138 
IX. 
HEPATITIS CONTAGIOSA 
(EPIDEMIC A) 
Translation prepared by2 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section 139 
1. Clinical considerations. 
Oberfeldarzt (Lt. Col,, MC.) Prof. GUTZEIT 
The name "hepatitis epidemica", chosen for this disease 
by LINDSTEDT, cannot be considered a fortunate choice since 
the epidemic spread of the disease can hardly be called more 
than an episode in the clinical history. Since that name 
for the disease does not cover the sporadically occurring 
cases, my suggestion is to have it called more correctly 
"hepatitis contagiosa (epidemica)", This term includes both 
its constant characteristics in a distinct form, i.e. involve- 
ment of the liver and its contagiousness. 
The high incidence of jaundice in the fall cf 1941 was 
preceded by scattered single cases in the fall of 1940 and 
1939* In autumn of the present year (1942) a severe epidemic 
has spread particularly among the Armed Forces fighting in 
the East, Evidence has shown regularly that the high point 
in the frequency of this disease is in October and November, 
and that the gradual simultaneous increase begins early in 
July and has been observed regularly over quite different 
and widespread areas. In the course of last autumn our home 
territory was affected by this disease in a similar manner 
and is even more apparent during the present year. The 
frequency of hepatitis contagiosa comes close to that of 
Volhynia fever and its rate is higher than that of the common- 
ly known infectious diseases. 
Besides its appearance as §n epidemic infection the.dis- 
ease also occurs without any evidence of existing, 
chains of infection. If Bay other pathogenic process or etio- 
logy were thought to be the cause of such sporadic oases one 
would e.xpect a difference of the curves of incidence-between 
sporadic and epidemic infections. Yet investigations made 
by three candidates for a doctor!s degree during the period 
? July 1939 and 30 June 1940 and furthermore from 1 October 
'940 until 31 December 1940, based upon the clinical records 
■~*f the "Archiv fuer Wehrmedizin" (Archives of Military 
Medicine) showed, that the rates of incidence in both the 
sporadic and epidemic forms of the disease are entirely 
parallel, thus proving that in the overwhelming majority 
the sporadic cases are hepatitis contagiosa. Single cases 
of the disease that are due to another kind of parenchymal 
involvement of the liver are numerically trifling and not 
worthy of special consideration. 
The infectious character of hepatitis contagiosa is 
indicated by the slow gradual seasonal increase in incidence, 
then its climax and gradual decline again, furthermore by 
its increased frequency in war time, and also in peace time 
in connection with unhygienic conditions - in camps or 
barracks and its side-by-side occurrence in both sporadic 
and in epidemic forms. Further typical evidence of its 
epidemic character is seen in the fact that sporadic cases 
exceed in numbers the epidemic infections when the epidemic 
is on the decline, as was observed in some places from January 
1940 onwards* Apart from this the disease in its clinical 
picture - and this refers in particular to the initial stage - 140 
is unmistakably analogous with true infectious diseases, 
such as e.g* poliomyelitis, scarlatina etc* It is true 
on the other hand that in only 50 per cent of the cases 
is a febrile initial stage observed, succeeded by an inter- 
mediate period of few symptoms, which then is followed ab- 
ruptly by the appearance of jaundice, whereupon all sub- 
jective symptoms frequently vanish ouickly* For this reason 
the afebrile cases of the disease, associated with preceding 
gastro-intestinal symptoms have led to the belief that they 
had nothing to do with hepatitis contagiosa, but more likely 
were part of the symptoms peculiar to the group of so-called 
"catarrhal icterus". Yet this certainly cannot be true, for 
1* both the febrile cases of the disease as well as 
those starting with intestinal symptoms occur in 
the same seasonal period, 
2. they both affect Juveniles in an equal proportion, 
3* under unhygienic conditions both forms increase in 
frequency, 
4* in the case of unmistakable epidemic infections 
the febrile as v.ell as intestinal initial phases 
occur side-by-side, 
5* in all other respects, clinical aspects and pro- 
cesses both forms are completely parallel with 
each other. 
All attempts so far to establish a clinical difference 
between the sporadic and the epidemic forms of the disease 
have definitely proved a failure* 
The icterus lasts 25 - 30 days on an average* Swelling 
of the spleen and liver, erythrocyte and leukocyte level 
as \vell as the other clinical subjective symptoms last for 
the same period. Galactose and Levulose tolerance, bili- 
rubinemia, bilirubinuria, urobilinuria as well as Takata-Ara 
tests do not show any difference in the course of either 
form* Lymphomonocytosis is characteristic for both forms. 
I cannot confirm HOLLER1s view, that lymphocytosis is 
typical for icterus catarrhal!s, and on the other hand 
monocytosis for hepatitis contagiosa. Finally in regard to 
the sedimentation rate ho difference is observed, it can be 
normal, reduced or considerably accelerated; in the second 
week of the disease it shows a moderate increase on the 
average* MEYTHALER observed, while the disease was progress- 
ing, bi- or tri-phase variations in the sedimentation fate, 
and he associates this with the well-known hepatic changes. 
Whether or not the so-called "icterus catarrhaHs" 
still exists can be decided only when the virus of hepatitis 
contagiosa has been detected, and can be proven for each 
single case. In my opinion cases of "icterus catarrhalis" 
which do not fit the diagnosis hepatitis contagiosa will be 
quite few. As regards the Jaundice associated with typhoid 
fever, the paratyphoid group, the enteric diseases due to 
infection, dysentery, as well as malaria, I think I can say is due to a mixed infection combined with hepatitis con- 
tagiosa* As to the so-called "Salvarsan icterus”, which 
just now is suddenly observed again more frequently, 
similar causes may be predominant. During and after World 
War I, just as it is now after the second year of the present 
war, when hepatitis contagiosa is spreading, Salvarsan com- 
pli cations are also appearing more frequently, - a somewhat 
strange and interesting - but certainly not accidental co> 
incidental occurrence. 
The change into a cirrhosis of the liver or the course 
of an acute liver dystrophy is seldom observed* We do not 
yet know enough about later developments and their connectleu 
with cirrhosis of the liver. 
Relapses occur sometimes, only after a latent period 
of 2 to 3 months; their duration of 40 days on an average 
exceeds that of the primary infection which averages 25 
days* Residual symptoms persist for a longer period. Re- 
infections - at the earliest date with the spread of a new 
epidemic -occur in not more than 1 to 2 per cent of all 
cases, thus proving that a strong and lasting immunity is 
firmly established. 
The treatment of the average mild case of hepatitis 
contagiosa can be limited to rest in bed, application of 
heat and a diet rich in carbohydrate and poor in fat. One 
need not be too concerned about the protein supply* Glucose 
and insulin administration as well as duodenal syphonage 
may be reserved for the few serious cases. In such instances 
a fruit and vegetarian diet, in particular uncooked food, 
appears to be advantageous* As to whether or not adrenal 
cortical preparations, Vitamin Bp or any of the other 
vitamins, as well as K and Ca supplies and the restriction 
of NaCl ere useful cannot be said as yet* Research on this 
subject, which could clarify this matter is In 
general all these measures surely may be dispensed with. 
To administer a cholagogue too early is considered as un- 
desirable. 
From a military medical point of view and in recapitula- 
tion it can be concluded, that on the whole hepatitis con- 
tagiosa 
a. is a disease worth serious consideration because 
of the involvement of the parenchyma of the liver, 
b* if treated with expert care usua.lly progresses 
mildly and a favorable prognosis may be expected, 
c* does not require medical care that could not be 
met with in any case by the physician and the 
medical service. 
Most patients will arrive at base hospitals with 
practically no jaundice after 3 or 4 days enroute, even 
without the appropriate diet during evacuation, and then 
they require nothing more than two or three weeks of re- creation along with a moderate diet# Moving them backwards 
to the home territory often will cause relapses which re- 
quire extended medical treatment# Thus all cases of icterus, 
as a matter of principle, should be treated in the collat- 
ing stations of base hospitals until the jaundice disappears, 
and then only should they be moved on to hospitals for minor 
or convalescent cases and be left there until fitness for 
duty is regained# Transport homewards is indicated only if 
the icterus lasts for 3 weeks# Such transports should be 
berthed in fully equipped hospital trains# Most of the 
patients will be fit for service after 3-6 weeks# Their 
remaining in the Army Groups and the rear areas retains 
this large group available for service in the Army, Ac- 
cording to our experiences it takes months in the home 
territory before the patients regain their fitness for ser- 
vice. To keep the patients isolated, as is prescribed by 
general directives, is not only quite impossible but also 
unnecessary, since practically the disease is contagious 
only in the pre-icteric stage# In the icteric stage it- 
self, however, it is no longer contagious, which is proved 
by the fact that infections occur in the hospital only 
rarely. Exceptions, if any, merely confirm the rule# To 
simplify medical care and to save personnel it will be 
advisable to have the patients collected on special wards. 
I do not wish to touch on the subject of the con- 
tinuing pathologico-anatomical as well as etiological re- 
search, base on liver punctures and inoculations from 
animal to animal, made by my coworkers Oberarzt (1st Lieut., 
MC#) Dr. VOEGT and Oberarzt (1st Lieut., MC.) Dr# DOHMEN, 
2# Pathology of hepatitis epidemics* 
Oberarzt (1st Lieut.# MC.) Dozent BENEGKE 
Reporting on hepatitis epidemica at the present time 
is still more difficult to the pathologist than it is to 
the clinician# The main reason may lie in the "case- 
material" per se, because: 
1# generally speaking the prospects for recovering 
from hepatitis epidemica are favorable and, therefore, 
it rarely concerns the pathologist, 
2# the overwhelming majority of available autopsy 
material does not permit a positive opinion, since 
most of the fatal cases in hepatitis epidemica - 
amounting to about 100 in the Army since the war 
began - developed from a uneventful be- 
ginning into a hepatic coma# In postmortem examina- 
tion these cases often reveal an acute or subacute 
liver atrophy, i.e. a histolysis so far advanced that 
hardly any positive indication as to primary changes in 
the tissue is possible# In other cases, hepatitis 
epidemica is found not to be the only reason for the 
fatal outcome# These cases either show complications with some other fatal diseases, or hepatitis epidemica 
developed quite separately in the course of some other 
fatal disease. Besides we know by experience that 
the mentioned diseases are infrequently due to infections, 
and so the question arises, as to whether the changes 
observed in the liver are due to hepatitis or to the 
fatal disease, 
3. in icteric corpses postmortem decomposition sets 
in very quickly after death. Therefore it will be 
very difficult to ascertain whether or not minute change 
of the tissues are relevant from a histologic point of 
view, or if these changes are only the consequence of 
postmortem processes. 
The above three points are primarily responsible for 
the fact that from the pathologistfs point of view a con- 
clusive report cannot be given at the present time. On the 
other hand there are some problems which should be considered 
In short they are: 
1. Is a marked histologic substratum observed in 
hepatitis epidemica and is it so characteristic as to 
allow in itself - even if the clinical course is 
ignored - a clear cut distinction from all other liver 
complaints regardless of their being associated with 
icterus or not? 
2. Do the minute changes of the tissues correspond 
to the so-called serous inflammation, as described by 
EPPINGSR and R0ES3LE? 
3. Is the pathologist in a position to establish 
whether hepatitis epidemica is an infectious or an 
exotoxic respectively endotoxic disease? Is he in a 
position to decide at the same time in which way the 
nens malignitatis" invaded the liver? 
4. Is HOLLER right in assuming that hepatitis epi- 
demica is a universal reticulo-endotheliosis? 
The pathologico-anatomical literature on hepatitis 
epidemica cannot be dealt with in this place. Moreover, 
this will be possible in an exhaustive manner only after 
the war as the result of a critical re-examination of all 
contributions so far published. All the same, it can be 
safely said even today that part of the cases of acute or 
subacute liver atrophy of peacetime must be classified as 
hepatitis epidemica in its highest degree of intensity. 
During the present war, reports were made principally by 
the consultant pathologists, Oberstabsarzt (Major, MC.) 
Prof. Dr. SIEGMUMD, Oberstabsarzt (Major, MC.) Prof. KRAUSE, 
Oberstabsarzt (Major, MC.) Prof. RaNDSRATH and Stabsarzt 
(Captain, MC.) Prof. WERNER SCHMIDT. 
My own case material, originating from autopsies in 
the Balkans, consisted of three cases of hepatitis epidemica 
which had developed into acute liver atrophy and consequently 
need not be considered here. In the other available autopsy material hepatitis epidemica did not cause the death either, 
but developed in the course of other diseases, such as post- 
diphtheritic paralysis with fatal outdome due to a Paralysis 
of the phrenic nerves, or infection of the thigh stump, 
streptococcus phlegmons etc. One case seems to be particular- 
ly worthwhile mentioning in which three years after a severe 
jaundice, death was caused by paratyphoid infection. 
Macroscopically. the liver shows an enlarged and pasty 
appearance, the frontal edge is bevelled and the surface 
smooth. The liver tissue appears through the capsule in 
a chestnut color with a green tinge or olive colored. The 
section of the parenchyma shows a cloudy and dilated appear- 
ance, and it dually presents a streaky greenish pattern in 
some places, and a net-like pattern in others* Sometimes 
the greenish tinged spots form little throughs as compared 
to the adjacent liver tissue. Nothing irregular is observed 
in the other bile ducts. The gall bladder reveals an edema 
of the wall, and in one of our cases which developed into 
atrophy, a slight catarrhal cholecystis (no flaring up in- 
fection) could be observed. The epigastric lymph nodules show 
an inflammatory swelling (histologically inflammatory sinus 
catarrh with bile-pigment and fat accumulation). The spleen 
is usually enlarged, even in case that a non-scptic disease 
caused the death (histological reticular coll reactjon, 
moderate multiplication of leukocytes and toxic follicular 
degeneration). Heart and kidneys show serious parenchymal 
damage, especially when death is due to an infectious dis- 
ease. Hemorrhagic diatheses in a more advanced form is a 
complicating factor. Associated with hepatitis it may be 
expected to develop into liver dystrophy or tending to 
hemorrhage, because of a septic basic disease. 
