90 2* Plasmodia. Tertian malaria is the most frequent infect!on. 18 - 29 per cent Plasmodium falci parum and 30-45 per cent Plasmodium malariae were found in Armenia in 1938. The number of tropica cases in Grusinia and in the Ukraine are reported to be on the decrease. The Soviet physicians are extremely unqualified to diagnose malaria cases either clinically or microscopically. Only 17.2 per cent of the cases, clinically diagnosed as malaria, could be proven microscopically by Dr* WINNING in Chersson in June 1942* In mass-examinations*carried out in the streets of Chersson, the number of cases, which were found positive, varied between 5-15 per cent* The "spleen index" proved to be impractical*.♦ 3» Anopheles* Anopheles maculipennis is the main transmitter of malaria in the Ukraine, especially the type of messea and atroparvus. Anopheles bifurcalus lives everywhere, but prefers walls and cisterns. Anopheles hyrcanur in the river plains of the Dnieper. Anopheles plumbeus is of no epidenological importance. Anopheles superpictus is found in the mountains and is the main transmitter of malaria in Azerbeidjan* Anopheles hvrcanus var* pseudopticus is the main trans- mi 11 er of malaria in Western Grusinia# r 4# Breeding places. The main reason for the spreading of malaria in the Ukraine is the entirely uncrontrolled rivers, which flood ■Ehe districts continuously. Especially in the area of the bends of the rivers, extensive swampy districts spiead over the country* I was able to prove larvae in the especially large swampy districts south of Saporosche even in June of this year. The whole area must be considered as a large breeding district of Anopheles* The breeding places are not restricted to some pools. Old branches of the river with stagnant water from the floods of the last spring serve as excellent breeding places* Another breeding place of mosquitoes transmitting malaria are the extensions of river valleys along the coast (formation of deltas). As an example, we mention the Molotschnoje-delta in the South of Melitopol, which offers an ideal breeding place for Anopheles due to its swampy edges* Most breeding places in the Crimea are found in the fresh water swamps along the coasTI fEe water oozing out of irrigation canals and reservoirs (Crimea, Azerbeidjan, Grusinla) forming numerous flat pools play a decisive part. The rivers without any fall form a swampy alluvial land in Grusinia, the formation of which is further favored by the high level of the sub-soil water. These water re- servoirs are marvelous breeding places for mosquitoes. The rice fields in South Russia arc important breeding places for Anopheles. These places arc flat and quickly become warm if continuously watered, No good results were observed in cases of a spraying. 7. Control of Anopheles larva by aircraft. Oberfeldarzt (Lt. Col.. MC.) Prof. ROSE In only two places of the Command of the German Air- force have aircraft (of the administration for the pro- tection of forests) bben used for spraying the chemical agents for combatting larvae. The results were satisfactory but the craft and equipment had to be changed considerably in their construction for this purpose. The possibilities of using aircraft for combatting larvae have often been overestimated. Examinations showed only exceptionally that large sheets of water serve as breeding places and are suitable for treatment from air- planes, Aircraft should never be used for such purposes without sufficient entomological ground organization. Discussion; MENK: Shares ROSE's hesitation to use highly in- creased atabrine doses as occasionally administered by MEYTHALER. Even in severe tropica cases the usual dose of atabrine was injected intramuscularly and sometimes together with quinine injections (MUSHLENS), In mild malaria cases a combined treatment lasting 5-7 days is recommended (1 tablet of atabrine 0,1 gram and plas- mochin 0,005 grams three times a day) and is usually well tolerated. If this type of treatment causes any trouble, it is advisable to use pure atabrine. The new type of treatment mentioned by HAUER is quite promising. RODENWALDT; I would like to express only one wish in this matter. The report of ROSE concerning prophylaxis and therapy in case of malaria will be confirmed, by every physician, who has followed the development of the thera- peutic aspects of malaria during the last 20 - 3U years. In this decade, it became clear that any increase of the dosage and any prolongation of treatment are steps in the wrong direction. On the contrary the general trend is to decrease the doses and to reduce the time of treatment. Our internists were not well enough acquainted with malaria in these two years of the war. They were definitely under the impression that relapses occur very frequently and therefore they have striven for a prevention of relapses by an in- crease of the dosage and prolongation of treatment, which is understandable from the viewpoint of medical ethics. But malaria is in any case a disease which has relapses. We can- not help it, as long as we do not have a therapia magna sterilisans for malaria. I address the urgent request to the internists here present, especially to the consulting internists, not to change the treatment in the future, this will only be useless. SCHXJLEMANN: By the well tolerated combination of 0.05 gram atabrine and 0.005 gram plasmochin administered once a day. it seems possible to obtain a stronger effect in latent; malaria as shown by daily parasite examinations than by a dose of 0.05 - 0.1 gram atabrine and 0.005 gram plas- mochin given separately once a day. A careful examination of the prophylactic effect of the combination is recommended. MARTINI: Geographical distribution of malaria and its influence on tactics and strategy. HOEHING; A report concerning serious malaria infection in soldiers of two railway engineer units revealed that 50 per cent of the soldiers were infected, 80 per cent of whom have suffered from relapses, on the average 3*5 times per patient and some men as many as 12 times. Probably each man was repeatedly bitten by mosquitoes. As malaria does not produce immunity in general, the soldiers may be in- fected not only with one but with many tertiana at the same time. The remedies act only on the breeds in the fever-producing stage, but not in the latent period, there- fore many relapses occur when patients are infected several times. This explains the inefficiency of a treatment with larger doses of atabrine and plasmochin and the "final treatment" with regard to the relapses. The only effect is that the atabrine prophylaxis will be prolonged for some weeks. Directive on the control and treatment of malaria. The booklet "Malaria", annex 2, Army Manual la, is still in force with the following supplement, which must be considered as a general instruction to medical officers. 1. The medical officer of the troop has to inform the commander of a formation of the importance of malaria prophylaxis with regard to the combat efficiency of the troops and of the effect to be expected from prophylaxis. Besides, the commander of a formation has to be informed that atabrine prophylaxis is innocuous and that the yellow discoloration of the skin is of no importance to the health of the patient. If prophylaxis is not used for the troops, their combat efficiency is jeopardized. The employment of prophylaxis is incumbent to military command and not the medical service. The well known fact that prophylaxis does not afford a 100 per cent protection from malaria is nrt synonymous with the failure of prophylaxis. A temporary increase of the prophylactic dose from 0,06 to 0,1 gram atabrine has to be requested through the Chief Surgeon of the Army in case of special hazard, A special hazard prevails if more than 2 per cent of the individuals of the exposed units of the troops are infected in spite of the employed prophylaxis. 2. The Chief Surgeon has to insist on the observation of mechanical protection against mosquitoes and on adequate measures to destroy the breeding places* as described in the booklet "Malaria", He further has to insist on being con-* suited about the choice of the billets for troops and that his opinion be taken into consideration. 3, The instructions concerning therapy given in the booklet "Malaria" should be adhered to in every case. All experiences made on malaria therapy for the last 30 years have shown that the reduction of relapses cannot be forced by an increase of the dosage or by the prolongation of treatment. Atabrine and quinine should not be injected parenterally in case of malaria tertians. During the war, a much higher percentage of relapses must be expected due to a variety of circumstances. V, bacillary and amebic dysentery Translation prepared by: Office of Military Government for Germany (U* S*.) Office of Naval Adv5sor Medical Section A. Bacillary Dysentery, 1. Bacillary dysentery* 1942. Oberarzt (1st.Lieut*. MC.) Prof* SYLLA As far as the number of cases is concerned, dysentery did not play an important part in the middle of the Eastern Front this year. Fortunately there were only very few cases as compared with the summer of 1941. The non-specific diarrhea occurred also more rarely this year. Bacterlo- logically all cases were exclusively diagnosed as FLEXNER dysentery. KRUSE-SHIGA dysentery was observed 3 times in one army and a smaller group was infected by SCHMITZ* s bacilli (11 men). The clinical progress of diseases did not show any peculiarity this year. The patients who remained with the medical service in the front lines recovered quicker than those, who were evacuated to the rear. Patients suffering seriously from the long-lasting diseases were hospitalized in military hospitals behind the lines. The well known complications occurred here too, such as rheumatoid, con- junctivitis, urethritis, ard REITER*s fully developed triad, but were no more prevalent than last year. The duration of the- disease was largely dependent on the complications. The tendency to relapses and c&ponlc irritation'of the large intestine was about the game as the frevious year. Slight diarrhea, which lasted for weeks, was not cured with the usual treat- ment. but good results ‘ we'r e obtained by treating the gastric anacidity. The statistics of the Army reveal that the mortality rate is higher than last year. The ambulatory cases of dysentery, however, are not taken into consideration; pro- bably many cases of ’’gastric11 dysentery were not reported. The error due to the low number of cases under report will certainly affect the comparability of the figures. The immunization had no favorable influence on the mortality in dysentery. None of the three mentioned patients suffering from KRUSE-SHIGA dysentery died. No particular news can be reported concerning the general treatment of dysentery* It is important to stay in bed, to keep warm and to observe a strict diet* To be without any food or drink for 1-2 days is quite favor- able* Intravenous or intramuscular infusions are used against dehydration* Experience has repeatedly shown that massive doses of sulfonamides may reduce the infection when used at the very beginning of the disease* Citoacol and eleudron are recommended, because of their slight side- effects on the stomach. These remedies cause constipation. The following doses have proved satisfactory: 6 grams on the first day, 5, 4-, 3, 2, 1 grams on the following days. Castor-oil should not be administered in this treatment. The bacteriophage treatment has only been used in single cases and without any remarkable success* In some highly toxic cases serum has been inoculated* A certain detoxication was recognized occasionally* Blood transfusions from healthy persons are also effective. The question, whether the low incidence is due to the immunization against dysentery, is certainly of great interest. It is impossible to answer this because no com- parisons are available. Our Army has waged a positional war* The hygienic conditions were comparatively much better organized than last year. The flea-nuisance was considerably reduced because of the cold spring and cold early summer. The patients could be isolated without great difficulties. Tho soldiers were act all vaccinated* Our statistics do not reveal whether unvaccinated soldiers are more fre- quently or more seriously infected. Even the mortality is not influenced by the vaccinations. The following ob- servations have been made in connection with the tolerance of the serum injections, when using Behring-serum, The severe reactions and abscesses etc, followed by the in- jections with Aldystox (HASTEN) last year, occurred only in single cases this year. If after the first injection patients suffered from dianhea, further injections had to be stopped. About 20 per cent of such severe reactions caused by injection were reported by certain medical officers. A serious anaphylactic shock occurred once, but the patient did not lose his life. Abscesses caused by injections were only observed in single cases, Some single cases exhibited a mixed infection which probably was due to the inoculation of germs. From the surgical point of view (STAHLINGER) perforation of ulcers of the stomach and duodenum are common after injection. Six soldiers had to be operated because of such perforations. 