Microscopically, the liver shows remarkable changes 
(numerous histological preparations are at hand) both in 
the parenchyma and in the stroma of the vessels. These 
changes are concentrated in the lobe diminish 
in intensity towards the periphery. Concomitantly an 
activation of the endothelium and frequently a massive bile 
and pigment accumulation in the stallate cells is observed. 
The portal vein capillaries may as a consequence of a damage 
to the walls contain many in the lobe center, 
whereas their wide lumina contains only homogenous protein 
masses. In fresh cases a multiplication of granulocytes 
the capillaries is Observed# Relatively early an infiltration 
with granulation tissue cells becomes apparent in Glisson’s 
connective tissue, the histiocytes show abundant fat and bile 
deposits. When the disease progresses these changes subside 
and the formation of connective tissue is observed^which 
takes rise in the lobe center as well as in the Glisson wedge. 
The final phase of the disease exhibits a cirrhosis-like 
picture varying in severity. For completeness1 sake it 
should be stated further, that in those cases which develop 
into atrophy the necrosis will not always be most pronounced 
in the lobe center, but it may as well exhibit an irregularly 
scattered spotty character, sometims even preferring the 
outer areas of the lobe. Changes in the transverse striated 
muscules, as observed by SIEGMUND, were also found in our 
material. Such cases of micronecrosis are particularly interesting. As a rule, one fibre or minute complexes of 
fibres only are involved which in later phases cause the 
formation of granulation (tissue. In no case, however, do 
such changes go so far as to deteriorate muscular tissue, 
as is a characteristic feature of Weil’s disease. In re- 
ply to the various questions raised it can be said: 
1. Hepatitis epidemica, as a matter of fact, shows 
a fairly characteristic tissue picture. However, the 
speaker is in doubt whether or not this picture is a 
specific one, because he encountered cases of amebic 
hepatitis, severe malaria hepatopathy and Salvarsan 
damage of the liver (latter case clinically not asso- 
ciated with icterus) in which considering only the 
histological aspect, a differentiation from hepatitis 
epidemia was quite impossible* Quite the same some- 
times applies to so-called septic icterus* Therefore 
the question must be raised - with a certain reservation 
for the present - whether or not changes observed in 
hepatitis epidemica are specific or inherent organic 
reactions of the tissue itself, due to various factors. 
A differentiation from icterus due to stasis, from 
icterus hemolyticus and from Weil’s disease and yellow 
fever should in any case be possible* 
2. Proof is missing so far, in the speaker’s opinion, 
that the microscopic hepatic changes under review 
correspond to so-called serous hepatitis* Furthermore 
it must be mentioned that the findings refer to autopsy 
material which in most cases was not available immediate 
ly postmortem. 
3* A universal reticulo-endotheliosis, in the sense 
of HOLLER, does not seem to prevail in hepatitis epi- 
demica, although a reaction of the reticulo-endothelial 
system of the epigastrium - liver, spleen, epigastric 
lymph nodes - is observed there is no universal reaction 
of the lymph nodes and of the reticulum of the bone 
marrow* If swellings of lymph nodes occur outside the 
epigastrium they may be due to some other cause, as 
for instance swelling of lymph nodes of the neck in 
our material was found to be due to preceding diph- 
theria or to staphylodermatitis* 
Recapitulating it can be said, that from the pathologico- 
anatomical point of view two factors will contribute mater- 
ially to clarify the hepatitis problem* One factor is a 
systematic examinationcf a great many cases of hepatitis 
epidemica immediately after death, especially in case of 
incidental deaths (mine or bomb explosions, traffic accidents 
etc*) and excluding cases with complications* The other 
factor of decisive importance is a close cooperation with 
the clinician, with the view of comparing the pathologic 
postmortem findings with the tissue obtained by liver puncture 
from the respective patients (ROHOLM and IVERSEN, VOEGT). 
For the pathologist too the solution of the hepatitis problem 
will depend on the detection of the suspected but not yet 
proven causative agent of the disease* 146 
Discussion; 
SIEGMUND: Refers to his detailed monograph on 
hepatitis epidemica. 
BUECHNERs In general specimen of liver tissue from 
living patients as shown to me by NONNENBRUCH, confirm the 
picture as reported by BENECKE. After a few months, the 
changes subside completely (see AXENFELD and BRASS in 
Frankfurter 2eitschrift fuer Pathologie, Volume 57, No 2, 
147, 1942). 
KAEMMERER: BORST could not observe the typical nicture 
of hepatitis serosa in three autopsies but in all of them 
he found distinct interstitial inflammations. One of these 
cases was a clear cut traumatic death (crash) and Just this 
case (completely recovered from acute icterus) exhibited the 
most severe interstitial inflammations and splenic fibresr 
only a few small lobes of the liver showed a fatty degenec: E 
and decay of cells of the liver. BORST raised the question 
whether this interstitial inflammation is a sequel to the 
primary disintegration of liver cells, or is an independent 
and only co-ordinated phenomenon, or if this interstitial 
inflammation in the further course of the disease develops 
into cirrhosis of the liver. It is suggested that special 
attention be paid to the distinct slow5nr subsiding form, 
which often is seen here, especially when the icterus lasts 
very long. The persistence of liver or spleen swellings 
as well as the aldehyde reaction and a strong Takata reaction, 
although varying qualitatively, should be given special 
attention. As to hepatitis contagiosa in the Army the new 
quantitatively apparently more effective Takata modification 
by GROSS may suit the purpose better. 
HOLLER; If icterus is the decisive diagnostic symptom 
it may be extremely difficult, if not at all impossible in 
the present circumstances to distinguish between sporadic 
and epidemic hepatitis. Cases of hepatitis epidemica with- 
out icterus are more frequent than cases with icterus. If 
one patient out of a number of cases without icterus develops 
icterus, this case, as it occurs sporadically, will be classe: 
as icterus catarrhalis. Monocytosis is an ever present 
symptom in hepatitis epidemica, Just as is th6 swelling of 
the spleen or liver. In younger patients, now and then, a 
general swelling of the lymph nodes is observed. For this 
reason, in pathogenesis and clinical treatment of hepatitis 
epidemica, I have tried to put the monocytic reaction into 
the center of my considerations. If BENECKE is of the 
opinion that a universal reticulo-endotheliosis is im- 
probable and furnishes proof of its presence in the abdomen 
only (liver, spleen, portal lymph glands), I agree with 
him on the whole. This also applies to cases associated 
with monolymphocytic reaction, as e.g. PFEIFFER1s glandular 
fever, and even more to monocytic angina characterized by 
changes of the pharyngeal tonsils Y’hich are, in accord with 
the above, local rather than general symptoms. I suggest 
that the concept of alimentary toxic disorder of the liver 
(icterus catarrhalis) under no circumstances be denied. Nowadays, it occurs very frequently along with hepatitis 
epidemics. Coincidence of both diseases in my opinion 
produces the picture of hepatitis epidemics associated with 
icterus. GUTZEIT has pointed out, that in epidemics of 
hepatitis contagiosa, Salvarsan icterus is more frequently 
observed. I fully agree with him, as this proves that, 
owing to a developing intercurrent new liver complaint, 
hepatitis epidemics without icterus develops into hepatitis 
epidemics with icterus. There are still other similar 
instances of developing infections and alimentary intoxica- 
tions etc. The sedimentation rate in hepatitis epidemica 
shows an acceleration even in an early phase. Finally, to 
underline my opinion that hepatitis epidemica is caused by 
a causative agent with a specific affinity to the reticulo- 
endothelium, I wish to add that DAVID - Vienna - succeeded 
in cultivating a little rod in a marrow biopsy of a patient 
suffering from jaundice. The properties of this rod show 
some resemblance to the bacterium monocytogenes (KYFELD). 
The latter produces monocytosis and liver parenchymal in- 
volvement in animals. 
UHLENBRUCK: The speaker was asked to furnish informatiu 
concerning the incubation period for hepatitis epidemica. In 
one instance an incubation period of 4 weeks was observed 
(man on furlough, his child, doctor, nurse). In other cases 
the epidemic spread rapidly progressing with short intervals 
of incubation has been observed. In sporadic cases, however, 
no indication as to the time of incubation can be given. 
Furthermore, the following observations have been made; In 
Africa, hepatitis epidemica appears, due to the change of 
climate, especially in new-comers, in cases of inappropriate 
diet, poor quality fat, cold, drinks and infections (angina, 
diphtheria etc.). One has the impression, that the virus 
is present everywhere and any involvement of the intestines 
or a decrease of the resistance of the organism may result 
in a manifestation of hepatitis. 
KALK; The question of suitability for military assign- 
ment following the recovery from hepatitis epidemica 
important. Much the same as in icterus catarrhalis, which 
after all I do not consider identical with hepatitis epi- 
demica, liver troubles are observed for some time, which 
generally last longer and appear in a^more serious form 
than in the case of icterus catarrhalis. It struck me, 
that just the galactose test, which ordinarily does not give 
a particularly exact test of the liver functions becomes 
positive for a prolonged period at a moment where the graduated 
Takata and the urobilinogen tests often become negative. 
Therefore after a severe hepatitis epidemica has-been over- 
come, it will be necessary to make a liver function test, 
before reassigning the man for duty. This particularly 
applies to soldiers liable for a new assignment in Africa 
where th£ liver affecting agents appear to be present in 
a particularly high degree. 
BERG: Acute painful conditions.in the epigastrium with 
meteorism are observed when the initial fever subsides, also 
in non-manifest icteric forms of hepatitis contagiosa (de- 
finable only by determination of bilirubin in the serum). These pains are considered to be due to a swelling of the 
lymph glands and may last for days. In the case of a 
soldier on furlough an incubation period of 38 days could 
be observed. Abnormalities in the remaining N or residual N 
determination, associated with Weil’s disease as described 
by DOHMEN of my clinic, were not observed so far; it is 
however presumed that existing tuberculosis may be badly 
influenced by an additionally developing hepatitis. 
DENNIG; In hospitals, infections of hepatitis epidemic 
are rarely observed. 45 hospitals reported only 10 cases oi 
infection and these cases who had been hospitalized for more 
than 4 weeks because of other diseases together with patients 
suffering from icterus. 
GUTZEIT: (Summary) Many cases of hepatitis proceed 
without icterus. An accurate diagnosis is only possible if 
the diseases occur in groups, because in Russia monolympho- 
cytosis and enlargement of spleen and liver often occur 
without hepatitis. Icterus is no complication, but a symptom 
of hepatitis, just as is the case with the exanthem in scarnei 
fever in spite of many cases progressing without exanthem. 
Icterus develops also without additional injurious agents 
(alimentary or infectious forms). Acceleration of the sedi- 
mentation rate in icterus catarrhalis was also often observed 
over the last ten years in patients of my clinic. Neither 
an inappropriate diet, nor typhoid-paratyphoid diseases will 
necessarily cause hepatitis contagiosa. The period of in- 
cubation is 4 weeks (2 to 6 weeks). The sudden appearance 
of several cases within a group of persons indicates a common 
source of infection (contaminated water or meals). Galactose 
intolerance and positive Takata-Ara test will be observed 
even in mild cases. The course of the disease is not uniform*, 
Considering the great number of mild cases in the Field Army, 
it is practically impossible to make fitness for duty de- 
pendent on liver function tests. In more serious cases re- 
sidual symptoms should bo carefully watched, such as; en- 
largement of liver and spleen, aldehyde secretion, Takata-Ara 
test, K.H. tolerance. 
Liver puncture biopsies were made at my suggestion by 
Oberarzt (1st Lieut., MG.) Dr. YOEGT in my Breslau clinic, 
as well as for one year in Greece on many patients. The 
results which are known to BENECKE, have not yet been 
published. There was no serous hepatitis. An early symptom 
is the increased growth of the capillary endothelium and 
enlarged Kupffer’s stellate cells, which are finally cast 
off into the capillary vessels which are partly thereby 
obstructed and filled with protein enriched fluid. More- 
over, there was often observed a large scale dissociation 
of trabecula liver cells with changes of size and nuclear 
conditions (vacuolar degeneration). The rehabilitation of 
these changes as observed in several liver biopsies on the 
same patient was really astonishing. Periportal heterogenous 
accumulation of round-cells is observed. 
Directives: 
1. Hepatitis contagiosa is an infectious disease. So 
far neither the causative agent nor the route of in- 
fection are known. The route of infection is probably 149 
not unique. Beside a transfer by droplets or smear, 
infection may also be caused by foodstuffs and water, 
or by an inanimate carrier. This explains the in- 
cidence of the disease both in series and in groups. 
2. An increase of the disease is seen in August, 
reaching its peak in October/November and subsidence 
from January to March. 
3* In most cases, the infection is contracted in the 
pre-icteric phase when a diagnosis is rarely established 
and thus it would anyway be too late for isolation. 
All the same, in order to simplify the medical treat- 
ment, and in consideration of the high incidence it wil 
still be advisable to keep the patients in separate 
rooms, etc. 
4. In addition to the typical icteric form there 
exists a form without icterus, which is characterized 
by the enlargement of the liver and spleen, the occasion, 
al rise of temperature? the increase of bilirubin in chc 
serum, a positive urobilinogen test of the urine and 
often by a monocytosis in the blood picture. 
5. In the greater part of the cases the disease pro- 
gresses uneventfully, the more so if the patient is con- 
fined to bed early and put on a diet (rich in carbo- 
hydrate and poor in fat and protein). Prolonged stay 
en route is harmful and causes much delay in the final 
recovery. Hospitalization should - if possible - be 
within the area of the same Army group - should last 
until the jaundice is gone (8 to 10 to 20 days). Then, 
relaxation and admission to a convalescent hospital is 
advisable until the patient is fit for duty again. 
6. The suitability for service after recovery depends 
largely on the subsidence of the enlarged liver and 
spleeh, on a negative aldehyde reaction of the urine 
with a normal diet and under physical strain, regain 
of lost weight, and with a reduction of the sedimentation 
rate. 
7. In single cases, especially if the patients are 
elderly, the recovery is slow and careful treatment 
is necessary. Muring this period of recovery frequent 
aldehyde tests of the urine? Takata reactions and de- 
terminations of the bilirubin in the serum are necessary. 