2m Dysentery* Oberarzt (1st Lieut,. MC«) Dosent WALTER Post mortem examinations were made on 20 bodies whose death was caused by dysentery; the water and chloride content of the skin, of the periosteal adipose tissue, of the muscu- lature and of the liver was determined, in order to explain the phenomenon of dehydration. The result was as follows: The water content of the skin was on the average 60 per cent in contrast to a norm of about 70 per cent. The lowest values were less than 40 per cent. The value in the periosteal adipose tissue has been found up to 9 and 14 per cent, the norm being 26 to 30 per cent, if the fat content of the periosteal tissue is very poor, its water content is considerably higher, but in most cases below the norm. The musculature and inner organs, such as liver and kidney, are not affected by the loss of water. The loss of chloride is even more striking. The skin revealed a value of 200 down to 120 milligrams per cent instead of 300 milligrams per cent of chloride. The periosteal adipose tissue exhibits a similar loss and the musculature had a lower chloride content on several examinations. Therefore it is necessary to supply patients who are seriously ill with a large dose of sodium chloride* as the loss of chloride is due to urine* stool and sometimes vomiting and cannot be balanced by their usual diet containing only 1-2 grams of chloride daily* One of the new sulfonamide preparations MGlobucid" has shown good results* The effect is similar to that of "Eleu- dron” and "Eubasin” and was considerably superior to bacterio- phages. The tolerability of this remedy was good* The morbidity rate distinctly decreased by use of bacteriophages as could be proved in more than 20*000 cases according to the findings of last year and which is con- firmed by the observations derived from Russian sources* There is no need to discuss this fact* as phages cannot be used in the Army for prophylactic purposes on a large scale* The increase of residual nitrogen in dysentery is chief- ly due to an increase in urea* Only ver3r seldom could an increase in residual nitrogen be observed, a fact which must be related to a disturbance of the liver* The difference uNfl (difference between nonprotein-nitrogen and residual N) normally amounts to 6 - 10 milligrams per cent* In case of dysentery this difference N is frequently increased and in some single cases is as high as 60 milligrams per cent, and will decrease quickly again during convalescence* The difference of nitrogen is sometimes increased, even if there is no increase of residual nitrogen* The difference "N" is obviously closely related to the increased decay of protein* A disturbance of the third phase of coagulation, the retraction of fibrin, is observed not only in severe cases but also in mild cases of dysentery and other infectious diseases. The definition of the number of thrombocytes, thrombocyte-agglutination and addition of thrombokinase and normal thrombocytes revealed that this phenomenon does not depend on thrombocytes and thrombokinase but is pro- bably due to a toxic damage of fibrinogen* The pathogenesis of dysentery* Obarstabsarzt (Major, MC>) Prof« BOEHMIG The etiology of dysentery is well known* The patho- genesis, however, is not quite clear. ho other intestinal infections start pathologico-anatomically in the rectum. The specific changes are limited to’the intestine and the non-specific dhanges to the regional lymph-nodes. The blood vessels and other organs remain free from germs and appreciable reactions, except for a strong alternating leucocytosis in rare toxic involvement.of the joints and neuritis. Thus dysentery stands outside the group of typhoid diseases which permit the proof of at least one bacillus in the blood, even with the toxic forms of para- typhoid, without showing severe changes of the mucous mem- brane in the intestine. Neither clinical observations nor bacteriology nor pathology have been able to clarify the peculiar course of dysentery. It seems as if the interest in a pathogenetic clarification has become generally very slight* Therefore, it will be my task to contribute to the pathogenesis based on macroscopic and microscopic autopsy findings during the campaign in Russia. LOEHLEIN writes as follows about his observations made during World War I: ‘'Today it should be generally recognized that each case of dysentery starts as catarrhal dysentery." ASCHOFF describes the bran-like coat as the earliest change. WESTEWHOEFER has the opinion that the disease starts in the follicles and that the catarrh is not a primary but an attendant symptom. BEITZKE and HART have observed early fatal cases characterized by diffuse gastro-intestinal catarrh and atypical ulcer.or by purely toxic disturbance of metabolism. The reason for this controversy is due to the fact that the pathologist very rarely sees a genuine early stage of dysentery, apart from merely incidental findings, as for instance in case of death subsequent to gunshot injury if the individuals happen to suffer from dysentery at the same time. We must consider the clinical conditions first and have then to examine the symptoms of dysentery. In this case not the secretion of mucus but the ordinary diarrhea has to be mentioned which can not be differentiated from a dyspeptic or alimentary diarrhea cr a diarrhea due to chill- ing which occurs rarely with alkali but usually with acid fermenting stools and shows unreduced bile pigment. The diarrhea which is due to a catarrh of the mucous membrane behaves as any catarrhal inflammation in other organss 1. non specific and 2. associated with watery secretion. I doubt whether the respective mucous membrane is really infected in a "catarrhal disease of the mucous membrane". The proof is still to be furnished concerning this fact. In the first stage of a catarrh of the mucous membrane no change of the glands are found microscopically but an enormous dilatation of the capillaries in the mucous mem- brane is observed which causes the watery secretion. Chill- ing, as well as every alimentary disturbance or chemically injurious agent, may produce such reversible^capillary- ectasia according to the individual sensitivity. As the second dtage an interstitial increase of cells between the glands of the mucous membrane follows which then causes an increase of the mucous secretion. Hoes this also apply to dysentery? Diarrhea as the first syaptoa is evidence of a decrease in the resorption capacity for food, as well as a symptom of watery extra- in case of capillary-ectasia. Whether the latter process is the only manifestation of a .toxic effect of dysentery-bacilli already active, or whether toxin is secreted through the blood vessels into the large intestine (as LETTSRER has stated according to the experiment on ani- calS made by JXIERR) has not y°t been established. Practical experience hap shown that dysentery* was always associated vith a coollJ%g off or to imperfect nutrition, the enteric •r oolitic symptoms of which may either subside or lead to acute dysentery. Earlier in the course of dysentery we observe a diffuse infiltration of cells between the glands of the large intestine as the only microscopic change. This same change affects the entire large intestine or meter-long parte of it. The same type of change has been observed in patients suffering from gunshot injuries without any infectious dysentery where the patients had been chilled during evacuation last winter and resulted in diarrhea. The finding of the mucous membrane is therefore non-specific and no diagnostic symptoms of dysentery could be observed. It is not a mere dialectic controversy if we assert that dysentery does not start with a "catarrhal in- flammation" as LOEHLEIN has already asserted, but is pre- ceded by a non-specific catarrh of the mucous membrane. Is this observation very important? I think so, because of the problem of culture of dysentery-bacilli# It has often been proven that dysentery bacilli are destroyed by the gastric juice (even within a few minutes). Theoretically bacilli may reach the intestine alive only in case of an insufficient secretion in the stomach or by anacidity. The question arises whether the toxins become free in the stomach or if they cause a hinderance or even a neutraliza- tion of the gastric secretion. This point is emphasized by findings of sloughing inflammations of the mucous mem- brane in the stomach with a positive finding of bacilli, which we occasionally established on Russians# Perhaps variable acidity values explain the individual differences in a dysentery epidemic; perhaps the clinicians are in- terested in this question. The first invasion of bacilli occurs In the rectum. Here we always find the first "specific" anatomical sign in the form of a bran-like coat. How does this localization in the rectum take place? If there was a normal function of the intestine or even an obstipation, it would be possible to think of an accumulation of bacilli within this part of the intestine# But on the contrary, enteritis, or colitis always precedes and causes a quick emptying of the intestine and watery secretion which makes any adhesion of bacilli on the intestinal mucous mem- brane impossible. Therefore only two factors explain the onset of dysentery in the rectum, 1. the slight or totally absent resorption capacity and probably the decreased secretion capacity of the mucous membrane of the embryonic rectum in comparison with other parts of the intestine; 2# intestinal spasm and defects of the mucous membrane. The intestinal spasms keep the stool in the rectum, sigmoio and in the descending colon. These facilitate the adhesion of dysentery-bacilli in places where the loss of epithelium is microscopically visible leaving the basal membrane ex- posed. The spasms must be the cause of the gradually retro- grade progress of the specific changes of the mucous mem- brane up to the cecum or because of insufficiency of the BAUHIN’s valve up to the small intestine. The specific changes of the mucous membrane show microscopically a typical inflammatory reaction (fibrin), toxic effect (necrosis) and non-specific chronic ulcerous inflammation. In the first stage, the inflammation is limited to the mucosa. The second stage of necrosis is 100 also limited to the mucous membrane; the toxic effect being recognized by the remarkable absence of reaction in the epithelium and connective tissues, furthermore by the re- newed lake-like distention of the capillaries, by the ab- sence of exudate cells or by the formation of a thrombus, and by the late onset of a well defined inflammation in the submucosa* The third stage begins preferably in the lymph nodes of the intestine* Here we observe physiological interruption of the muscularis mucosae, so that after the necrosis and discharge of the lymph nodes, the infection located in the follicle bed may advance and spread in all directions in the submucosa* According to our microscopical findings the toxic effect of dysentery bacilli is limited to the necrosis of the mucous membrane and the intestinal lymph nodes. The subsecuent ulceration is non-specific. • It is believed that it is maintained by dysentery bacilli, but this has not yet been proven. Pseudo-membranes or fresh necrosis are missing in all larger or older ulcerations, that is to say all characteristic changes of tissue in dysentery. It is remarkable how early the regeneration of the exuberantly growing mucous membrane starts in the newly formed flandular epithelium in the lymph nodes and to what extent such regeneration of mucous membrane spreads parallel to the surface below the muscularis mucosae, in the submucosa, and into the recesses of the undermining ulcers. Most of the regenerated tissue is destroyed by non-specific inflammation. After discussing the microscopic changes in the in- testine we return to the details concerning dysentery: the finding of bacilli is limited to the intestine and the regional lymph nodes. A bacillemia does not occur, an essential toxemia can generally not be expected, be- cause in that case circulation and the blood picture would appear differently and the regional lymph nodes would show characteristic changes. The only specific effect of dysentery bacillus - after a non-specific earlier involve- ment of the mucous membrane of the large intestine - is the sloughing inflammatory reaction, the necrosis as a toxic effect. The causative agent which maintains the non- specific ulcer extending along the surface remains doubt- ful* The formation and resorption of endotoxin must be in- comparably less important than in diphtheria. This is perhaps due to the presence of numerous bacteriophages. Only the rare cases of early death in dysentery are due to the toxic effect and must be considered as a toxic vasomotor paralysis. The late death which'occurs more frequently, is considered to be a death of exhaustion, nat due to a direct toxic effect but to the loss of mucous membrane in the large intestine. These facts will indicate that the problem in dysentery is the pathogenesis* This problem cannot be cleared up from the pathologico-anatomical aspect* We should like to urge the clinicians to go deeper into this matter. Remark: The divergent opinions of some of the patho- logists present could not be discussed after the lecture of BOEHMIG due to the lack of time (LAUCHE)* p^nfssion: LAW: No specific differences between immunized and non-immunized patients could be observed with regard to morbidity and severity of the disease in cases of dysentery in a loeal military hospital in the summer of 1942* GCTZEIT: I am familiar with the conditions of dysentefy in several Eastern Armies* Generally speaking the course of dysentery was less severe and fatalities were less numerous this year. On the whole, FLSXNEL-dysentery was more frequent and there were only a few cases of SHIGA- KRU3E dysentery. The severity of the disease increases with the distance behind the front line due to evacuation problems. The course and severity of FLEXEER'dysentery was not influenced by the type of vaccination. 'Whether Behring or Zeiss-serum or Aldytox had been used, the result was always the same. One part of the unit was vaccinated with Zeiss-serum, another part with Otten-vaccine (only SHIGA vaccine) and Dysperos (a combined vaccine, administered by mouth), a third part of the unit only with SHIGA vaccine, and a fourth part of the unit was not vaccinated at all. due to difficulties of supply. In all these different in- stances, dysentery was manifested only by mild symptoms. As a matter of fact not all the requested reports have come to hand so far, and in my opinion, we will have to precede with the utmost reserve in the evaluation of immunization successes in the case of FLEXNEF dysentery. BICFEFT: It has not been clarified what accounts for the small number of cases and the mild symptoms in the course of dysentery in 1942. Dysentery occurred only in soldiers who had not been immunized among troops of the field re- inforcement division while the immunized soldiers were pro- tected. In cannot be said without further investigation that immunization against dysentery is worthless# HODENWALDTs It has never positively been reported that the immunization is against FLEXNEE dysentery but it 1e effective against SHIGA dysentery. On the whole, SHIGA-dysentery occurred very rarely and. did not play an important part in 1939/40. But I would like to refer to the fact that a SHIGA epidemic was spread by a patient in Kaisers- lautern who returned from the Eastern Front, and which caused many fatal cases. This was a SHIGA epidemic imported from the East. The question arises if the immunisation has been effective against SHIGA dysentery. Directives: (Amendments of the circular concerning dysentery)« 1. Eubasinum, respectively Eleudron must be mentioned first for the therapy. 2# Bacillary dysentery should not be treated with Rivanol tablets. 3« Laxatives (castor oil, calomel) will be administered only in the incipient stage of the disease. If the patient is transported to another hospital no other laxatives should be prescribed. 4. Treatment with hydrochloric acid should not be forgotten in cases of chronic dysentery and chronic disturbance of the intestine following dysentery. (Hydrochloric acid, non dilutum 20, distilled water ad 200. one tablespoonful in a glass of water). But since the supply of large quantities of liquid is vrry difficult, it is better to take hydrochloric acid tablets such as were delivered to the Africa-Corps by the main medical depot. B. Amebic Dysentery* 1. Experiences with amebiasis in Lybia• Stabsarzt (Captain. MC.) Prof, HORSTER While amebic dysentery is the most widespread disease (TABABELLI) in peace time in Lybia, bacillary dysentery has never caused an epidemic; but during the war it was just the other way around. Amebic dysentery is usually manifested secondarily as a complication of a gastro-intestinal disease, especially following bacillary dysentery. While the latter is diagnosed by its clinical symptoms and the proof of the bacilli is not essential for our point of view, the proof of araebae is absolutely necessary, however, for the treat- ment of amebic dysentery. In the many cases of gastric disturbance the carrier of amebae can only be discovered by a careful microscopic examination of the stool. A stool resembling raspberry jelly is only rarely a positive indication of this dis- ease. The diagnosis of amebiasis is in the first place a problem of systematic stool examination. As with almost all patients suffering from gastrlco-intestinal disturbance and frequent passage of stool, a repeated examination of the stool is necessary (saline cathartics after provocation)* Therefore we have trained suitable soldiers for the troops and for the hospitals so they are able to examine the stool (students and other indigoious persons in laboratories). The result was that about 25 per cent of the soldiers suf- fering from intestinal disturbances and being treated in military hospitals were found to be harboring dysentery amebae. We looked thoroughly into this matter when the stool of patients was regularly examined by WESTPHAL, his staff and well-trained personnel in all military hospitals. The investigation was completed by monthly reports of all cases of dysentery including the diagnosed forms of the disease. These reports showed that the findings correspond to those of the Autumn 1941 and that in May as well as in July 1942 approximately 25 per cent of all patients suf- fering from intestinal disturbance, which have been treated in military hospitals, were infected by amebic dysentery. Most of them suffered only from infection of the lumen with cysts and small forms. Genuine amebic dysentery occurred very rarely. These conditions compel us to examine each patient suffering from intestinal disturbance for amebic infection, regardless of whether the diagnosis of bacillary dysentery, enteritis or another type has been established or not. This observation is of special practical importance because amebic dysentery is likely to be superimposed in case of complex intestinal diseases and especially in the case of bacillary dysentery (lantern-slides showing two temperature curves). Only three weeks after the onset of acute bacillary dysentery tissue structures of Endamoeba histolytica are observed in the stool. These observations fall in line with the course of the experiment carried through on him- self and demonstrated by PTSSTPHAL in which case a histolytica infection was active for 8 months. This infection developed into an acute amebic dysentery with numerous vegetative tissue structures 23 days following a secondary infection with pathogenic intestinal bacteria. But conditions are not always that clear, as tissue structures may be observed even in the first acute days of bacillary dysentery, even without prior intestinal dis- turbances being included in the anamnesis* The clinical aspect of bacillary dysentery does not change by this double-infection. It is possible that small amebic forms develop rapidly into large forms In the mucous membrane of the intestines and in the necrotic tissue which have been damaged by toxins of bacillus dysenteriae. Thus they can be found in the stool without a genuine infection of the intestinal wall. But even in these cases only the acute bacillary dysentery is the reason for discovering the amebiasis. A thorough drenching by rain or immersion or extensive consumption of alcohol may lead to an acute on- set of enteritis in which amebae (tissue structure) may be observed. The anamnesis of intestinal trouble among these patients goes back over many months, and is characteristic for a chronic subacidity respectively anacid gastro-enteritis, as was frequently observed in troops stationed in North- Africa. In such cases dyspepsia coexists with latent amebic infection and it is not possible to indicate the onset of amebiasis. Outside influences lead to severe acute clinical symptoms. But it would certainly be wrong to diagnose an acute amebic dysentery in these cases. Patients also developed amebic dysentery almost under our very eyes. Pfc. E.D., 20 years of age, had been hos- pitalized since the end of October 1941, because of diph- theria. No symptoms indicated gastro-intestinal disturbances. The stool was perfectly normal. During the period of con- valescence a frequent passage of stool containing blood and 104 mucus as well as many tissue structures without any associate fever was observed on 29 November. Probably the general, and especially the local, disposition of the intestines were so much changed by the diphtheria that a latent amebic infection (cysts and small forms) could develop into a clear cut amebic dysentery. In another case an amebic infection was only dis- covered after extensive abscess formation in the liver. Emetine had a favorable effect on patients suffering from abscess of the liver. Important clinical symptoms are the following: large liver, sensitive to clearly visible in X-ray examination, high temperature, leucocytosit, and the stool sometimes containing Endameba hystolytica. Th immediate effect of Emetine supports the diagnosis. Other complications due to amebic infection were not observed. Treatments Patients suffering from intestinal dis- turbarices with tissue structure in the stools should be ad- mitted to the hospital and kept at rest. The same refers to the majority of patients suffering from intestinal dis- turbances with small forms when observed, in the beginning stage. The general treatment (basic therapy) corresponds to the one used in bacillary dysentery such as cathartics, heat and at first a tea and porridge diet, after that the patients soon need a diet which consists of food rich in calories and vitamines, and it has further to be full of variety and easy to digest. The "specific" treatment of amebiasis is usually not very urgent. In most cases in which bacillary infection is predominant, a Eubasin or Eleudron- therapy (2 tablets five times a day for 2-3 days) should begin the treatment for amebiasis. Further Acidolpepsin should be given regularly even after the disease begins to subside. Emetine is the basis of an energetic chemotherapy in all cases of tissue infections. The following doses are recommended: Patients with a strong constitution need 0.06 gram intravenously once a day, other patients need 0*03 gram twice a day. The total dosage is 0.6 to 1.0 gram. On principle we combine Emetine treatment with an oral and also a rectal treatment with Yatren, In strong patients with new infections without a long lasting preceding intestinal dis- turbance, the diarrhea as well as the endamebae disappeared after a few days, while the result of the treatment was not very satisfactory in patients suffering from chronic intes- tinal disturbances. Yatren appears to have an unpleasant effect in the beginning on most of the patients v'hen administered in large doses. Diarrhea and tenesmus increase. RiVcnol has a comforting action due to its spasmolytic effect. We have come to the point that we no longer use Rivanol exclusively, for we have frequently seen an amebic dysentery developing in patients who were treated with Rivanolettes because of bacillary dysentery. All patients suffering from intestinal disturbances and in which cases an amebic infection has^also been recognized, were given an intensive chemotherapeutic treatment, even if it might only be a lumen infection with cysts and small forms. It may easily happen that a true tissue infection occurs in the injured intestines. The clear 105 cut lumen infection has been treated orally and rectally with Yatren but without Emetine# The majority of the patients suffering from intestinal disturbances with a histolytica infection had to be evacuated. Those patients have not much chance of recovery under war Conditions in the North African climate# Healthy carriers of cysts do not require any treatment. Prophylactic treatments are based on the same pro- cedures as used for bacillary dysentery# It is important to prevent and to combat the frequent dyspepsia and anacidity and subacidity by the use of hydrochloric acid# It is nec- essary to supply the patient with a suitable and nourishing diet which does not upset the intestine during the hot weather (further information given in the field cookery book for hot countries)# Chemoprophylaxis by using Yatren or Rivanol did not show satisfactory results. Summary* 1* The most important thing in combatting amebic dysentery is a reliable system for the examination of the stool. 