If the icterus lasts for 3 to 4 weeks early recovery 
cannot be expected. In that case evacuation to a hos- 
pital at home by hospital train,in bed and a special 
diet will be necessary. 
0.. It there are a great number of jaundice and other 
minor cases at the same time (In autumn), it will bd 
advisable to establish special convalescent hospitals 
within the area of the annlei* for the hospitalization 
Of less severe cgHseS to* keep the patients near to the 
•armies. 150 
9* Glucose, insulin, duodenal syphonages should be 
reserved for serious cases. 
10# The pathologico-anatomical examination reveals the 
presence of changes of the liver stroma and of the 
parenchyma which are generally more accentuated in the 
center of the lobules than in the periphery. Necrosis 
of the liver cells and thrombosis of the bile are also 
observed. At the same time we observe an increased 
growth of the endothelium and an early Infiltration of 
the interlobar connective tissue of a resorptive charac- 
ter. The process of healing often proceeds with a very 
slight tendency to scar-formation. The pathologico- 
hlstological changes are not specific for the disease. 
The pathologico-anatomical picture shows swelling of the 
lymph glands in the epigastrium enlargement of the 
spleen and from a histological aspect micronecrosis in 
the transversely striated muscular system. Inflammatory 
changes of the kidneys and of the cardiac muscle do not 
pertain to the pathologico-anatomical picture. The 
extra-hepatic bile ducts remain unchanged. The gall 
bladder shows edema of the walls* 
11. In times of an epidemic spread of hepatitis con- 
tagiosa potent remedies, such as dalvarsan, mercurial 
preparations etc. should be used only after having made 
a careful physical examination and If necessary a liver 
function test in order to avoid toxic effects. 
12. Hepatitis contatiosa is a disease which must be 
reported as a communicable disease. If jaundice occurs 
frequently the case must be supposed to be hepatitis 
contagiosa unless other clear cut reasons are diagnosed, 
such as stone obliteration, hemolytical icterus etc. 
Relapses and sequelae may occur* Relapses usually show 
a more serious course. X. 
W A R NEPHRITIS 
Translation prepared by: 
Office of Military Government for Germany (U* S* ) 
Office of Naval Advisor 
Medical Section 1. War Nephritis, 
Marine Oberstabsarzt (Lt. Gomdr., MC»y Navy) 
Professor VOLLHAHD 
First of all it must be emphasized that the so-called 
"war nephritis" is not a special type of nephritis whose 
course differs from the peace-time form in any way. Similar 
to the "trench" nephritis of World War I, it is identical 
with the diffuse glomerular nephritis known from pre-war ti 
as described by LANGHANS, LOEHLEIN, and FARE. Its etiology 
is not yet clear. An increase of the incidence of the dis- 
ease was observed for the first time only in the winter 
campaign in Russia in 1942. The relation between the number 
of cases in troops at home and in the field nay be of interes' 
The so-called absolute figures for nephritis apparently have 
risen also in the Reserve Army in 1942. In the Field Army a 
rise could be observed even before that time. However, the 
relative figures based on the total number of soldiers, re- 
veals that the increase refers exclusively to the Field Army, 
and only in 1942, with an extraordinary peak in March and 
April. This high incidence persisted during the summer months 
too. 
The local distribution of the new cases in the various 
months is very remarkable. I am indebted to by distinguished 
former co-worker, HILDEBRAND, well known to be an expert of 
repute for nephritis for the following figures from a hospital 
unit under his command: 
I II III IV V VI VII VIII IX Months 
16 22 8? 50 131 71 70 39 15 Cases 
The sharp rise at the time of snow-melting is indeed 
very impressive followed by the high incidence in May and the 
decline in August. A similar monthly survey from the same 
sector of the front of all new cases of angina and colds 
caused by infection would be of value. The rise and fall of 
the curve can hardly be interpreted as the specific mani- 
festation of a particular disease, as related to a specific 
infectious agent or perhaps a virus. This also applies to 
the increased frequency of nephritis in certain communities. 
The same increase is also observed in case of angina. Any 
comparison with the unrestrained epidemic spread of icterus* 
is absolutely out of place. 
*) NETZLAFF reports that he found hemolytic streptococci 
in throat smears of patients suffering from nephritis 
without upper respiratory disease at a time when a 
remarkable prevalence of nephritis was observed. 
Most patients believed the viet weather was responsible 
for the outbreak of the disease. The patients had arrived in 
groat numbers from swampy regions, where even in summer-time 
the land did not become dry. No doubt, wetness followed by a 
cold, or even a cold alone without preceding wetness can be 
the cause of acute diffuse glomerular nephritis, as stated and 
illustrated by various examples in publications of World War I. 153 
It is also firmly established that an upper respiratory in- 
fection can often be an additional factor. It is a question 
which probably has to be answered in the affirmative whether 
or not the diffuse nephritis can be contracted solely through 
exposure to wetness and chilling without any infection or 
fever being associated with it. * 
It must, however, be admitted that the etiology of 
nephritis is not consistent. Exceptional statements are 
also made such as that of a car-driver, 35. who never suffer' 
from tonsillitis neither got wet nor caught a.cold and who 
had good billets throughout the winter. On 24 April he saw 
the doctor because of pains in the lower legs and around the 
stomach, when moving about or running. A urine test was not 
made. Late in April his face got swollen, his breath was 
short, he suffered from fainting spells and an edema apneared 
Early in May he was admitted to the hospital, showing a 
marked edema and a rise of blood pressure* The diagnosis 
was as follows: Tonsils somewhat enlarged, purulent pustules, 
dental granuloma. 
In any case, wetness and chilling alone can hardly be 
responsible for the disease although both certainly play an 
important part, either as the releasing factor or sometimes 
as the cause itself. In my opinion, in order to fight the 
disease from the etiological point of view it would be 
helpful to encourage the installation of Finnish Sauna Baths* 
Statistical data on the etiology of nenhritis according 
to HILDEBRAND: • 
Causes 
Angina 
— 
Skin 
suppu- 
ration 
Suppu- 
ration 
in the 
acces- 
sory- 
nasal 
sinuses 
Inju- 
ries by- 
cold 
with 
subse- 
quent 
infec- 
tions 
r 7 
•General 
febrile 
infec- 
tions 
1 Severe 
inju- 
ries 
caused 
by in- 
tense 
cold 
No rec 
ogni- 
zable 
cause 
in one 
hundred 
cases 
29 56 
13 9b 
6 % 
3 % 
13 % 
ii % 
25% 
in two 
hundred 
cases 
15 9b 
12,5 % 
12 % 
6 % 
11 % 
12,5 % 
31% 154 
The figures of the column headed "No recognizable cause" 
refer to persons who for weeks and months had successfully 
endured extreme cold and thus withstood all hazards of catch- 
ing a cold. From time to time the "louse exzema" became in- 
fected and finally in the throat suppurative foci developed 
repeatedly during the treatment. Cryptogenic foci of infec- 
tion therefore play a considerable part even in these cases. 
I would like to point to retronasal angina which is not 
always associated with dysphagia, and it should also not be 
overlooked that even in peace-time patients often denied 
having suffered from tonsillitis although they admit a slight 
dysphagia. 
In summary* I believe that the etiology of war nephriti: 
is infectious, and especially infection by streptococci, play- 
the same important part as in the peace-time form. Cold and 
dampness play an important role as initiating factors. Cer- 
tainly it is the influence of dampness and cold which very 
frequently mobilize the infection. Material on the subject 
is published in my contributions to the Manual and no doubt 
you will find my reports confirmed by your own experience. 
I myself recollect very well after breaking into the ice in 
thawing weather in my childhood, that I and also my brothers 
contracted angina the day afterwards. 
It would be very desirable to have the anamneses of all 
cases of. nephritis taken down much more thoroughly and 
carefully and with more expert knowledge than is commonly 
done. 
The attention of the medical officers in the units and 
hospitals should be directed to another and even more im- 
portant matter, l.e. making an early diagnosis. This is the 
principal condition for an early recovery, i.e. recovery ad 
integrum. If diffuse nephritis is not cured completely in 
s|)ite of a quite correct treatment it is usually due to a 
delay in making the diagnosis, i.e. in making it within^the 
relatively short period where the histological changes in 
the kidneys will allow a retrocession. 
An early urine test for albumin is usually neglected in 
"trench nephritis". Such carelessness is hardly comprehensib.1 
the more so as according to World War I, experience and many 
anamneses at hand, "trench nephritis" begins in nearly all 
cases with a marked edema. Therefore it is imperative to 
make a thorough urine test, because it must be^kept in mind 
that the extra-renal syndrome of nephritis without albumin- 
uria occurs not infrequently as described by NONNENBRUCH. 
Therefore the blood pressure should be checked, or in the 
absence of a sphygmomanometer the pulse rate should be noted. 
An absolutely typical and especially frequent symptom 
of both the mild hypertension and the acute hypertension of 
nephritis is tiredness and weakness. Possibly this is also 
an indication' of a general contraction of the vessels, in- 
cluding the vessels of the muscles. Moreover it appears to be insufficiently known that the 
specific and abrupt change in the circulatory system, as is 
typical for acute nephritis is most frequently attended by 
shortness of breath, chest trouble, dyspnea while in motion 
and even at rest. This is constantly reiterated in practical- 
ly all the anamneses at hand. Furthermore it should not be 
overlooked that the shortness of breath is due to cardiac 
trouble. This overstrain of the heart and the stasis in 
the lesser circulatory system is a most alarming symptom 
of immediate danger in acute nephritis and misjudging this 
state of affairs may have deleterious consequences. By far 
the greater part of the fatal cases of acute nephritis must 
be attributed to such failure of the heart in association 
with an edema of the lungs, which is manifested in shortness 
of breath and cardiac cough* If these seriously•threatened 
patients, with swollen faces, gasping for breath, are sub- 
ject to a hunger and thirst treatment in combination with 
intravenous injection of Strophantin really excellent and 
startling results are obtained, such as have never been seen 
before# The application of this therapy brings no relief to 
the kidneys, on the contrary they are induced to work ef- 
ficiently again# Rathei the tension is lessened in the 
circulatory system and the strain on the heart relived thus 
preventing heart failure due to dilatation# 
Certainly this is not the only way to cure diffuse 
nephritis, but according to my experience it is the best, 
i#e# it is most reliable in preventing a dangerous course, 
besides it is the fastest method. 
From clinical reports at hand it can be seen how much 
can be endured by nephritic patients, starting from long- 
distance runs despite nephritic dyspnoea to the prohibition 
of rest in bed, from taking Albucid to drinking tea of 
bearberry leaves and urotropin, or traveling sitting up in 
an unheated train, taking all kinds of salted food, etc* 
At the same a great part of these cases were cured, some- 
times, however, only after many monrhb stay in a hospital, 
Provided that a diagnosis is made in good time the hunger ai . 
thirst cure offers the advantage of enabling a surprisingly 
quick cure within 1 to 2 weeks# In consideration of the 
great number of patients this certainly is of much importance 
in military respects. 
Furthermore the hunger and thirst cure offers also the 
advantage of being applicable wherever beds are available. 
Confinement to bed is necessary in any case and also a 
doctor w'ell conversant with the treatment of nephritis. 
Since transport is harmful and delays recovery, the collec- • 
tion of all new cases of nephritis in specially erected 
barracks close behind the front near surgical or base 
hospitals should be considered and their treatment there 
according to the hunger and thirst cure (and with Strophanti 
until the edema is gone, the threat to the heart passed, 
and the blood pressure reduced. Day by day control of the blood pressure is absolutely 
necessary, as the favorable issue depends almost exclusively 
on the reduction of the blood pressure to normal level, or 
better still below normal# If this aim is attained it is 
no longer a risk to give the fasting patient If- liter tea 
with 0.4 theocin, in order to accelerate recovery. Even 
if the blood pressure is not yet reduced but the threat to 
the heart is overcome, one can risk reducing the blood pres- 
sure by using a massive dose of water and sometimes an abrup' 
decrease of the blood pressure is observed# 
Removing the patients to the rear or home hospitals 
where a diet appropriate to nephritis patients can be pro- 
vided will only come into consideration after the hunger and 
thirst cure has been carried through# En route the patients 
should be berthed in heated hospital trains* 
In those cases where no favorable reaction to the hunger 
and thirst cure results, i*e# no reduction of the blood 
pressure, tonsillectomy may be considered as a last resort* 
In this connection it should be pointed out that oven an 
expert is sometimes unable to recognize from the outside 
whether or not any suppurative focus may still be inside; 
only the removal of which makes recovery possible. 
A second serious threat in the acute hypertension of 
nephritis must be seen in the fact that the cerebral vessels 
are implicated in the general vascular contraction. The 
result is a cerebral edema and the apocarance of cerebral 
pressure which anatomically shows a gradual swelling of the 
cerebral ventricles and in the characteristic cone-shaped 
prolapse of the cerebellum into the large occipital foramen, 
as in the case of a cerebral tumor# Clinically this menacing 
condition manifests itself in mental dullness and headache, 
now and then associated with vomiting, furthermore in a choke 
disc, or amaurosis due to an edema in the optic centers, or 
even in convulsions, i#e. a clinical picture conforming to 
eclamptic pseudo-uremia and equivalents. The treatment con- 
sists also in these cases in combatting first of all the 
hypertension, then in using - apart from the hunger and th±: 
cure combined with Strophantin - a general blood-letting with 
subsequent lumbar puncture* In order to diminish the ex- 
citability it will be necessary to administer a sedative, sm 
as sodium luminal intravenously, and in order to have the 
brain freed from water, 20 cubic centimeters of a solution 
of 25 per cent of sulfate of magnesium may be injected in- 
travenously# Yet it will be advisable to keep a syringe 
calcium solution immediately ready for use to curb any possibi 
undesired effect of the magnesium on the respiratory center. 
Those cases are to be considered suspicious of pseudo-uremia 
where in the beginning the patients complain of headache. 
Since applying the hunger and thirst cure such complaints 
are very seldom observed, and only during the absorptive stop 
of the edema# 
As a third menace in acute nephritis the retention of 
the urine must be considered i.e. the appearance of anuria. 
Such cases are rare but of an extremely dangerous character. 