2. Combatting infectious and non-infectious gastroin- testinal diseases is the most effective prophylaxis which may be used in the control of amebic-dysentery. 3. The best specific therapy used for tissue infection with dysentery amebae consists at the present time of the use of a combined Emetine-Yatren cure* 4. A clear cut lumen infection should not be treated with Emetin. 5. Individuals, in whom only cysts or small forms have been found, have to be treated only if the danger of a subsecuent development of a tissue infection ex- ists because of an additional disease, particularly an additional intestinal disease. 2. Parasitology of amebic dysentery* Senderfuehrer (Special Consultant.)_ WESTPHAL In the beginning of this report reference was made to the discovery of the amebae causing dysentery, the EndameMe histolytica, in 1875, when for the first time the cause of this disease could be proved. Around the turn of the century the dysentery bacilli were discovered. Amebic dysentery vand bacillary dysentery have been treated separately'ever since. In addition to the patients suffering from amebic dysentery properly speaking, we have to dea-l tith the' "carriers" of dys- entery amebae which are practically free from symptoms, espe- cially in the tropics and subtropical districts* The propaga- tion of Endameba histolytica as small forms in the intestinal lumen and occasional cyst-formation of the small form in the intestinal lumen and the occasional development of the large form on invasion of the intestinal wall are demonstrated by means of a chart of the schematic cycle. This invasion into the intestinal wall and thereby the development of the real amebic dysentery is due to a lowered resistance of the intestinal wall, especially owing to bacillary intestinal injuries. Today, amebic dysentery and bacillary dysentery must not be treated separately because of their common pathogenesis# In a series of histological sections of an infected cat*s intestine, different chan:'ng effects of the preceding bacillary dysentery and the follow- ing amebic dysentery are demonstrated. The spreading bacillary injury of the tissue is followed by a burrowing invasion of the healthy tissue by the amebae# The muscular!:, mucosae will not be passed by amebae. The toxic bacillary irritation causes a swelling of the submucosal lymph follicL from which the invasion of the muscularis mucosa and of the mucosa itself begins. Amebae are likely to invade the ad- joining submucosa from these prepared, positions and then produce the typical amebic ulcers. The vascular system can be exposed in the mucosa without causing any considerable intestinal injuries. This process leads to the formation of abscesses of the internal organs, especially of the liver, apart from a marked amebic dysentery# These con- ditions, microphotographically demonstrated, compel us to take great care in amebic dysentery as well as in ordinary intestinal lumen infection with amebae causing dysentery which may infect combat troops in hot climates# Therefore a thorough training of the personnel in laboratories is necessary which will be supervised by the hygienists of the Army, and will be assisted by the consulting internists. The training authorities at home are supervising the in- doctrination of these personnel, in order to keep them abreast of their important mission. VI. TYPHUS Translation prepared by: Office of Military Government for Germany (U# S.) Office of Naval Advisor Medical Section 108 1« Early symptoms* problems of evacuation and treatment• Oberstabsarzt (Major, MC.) Prof* DENECKE The early diagnosis is of decisive importance for the isolation and treatment of patients, but at the same time very difficult to establish* The early symptoms are extra- ordinarily rare. Subjective reports of physicians who were positive as to the time of infection state that restless- ness, pains in the back, and in the muscles made their appearance in the last week of the incubation period even before any fever was observed. The aching of the muscles is most generally observed as a slight fluctuating pain or a barely perceptible trembling. A slight tendencjr toward mental flightiness was observed in two physicians who are described as especially quiet persons in their healthy days. This mental aberration is of minor importance and not of a whimsical character, but comparable to the unrestrained feeling after having consumed too much alcohol* I have tried to check on these statements in other patients suffering from typhus and have found out that many patients could remember similar sensations at the onset of the disease. We have to beware of any suggestive questions and must be careful in the interpretation of psychic disturbances which are a part of the picture of the disease. The onset of typhus does not always occur suddenly and impetously, but is lingering and gradually increasing in about one third of the cases, similar to typhoid fever. Besides these subjective anamnestic symp*- toms, the following objective symptoms in the incipient stage of the disease should be mentioned* The yellowish color of the fingertips, similar to what is observed after the use of Prontosil, a slight trembling of the lips, a certain involvement of the facial musculature and a fearful alert expression, which is rather striking in contrast to typhoid fever and a deep respiration. This deep respiration usually continues even if pneumonia is added as a complication. I have rarely observed labored breathing in a typhus patient suffering from pneumonia. Constipation and palpation findings in the cecal area are some of the early symptoms which not infrequently raise the suspicion of appendicitis. The area of the cecum is sensitive to pressure over a wider area than in cases of appendicitis and furthermore the physician feels and hears a gurgling doughy mass during the palpation. The exanthem is preceded by some sort of pre-exanthem which gives the skin a marble-like appearance# STURM believes one can see an early symptom in the behavior of the white blood picture. He mentions an enormous shifting to the left of the leucocyte formula with the absence of eosinophiles and a proportion of 25 - 50 per cent of the stab cell leucocytes. Unfortunately this is not only an early symptom of typhus, but also of numerous in- fectious diseases, especially in young people* The reaction of the myelocytic apparatus to infections causes the same shifting to the left also in Volhynia fever, in angina, 109 diphtheria, and pneumonia* We also agree with STURM re- garding the importance of the dry leathery tongue, but also this early symptom is too general to give the medical officer any differential diagnostic clue* But important indications should be given to troop medical officers with regard to early symptoms* If the medical officers do not discover typhus in patients early, the disease will spread and cause injuries to the patients who as a consequence will be evacuated too late* The treatment has to start the very moment the evacuatio begins* The patient suffering from typhus is probably the most sensitive of all infectious disease patients to trans- portation. The earlier the patient is evacuated the better he gets over the disease, unless he suffers from the rare stormy type of the disease. The reason for the transport hazards to patients suffering from typhus is the early involvement of the vasomotor and the almost regual simultane- ous involvement of the myocardium. Therefore, it is necessary to take special preventive measures for such transportation. First of all the shortest possible route should be chosen and special protection against cold should not be forgotten. It is only possible to cut down the time of transportation if we desist from establishing special hospitals for in- fectious diseases and typhus patients, for these hospitals have to be located centrally in the Army District, that is to say far behind the lines. Moreover these hospitals for infectious diseases have a kind of suggestive influence on physicians who believe that the best care of the patients is guaranteed in such hospitals and therefore accept the long route of transportation. But this has a disasterous effect on the patients. The generally known better tolerance of the Russians to typhus is partly due to the fact that no transportation was provided for sick Russians. If it is possible to persuade the competent Army Surgeon to instruct the advanced field hospitals of the divisions, the main dressing stations and collecting points to establish small wards for patients suffering from typhus this would first of all prevent the hazard of a spreading of the disease during the evacuation to the hospital and second it will considerably decrease possible damage to the general cir- culation of the patients* A suitable protection egainst cold is imperative to prevent any collapse* This point must be given attention Incase of transportation in "Akja" carrieages (a Russian carriage) anc especially if carts or sledges are used. Many physicians attempt to stimulate the circulation by the administration of drugs, but I have never observed any advantage derived therefrom* It must especially be pointed out that peripveral vasoconstrlcting drugs such as Sympatol lend themselves for that purpose. But Cardiazol or Pervitin should not be used as they are stimulating drugs* If the patient is evacuated to a hos- pital, he will be left for quite a long time without any supervision and even the driver is not able to attend to him. The condition of the patient may quickly change for the worse and these drugs, due to their spasmodic and cerebral effect, may prove dangerous to the circulation. 110 The patient will rarely show cardiac symptoms during the first transportation. Therefore it would be premature to administer Strophantin on this occasion as is often suggested. If the patient is really in such a bad con- dition, it is not advisable to transport him at all, as such a transportation may prove dangerous to life Bven with an injection of Strophantin. STURM suggested that patients showing any symptoms of heart trouble should be treated with Digitalis. Digitalis would not have any effect on a periph- eral collapse but the treatment with Strophantin is superior to Digitalis for acute cardiac insufficiency in patients suffering from typhus. In my opinion, the treatment with Digitalis could only be used for convalescents with per- sisting myocarditis or cardiac insufficiency. Third: The treatment with the blood of convalescents should be discussed in addition to the early symptoms and the question of transportation. The most successful use of convalescent blood is, according to nur experiences, a transfusion of 400 - 500 cubic centimeters intravenously on the fourth or fifth day of the disease for the first time and which may be repeated several times. Naturally we do not have so many cases that we are able to compare treated and non-treated patients. We routinely gave this blood transfusion to all cases of typhus after we observed the good results of this therapy in some serious cases. Since this change in therapy was introduced in January 1941 when typhus reached its peak, it can hardly be presumed that just this same time should mark the turn in that the disease was milder in its course from then on. The blood transfusion from a convalescent does not cut down the fever nor the duration of the disease, but it acts favorably in the sense of bringing about a milder course. MALY supposes that the blood of convalescents stimulates the formation of anti-bodies quite intensively. He even believes in a passive transfusion of anti-bodies and he therefore suggests to transfuse the blood on the fourth day after the defervescence at the highest titer value of the WEIL-FELIX reaction. As there are only a few patients in the field hospitals from whom large amounts of blood can be taken on the fourth day of defervescence, we have taken the blood of convalescents only on the fourteenth day or even later and have finally because of the evacuation of convalescents, also transfused the blood of healthy soldiers who never suffered from typhus. The same satisfactory effect was observed. Therefore it may be assumed that the transfused blood is not effective because of anti-bodies, but for some other reason. I suppose that we have to deal with two different kinds of reactions. The first reaction of the absorptive effect of the surface of the erythrocytes on toxins. Typhus is, just like diphtheria, one of the diseases which causes an early and frequent toxic condition. The blood transfusion seems to be the only successful remedy. The absorptive effect is inherent in the blood of a healthy donor as well as in that of a convalescent, but it may be. that in ad- dition to this the blood of the convalescent contains specific anti-toxins. But this factor is probably not decisive as otherwise the serum of convalescents should be effective, which is not the case according to all our ex- periences and to the findings of WALTHER. Only SCHMIDT- OTTO has expressed an opposite opinion based on the ex- periences made by LYDTIN. I hope for a second effect of the blood transfusion on patients suffering from typhus in offsetting collapse* Because of the tendency of typhus to a paralysis of the vasomotor system the typhus patient is in constant danger of collapse. Since it is known from the treatment of shock that a large blood transfusion is the treatment of choice to prevent collapse by filling up the circulation and presumably by a reflex initiation of a peripheral vasoconstriction* It may also be replaced by preserved serum. I have suggested that the military hos- pitals behind the front lines, which hospitalize our con- valescents recovering from typhus, preserve the blood of the convalescents and send it to the hospitals near the frontline. But there will be no need of preserving the blood of convalescents if it proves that the blood of healthy individuals has the same effect. The blood transfused for the first time on the fourth day of the disease, which may be repeated every second or third day, according to the course, is the best remedy for treating dystonia and is superior to all other methods for treating the circulatory system. In my opinion one should be particularly careful with the use of remedies stimulating the circulatory system in case of typhus because when a toxic clinical picture prevails only such additional medica- ments should be used as are absolutely necessary and which promise definite success. In cases of myocarditis Strophan- tin only should be administered. Dystonia reaching a high degree in typhus, generally occurs, according to the new investigations made by STEIN, in soldiers who are thoroughly exhausted and overstrained in the front lines* As spot checks revealed hypocalcemia was recently observed in typhus concomitantly with the other symptoms* It is therefore possible that the calcium therapy, as suggested by MEERENDONK, does not treaty a specific symptom of typhus but a wide spread general condition. The favorable effect of calcium, especially with regard to the nervous symptoms is beyond question. The combination with AT 10, as proposed by STURM, is dangerous, if used without appropriate control of the calcium level, as has actually been done several times because of the influence of a certain publication. A critical examination of the whole scheme of treatment as proposed by STURM is recommended because of the overdosage and use of Cardiazol without even mentioning the necessary Strophantin and the success- ful blood transfusion. 112 2> Therapy for typhus. Oberstabsarzt (Major. MG.) Prof, von FALKENHAUSEN No form of chemotherapy has shown satisfactory results in the treatment of typhus# The continued supply of large quantities of liquid is very important# 5 per cent glucose administered by continuous intravenous drip until about 5 liters are given, is advisable# The flushing out of toxins is the objective of this treatment# The therapy with convalescent serum has not siicceeded at all# Blood transfusion from convalescents which has been used in seriously toxic cases of scarlet fever, based on analogous- ly favorable observations has shown good results# About 30 very serious cases were treated with the blood of con- valescents# host of the patients showed prognostically unfavorable extrapyramidal symptoms. Only three patients died. Among them were the only two patients suffering from severe erysipelas and the other (38 years of age) suffering from severe necrosis of the muscles of the right arm. The third patient was hospitalized in a moribund state. There is no doubt that the blood transfusion of convalenscents is the best available remedy for treating ’ tlFpHus' at present• IF case a further severe incidence of typhus occurs, the opportunity should not be missed to establish the definite proof by a series of comparative examinations. The blood transfusion of convalescents may be compared with the normal blood transfusion. Not more than 100 cubic centimeters of convalescent blood was transfused in a single dose. This amount, how- ever, was given on eachcf three successive days# Venesection stimulates the formation of blood, but is not quite harm- less for a convalescent recovering from typhus because of the long lasting hypotonia. Treatment with convalescent blood should be started as soon as possible (between the first and fourth day) but a rapid recovery has also been observed in the advanced stage of the disease. In regard to the therapy of the circulatory system which is the usual approach to the therapy of typhus, it must be mentioned that the patients suffering from typhus usually have to undergo an unnecessary and unsuccessful treatment with Digitalis. Only in the incipient stage of decompensation it is necessary to use a glycoside and then it should be Strophantin. But usually an increase in peripheral tonus is sufficient (obtained by a continuing medication of Sympatol). An unfavorable effect of Sympatol on the seriously injured nervous system has never been observed, while Strychnine often produces irritation. The use of Cortenil (an adrenal cortex preparation) has shown good results, especially in shortening the long lasting period of convalescence due to the chronic hypotonia. Discussion: DENNIG: Electrocardiographic disturbances are re- gularly observed in patients suffering from typhus. This refers mainly to the QT-wave and there is no deflection of 113 Q as occurs in diphtheria and articular rheumatism, QT is prolonged while T is levelled off. It usually lasts for 6 weeks but sometimes even many months. But this is of no importance to the prognosis. LYDTIN: The most essentail part of the objective early symptoms in typhus seems to me to be the enlargement of the spleen# This enlarged spleen may clearly be ob- served in the first three days of the disease. In 80 - 90 per cent of the cases, patients suffer from typhus before any symptoms of an exanthem appear. The following indicates the result of the treatment with the blood of convalescentsJ 1# The blood of the convalescent who is in the late stage of the disease has no more effect than a normal blood transfusion. No decrease in the fatality rate has been observed. 2. In comparable investigations with serum of con- valescents in the early stage of the disease, giving 125 cubic centimeters intravenously each of the first three days of the infection before the eruption of the exanthem - I have observed a considerable decrease of fatalities in all age groups* The results are statistically not quite guaranteed, but a high degree of probability has been ob- tained. A series of treatments with atabrine-plasmochin used so as to be comparable in large numbers did not show any satisfactory results. von BORMANN: The early symptoms of typhus mentioned by DENECKE are much too complicated and as they need a long clinical experience, it won*t be of much use to field medical officers. A medical officer is not able to detect a barely visible exanthem in the serdnhed and dirty skin of a soldier in a badly lighted bunker. The psychic prodromal symptoms, the motor restlessness, the aching of nmuscle waves” may - if they occur at all - perhaps be recognized and noted by a physician, who is just developing the same disease, but never by a youngster from the country. The medical officer needs some evidence, such as fever, headache and perhaps a palpably enlarged spleen. If in addition other symptoms are exhibited such as coarse finger tremor, somnolence, insomnia and bloated face, the surgeon will know how to proceed. At first it is not important that the diagnosis is exact but all cases of typhus have to be delivered to the main dressing station at the earliest possible time. It is of great importance to inform all medical officers of the epidemic situation in the area. Just as a commander of a battalion has to perceive the tactical situation of his neighboring formation, the medical officer has to report the epidemic situation. Then he will be able to diagnose the feverish disease. SYLLA: In 80 per cent of the cases of typhus a clear prolongation of the latent period of dermographism has been observed in the first day of infection* This prolongation shows the decrease of the readtion capacity of"the sick organism. If the time between the rubbing of the skin and the eruption of the rash takes longer than 15 seconds, typhus is expected and this helps one to recognize the disease in its early symptoms. The danger of gangrene of the extremities in cases of typhus has especially to be feared during the cold periods of the year* The reason for this gangrene may be the disposition to vascular spasm (cerebral irritation), which reactions are favored by chilling. Therefore it is necessary to keep the patients in well heated rooms in order to warm their extremities. - Finally one has to be careful to not overevaluate a new type of treatment, particularly as long as no reliable comparative reports are available. The death rate varies very much and gives rise to illusions. The total death rate of our Army amounts altogether to only 5.5 per cent* GUTZEIT: The discussion has shown that again no proper opinion has been given concerning the best therapy in cases of typhus. This can only be gained by comparable investigations, the principles and application of rhich I have elaborated since 1940, Just the fact of the temporal changing of genus epidemicus compells us to use the con- trolled method of treatment at the same time in the same hospital without any separation according to the gravity of the disease. When testing the different methods of treatment one after the other the disturbing influences of genus epidemicus are never eliminated. 3» The psychic disturbances in typhus• Oberstabsarzt (Major. MC») Prof« von STOCFERT The psychic disturbances associated with typhus can easily be reduced to 4 stages, the prodromal stage during the first three days, the peak of the disease from the end of the first week to the end of the second week, the stage of defervescence and fianlly convalescent. Two series of symptoms pass through all these phases like Ariadne’s clue. Mental disturbances and a series of symptoms arising from the diencephalon which are character- ized by blurred responsiveness of the mind, and amnesiac disturbances. While in the prodromal stage hypochondriac Repressive and sometimes irritating euphoristic conditions occur quite often, and slowly change into a somnolence with a psycho- motor inhibition, a delirious condition may develop during the height of the disease, which usually appears in the even- ing and night. In the stage of defervescence, or even three weeks after the defervescence occurs, sometimes an expansive confabulatoric psychosis develops and the patient nay assert that he has been promoted out of turn and has been decorated with the KnightTs Cross of the Iron Cross. These psychoses usually subside after about 8-14 days# Finally a stage of convalescenee follows after the disease which does not last longer than 3-6 months, which is character- ized by a special irritation, mental derangement, disturbances in the throat and weakness in the mind. These psychic symptom, are usually accompanied by clear vegetative irritations such as disposition to sweating, alopecia and increased mechanical sensitivity of the musculature. It is advisable not to send a soldier, who has just suffered from typhus, to the front lines before a period of 6 months has elapsed# Discussion; SCHELLERs The following meningeal symptoms occur in the onset of the disease; Headache, sleeplessness, increased, sensitivity. The reflexes of the legs are often diminished. The cerebro-spinal fluid shows a changeable inflammatory character, and the pressure is increased* Favorable in- fluence of lumbar puncture on headaches, sudden irritation and in status epilepticus* At the end of the first week patients may suffer from delirium, epileptic fits and a semiconscious state* Amental psychosis usually occurs in the beginning of defervescence. Pseudobulbar disturbances (dysarthria, dysphagia, increased reflexes of the lower jaw) also striate disturbances of motion and catatonic symptoms all occur. Vegetative disturbances due to focal injuries of the diencephalon are seen. After the defervescence the following symptoms have been observed; peripheral paralysis, mostly ulnaris (4 to 5 per cent) and peroneus (3 per cent), the period for convalescence usually takes a long time and is marked by emotional weakness, disturbances in the memory and vasolability. The treatment with calcium has shown good results. ZEISS; Referring to “The Escape'1 by G. GESEMANN - parts of a Serbian diary 1915/16 (Langen 1935). Self- observations about the symptoms of the disease during the first days as well as the dreams occurring during the acute fever-stage are recorded. 