Apart from combatting the hypertension as has been described 
before, it will be advisable to apply heat locally to the renal region, c.g. by hot linseed poultices or cataplasma 
of mashed potatoes, or else by intensive short-wave therapy 
twice daily for two hours. Controlling the urea values in 
the blood will be necessary. If by all these measures the 
retention of the urine cannot be reversed one should con- 
sider stimulating the kidneys by a deep penetration of 
X-rays, or by applying paravertebral anesthesia of the renal 
nerves, and lastly decapsulation of the kidneys* 
Exlampsia of pregnancy being due to the same cause I 
wish to draw attention to the following way of treatment^ 
BACH could see a striking success with a severely eclamptic 
woman, who had lost her sight completely, and suffered from 
somnolence and anuria after Caesarean section, by setting 
24 leeches, 12 on each leg* Since then he has treated all 
cases of preeclampsia and eclampsia in the same way and thus 
has no more fatal issues due to eclampsia* He has the same 
good results by venesection plus intramuscular injection of 
20 milligrams of Hirudin, 3 to 5 times within 24 hours. An 
abundant diuresis resulted with a corresponding reduction 
of the blood pressure. Since Hirudin is not on sale at 
present any other drug inhibiting coagulation of the blood 
will come into consideration, e.g. Heparin. If there are 
leeches available quite a number of them ma.37, be applied on 
both sides of the renal region instead of making a venesectior 
Threatening oliguria or anuria may thus be curbed. 
A fourth threat must be considered if the disease is not 
cured and becomes cHronlc. Under the favorable conditions 
of pre-war tines an early diagnosed acute nephritis was cured 
at a rate of almost 100 per cent. What is the matter now wit: 
war nephritis? After World War I it turned out that hardly 
50 per cent of the cases of war nephritis had been cured. 
Figures concerning the result of trench nephritis in the 
present war are not yet available* HILDEBRAND reports on 
his nephritis patients as follows: 
Treatments Administration of magnesium sulfate, 
intestinal purge as is usual prior to a hunger cure, then 
fasting and thirsting for 6 or 8 to 15 days, 1 tablet of 
Vitamin C three times a day, now and then two tablets of 
Vitamin 0 and daily Strophantin; possibly venesection and 
renal diathermy. Effect: At first the edema is influenced, 
a loss of weight l8 to 22 to 32 lbs occurs within 8 to 10 
days* Further treatment: Administration of "potato days", 
gradually increasing portions of vegetables, application of 
a massive dose of water, and finally curing of suppurative 
foci* Several very Impressive cases have been seen. Result: 
3.2 per cent of the patients died, but only 15 of nephritis 
proper$ one patient died of a most serious edema of the lungs 
18 hours after hospitalization, one of an eclamptic attack, 
another one — admitted to the hospital not earlier than 5 
weeks after the outbreak of the disease - died of subacute 
"half moon" nephritis, another 2.2 per cent of the-patients 
died of complications such as pneumonia, parotitis,*sep|is 
etc. 2.57 per cent of all cases could not be cured, 8.65 
per cent were transferred to other quarters, mostly for treat- 
ment of suppurative foci, 85.5 per cent were cured* This is :• ' 
fact, a very satisfactory result considering that in contrast 
hereto In a rfiservfi convalescent hospital only 36 per cent were cured completely, and 6l per cent were dismissed un- 
cured* These cases had been treated in other hospitals for 
a prolonged period and then they were moved to this health 
resort for another 4 weeks observation* In another reserve 
hospital which now is being run as a hospital exclusively 
for nephritis patients, 0*75 per cent of the patients died 
of severe nephritis, 42*7 per cent were dismissed as followsi 
Of the latter, 43*5 per cent of them were cured completely. 
34 per cent with persisting defects and 22 per cent remained 
uncured* Of course any decisive conclusions cannot be drawn 
from these statistical data* They reveal at best that first- 
ly, we have to reckon even now again with a groat number of 
uncurcd cases of chronic nephritis tending to turn into 
secondary cases of contracted kidneys* It would certainly 
be worth-while to do everything favoring an early diagnosis 
and to treat nephritis at an early phase* Secondly, in 
order to obtain results as favorable as possible, all neph- 
ritic patients should, be collected as close behind the front 
as circumstances will permit and then have them treated with 
expert care. 
All suggestions made as a result of these investigations 
will be found in the directives, page 132 (Mo. 7 to 10). In 
addition special attention is invited to preventive and nro- 
phylactic measures in order to prevent damages cue to cold 
and dampness (Sauna Baths)* 
2• Patho 1 ogico-anatomical bases for the concept of ."Far 
- * 
Oberfeldarzt (Lt* Col.« MC») SPONHOLZ 
Since World War I the clinicians regard "war nephritis" 
as the clear cut manifestation of a disease associated with 
edema, hematuria, and albuminuria, which under certain con- 
ditions occurs frequently in war-time* Thus it is the task 
for the pathologist to investigate this picture to see if it 
can be based anatomically upon a substratum with character- 
istic organic changes, which in regard to interpretation and 
special clinical processes correspond to the picture of 
nephritis known from pre-war times* All reports of the 
pathologists of World War I, in particular the expose by 
HERXHEIMER in the Manual of Medical Practice of World War I 
came finally to the conclusion that from a pathologico- 
anatomical aspect the clinical picture of war nephritis_ 
corresponds to glomerular nephritis, which shows no variation 
from peace-time nephritis* At the last Conference (East) 
of the Consultants1 Committee, in May of this year, RANDERATH 
came to the same conclusion* Meanwhile statistical data 
compiled by the Central Archive for Military Medicine could 
be made more complete. They now comprise all findings on the 
subject since nephritis first appeared in this war. T under- 
took the trouble once again of looking through all these 355 
reports, taking into due consideration all the views expressed 
by the clinicians which repeatedly said that the disease may 
perhaps be due to infection by some virus* In excluding all 159 
such cases as were suspicious of being associated with a focal 
infection, and going so far in this respect as to eliminate 
all cases of wounded soldiers and those with frostbites it 
was my endeavour to find mutual bases with the clinician 
and to examine the unsolved problems from that standpoint. 
I found, by separating them out, 136 unobjectionable cases 
of nephritis# Reports on the result of these examinations 
are submitted herewith. My own practical experience in 
the Reserve Field Hospitals, Group A in Southeast Poland is 
restricted to 14 cases in all, a very small figure indeed. 
However, excepting Group B with 17 oases which came next, it 
is the highest figure met with in the whole area of the same 
army, kith the exception of 3 cases all reports originate 
from the East - as far as can be determined from records of 
home hospitals* Considering the small totals of the separate 
figures in the respective armies they are of interest only 
after being combined according to the area of the front 
sectors* Accordingly the death toll of war nephritis shows 
the following distribution: 
Northern Sector 8 casualties 
Middle Sector 25 casualties 
Reserve Field Hospitals, Group 3 17 casualties 
Southern Sector 17 casualties 
Reserve Field Hospitals, Group A 14 casualties 
Balkans 3 casualties 
Home hospitals 52 casualties 
The widely differing figures in the separate sectors 
of the front can be interpreted in various ways# I believe 
the low number of casualties in the Northern Sector is due 
to the fighting forces in that sector being the closest to 
the large hospital bases and difficulties of transportation 
having been less in comparison to the other sectors, at 
least as far as the patients1 period en route is concerned. 
The incidence of the highest figure of casualties in the 
Middle Sector inclusive of Reserve Field Hospitals, Group B, 
explains itself because of the military operation which took 
place all winter in these sectors* On the other hand in the 
hospital base of Southeast Poland the first collecting hos- 
pitals of the Southern Front were included and those could 
be reached only by an extraordinarily long route of trans- 
portation rearwards and by most primitive means of trans- 
portation. Of those patients who died in home hospitals it 
could seldom be determined from which sector of the front 
they had come# 
Anatomically this group of nephritis shored the kidneys 
either pale or colored and enlarged, so far as uncomplicated 
cases came into consideration. Any difference from peacetime 
nephritis could not be detected. Most frequently the remark- 
able edema of the skin and the inner organs, and especially 
the edema of the lungs, was predominant* It; was very frequent 160 
and striking that serous exudation tended to secondary in- 
fections and this may be due to the reduced biological de- 
fense status of the body. Frequent appearance of enteritis 
and bronchopneumonia should be interpreted in the same way. 
There has been a special group of strange sudden -deaths* 
Quite unexpectedly a man fell ill, afflicted with a severe 
edema, or looking as if there was a sudden failure of the 
circulatory system. Death occurred within 24 hours. Autopsy 
revealed in all such cases acute nephritis as a primary cause. 
The immediate cause was uremia in some cases whilst in others 
one had the impression that it was caused by an acute dilata- 
tion of the heart. Such sudden deaths due to acute nephritis 
are not characteristic of war nephritis, yet thejr make us 
consider the matter. In my opinion the fatal outcome could 
have been avoided if the medical officers in the units had 
used greater care in observing the initial symptoms. A great 
many of these deaths occurred immediately after transportation 
In fact the death-rate of nephritis in temporal or causal con- 
nection with transportation is frighteningly high. 
As is apparent from all reports that the examination 
of the kidneys showed the microscopic picture of an acute 
or subacute glomerular nephritis. The capsular spaces were 
tightly filled up, the loops wera rich in cells and more or 
less infiltrated with leukocytes. In the beginning the 
capsular epithelium was not affected, only in a later phase 
does the formation of "half moons” (casts ?) begin, but never 
to an extensive degree. Therefore in all cases the intra- 
capsular form of glomerulitis was concerned, distinguished nox 
and then by its stability and by lack of tendency to glomerular 
obliteration. In quite a number of cases the beginning of 
the disease dated as far back as 3 and 34* months. All the 
same even in these cases no damage of the kidneys, such as 
contracture, could be observed. For the first 3 to 4 weeks 
the tubular epithelium showed only minor changes, in later 
stages it began to show signs of degeneration and cloudiness 
of the protoplasm was observed, and in addition a slight 
adiposis and occasional formation of vacuoles appeared. How- 
ever, from a clinical aspect these tubule changes are not very 
important as compared with the damage due to severe nephrosis 
In general the presence of blood in the capsular spaces 
and tubules was trifling and in no way influenced by the 
duration or seriousness of the disease. Those cases in which 
the surface of the kidneys showed a flea-bitten like, dotted 
appearance indicate a more hemorrhagic character of the dis- 
ease and were in the minority. 
A special group within that group is war nephritis asso- 
ciated with typhus. It leads to diffuse glomerulo-nephritis 
of a most dangerous hemorrhagic character. It is of no im- 
portance and often cannot be decided clearly in which order 
the two diseases follow one another. It is affirmed by many 
clinicians that such cases imply a very grave prognosis. They 
must be distinguished distinctly from diffuse glomerulonephriti 
which incidentally occurs in typhus, though in my opinion 
seldom. RANDERATH and HERZOG state, in contrast hereto, that they had observed it in 25 per cent and 6? per cent respective- 
ly of all cases of typhus# Concerning the alteration of the 
permeability of the renal capillaries in war nephritis asso- 
ciated with typhus, it may be due to the damage done to the 
vessels in general by the typhus. In case of an additional 
interference with the causative agent of war nephritis, a 
particularly high-grade of erythrodiapedesis results. 
Although it can be concluded from all these investigatec 
that, from a pathologico-anatomical or histological aspect, 
a clear cut distinction between war nephritis and the peace- 
time forms of this disease cannot be made, one must not ex- 
clude the possibility of a particular, maybe infectious, 
etiology for war nephritis. Quite a number of clinical in- 
dications imply unequivocally that such an assumption is 
correct* Experimental tests made by MASUGI point to some 
kind of allergic reaction. Eventually a particular dis- 
position of the body may exercise some influence, a factor 
which should not be underestimated. All this, however, does 
not give us any basis for medical action, the more so as the 
nature of such peculiarities of disposition are apparently 
still very much in the dark. 
I pointed out in my report that certain anatomical 
findings ordinarily indicate a decline of the defensive 
power of the body. Exhaustion may come into consideration 
as an important although not causative facixfr, itdessrves attention 
A fact which may be of much interest is t.nivc war nephritis 
was well known to the French and English during TTorld rrar I, 
whereas captured and civilian Russian doctors, who have been 
questioned upon the subject this summer, had no knowledge 
of a special "trench nephritis". Any increased frequency 
of nephritis in Russian prisoner camps is also not known 
to me* It would appear as if war nephritis were a typical 
disease of certain standards of living due to too great a 
susceptibility of the human organism. 
In summary I wish to suggest: 1* More blood pressure 
tests in series should be made on troops relieved from the 
main defense line. This would give an idea, even if only 
rough of the status of the tonus, which permits one to draw 
general conclusions on the general defensive status of the 
body* More thorough examinations would be impossible. 2. Ii 
order to define the concept "war nephritis" more clearly from 
those forms of nephritis that arise from focal infection, 
special attention should be directed to a potential focus 
when reviewing the anamneses and findings on all nephritis 
patients when admitted to the hospital* 
Discussion; 
BOEHMIG: Early deaths due to "trench nephritis", oc- 
curring 8 days after the manifestation of the first clinical 
symptoms, show a marked swelling of the loops of the glomeruli, 
yet no increase of cells, and a high-grade anaemia of the loops. 
In accordance with the observations made VEITH we found the 
similar slight homogeneous swelling of the loops as a sign of the general effects of cold without or with local injuries. 
In addition there was simultaneously considerable albuminous 
secretion in the curled uriniferous tubules, due to chilling. 
Chilling apparently causes some sort of glomerulonephrosis. 
BUECHN3H: 1, No acute glomerulonephritis could be 
observed in 20 cases of chilling, yet albuminous cylindrical 
scars were in the tubules and droplet-like accumulation of 
albumin in the main parts of the epithelium* 2* In animals 
exposed to chilling we found similar observations. 3* In 
rabbits, the renal region of which was exposed daily for a 
prolonged period to severe chill, we could not observe any 
glomerulonephritis, but only an excretion of albumin. 
MUNK: During the last war, I was able to study on 
ample material the clinical and anatomical manifestation of 
renal disorders in various infectious diseases including 
cholera, malaria and "five day" fever. Briefly, the result 
was that glomerulonephritis could not be found in any of 
these acute infectious diseases. Of course the various 
anatomical renal changes frequently showed the glumeruli to 
be involved. Hemorrhages occurred and also a cons3d erable 
exudation of cells and the formation of crescents (casts) 
in the glomeruli, as especially noticed'in some cases of 
severe grippe. Anatomically, therefore, the glomeruli fre- 
quently showed an inflammation, apart from other changes. 
Yet such renal changes must not bo considered to be glomerulo- 
nephritis* Under that name we understand a certain clinical 
picture marked by more or less conspicuous acute swellings, 
which extend not only over the renal region but also over 
the capillary system of other organs especially the brain. 
Secondary inflammatory symptoms are added to these swellings, 
so in chronic cases an extensive inflammation of the connect- 
ive tissue, in short, a contracted kidney is developing. Sue! 
an issue can never be the consequence of renal changes which 
were caused by all acute infectious diseases, typhus and 
malaria. Sometimes both acute and chronic glomerulonephritis 
happens to occur simultaneously. It is of the utmost im- 
portance to distinguish clearly between those changes caused 
by acute infections in the glomeruli and the true glomerulo- 
nephritis in the clinic. Otherwise all therapeutic measures 
which are required only in the case of glomerulonephritis 
might also be applied in the other case. Apart from scarlet 
fever I know of only one infectious disease which causes true 
glomerulonephritis, it is impetigo contagiosa. This shows 
that the skin is an important factor from which streptococcic 
infections, such as paronychia, may be the cause of glomerulo- 
nephritis. It would appear as if the streptococci are no 
sooner in the lymphatic vessels than the3r gain virulent power 
to cause true glomerulonephritis, the special feature of which 
is a general swelling of the capillaries. 
BEHG: Patients arriving from the Eastern Front and suf- 
fering from edema are now and then automatically subjected 
at first to another hunger and thirst cure after being moved 
to a new hospital* In order to avoid the possibility that 
non-nephritie patients suffering from hunger edema, as occurrec 
in the case of troop units which were encircled for a long period? are subjected to a further damage due to the hunger 
and thirst cure, attention should be paid to an exact diag- 
nosis as to the origin of the edema. This may be assisted 
by the table of my coworker BURNING (Militaerarzt, 1942), 
dealing with the differential diagnosis of diseases ac- 
companied by edema. 
Stimulated by a publication of GAISBOGK, I succeeded 
in curing war nephritis rapidly in a phase of eclampsia, 
oliguresis and albuminuria by intravenous injection of 
adrenalin at the v. BERGMANN clinic as long ago as 1919. 
Following an additional increase of the blood pressure due 
to these injections, associated with an alarming arrhytmia 
lasting for about 20 minutes, there was a rapid discharge 
of urine as clear as water and free of albumin from that 
moment on, succeeded by an astonishingly quick recovery. 
Retrospectively this may be explained by the recent in- 
vestigations made in regard to MASUGI nephritis. 
MUNK:3*Not infrequently a quite unusual anemia forms 
a striking feature. It often shows a hemoglobin value of 
less than 50 per cent. This cannot always be proven at the 
initial stage of the disease, but frequently only in the 
course of the treatment or convalescence, and it is very 
difficult to cure. Deficiency of iron in the blood, due 
to the infection, is the probable cause. 
2. It is extremely difficult to determine whether or 
not the disease is cured. Therefore particular care should 
be devoted to its treatment, for if it is left uncured it will 
progress continuously, causing death in consequence of renal 
insufficiency. 
Blood pressure, albuminuria, hematuria, and power of 
concentration are not absolutely reliable symptoms in each 
individual case. Cure wall be possible even as late as 6 
months after the onset. 
HORSIER: In North Africa, bacillary dysentery and 
hepatitis occurred frequently, just as in the East. There 
were many skin infections by streptococci and staphylococci, 
but no damage due to cold or dampness. No nephritis was 
observed. 
SYLLA: Bacteriological urine tests showed up to 80 
per cent positive findings, usually hemolytic yellow staphy- 
lococci. In the simultaneously present pyodermia the 
bacteria found in the suppurative pustules and in the urine 
corresponded in almost 100 per cent of the cases. "Trench 
nephritis" is considered to be an antigen-antibody reaction. 
Sensitization is caused by some kind of infection, whereby 
the particular kind of germ may be a decisive factor. 
Damage due to cold in all probability favors infection and 
this leads to temporary bacteremia and bacteruria. Neph- 
ritis could be the reaction to the entrance of bacteria. 
This matter urgently requires further investigation. 
VOLLHARD: I would suggest testing the urine for staphy 
lococci even though pyodermia is not associated with nephritis* Directives: 
1* ’’Trench” nephritis basically shows no distinction 
from acute diffuse glomerulonephritis of peacetime. 
However, the edema is usually more marked and thus 
represents an early symptom# 
2. The typical complex of symptoms'includes edema, 
blood oressure increase, albuminuria,in some cases 
is irregularly present. Monosymptomatic forms also 
occur. 
3. Pathologico-anatomically the picture of a typical 
glomerulonephritis is in fresh cases the de- 
generative changes in the tubules are less marked in 
comparison to the pronounced nephrotic aspect of the 
clinical picture. 
4. As to the development of the disease some predis- 
position may play a role, due to dampness ard chilling, 
yet this need not necessarily be the case. Infection 
may also play a part either by known (streptococci, 
staphylococci etc.) or unknown agents (viruses). 
5. In December, the disease increases in frequency, 
the climax is in March-April. Single cases are spread 
throughout the entire summer. 
6. In most cases the disease will progress favorably, 
provided it is recognized early and treated with experx: 
care, and additional damage is prevented. 
7* For that reason it is necessary to instruct and 
inform medical officers of the units regularly of early 
diagnostic symptoms (dyspnoea, tiredness, headache, 
pains in the chest, putty-colored face) and their 
colleagues in the hospitals of the way the disease must 
be treated. Whenever there is an increase in frequency 
of renal diseases it is necessary to test the urine for 
albumin, and whenever possible to measure-the blood 
pressure of all sick and wounded patients, especially 
of out-patients and of those suffering from ill-defined 
general troubles. 
8. Whenever possible the patients should be treated in 
medical units close behind the front, transportation 
being harmful both to new cases and. to those in an 
initial stage of treatment. 
9# The treatment consists in immediate confinement 
to bed and application of heat. After a purgative dose 
of castor-oil or magnesium sulfate, a thorough hunger 
and thirst cure should be made, with tea or fruit-juice 
days (750 cubic centimeters a day) and a fruit and apnlc- 
rice diet to follow* After the edema is gone and the 
blood pressure has returned to normal a saltless and meat 
less diet, poor in fluids (1000 cubic centimeters) should 
follow. Bread and butter must be free of salt. In the 
case of dyspnoea and high blood pressure i milligram Strophantin may be administered, up to two tines a dajr, 
even if the pulse is slow. In the case of oliguria and 
anuria the application of 10 to 12 leeches in the renal 
region vill promise good results# In more acute cases of 
“trench” nephritis it is by no means allowed to treat 
the edema with mercurial preparations# If the decrease 
of the blood pressure and of the edema is delayed, a 
massive dose of water may sometimes be of advantage, 
yet only after the definite disappearance of the symp- 
toms of the circulatory system. The hunger and thirst 
cure should not be repeated ad libitum, but only in 
the case of obstinate residual conditions or if an 
acute turn for the worse takes place# 
10. Nephritic patients should not be transported be- 
fore the edema is entirely gone and only after the 
pressure has become normal. In order to assist the 
medical officers of the evacuation units in identifying 
the nephritic patients at first glance, they should be 
marked by tags showing the inscriptions: “Trench” neph- 
ritis, confinement to bed, salt!css and pulpy food, 
restrict fluids. Care should be taken to keep the 
patients warm en route. After the edema is gone and 
the blood pressure normal again the patients should bo 
moved to suitable home hospitals, berthed in hospital 
trains and subject to diet restrictions# Also on this 
route the tags should be left on# 
11. Ordinarily the cleaning up of a focus of infection 
will not be indicated, neither in an early nor a la bo 
stage of “trench” nephritis. In the case of residual 
hematuria, a persistent elevated blood pressure and a 
tendency to recurrences treatment of the infectious 
foci may contribute to the final recovery. 
12# Even after all clinical symptoms have disappeared, 
nephritic patients will need another 3 months1 time 
before being fit for duty again. XI. 
INFLUENCES OF CLIMATE AND OF 
NUTRITION IN AFRICA; 
S CURVY 
Translation prepared by: 
Office of Military Government for Germany (U, S. ) 
Office of Naval Advisor 
Medical Section 1. Influence of climate and kind of nutrition of German 
soldier's in Worth Africa. 
Stabsarzt (Captain. MG.) Prof. HORSTER 
Up to now the operations in North Africa took place in 
a territory of typical Mediterrean climate: Dryness, hot 
temperature, mild winter weather, and intense sunlight. 
In the dry, slightly agitated air, the necessary radiation 
of body heat is generally guaranteed* Acute injuries by her 
are, therefore, very rare. Tetanic (chlociprivic) states 
are often observed during the hot season. Many healthy sol- 
diers are found during the hot season with a hypotonia, 
which, however, does not cause subjective troubles. As a 
matter of fact, complaints are often reported about abnormal 
physical and mental tiredness, dizziness, particularly 
getting up, violent beating of the heart, dyspnoea, angina- 
like troubles, disturbed sensitivity of hands and feet. 
Findings: Respiratory arrhythmia, irregular heart 
sounds, in particular above the pulmonary arteries, enlarged 
but not pathologically dilated heart, slight evanescent 
edemas of the lower extremities. The EKG frequently shows 
a steep, vegetative T, sometimes prolonged transition time 
or a broad P# The examination of the regulation of the 
circulation according to SCHELLONG often showed the following 
result: Drop of the systolic pressure following a primary 
increase of about 20 millimeters and more; after physical 
exertion, the increase of blood pressure does not occur when 
the patient is standing* Analogous observations were made 
40 years ago in the German Colonial Troops in South Africa, 
according to the literature* Our examinations on South 
African negroes at Tobruk showed normal regulative conditions 
of the circulation. The insulin test showed in some soldiers 
suffering from hypotonia a defective counter-regulation 
(hypofunction of the chromaffin system)# This lability or 
insufficiency of the peripheral blood circulation is con- 
sidered as the result of an exhaustion of the neuro-hormonaD 
system, in consequence of the long lasting, unusual and ad- 
ditional stress on the heat-regulation. While judging and 
treating infectious diseases of all kinds in hot climates, 
this lability of the blood circulation is of great importance 
The administration of small doses of ephetonin for a longer 
period has shown good results. 
Serious aftermaths of commotio are very frequent in hot 
climates. Patients r7ith definite commotio are in hot climate 
not fully fit for service for at least 6 months to 1 year. 
During the hot season the high susceptibility of the 
skin to all kinds of infections due to dirt proves to be 
most hazardous with respect to the combat efficiency of the 
troops. In summertime, round or bean-shaped ulcers, usually 
on the legs, with slight formation of pus and a black, centra.' 
necrosis, following trivial skin injuries appear epidemically. 
There is little or no healing tendency. In my opinion the 
above described disturbance of the regulation of the cir- 
culation which is associated with an extravasation of liquid 
into the tissue, provides the conditions necessary for the spread of indicental infections of the skin, particularly 
on the lower extremities. The protection of the legs by 
wearing long trousers or high boots, as well as an immediate 
treatment of injuries of the skin, even the most trivial 
ones is of prophylactic importance. Therapeutically, the 
restoration of the local conditions of the blood circulation 
is important. 
We know from experience that the function of the 
digestive organs is reduced in hot climates. Digestive com- 
plaints are much more frequent. Sub-acidity, respectively 
anacidity is frequently observed in our soldiers in North 
Africa. Food difficult to digest such as legumes in par- 
ticular are, therefore, poorly tolerated. The bacteriologies' 
picture of the intestines changes in most cases? numerous 
protozones are observed in the stool. Systematic 
administration of (HC1) hydrochloric acid CAcidol-Fcpsin) 
helps to overcome these disturbances in a veiy.r short time. 
Prevention, respectively treatment of these dyspeptic 
symptoms by an appropriate diet is important to avoid sub- 
sequent infectious diseases, including amebic dysentery. 
The soldiers diet in hot countries has to take into 
consideration the climatic conditions* The food must be easi 
ly digestible, appealing end provide the necessary variety. 
The salt lost by perspiration "ust be replaced. A diet, 
rich in carbohydrates, and possibly served in several small 
meals, proved advantageous in cases of a hypotonic syndrome. 
Butter should be given preference to cover the fat require- 
ment of the body. Lard or bacon are less suitable during 
the period of the warmer months. The best source of vitamin 
G is lemons. Fresh potatoes will seldom be available • 
(Further details appeared in the Field Cookery Manual for 
hot countries, 1942). 
Our observations led to the following, practical con- 
clusions ; 
1. Only older soldiers of the Regular Army, minimum 
age 22 to 24 are eligible for service in hot countries. 
2. A transition period for mental and physical adapta- 
tion should be provided before combat assignment in hot 
zones. 
3. An interruption of the assignment in hot zones 
should take place after 12 months of service to secure 
the restoration of full efficiency of the soldier by a 
period in the homeland. 
4. Careful observation of all hygienic measures 
among the troops. 
5* The field surgeons must be well advised about the 
significance of the various kinds of complaints of the 
blood circulation. (Best of all by attendance at a 
course in tropical medicine.) 6* Special caution is to be observed with regard to 
transportation of patients during the hot season, be- 
cause of the ever present danger of collapse. 
7* As severe cases will recover ad integrum very slow- 
ly in hot climates, evacuation to the homeland will as 
a rule become necessary. 
2» Cardiac findings among soldiers of the Africa Ceres. 
Oberstabsarzt (Major, MC.) Prof. KAE1IMERER 
(Observations on the report of 3ta.bsa.rzt (Captain, MC.) 
Prof. HORSTSB). 