4« Pathological anatomy of typhus. Stabsarzt (Captain, MC.) Dozent BO.DHNB 1* Complications and cause of death in typhus. Of 51 cases clinically and anatomically evaluated, 13 patients died of acute peripheral circulatory collapse (between the 9th and 14th day), 11 patients died of lobar pneumonia (between the 10th and 28th day), 13 patients died of broncho-pneumonia (between the 8th and 23rd day), 4 116 patients died of diffuse henorrhagic glomerulonephritis (between the 11th and 41th day), 5 patients died of general Infection (between the 19th and 32nd day), one patient died of purulent meningitis (otitis media) (on the 42nd day), nne patient died of purulent pyelonephritis (on the 41st day). a• Acute hemorrhagic glumerulonephritis was observed in 15 of 60 autopsies. This was only recognized clinically in two cases. Macroscopically there was a charac- teristic picture. Albumin, erythrocytes and leukocytes could be shown microscopically in the capsular space. Cy- lindrical erythrocytes and leukocytes and distinct peri- glomerular infiltration was seen. There was a frequent association with petechiae and hemorrhage into the mucous membrane of the kidney pelvis and the bladder. b. Icterus hemolyticus was proved in 22 of 47 cases. Histological of a hemolytic icterus; the strongly distinct hemosiderosis of the spleen, bone marrow and kidney, also in new cases between the 10th and 12th day, a hemoglobin-nephrosis and hemoglobin casts, a pleiochromia of the bile and bile casts in the biliary ducts, chemically an indirect positive diazo reaction in the blood and a negative bilirubin and positive urobilin reaction in the urine. The hemolytic icterus has also been observed in fatal cases of typhus without any complications. c. Erysipelas of the mucous membrane in the throat In two cases a general streptococcus infection appeared as a severe edema of the mucous membrane with few leukocytes, but with many diplococci. In both cases a purulent peri- chondritis of an arytenoid cartilage was observed. 2• The histological picture of typhus exanthema as found by examination of 14 roseolas from the 4th to the 18th day of the infection. Exclusively lymphocytic and plasma cell infiltration around the arterioles of the sub- papillary structure of the skin. No wall necrosis and no papules have been observed on arteries. Uo differential diagnosis can be made from similar infiltrations in the exanthem of streptococcal and meningococcal sepsis. It is of practical importance for abortive cases of typhus with negative WEIL-FELIX reaction. 3• Histology of typhus papules in the brain. In new cases (8th to 10th day) clear cut mesodermal reactions may be observed especially in the arterioles, which, however, do not involve the gliosal basal membrane. Distinct regressive changes of the wall with swelling, plasmo- cytic imbibition, dissolution and pyknosis of endothelium. By thorough examinations of new cases there were no symptoms of loss of protein from the vascular lumen nor by the application of fibro-stains. Erythrodiapedesis which even in old cases is without reaction of the surroundings, is probably due to peristatic or prestatic (original German testprestatic) processes in the final stage. The disappearance °£ the papules takes place by a progressive scattering, during which the Hortega cells disperse and are lost in the surround- ing tissues after the poisonous effect has ceased. No glial scars can be demonstrated. 4. Myocarditis exanthematica is marked by a diffuse interstitial, mostly histiocytic, in- flammation which generally disappears on the 30th day. No regressive changes of the muscle fibres and no parietal en- docarditis or thrombosis has been observed in clear cut cases of typhus. Arterial thrombosis has been proved in three cases and a purulent mesarteritis of the A. tibialis ant. was histologically demonstrated in one case. 5. Changes of the fundus in cases of typhus• 39 cases were thoroughly examined. Severe infiltration in the supporting tissue of the optic nerve and hyperplasia of the glial cells. In the soft covering of the optic nerve, a slight endothelial proliferation, as well as a slight peri- vascular lymphcell infiltration has been observed. Severe capillary enlargements with lymphocytic infiltration in the choroid, either lymphocytic or pure histiocytic infiltration is seen in the retina. 6• Bacteriological investigations on corpses. Thorough bacteriological examinations are always necessary in order to investigate the cause of death and to classify the histological parenchymal changes. Typhus is inclined to severe secondary infection, in numerous cases rickettsia con- ceal a general infection by streptococci. In 26 cases the smear of the throat and larynx showed 12 cases of bacterium diphtheriae, while 23 smears of the bronchi showed hemolytic streptococci or staphylococci 19 times. 7• Serological examinations on corpses• Serological examinations of the blood, spinal fluid, and serofibrinous pericarditic fluid after the method of vVEIL-FELIX have been made on 3$ corpses. Positive loss of reaction in accordance with the findings in clinics with a titer up to 1:51,200 in the blood and 1:512 in the spina}, fluid. In 3 cases a negative failure of reaction has been observed similar to the negative MWEIL-FELIX,r findings in living persons. Non-specific positive failures of reaction were sometimes observed in icterus and miliary tuberculosis. The ’TOIL-FELIX" reaction on corpses is considered important in vague continued occurrence of infectious diseases under field conditions without any anatomically specific basis. Discussions HERZOG: Neither in all the cases of typhus I had to deal with during World War I (about 40 cases), nor in the present cases (about 20), have changes of the heart been absent. They are quite different than diphtheria* In spite of severe inflammatory changes, almost no muscle necrosis has been observed. In the skeletal musculature it usually appears as wax-like degeneration* Severe interstitial hemorrhages occur, sometimes in the kidney, due to considerable changes in the small and medium sized arteries with necrosis of the media* As for the rest one may refer to the report in the ,fZentralblatt fuer Allgemeine Band 29, 1918 (Central Journal for General Pathology, volume 29, 1918). DIETRICH; BOEHNE and the physicians who were present during the first of these meetings, have given little con- sideration to or have denied the possibility of early diag- nosis in typhus on the basis of the microscopic changes of the skin in the stage of exanthem. I have taken up again the quick diagnosis, recommended by PRAENKEL, because the WEIL-FELIX reaction is, as a result of my experiences, frequently negative in the beginning and the early recognitior of sporadic cases at home make an early diagnosis desirable. It is possible to obtain a positive finding on the roseola in a few hours by rapid imbedding (acetone-paraffin). This method naturally is the source of certain errors which begin with the excision* But in numerous cases we were successful. We cannot yet give a decisive opinion about the accuracy, but further investigations should be made* BOEHNE: In contrast to the previous opinion that the incubation period amounts to 21 days, an incubation period longer than 12 days was never observed* As a rule^the period of incubation is 9 days# In cases where a longer incubation period has been reported, the exact time of the infection usually could not be established. HALLERVORDEN; Typhus is a meningo-encephalitis. In each case of meningitis the outer and inner surface of the brain is infected. In this latter kind cf the disease the vegetative center is affected so that no special infection of it has necessarily to be expected. The papules arc over- evaluated, as they are so striking. They are a reaction^of the brain to the extravasation of blood and plasma. Their presence is not a symptom of the involvement of the part concerned. Mesoblasts have only a slight effect on the papules and do not show any persisting changes* DIETRICH: In cases of hemolytic changes (liver, kidney), one has to inquire whether the patient has been treated with the blood or serum from a convalescent* OSTERTAG: It is important to recognize those diseases which make typhus more complicated. The complications and contradictions in diseases have to be differentiated. I have observed for instance positively diagnosed scarlet fever and 8 days after the scarlet fever exanthem appeared, typhus and agranulocytosis. Some infections of the nursing personnel seem to take an extraordinary course* who took care of Russians suffering from typhus fell ill with an undulating fever (clinical influenza, autogenous typhus). The appearance of damage in the liver due to sulfonamide therapy should be especially looked for in cases of typhus. MUELLER (Koenigsberg): In 100 postmortem examinations of typhus cases only one clear case of icterus has been observed. The increase of icterus in cases of typhus may depend on regional conditions. BOEHMIGs Other organs (heart, kidney) seem not always to be infected. In numerous cases I have neither observed any changes of the heart or kidney nor any principal changes, such as have been described by FHAENFEL. SIEGMUNDs I refer to the conformity/- of the histologic picture which has often been observed in diseases of the same derivation, such as hospital infections. In all the examined cases an unusually wide-spread arteriolar necrosis of almost all organs has been observed* The formation of papules in the brain are ectodermal gliosal proliferations due to resorption and they are not only in correlation with capillaries but also with arterioles, in which the symptoms of an increased permeability after damage to the endothelium may more easily be proved anatomically than in capillaries. BOEHNE; (Summary) No effect of blood transfusion has been observed on the histological pictures, which are in general like hemolytic icterus. During the postmortem examination of typhus cases no icterus epidemic was present. The sector-shaped arteriolar necroses with formation of papules have not been observed. Diffuse histiocytic in- filtrations of the myocardium were observed in almost all new cases. No correlation of extravasation of blood cells or plasma with newly appearing papules has been observed. Directions s Important for diagnosing typhus is the early appearance of psychic disturbances in the manner of an exogenic type of reaction. A remarkable characteristic is the absence of the usual feeling of being sick and recognition of this disease in the prodromal stage is unusual because of a kind of mixed effect. During this time there is the additional danger of self-injury and committing suicide. If the fully developed symptomatic picture of the disease is subsiding, one has to be cautious about expansive confabulation with boasting and swindling tendencies. The WEIL-FELIX reaction, which usually reacts positively on such patients, has to be used even if no physical ap- pearance of typhus has been observed. It is advisable to treat the patients in a hospital for typhus for a period of about 6-8 weeks. After that they have to be evacuated to a sanatorium where they may stay for about two months. It is also advisable to grant the patient a sick leave for about 4 weeks to recover his health* As a rule patients are therefore on the sick list for about 6 months. This also refers tc cases of infection which seem to have taken a mild course, as they also produce temporary changes of the character, which may give rise to considerable disciplinary difficulties. In the forensic-psychiatric judgement, special care has to be taken on patients who have just recovered from typhus. The WEIL-FELIX reaction has to be used in such cases. 