We were directed to examine soldiers, returning from 
Africa and complaining about heart troubles, by exact, 
clinical methods with the chief object of establishing, 
whether or not a Bl-hypo-vitaminosis could be responsible 
for alterations of the heart. The calculations of the food 
based on statements of the patients showed that the B1 content 
according to the formula of WILLIAM and SPIESS clearly ex- 
ceeded the minimum value of 0.3 in all patients, and amounted 
in all instances to 0.35 to 1.1. As a matter of fact, none 
of the cases in the past relatively mild summer and autumn, 
with regard to the war events, showed no evidence whatsoever 
that a B1 hypo-vitaminosis had been the dicisive factor in 
a clear cut heart disease. Only 16 per cent of the cases 
had a clear cut cardiac disease. 56 per cent showed no change 
of the heart at all; the rest showed a more or less vague 
suspicion of an impaired myocardium or only symptoms of 
vascular lability, hypotonia, vegetative neurosis, or mild 
thyreo-toxicosis* 
It is, of course, not entirely impossible that a B1 
hypo-vitaminosis may be considered in some cases to be 
acting simultaneously. This has to be considered, especially 
in patients, who owing to a long standing involvement cf the 
gastro-intestinal tract has hindered the absorption of vitamin 
or if infections absorbed the B1 reserves to a great extent. 
Such possibilities have to be taken into consideration es- 
pecially as our soldiers in Africa, have not infrecuently 
been suffering from long-lasting dysentery diarrhea? and im- 
pairments of the ferment-secretion. It seems that dysentery 
may be held responsible in many cases for cardiac diseases. 
The African climate in itself cannot be considered as the 
decisive factor for the heart troubles of our patients. But 
still, it seems that soldiers, who arc'susceptible to neu- 
rosis, vaso-lability, thyreo-toxicosis, have to suffer uar- 
ticularly from this climate with its sudden changes from hot 
to cold, its sandstorms, etc. Soldiers with a previously 
defective or susceptible heart will, of course, show objectir 
ly recognizable defects much easier than in their customary 
climate. Importance must be attached to infections, of which 
piaya|?iie molfnimpoftanl;apariS angina and diphtheria 170 
In contrast to these cases, admitted to our hospital 
during this summer and early autumn, in which heart troubles 
caused by B1 hypo-vitaminosis were very few, I had within 
the past weeks, since the period of heavy combat in Africa, 
the opportunity to gain more impressions in various hos- 
pitals cf our Military District. There are lately auite a 
lot of patients from Africa who, in spite of a severe 
dysentery, often had to endure a strenuous long evacuation.. 
Nearly all these patients told us that, because cf their 
very poor appetite, their food intake was very insufficient 
Furthermore we had to suppose an insufficient absorption of 
vitamins, because ~f the severe diarrhea. A great number 
of the patients complained about paresthesia in the legs 
and an extreme sensitivity to pressure of the nerve trunk: 
and also about a considerably reduced, flabby musculature, 
besides an excessive atrophy of the fat cushion and a 
serious myasthenia. That is to say those patients exhibited 
clear cut symptoms of poly-neuritis. 3ome of the patients 
exhibited symptoms of funicular myelosis and a great many 
had edemas. There is hardly any doubt that these c~rd.it i "'ns 
are synonymous with post-infectious 31 hypo-vitaminosis, 
having its origin in an insufficient absorption and insuf- 
ficient supply of food due to anorexia. A great many of . 
these cases from Africa were transferred to the homeland \ 
with the diagnosis "insufficiency of blood circulation", \ 
and this fact clearly indicates that already in Africa there 
were certain symptoms of complaints of the heart and of the 
circulation. There also were symptoms of weakness of the 
myocardium and the blood circulation of a great many cases 
in the hospitals of our Military District 5 but still, 
exact analyses could not yet be made in our hospital. 
The examinations hitherto made seem to confirm that 
heart troubles due to 31 hypo-vitaminosis can hardly be 
considered as a consequence of the African climate or of an 
insufficient or inappropriate nutrition in the theater cf 
operations, but heart troubles have occurred lately in 
many instances as an aftermath of dysentery and possibly 
other infections too. 
3# Scurvy. 
Stabsarzt (Captain, MC.) FAJ3HNDRICH 
The speaker submits a renort about the treatment 
83 patients aged from 2D to 50 suffering from scurvy *) 
who clearly exhibited - some in a severe form - spongy 
gums, superficial and deeply located hematomas, small or 
large scattered hemorrhages into the cutis and disturbances 
in gait so that the cases had to be considered as clear cut 
avitaminoses# The determination of the vitamin C contents 
*) The experimental examination has been made by the 
Institute for Physiological and Military Chemistry 
of the Military Medical Academy (Oberarzt (1st Lieut., 
MC.) GRAB). 171 
of the bloodserum at the beginning of the therapy showed 
in all. patients 0*00 mg per cent. The patients involved 
were in a bad general condition of health due to hunger 
and fatigue and often suffered from additional infections. 
Therapy. The patients were given in the beginning 
a diet consisting of 1800 calories, however, without vitamin 
C and with 50 grams of protein, the latter of biologically 
high value. A daily dosage of 10, 30* or 60 milligrams of 
ascorbic acid in the form of lemon juice was given to thre-. 
groups of 30* 30 and 23 patients, as tablets oy mouth or 
intravenous injections. 
Result. 4 to 12 days after the beginning of the therev 
the changes, especially of the guns, were considerably im- 
proved; severe hemorrhages into the cutis or into the tissue 
as had been observed in a large number of cases prior the 
therapy were not observed any longer. After 4 to 6 weeks, 
a recovery ad integrum of scurvy was achieved in all cases- 
It is especially important to that the clinical success 
of the treatment occurred in all patients regardless of the 
dosage and the administration of vitamin C. (Yet the 
general condition of health was not as good as it should be, 
in that the patients continued to lose weight for the tine 
being. By increasing the intake of calories to 3600 and 
that of protein to 100 grams daily, an average increase of 
weight of 6 kilograms was achieved within 2 months). It is 
particularly striking, that the vitamin C content of the 
blood of all patients including those who received dosages, 
did not appreciably increase during the treatment, and re- 
mained at an average of below 0.2 milligram per cent towards 
the end of the eleventh week. The value of 0,4 milligram 
per cent which is considered as a "poor value" by most of 
the authors, was not even approximately attained. 
Conclusions. It has been observed that even small, 
daily doses of vitamin C are sufficient to cure even severe 
cases of scurvy; doses that only present a fraction of that 
amount which is considered as a normal requirement of the 
healthy organism are sometimes sufficient. It may be taken 
for granted that the same dosages, by which scurvy can be 
cured, will also suffice to protect the organism against 
scurvy. It is doubtful, however, whether an organism suppliec 
only temporarily with an insufficient amount of vitamin C 
or none at all is really endangered to a notable extent as 
is generally maintained. Such vague concepts as "primary", 
"secondary", Relative" hypo-vitaminosis - as previously con- 
sidered - become still more problematic in the light of these 
findings. A deficient supply of vitamin must obviously exiso 
a rather long period and furthermore be associated with other 
particularly unfavorable circumstances (such as strain, in- 
fections, hard physical work) before scurvy really sets in. 
If this were not true, there would hardly be an explanation 
for the fact that we are not aware of a considerable number o?. 
scurvy cases, neither of the civilian population nor in the 
German Army, although it seems to be doubtful that in the now 
wide spread system of mass cooking more than 10 to 20 milli- 
grams daily of fragile vitamins which are only contained in a 
few food-stuffs are actually being served. These observations are,, of course, only intended to 
refut% exaggerations and we are far from speaking in favor 
of a reduced supply of vitamins. The scurvy epidemics in 
the years after 1916 are particularly recalled* A well- 
balanced, well-prepared and Immediately eaten diet is not 
only desirable, but highly necessary. 
Discussion: 
KOCH: Has made a postmortem examination in some of the 
described cases and has verified that the scurvy was cured. 
This became evident first by the color of the exanthematous 
scurvy, which is not red or blue-red*any longer, as during 
the period of hemorrhages, but changes into a small-spotted 
dark-brown (HaemosiderinI); and secondly the healed scurvy 
is proven according to ASCHOFF by the extensive, nearly 
mahogany-brown deposits of pigment which are found on the 
fascia and in the cellular tissue of the lower leg. 
alterations of the gums must not be considered of primary 
importance! they are rather co-ordinated to the hemorrhages 
of the fascia and the tissue, (They are not an 
symptom of scurvy.) They may, however, turn into stomatitis 
by a mixed infection (particularly apparent with carious 
teeth), which may lead to most severe gangrene of the gums 
and further to furdhcle-llke, most intense mebastases spread- 
ing from the mouth into the mucous membranes of the intestines, 
where the follicles are effected similarly to what is seen 
in PLAUT-VINCENT1s angina. A further symptom of healed 
scurvy are the closed separations of the epiphysis in the 
centers of growth of the bones, which can be traced even on 
adults of 20 years age who suffered as a baby from MOELLER- 
BARLOW1s disease, which is synonymous with early scurvy in 
babies. 
GUTZEIT: Underlines the conclusions of FAEHNDRICH. The 
supply of vitamin shall certainly not be neglected in the 
German Armed Forces. If, however, 10 milligrams of ascorbic 
acid are sufficient to cure scurvy, a much lower dosage is 
certainly .sufficient for prophylaxis and this is surely 
present in the every day diet of the German soldier. It is 
important that neither the so-called C-deficiency nor the 
vitamin C-level in the serum may be considered as a criterion 
for the diagnosis of scurvy. The opinioh which is maintained 
by some physicians, that hemorrhages of the gums must nec- 
essarily be due to C-hypovitaminosis, is certainly erroneous. 
It is quite certain that the hemorrhages of the gums due to 
paradentosis cannot be averted by vitamin C artless it is 
intravenously injected in large doses. It is then effective 
as a drug and not as a vitamin per se. 
FIKENTSGHER: Frequently and especially in the troops 
on duty in the north, the mistake was made to consider any 
hemorrhage or inflammation of the gums as a pre-s«urvy symp- 
tom. The physicians should, in every case refrain from lett- 
ing such assumptions reach the soldiers or officers in the 
command as this could immediately rise to false and alarming 
humors, which in turn will be repeated in the letters to the 
homeland. Fortunately, scurvy so far has not attained any 
significance in the whole German Army and precautions have been 
taken to ensure that in the future no danger will develop in 
this respect. XII. 
LUES. GONORRHEA* SCABIES 
Translation prepared by; 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section The directives stated below cover the essential part 
of the reports presented on these subjects. Therefore it 
can bo dispensed with to go into details concerning the 
individual statements. 
1. Salvarsan poisoning. 
Oberfeldarzt (Lt. Col. , MG.) Prof. LQEHE 
During the last years alarming reports have been made 
concerning Salvarsan poisoning during the treatment. These 
reports are unjustified and exaggerated. This is evidenced 
by a statistical inquiry made by SPIELHOFF in July 1942 
and by practical experience in clinics, largo special wards 
and military hospitals. 
It is not the lues which is to be treated but the lues 
patient. This means to consider individually the state of 
health of the particular diseased person before and during 
the treatment, in establishing the dose of the drugs, and to 
observe the sequelae of the injections. Due consideration 
should also be directed to preceding and intercurrent dis- 
eases, especially malaria, dysentery, liver troubles, in- 
fluenza, papatacci fever and renal diseases. A Salvarsan 
course in combination with bismuth preparations is indicated, 
starting with 2 or 3 injections of bismuth, and the weight 
and urine must bo regularly observed, as well as the appetito 
and sleep. Salvarsan is injected at intervals appropriate 
to the condition of the individual (3-5 days). For each 
course the total dose of 6.0 grams, and 15 - 20 cubic centi- 
meters of bismuth must not be exceeded. According to the 
check tests of the seroreaction of the blood further courses 
are to be made at intervals of 4 - 6 weeks. In the first 
stage of seronegative syphilis, 3 courses will be necessary, 
in secondary lues more (up to 5)• A single dose of Salvarsan 
must not exceed 0.6 grams. Each dose must be dissolved 
separately and must be injected with the patient lying down 
with the upper part of the trunk bare to permit observation 
of any possible appearance of a cutaneous eruption in order 
to avoid any possible irritation of the skin. In order to 
make it more tolerable to sensitive patients Salvarsan 
should bo injected along with a 20 per cent solution of 
glucose. 
In the course of a Salvarsan-bismuth treatment the 
following side-effects may be observed: 
1. Angioneuritic complex of symptoms, 
2. Exanthemata or even as severe as dermatitis, 
3. Hepatic complaints including jaundice and acute 
yellow atrophy of the liver, 
4. Purpura cerebri, $. Hemorrhagic diathesis, 
6. Agranulocytosis. 
By extending particular attention to apparently in- 
significant initial symptoms (isolated spots of bleeding, 
nosebleed, hematoma) and by having always in mind the chief 
principle: "Treat the individual" most cases of severe 
damage may be prevented. 
2. Chemotherapy of gonorrhea in the Army. 
Oberfeldarzt (Lt. Col.t MG.) Prof. GOTTRON 
Gonorrhea is treated with sulfonamide preparations, 
especially thiazol preparations such as Eleudron and Cibazol, 
while the other types should bo excluded whenever possible. 
The treatment is carried through by massive doses during 
2 or 3 days, the daily prescription being 5x2 tablets. 
Local treatment should bo dispensed with under these cir- 
cumstances. No more than 3 massive doses are of use. Should 
the first course fail, another course after an interval of 
4 days should be given. If the failure recurs a third course 
is required in combination with an alterative treatment 
(vaccine, pyrifer, olobintin 40%), consisting of 5 - 6 in- 
jections of pyrifer with the third missive dose of Eleudron or any 
similar preparation to follow. Confinement to bed is im- 
perative. The tablets should be taken along with an ample 
supply of fluid and under observation. The simultaneous 
intake of sodium bicarbonate and sulfonamide preparations 
is not advisable. 
Patients afflicted with gonorrhea should always be 
cared for in hospitals. Ambulatory treatment cannot bo ad- 
vised. "Prophylactic treatment" in the absence of an micro- 
scopically certain diagnosis is prohibited. As to the few 
remaining failures the long-established classical local 
treatment with thorough irrigations and injections should 
bo resorted to, supplemented by surgical intervention if 
necessary. 
When treatment is finished a tost period is necessary 
by using provocative moans; as a rule 6 days will suffice 
for the purpose. 176 
3. A rapid form of treatment for scabies. 
Marinooberstabsarzt (Lt. Comdr., MG., Navy) 
Prof. BIHNBAUM 
For a diagnosis of scabies the presence of ascarus 
burrows is unobjectionable proof. Bettei still is the 
microscopic evidence of the mites themselves, or their eggs. 
Scabies may bo treated in wards or sick bays, yet in the 
latter case disinfection of the laundry ought to be assured 
under all circumstances. Ways and means for the treatment 
of scabies depend on the economic conditions created by the 
war. At present sulphuretted vaseline 30% is indicated only 
if the skin is intensively irritated or in the case of ex- 
tensive secondary changes of the skin, Two stage treatment 
with first a solution of sodium thiosulfate 40 - 60% and a 
subsequent application of a solution of hydrochloric acid 
60%f during 2-3 days, may be recommended, twice daily. 
The solution of sodium thiosulfate (showing a yellowish- 
shite coat on the skin) must be applied thoroughly and must 
be left to dry for some time, thus preventing the hydro- 
chloric acid spread on afterwards from causing injury. 
Another remedy is Vleminxgkvs solution, which is brushed on 
for half an hour, baths have to precede and follow its use. 
There is no danger for scabies spreading within the 
area of our homeland as widely as it is in France at the 
present. All the same its appearance should bo kept under 
special control, as in wartime it may easily spread. 
In order to get reliable statistical material con- 
cerning the frequency of scabies it is suggested to have 
scabitic patients listed separately under serial number 25 
in the army and hospital records of diseases. 177 
XIII. 
PROCEEDINGS OF THE CONSULTANTS 1 
COMMITTEE ON PSYCHIATRY 
Translation prepared by: 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section Psychic irregularities associated with typhus 
(See SectionVI, Article 3) 
A. Psychogenic Reactions. 
1* Hysterical reactions in the Field Amy. 
Oberarzt (1st Lieut., MC.) Dozent MIKOEEY 
As comparod to World War I hysterical reactions in tho 
Field Army during tho present war are rare so far. They 
amount to less than 10 per cent of the admissions to neuro- 
logy departments. In armies on the attacK they arc very 
rare. They are a little more frequent at stabil front lines 
and in the rear areas. Among the different symptoms the mild 
or easily influenced syndromes predominate. Various forms 
of debility are common while serious convulsive trembling is 
relatively rare. 
Early treatment in tho area of the army group is decisive 
for the further progress. By a professional reassurance and 
consequent treatment tho fixation of fright reactions etc., 
and hysteria are avoided. From the very beginning, 
hysterical reactions should be kept away from any sounding 
board and it must be clear that it docs not lead to any 
considerations worth striving after. The treatment is to 
be performed as much as possible under the control of tho 
army group. Most hysterical reactions have proven to be 
easily influenced by therapeutic measures. After a sub- 
sidence of a first mild reaction the patient may be trans- 
ferred to the fighting troops again. But it is to be dis- 
couraged that hysteriacs with serious and obstinate reactions 
are returned to the fighting troop, because they may become 
panic centers. They should bo ordered to the Labor Service 
in the rear areas. By no means should they be discharged 
as unfit for military service, in order that no incentive 
for imitation be given to draft dodgers. Such serious 
hysterical reactions, which arc not at all amenable to 
therapy, should bo interned in public sanatoria during tho 
war, because of tho psychic infection danger. 
Discussion: 
Stabsarzt (Captain, MC.) Dozent BUESSOW: The lecture 
has shown, that tho principles of dealing with the problem 
of hysteria are clear. I have found everywhere the same 
attitude in the Consultants1 Committees of the Field Army. 
I also have observed the overlooking of coarse hysterical 
cases in favor of the finer ones. There^are difficulties 
concerned with tho evaluation of these finer syndromes, most- 
ly projected to an organ, as non-psychiatrists are inclined 
to overestimate minor organic findings. Tho alternative 
question ’’psychogenic or somatic” is asked and is decided, 
on the basis of insignificant organic findings, to be somatic. I also have the impression, that in such cases the patientfs 
attitude towards his suffering conditioned on his personality 
and his background is not always given enough attention. In 
such cases the psychiatrist is able to assist the internist 
especially regarding tho judgement of the patient. It seems 
to me to be of a special importance, that we facilitate the 
understanding of our diagnosis to the non-psychiatric trained 
physicians by a clear and, as much as possible, uniform 
nomenclature. 
2. Hysterical reactions in the Reserve Army. 
Oberkriegsarzt (Col., MC.) Prof. BUMKE 
We have hospitalized during 4 months from Military 
District VII, 50 soldiers with the diagnosis war hysteria. 
The number of mild cases which could be freed of their 
irregularities by an outpatient treatment is a much greater 
one. 28, or more than 50$ of these hospitalized cases, 
have had to be considered as not of full intellect. 17 of 
them had shown psychogenic reactions before their enlistment 
in the Army, such as trembling or similar disturbances. 
8 of them were said to have been under medical treatment 
for nervous disorders or to have had a "nervous breakdown". 
One man has already tried to commit suicide in earlier times. 
In 7 cases an organic cause behind the psychogenic symptoms 
was found. In 2 cases which were sent to us, the diagnose 
hysteria was fundamentally wrong. In 17 of the 50 cases 
it has been possible to establish that the trembling or 
other psychogenic symptoms have probably been the conse- 
quence of a fright. 
How can w'ar hysteria be avoided? Most surely, if at 
all possible, by not enlisting unfit people. But if a 
psychopath has been enlisted and then shows hysterical 
symptoms, he is not to be discharged again under any con- 
ditions during the war. If therefore the therapy remains 
completely without success, or in case he has a recurrence 
after primary successful treatment, there is only one form 
of further treatment: it is necessary to isolate these 
people, with the same right and for the same reasons as 
infectious patients are to be separated from the healthy 
people. This is done best in special houses of the hos- 
pital accommodations in lunatic asylums. The weak-minded 
may be excepted and may be discharged, if at the same time 
they are sterilized, for then everybody has notice, that 
they are not discharged from military service^because of 
their trembling but because of their feeble-mindness. 
Discussion; 
Stabsarzt (Captain, MC.) Prof. PANSE; In connection 
with the dissertation of Geheimrat (Privy Councellor) BUMKE, 
I am satisfied with the remarks about the necessity and 
success of an energetic treatment of the psychogenic re- 
actions with the aim of their rapid correction in the Mili- 180 
tary District VI. 134 patients with acute psychogenic dis- 
turbances have been treated by suggestion combined with 
strong galvanic currents in the Reserve Military Hospital, 
ENSEN from 11 March to 11 November 1942. 79% of them were 
affected with psychogenic paralysis and fixed mental atti- 
tudes of immobility after wounds of the extremity, with and 
without lesions of the nerves, contractures or disturbances 
of walking. Tremblers have occurred in only 7% until now. 
The rest were stutterers, mutisms, pseudo-dementias, seizures 
and similar things. In all cases a relief of the psycho- 
genic conditions was obtained. At the moment they are still 
more masked, are connected closer to an organic center, are 
less conditioned on real events, and less demonstrative than 
1914/18, but non the less dangerous, as they may be over- 
looked easier or be mistaken as organic troubles and then 
may lead to unjustified supposition of decreased or lost 
fitness for duty. Their number has been increasing steadily 
for about one year. The treatment by suggestion, combined 
with strong galvanic currents, does not correspond with the 
treatment of KAUFMANN particularly as in this case galvanic 
currents are used and the cure is not possible in one session- 
After an oral explanation in a kindly and confident manner, 
and without showing the patient that his attacks are not 
considered to bo serious, in a session of 2 or 3 minutes, 
(adjustment to 10 to 10.5 of the regulation switch of the 
pantostat, corresponding to 80 to 100 milliamperes resistance) 
a treatment with the rolling cylinder electrode is performed. 
Hereby the heart remains as far as possible outside of the 
course of the current. Between 1 to 2, at most 3 applications 
of current followed immediately by movement exercises which 
are adapted to the condition. At the beginning even in- 
significant results arc sufficient; the further suggestive 
and exercise therapy is to bo developed upon them. In 
obstinate cases repetition of the treatment from time to 
time at 7 day intervals is used. But in most cases a single 
treatment is enough. Every injury of the sense of honor 
of the soldiers is avoided. The patients must have the 
feeling they are being treated with a particularly efficient 
method, but not threatened by a current treatment for the 
purpose of giving up the psychogenic mechanisms. In my 
opinion such a treatment is not dispensable, as there is no 
other treatment, non-injunions to health, with the same 
impressive and suggestive power. The treatment is to be done 
by neurologists and psychiatrists who are certain in diag- 
nosis and with good experience. Under this supposition it 
has already proved good in the field. In single cases we 
have received notice of recurrences. 
Directions for the evaluation of soldiers with mental- 
nervous irregularities ("psychopaths") and 
mental-nervous reactions. 
iU General. 
The so-called hysterical reactions, represented by 
simple psychogenic superpositions and hyporaccentnation 
and*including the presentations of apparent irregularities 
such as trembling and shaking are to be distinguished for the 
beginning from those abnormal reactions, which occur after 
an overload and from such ones, which have to be considered 
as the expression of a psychopathic predisposition. Furthermore wo must not forget that there is a diminished 
resistance of the youngest and oldest ages; of the youngest 
because of their immaturity, of the oldest because of their 
exhaustion. If they react in an abnormal way we have by no 
means to suppose in every case that there is a psychopathic 
personality. That means for the evaluation of the juveniles 
that we can give them, in most cases, a favorable diagnosis, 
whereas it will be unfavorable for the older group. The 
young are to be gradually brought back to front service, 
whilst the oldei patients are to be withdrawn from the front 
and employed according to their capacities. 
On the other hand, abnormal reactions shown by midale 
aged soldiers are to be considered in most cases as the 
expressions of an irregular predisposition. Their antecedents 
(previous history of their family, period of sojourn in an 
asylum and previous convictions) are to be clarified and an 
education program is to be tried after curing the symptoms. 
All psychotherapeutic measures are to be started only 
after the most exact examinations with regard to organic 
changes. Soldiers who for example complain about disturb- 
ances of stomach, intestines, circulation, or bladder belong 
to the internist. The neurologist is consulted in these 
cases at the beginning only in case of necessity. On the 
other hand, one should insist upon the consultation of a 
neurologist as early as possible for these wounded soldiers, 
who have to lie at the beginning in a military hospital where 
no neurologist is available. Thus it is possible to avoid 
various accommodation or defense attitudes. 
The treatment of psychogenic troubles has to begin as 
early as possible. The milder reactions usually disappear 
quickly by themselves or by means of camaraderie. Some of 
them need medical treatment as early as possible. If after 
several days no involution has occurred, transfer to the 
neurological department of a field hospital becomes necessary. 
If in this case it is not possible to obtain any results, an 
energetic treatment is to be instituted as quickly as possible 
which is still limited to hospitals of the occupied terri- 
tories and those near the borders of Germany (sub-hospitals). 
Besides other methods, the treatment with strong galvanic 
currents has been successful. But it is only to be performed 
in such a way, that the patient is convinced of its purely 
medical indications. In any case the impression of a moral 
influence or even of a punishment is to be avoided. 
In many cases the accommodation of organically sick 
persons on psychiatric closed wards is therapeutically 
favorable. This measure has proved good in case of psycho- 
genic reactions in which simple psychotherapy has no in- 
fluence . 
The cases, which by every treatment are without lasting 
success, are - after asking the consultant psychiatrist - 
to be interned in the sub-hospital of a sanatorium. A war- 
unfit discharge does not come into question, except in those 
cases whore foeble-mindedness has been diagnosed simultaneous- 
ly. In order to prevent the enlistment of such persons 
liable to military service the writing of a test dictation 
combined with the first medical examination and classification 
of recruits is recommended. Attention is to bo paid to 
former diseases, hospitalization, ana sojourn in an asylum 
or nursing home. Wa give the following airectives: 
The treatment of the psychogenic reactions has to take 
place chiefly under the control of the Field Army and hos- 
pitals in the rear areas, whilst the treatment of lesions 
of the central and peripheral nervous system of soldiers of 
the Field Army is the business of the hospitals in the home- 
land . 
It is the particular duty of the physicians with ad- 
vanced troops to have an exact knowledge of the different 
personalities of his unit, and for this a close cooperation 
with the commanders, also with the lower unit-loaders, is 
indispensable. Only by this is a just treatment and judge- 
ment of soldiers with mental-nervous disturbances possible. 
A moral judgement as to value based on generalities is to 
be avoided as among the soldiers there are always obstinate 
ones and many good natured and tractable ones. In order to 
make possible a suitable judgement, designations such as 
"neurosis, psychopathy”, "psychopathic reactions” and so on, 
are to bo replaced by a short description of the personality. 
B. Special syndromes. 
Mental-nervous abnormalities (psychopathy) are dis- 
turbances in the sector of the will, the emotions and the 
instinctive sexual life. They are permanent conditions and 
of themselves are not diseases, but sometimes they are of 
so high a degree, that they have the "pathologic value” of 
a disease (i.e. obsessions). When this is the case they 
must bo classified as ”U” in the "Medical Instructions for 
the Classification of Registrants - with regaidto their 
Fitness for Military Service in Wartime”, abbreviated 
"M.I.C.M.S." (Editor1s Note: ”U" or ”vU” 15.3 is the code 
for "Serious Mental Abnormality of Pathologic Value i.e. 
Obsessions, Constitutional Depressions, Phobia"; Folio I 
Project I Translation of this Section). Practically three 
large groups may be distinguished. 
I. Soldiers with a sound physical and mental con- 
stitution. 
Abnormal reactions (conditions of anxiety and perplexity, 
trembling, functional paralysis, etc.) occurring coincidently 
or susequent to certain conditions (catastrophic events, ei- 
haustion, secondary or subsequent effects of physical dis- 
eases) . 
Treatment: In case camoradorie and medical encouragement 
doos not help), as will usually be the case, return to a field 
or base hospital. Establishment of an exact anamnesis as soon 
as possible. Plenty of food, possibly insulin (10 - 20 units before the meal) narcotics. After 8 days at the most, ordered 
back to work and to military exercises. In case of recovery 
use of service or convalescent homo for a short time. In 
case of failure of the treatment {"hysterical fixation") 
transfer to the neurological department of a base hospital 
{see group lie). 