120 VII. PARATYPHOID C. WOUND DIPHTHERIA. SCARLET FEVER AND HEMOLYTIC STREPTOCOCCI Translation prepared by: Office of Military Government for Germany (U* S*) Office of Naval Advisor Medical Section 121 A. Paratyphoid C. 1« Paratyphoid C« Stabsarzt (Captain, MC.) Prof, HABS and Kriegs- arzt (War Surgeon; BADFR “ Paratyphoid C is a febrile disease with symptoms re- sembling these of typhoid fever. caused by a of~“ the Suipestlfer-grouffl Paratyphoid C was observed in the Balkans and in the near East during World War I and in Russia after the War* It has also been observed in the Balkans during World War II. The disease starts with a sudden fever which lasts from a few days up to two weeks and which subsides by lysis. During the continued fever a bradycardia has been observed. Roseola are generally missing but an enlarged spleen has al- ways been observed. The intestinal canal is not infected. A bronchitis is almost regularly observed, which may develop into broncho-pneumonia. A leukopenia is important for diag- nosis. The diazo test may show a positive reaction in the urine. The sedimentation rate is comparatively rapid. The excitants are easily found in the blood, but only exception- ally in the stool. Paratyphoid C may occur as an autonomous disease, but is usually observed as a complication appearing in malaria, relapsing fever, dysentery and other infectious diseases. The excitant of paratyphoid C has been proved as the type Orient (Salmonella paratyphoid C) and the type Sui- pestifer Kunzendorf (Salmonella cholerae suis van. Kunzen- dorf). Probably the type America (Salmonella cholerae suis) is also an excitant. The route of infection by paratyphoid C is not yet quite clear. Since the excitants are very rarely excreted with the stool and constant carriers are not known, a spread of the disease exclusively by contact from man to man is not likely. It is assumed that animals are the primary sources of infection. But there is no such proof for the type Orient. The type Kunzendorf is often found in animals, especially in pigs. Suipestifer bacilli and usually the Kunzendorf type may cause acute gastro-enteritis just as the other typhoid diseases, which are usually due to eating contaminated food from infected animals and which may lead to mass- infection. Suipestifer bacilli are found, just as other bacilli, in the paratyphoid enteritis group, as the excitants of purulent inflammation and acute septic diseases, which usually occur in the course of other infectious diseases. Only diseases resembling typhoid fever may be called paratyphoid C. Full particulars will be described in the Klinische Wochenschrlft, 1943 • B. Wound diphtheria. 2. Wound diphtheria* Qberfeldarzt (Lt. Col., MC.) Prof* BUERGERS Wound diphtheria, which was first observed by BARD in 1771 and was described anew by BRUNNER in 1893* has probably played a greater part in older times than more recently. The cases of this disease which frequently occurred aftef World War I, have been described by LAEWEN and REINHARDT, ANSCHUETZ, KISSKALT, ITS INERT, LOEHR, ROHDE, DONGES and ELEFELDT, NIETER and KEHL and have drawn the attention of surgeons and bacteriologists to this disease* The extra- ordinary variable percentage of positive cases, something between 5 to 75 per cent probably is correct because the cultures which were found were not examined in regard to all the characteristics of true diphtheria* Besides the works of the above mentioned authors, we refer to those of BRUNNER, ROSER, EHRHARDT, ZUELIG, DEUTSCHLAENDER, LANDE, LANDAU, GR0S3MANN, RADICE, HOFFMANN, KILIAN, BALHORN, and HORN. The following bacteriologists have made investigations from the bacteriological point of views KLIEWE, LUBINSKI, PESCH, HETSCH. SCHLOSSBERGER, and CLAUBSRG* WEINERT distin- guishes clinically the following points: 1* Surface and croupous form 2* deeply seated, diphtheritic-necrotic form 3* phlegmonous form. DEUTSCHLAENDER distinguishes the following: I* Skin diphtheria as a part of a generalized diph- theria, II* Skin diphtheria as a locally limited independent disease, 1. Skin diphtheria of the pathologically changed skin, a. True wound diphtheria (real wounds, not only injuries of the surface of the epidermis, b. Diphtheria with inflammatory skin processes, 2. The diphtheritic inflammation of healthy skin, a. the ulcerating skin diphtheria, b. the phlegmonous skin diphtheria# LANDE describes the following forms in children: Ulcerous form, naval diphtheria, intertriginous form behind the ear, superficial form with a thin membrane, im- petiginous form, small blisters similar to varicella, diph- therial paromychia, vulvar diphtheria and phlegmons as hard as a board. The following classification seems to be suitable for surgery during the war; 1. True wound diphtheria rapid deterioration of the wound, excess granulations, ulcer formation with pseudo-membrane, pointed undermined margin of wound, intense rubor of the environment, pure cultures of diphtheria bacilli or mixed cultures with enterococci, staphylococci and streptococci. 2. Clinically suspected wound diphtheria of similar appearance or with greasy coat, with bacteriological findings of all kinds of pus forming bacteria but not true diphtheria bacilli. 3, Normal appearing v/ounds with bacteriologically proved true diphtheria bacilli, either in pure culture or with pus forming bacteria. Forns 1 end 2 show an inadequate tendency to heal. Form 1 only should be described as wound diphtheiin# Form 1 usually shows no temperature, while form 2 frequently has a high temperature and form 3 is entirely free of temperature. Since either LOEFFLER's serum or CLAU3ERGfs culture medium dextrose has been used for diagnosis in most laboratories, diphtheria has often been mistaken for hyueracidic pseudo- diphtheria. True diphtheria can easily be differentiated Tr om hyperacidic pseudodiphtheria by the use of modified CLAUBERG culture medium using serum or ascitic fluid instead of blood and with saccharose. Intracutaneous tests on guinea pigs with true diphtheria shows a clear suppuration and necrosis as well as edema in cases of gravis and inter- medius strains but slight suppuration and edema was observed with the mitdjs strain, while in cases of hyperacidic pseudo- diphtheria, only leucocytic infiltration without any edema has been observed. Subcutaneous tests with hyperacidic pseudodiphtheria will never kill a guinea pig# The importance for pathology must be established by histological investiga- tions. The appearance of throat diphtheria proceeding from ferns 1 or 3 may occur. (Because of the possibility of in- fecting the air by the carriers of diphtheria bacilli among the soldiers and visitors, it is difficult to establish the causal proof for the infection of wounds#) Only few cases of paralysis have been observed with form 1, they have never been observed with form 3* Serum injections are indicatpd in toxic cases, but they do not influence the healing of the wounds. The treatment with chinosol is recommended for therapy in form 1 and 2; 1.1,000 up to 1:2,000 alternately with Marfanil powder# As to the necessity of the local serum treatment recommended by.CLAUBERG, critical examinations must shed light on this question. The local serum treatment seems to be superfluous in fnrm 3. The examination of the environment, as suggested by CLAUBERG seems to be too extensive a measure because of the shortage of mateiial used in laboratories and the fre- quent moving of wounded soldiers within a hospital. This method should be used only in true clinical cases cf diph- theria. In all cases in which diphtheria bacilli have baC- teriologically been proved in wounds, a diagnosis of the type would be advisable# Discussion: HAAG: Cases of throat diphtheria occurring among the nursing staff were followed by a true wound diphtheria in 3 military hospitals in Bad Nauheim# It is absolutely necessary to differentiate between corynebacterium diph- theriae and corynebacterium pseudodiphtheriae in cases of wound diphtheria and in carriers of diphtheria bacilli. In order to get a general view of the present criteria, I have sent a circular with the corresponding questions to about 100 civilian laboratories. The answers to these circulars show that greatest importance is attributed to the morphological picture and to the examination of toxicity. SIBLING: Soldiers with reportedly positive findings of diphtheria bacilli in wounds, throat or nose, based on bacteriological examinations, should be isolated for many weeks# When examinations on guinea pig*s (intracutaneous) show no toxin-forming strains, the patients do not need to be isolated. An antitoxin treatment in cases of wound diphtheria will be administered too late if specific general toxic symptoms have already developed. Therefore it is advisable to treat each case of true clinical wound diph- theria prophylactically r-ith several thousand units of anti-toxic serum. Directions for the diagnosis of wound diphtheria. Only those cases should be diagnosed as wound diph- theria which show clinical pseudomembrane or a greasy coat, sharply undermined margins of the wcunds, glassy granulation and intense rubor of the area, when true diphtheria bacilli with all typical symptoms have been found. As such wounds frequently have been mistaken for hyperacidic pseudodiph- theria, the modified CLAUBERG culture with saccharose has been recommended. The finding of diphtheria bacilli in normal wounds should not be diagnosed as wound diphtheria but as "bacilli carrier". C. Scarlet fever and hemolytic streptococci. Scarlet fever and hemolytic streptococci* Oberarzt (1st Lieut.. MG.) Prof# von BORMANN In'the report of the "Army Medical Inspectorate" of June II5 1942 it says: "The appearance of hemolytic strepto- cocci is only an accompanying symptom in cases of scarlet fever, and is not to be considered as the cause of scarlet fever according to the present state of information". At first I should like to examine whether the designation: of the hemolytic streptococcus as a causative agent is justi- fied. The old standards of HENLE to prove the causal re- lationship of a germ to a disease are as follows: 1. regular finding of the germ in all patients, 2. the possibility of obtaining a pure culture of these germs, 3. Imitating the disease by infecting an animal with a germ obtained from a pure culture* To 1: Hemolytic streptococci are found in all new cases of scarlet fever. They are found in pure culture or almost pure culture. It has to be considered that a 100 per cent culture occurs only if the smear is inoculated immediately on a culture medium at the patient’s bed side. The previously transported tests show a negative result in most cases. Hemolytic streptococci have regularly been found in complications containing pus. Numerous hemolytic streptococci have also been observed in the environment of the patient such as the bed, crockery, room etc. To 2: The pure culture of hemolytic streptococci from scarlet fever presents no difficulties. To 3: We don’t know any experimental animal which is sensitive to scarlet fever. The Drs. DICK have painted the throats of 12 adult volunteers with pure cultures of hemolytic streptococci from scarlet fever patients in 1923* Three of them suffered from scarlet fever, two of them suffered from angina, and it should be emphasized that they were adults. TOYODA and his colleagues have tried the same experiment on three children 3-7 years of age. All three children suffered from scarlet fever. The diagnosis has been proved perfectly by the positive signs of scarlet fever. One has referred, however, to the experiments made by Americans and Japanese who used fresh streptococcus cultures. It might be that the virus - presumed by the proponents of the virus theory - adheres to such fresh cultures of streptococci and these two combined produce scarlet fever. CYNCA and GHEORGHIN could not actually cause any scarlet fever in men with the 5th and 12th passage of scarlet fever streptococci and TOYODA and his colleagues did not succeed in the 150th passage. The passage referred to no longer had a toxic effect, but had forfeited the ability of producing scarlet fever toxin. Scarlet fever streptococci have fulfilled the three standards described by HENLE as stated by the above men- tioned authors and proved by his own experiments. But not only that - he is able to explain the very complicated scarlet fever pathogenesis. The Drs. DICK have proved that scarlet fever streptococci produce an ectotoxin. If a predisposed person is vaccinated with a sufficient quantity of the so- called DICK-toxin, this may produce a scarlet fever-like rash. Such a scarlatinoid is not infectious, it shows also no complications, no angina and the streptococci are absent. Persons who are pre-disposed to scarlet fever become immune when vaccinated with the DICK-toxin. The skin test using this toxin made the prediction of predisposition to scarlet fever possible - similar to diphtheria cases. For some time there ?;as a great confusion about this DICK-test. Persons with a negative reaction suffered from scarlet fever and on the other hand patients who recovered from scarlet fever showed a positive result* The occasional misunderstanding has been entirely explained by TOYODA and SZIHMAI. The so-called DICK-toxin contains products of disintegration of streptococci - that means secondary toxin besides the ectotoxin. This gave rise to the confusing results, but when using a purified toxin, everything harmcn izes well. If horses are inoculated only with toxin or with streptococci without toxin, an antitoxin serum will be produced, the antitoxic effect of which in scarlet fever is rapid. It has been tried to put scarlet fever on equal terms with diphtheria and to explain its clinical symptoms with the idea that scarlet fever streptococci occur in the throat and flood the whole body with toxin. Only the symptoms of the onset of scarlet fever, such as fever, rash and so on - are herewith explained. 3csid.es scarlet fever streptococci have - in contrast to diphtheria bacilli - a pyemic septic effect. This explains the invasion into the sick body, complications and sequelae. The immunity after scarlet fever is twofold. The convalescent gains a lifelong anti- toxic immunity. He will never be reinfected by a typical case of scarlet fever. The antibacterial immunity remains for only a short time. The patient being immune against the disease scarlet fever, may often be infected with the causative agent of scarlet fever, angina rhinitis, otitis, abscesses or even erysipelas. Therefore such mild cases of the disease occur frequently in the environment of a grown up suffering from scarlet fever* These cases usually take a mild course as the toxin has no effect on these patients* It Bould not yet be decided whether the ability to produce large quantities of DICK toxin is due to a special strain of streptococci, respectively if each hemolytic streptococcus may undergo such a state at some time. But this is of no practical importance. For us it is enough to know that hemolytic streptococcus is the causative agent of scarlet fever. New returning to the report of the "Army Medical Inspectorate"# "We can only agree with the refusal ex- pressed in the above mentioned report of extensive bacterio- logical examinations for hemolytic streptococci and the treatment or even setting apart of streptococcus carriers. It makes no sense to examine the environment of a patient showing hemolytic streptococci. They are found in some patients in any case, but the bacteria wander about and they are found in one patient today and in another tomorrow. 127 The patient suffering from scarlet fever has to be isolated as otherwise too intensive infections would originate from him and besides he needs careful nursing* The environment has to be treated differently, it depends on whether the disease occurs in a fighting troop or in a unit behind the lines* The unit of combat troops has especially to be watched and they must not get in touch with healthy units for about two weeks* But all the men of the infected units do not have to undergo treatment* If a man from a unit behind the lines is infected, all the men of this unit have to be put in quarantine for 10 days* This is necessary, especially in towns with a large population# In a unit where scarlet fever occurs over and over, all men of the unit have to be inoculated* Discussion: HABS: Would like to have a directive for isolation and treatment* BUERGER: Protective inoculation has to be followed by careful observation* Scarlet fever convalescents have to be treated with sunlight and fresh air* Gargling with a disinfectant three times a day sometimes shows good re- sults. WAGNER: Whenever cases of scarlet fever have occasion- ally increased in the Navy, immunization with Ccarlatox has been tried besides the general preventive measures* Severe reactions occurred occasionally* In counteracting scarlet fever by immunization, it would be necessary to inoculate the recruits directly after having joined the Army. KROEGER: Protective inoculations made during an epidemic occurring in the Labor Service did not show any convincing result (this has been the experience for two years)* All recruits have been inoculated against scarlet fever in the autumn of 1942f in order to prove the effect. RODENWALDT: House epidemics in large hospitals dis- appeared entirely after a thorough scrubbing-disinfection. Importance must be attached to the necessary limitation of crowding in regard to scarlet fever streptococcus as related to house infections* KLIEWE; Reported about the good results gained with disinfectant aerosol for counteracting scarlet fever* A mixture of ethylenglycol-resorcin-alcohol-Ymiter has been vaporized in a suitable apparatus twice a day for one hour. NERLICH: General measures had almost the same effect as inoculation on the Eastern front® Critical remarks vere made about the evaluation of preventive measures# VIII. T U BERCULOSIS Translation prepared by: Office of Military Government for Germany (U. S. ) Office of Naval Advisor Medical Section 129 1. The effect of special types of climate on the treat- ment of soldiers suffering from tuberculosis. Oberstabsarzt (Manor, HC») Dozent PIS 1ST In greater Germany one can find all typos of climate besides the high mountain climate and the Southern climate which are suitable for rest cures. The courses of treat- ment for soldiers in high mountains can be followed at the German Military convalescent hospital in Davos but the smal number of beds available limits the number of patients. Tb_. effective factors of the high mountain climate characterize it as a stimulating climate which is advisable as a healing factor only for cases of active tuberculosis. A spotcheck of soldiers who have been treated there since the beginning of the war, shows that this indication has not been observer in about 40 per cent of the cases. Transgression occurred in both directions. In some cases the necessity of high mountain cures was exaggerated and on the other hand the uselessness of such a therapy was stressed. The patient suffering from tuberculosis is oversensitive to the rays of the sun and as this is an important factor of the high mountain climate, this means a burden to him. Patients suffering from pulmonary tuberculosis will profit by the high mountain climate not only if they can tolerate but also if they can utilize stimulation. Elderly patients with progressive tuberculosis with complications in the heart are not suitable for high mountain cures. Patients suffering from extrapulmonary tuberculosis may be very suitable for high mountain cures, if they do not suffer from active pulmonary tuberculosis at the same time, because the rays of the sun influence these tuberculosis processes favorably. Necessary operations have to be performed before the be- ginning of the high mountain cure. 2« Russian P«W»1s suffering from tuberculosis and their effect on the German population. Oberfeldarzt (Lt. Col.. MC.) Dozent NICOL The introduction of masses of people always increases the danger of epidemics such as infectious tuberculosis. Russian P.W.’s working in Germany constitute a danger for the German population. 75,000 X-ray pictures have been evaluated in regard to the incidence of tuberculosis in Russian P.W.'s. There is considerable danger for the German population as a result of the use of Russian P.W.»s working in Germany. These P.W.’s have to be X-rayed before being assigned to labor duties. Moreover the P.W. must be hygienically satisfactory since no valuable working power should be lost or become new sources of Therefore the method of X-ray should be applied. If active tuberculosis has been detected by examining the sputum, the patient has to be isolated in special departments of the P.W. camps for protection of the others. As to active 130 tuberculosis in the P.W. camps, there were more than 3860 fatal cases reported by 11 different Military Districts. These reports speak of rapid death which shows that active tuberculosis is concerned. The photofluoroscopic examina- tions showed a relatively small number of old cases of tuberculosis, but usually early cases. The incidence of tuberculosis seems to be an early epidemiological stage in Europe and above all in Asiatic Russia, as has been observed in cases of tuberculosis among the Kalmuecken and Kirgisen peoples during World War I (Negro tuberculosis The process of tuberculosis is accelerated in the Russians by malnutrition and great physical strain# If Russian P.W.1s have been assigned for labor duties in Germany before being systematically examined by X-ray, this must be done afterwards by the Board of Health or by the physicians of the factories. PCW«*s found to be in- fected have to be evacuated to a military hospital for P#W.*s. It is necessary to report such cases to the Board of Health in order to investigate the environment and to warn the population. 3# The different types of tuberculosis in soldiers at the front. Oberfeldarzt (Lt» Col«« MC«) STBIM/IEYEH My report relates only to soldiers of the Eastern Army and only to 1282 cases occurring from the 22 3nne 1941 until the 15 September 1942. These cases consisted of 1064 men of the Army, 173 men of the Airforce and 45 sailors of the Navy. The number of 72 officers is relatively high in proportion to 1210 non-commissioned officers and soldiers• The distribution of ages is rather interesting as in 102 soldiers under 20 years of age the inherited pre- disposition to the disease amounts to 24.5 per cent, and if acute onset is considered the figure will be 38.2 per cent* That is to say, the younger they join the Army, the more cases of the disease occur and the more severe is the disease. Thus the considerable percentage of all age groups with an inherited pre-disposition is 19*8 per cent which together with 7.02 per cent of erroneous inductions makes a total of 26.82 per cent of unfit soldiers due to tuberculosis* That proves that a careful recording of the anamnesis at the mustering of recruits and at the first medical examination would have prevented a considerable number of cases and would have kept the Army free from infections. It is remarkable to observe the increase of cases amounting to 27.6 per cent occurring in officers be- tween the age of 41 - 50 years and an increase of 100 per cent among officers over 50 years of age# While the age group between 21 - 25 years holds the first place with 390 patients, the age between 31 - 40 years holds the second place with 377 patients* As to the acute onset of the disease the number of men under 20 years of age is, with 38*2 per cent by far the highest, while among patients falling under the group I of RANKE's classification the percentage will be 14.7 per cent and under group II the percentage will be 35.2 per cent. The total examination of the material was classified by RANKE’s concept in order to guarantee a uniform and uncomplicated task. If the patient material under treatment, falling under group I of RANKE’s classi- fication, is considered as not infected at the outbreak of the war, we will arrive indirectly at a percentage of 73*5 per cent. Considering, however, only the patients of group I of RANKE’s classification, the percentage will be 95.3 per cent and if finally an acute onset is considered, the percentage will be 74.8 per cent of positive reaction to the Pirquet test on the day of admittance. Undoubtedly the soldiers catch an infection more easily and much more rapidly after having left school while at their trade or after entering the Labor Service, so that in my opinion, the estimate of at least 75 per cent may be considered as infected persons (sic). This explains that in recruits of the Labor Service the most primary forms of tuberculosis have been observed with the similar course as in cases of postpuberty tuberculosis with a general spread immediately following a primary outbreaks Meningitis, miliary tuber- culosis, severe caseous foci and extrapulmonary forms. The number of 870 cases with lingering onset among 942cases of group III of RANKE’s classification corresponds to the clinical opinion that the lingering onset is due to immuno biological factors and gives the cardinal number of exacerbations of tuberculosis only after breaking through the resistance to the infection. The relatively high number of 340 primary, super and newly infected persons proves that the unknown source of Infection is all the more dangerous the larger the number of non-infected soldiers in the Field