Classification; After removal of the disturbance, fit 
for active service as previously, 
II. Abnormal personalities with pure mental abnormal- 
ities. 
a. Abnormal characters ("characteropathies") as for 
instance patients with a feeling of insecurity with an undue 
sense of self importance, swindlers, asocial and antisocial 
personalities. 
Treatment; Their treatment because of the absence of 
a mental disease is not medical, but rather a disciplinary 
matter. 
Classification; In case of physical fitness, "k.v." 
(fit for service) and with regard to above mentioned 
"M.I.C.M.S." A 15.3 ("Low grade psychological degeneration 
of a person, who apart from this deficiency will bo con- 
sidered fit for service"). 
b. Weakness of resistance ("psychasthenics"), i.e. 
timid people and those weak in forming a resolution who in 
spite of their best will are not able to act independently 
because of their helplessness, anxiety and exaggerated feel- 
ing of personal responsibility. 
Treatment; No particular treatment required other than 
encouragement. 
Classification; According to productive power (i.e. 
Supply Corps, but by no means construction battalion). 
c. Soldiers with the tendency of fixation^and pro- 
duction of abnormal reactions ("hysterics"). 
Symptoms; Coarse trembling, seizures, functional para- 
lysis, loss of voice, deafness etc. Abnormal reactions are 
partly prolonged (adherence to wish and desire ideas), and 
in part they are first formed in rear hospitals. 
Treatment; Assignment to neurological department of 
a base hospital. The best thing to do there is to place the 
patient with cases of brain injuries. In case there are 
qualified medical specialists available, removal of the symp- 
toms by suggestion hypnosis or galvanic current. After this 
assignment to a convalescent company. It is better to not 
undertake treatments of doubtful success among those patients 
showing symptoms resistant to treatment, but it is better to 
transfer the patient to the hospital department of a medical 
establishment of the occupied territories or near the bound- 
aries of Germany. They should not be transported to the home- 
country, at all events not to their native province. They 
should not be discharged as war unfit before removal of the 
sympt oms. Classification; After an unfavorable issue once, 
one more attempt with earlier employment is justified; 
in case of repeated recurrences transfer to the hospital 
department or sub-hospital of a medical nursing and oon- 
valenscent establishment. 
III. Personalities with combined mental and physical 
abnormalities. 
a• Soldiers with physical defects of the constitution. 
disturbances of growth, infantilism and retarded 
development. 
Treatment; They should not be assigned tasks beyond 
their ability. Cases of infantilism should bo transferred 
to replacement units to await more maturity. 
Classification; According to mental-physical maturity. 
Sometimes "g.v.H." (fit for garrison duty at home) and with 
regard to above mentioned "M.I.C.M.S.” L 15 or L 1.2.(Refer 
to Folio I Project I Translations of this Section)• 
b. Patients with a labile constitution with tendency 
to functional disturbances of the separate organic 
systems (i.e. vasomotor lability, vegetativoly 
labile patients with a tendency to brain edema, spasms, 
twilight states, tetanoid symptoms after physical exertion, 
etc.) 
Treatment; Stabilizing remedies; Bollergal, Luminal 
tablets. 
Stimulants; Cardiazol, grape-sugar. 
Classification; Limited employment (according to L 15, 
see above) according to their ability. 
C. Older soldiers with symptoms of retrogressive 
metamorphosis caused by age, prescleroTlc or presenile 
disturbances (high pressure\ irritability, forgetfulness, 
diminished functional capability -etc.). 
Treatment; Iodine, lodine-calcium-diuretine• 
Classification; According to above mentioned L 15 or 
L 49, and "g.v.H." (fit for garrison duty at home) or "a.v," 
(fit for labor duties only). 
C. Principle consideration for transfer to 
special units7~ 
1, Soldiers of all degrees of fitness with the ex- 
ception of epileptics and the weak minded may be transferred 
to special departments or to special field battalions. 
2. Special departments are training departments in 
the replacement areas for the soldiers who learn slowly. 
If they are unfit because of bad will, they are transferred 
to the special field battalions. 185 
3. The special field battalion has predominantly 
the character of punishment. If soldiers are even unfit 
for them, they are transferred to a concentration camp# 
B. Differential diagnosis between schizophrenia 
and event-reactions. 
Schizophrenia and event-reactions, 
Oberstabsarzt (Major, .MG.) Prof, Kurt SCHNEIDER 
At the front diagnosis is often not possible since 
usually only one examination is done. Inaccuracy is al- 
most to bo expected. But sometimes diagnoses could bo 
recognized as erroneous and corrected by the physicians 
themselves. Drugs transform the picture into a toxic one, 
an external aggravation of the diagnosis. You then only 
see an intoxicated or bonumbod individual. .The difficultios 
in the case rest on the inadequate preceding history and 
on certain traits of tho symptomatology, which may occur 
in both cases in the same manner. You rarely are informed 
if a soldier has had a particularly frightening experience, 
which could justify an abnormal event-reaction with 
spending contents. Even cases of acute schizophrenia in tho 
field often have fighting and dangers of the front as con- 
tents. The difficulty is increased by that. You see the 
following syndromes: anxious excitement, ceremonius atten- 
tion or expectation, apathetic stupors, pictures as de- 
scribed by GANSER-(GANGER, 1853 - 1931, was a psychiatrist 
in Dresden, GANGER’S syndrome is: amnesia, disturbance 
of consciousness, hallucinations, generally of hysterical 
origin: tho condition is marked by senseless answers to 
questions, and by absurd acts. Called also ’’acute hallu- 
cinatory mania”.) Even tho finding of the single symptoms 
does not lead to further clarity, as usually they arc neither 
characteristic for schizophrenia nor for event-reactions. 
Principally only the ’’symptoms of the first class”, which 
have been repeatedly brought to prominence, are positively 
decisive for schizophrenia. The frequent occurrence of ill 
defined psychoses at certain places speaks against a schizo- 
phrenia even in a single case. There is no experience about 
their‘course in tho field. Also in this war, schizophrenia 
is assumed in too many cases. Concerning'the defect, it 
should be considered, that also after serious events and 
experiences as well as after diseases a long period of 
apathy and indecision will occur. These early doubtful 
cases are by no means all of them transition states be- 
tween schizophrenia and event-reactions, which should be 
dismissed without any psychiatric diagnosis. Here it is 
only tho question of a particularly difficult^diagnosis. 
We have to warn against the vague use of ’’schizophrenic 
reaction”. Either it is the question of abnormal event- 
reactions or of schizophrenia, which take their contents 
from their surrounding world, as does every schizophrenia, 
and in this case the surrounding world is the field situa- 
tion. We must be skeptical of the first diagnosis even if it has been established by a prominent physician. This is 
of practical importance. We have no right to reproach 
soldiers with event-reactions for even the best soldiers 
may break in case of great stress of circumstances. They 
are also criticized by the troops in a remarkably wise way. 
Discussion; 
ERNST; With regard to the consideration of endogenous 
psychoses, especially of schizophrenia, we have to observe 
certain reservations, concerning the Field Army. We have to 
think of the possibility of symptomatic, exogenous or re- 
active diseases, above all if preceded by severe mental or 
physical stress (exhaustion, chilling, insufficient food 
or lack of sleep) in case there is a physical disturbance 
or an obviously weak general constitution. During the 
special conditions of the winter 1941/42 such difficulties 
could bo observed frequently. The clear diagnosis will be 
facilitated if wo succeed in obtaining the preceding history 
from the troop physician and from the troop (exterior in- 
fluences and strains, time and form of the first mental 
symptoms, physical changes, promorbid personality perhaps 
even behavior at former difficulties of live, family) and 
are able to study the man (also the reactions to exterior 
influences, air raids, evacuation of comrades etc.), 
Evipan-narcosis (in case of psychogenotics sometimes at first 
combined with "psychocathartic excitement"), Cardiazol con- 
vulsions, Insulin-half-shock are able to facilitate diag- 
nosis and to improve the condition enough for eventual 
evacuation. First of all the establishment of indications 
is important; evacuation or not? how far? and only then 
may an-exact diagnosis bo proposed. 
Directions concerning differential diagnosis between 
schizophrenic mental discurtances and event- 
reactions in the field"! 
Because of the similarity of the early symptomatology 
the cases which do not subside in a few days are to bo 
assigned to a psychiatric department. 
Wo have to recommend that the troop physicians be 
conservative with the diagnosis "schizophrenia". 
As far as the military situation permits the patients 
are to be left.in the base hospital until a clear diagnosis 
has been established. 
On account of the difficulties of establishing an * 
adequate previous history, diagnosis is to be based on the 
recognition of the acknowledged cardinal symptoms of schizo- 
phrenia. C. Problems of encephalitis. 
1. Stabsarzt (Captain, MC.) Prof. Carl SCHNEIDER 
At first the lecturer discussed classification and 
pathological anatomy of the different types of encephalitis. 
In the moment only the virus-encephalitides, with exception 
of ECONOMO’s encephalitis are important and of these again 
the panencephalitis of the type St. Louis. The so-called 
tick-encephalitis "Zecken-Encephalltis") or "Teiga-ence- 
phalitis" may become significant. The clinical symptoms 
were discussed: serious psychic symptoms are always com- 
bined with extensive, but constantly changing neurologic 
symptoms and more serious vegetative syndromes: delirious 
and amenta! conditions, numbness, paranoid syndromes, som- 
nolence and coma. Neurological symptoms: transient pyra- 
midal symptoms, cerebellar or olivar disturbances, especially 
ataxia-bulbar symptoms: trismus, dysarthria, even total 
inability of speaking, dysphagia. In most cases myoclonus, 
choreiform and athetoid phenomena, sometimes the "appalic 
syndrome”: stiffness, hypokinesia, reflex of seizing or 
sucking, irritation caused by external stimuli, listlessness, 
adynamic speech. The particular symptoms can change from 
day to day; it is very rare to find the same picture during 
several days. During this time the general condition always 
remains considerably affected as is shown especially by the 
conduct of the vegetative functions: marked perspiration, 
pronounced lability of pulse and of blood pressure, 
excess salivation, bloated face, dry skin. Bulbar-vestibular 
forms: apoplectic forms, pronounced dizziness, usually 
without any precursors and nausea often forces the patient 
to complete tranquillity. Besides that nystagmus, diffi- 
culties of equilibrium, Romberg’s syndrome, deficiencies of 
cranial nerves (paresis of facialis and abduoens), bulbar 
deficiencies of sensitivity. There also occurs thalamar 
and diencephalic pictures, as well as atypical ones: poly- 
radiculitis or polyneuritis, Landry’s paralysis, psychoses, 
only after subsidence of the neurologic syndromes and masked 
forms, grippal and subchronic and chronic neurasthenia-like 
conditions of feebleness. There is to be found also a slight 
change of character in the direction of anxiety, fearfulness, 
whining, pictures of the type of psychic-emotional conditions 
of feebleness after symptomatic psychoses. Added to that 
brisk vegetative syndromes, sweating, often in a 
profuse manner, emaciation, polyuria, polydipsia, lability 
of circulation, tendency to collapse, changes of blood 
pressure combined with minor pareses, mild pyramidal symp- 
toms, altered reflexes, especially those of the abdominal 
wall, Rossolimo’s sign, Mendel-Bechterew’s sign etc. Most 
of these patients were mistaken as psychopaths and draft- 
dodgers or they were given the diagnosis of vegetative 
stigmatization. Important for diagnosis are the findings 
of the spinal fluid and here especially the cell-picture. 
But the spinal fluid findings are often inconsistent and 
are often found to be normal. This fact is especially 
important, but evidently unknown, and therefore diagnosis 
is often missed. In most cases there exists a pleocytosis, 
of between some 20 to 30 and some 100 cells, in the first days leukocytes, later on lymphocytes and plasma-cells. 
Therapeutically effective are Eubasin, sweating procedures, 
supply of sufficient fluids, irradiations with X-rays, 
frequent blood transfusions, high protein enemas at inter- 
vals of about 5 days and grape-sugar intraiienously. 
Point of view of the Consultants* Committee regarding 
Problems of encephalitis. 
Until now the observations are not yet sufficient for 
the establishment of new directives. It is certain, that 
besides the known types of inflammations of the peripheral 
and central nervous system which have been observed before 
the present war there were disease-pictures in Japan, America 
and with us (which wore designed as encephalitis japonica 
and St. Louis) and also the so-called tick encephalitis 
should be mentioned in this connection. Etiologically those 
diseases are not yet sufficiently clear. In consequence, 
a special treatment cannot yet be recommended. This is 
especially true for the non-suppurative forms, some of which 
are said to not even show inflammatory changes in the spinal 
fluid. In cases of the suppurative brain diseases one should 
use sulfonamides, especially Eubasin, Cibazol, Eleudrin, 
Globucid etc. According to the present situation it is 
urgently necessary to carefully consider at the next meeting 
the problems concerning primary inflammatory diseases of the 
brain, spinal cord and of the peripheral nerves, as well as 
those subsequent to infections, either general or focal. 
The consultant psychiatrists have already boon collecting 
material and have referred to the need of further work on 
this problem. 
D# Causalgia. 
1» Oberstarzt (Colonel, MC.) Prof. WUTH 
Causalgia, known ever since the American Civil War, 
but in peace-time often forgotten in spite of the reports 
of several researchers, appeared in World War I and now 
again in this one. It is not to be mistaken with neuritis. 
Its symptom picture (burning pains after dry touch, even 
following noises, even in the uninvolved extremity) must 
become better known in order to avoid confusion with hysteric- 
al reactions and thus result in wrong and possibly unjust 
treatment of the patients. 2. Oberfeldarzt (Lt. Col., MC.) FUCHS 
Among 13 gunshot injuries of the extremities, with and 
without peripheral nerve injury, the following syndrome 
was observed; 1. "Indefinable"continuous pains, not in- 
fluenced by analgesics. The pain distribution chiefly 
involves the palm of the hand or respectively the sole of 
the foot of the injured extremity, 2. Increase of the 
pain due to movements of extremities which may be distant 
from the injury. Attacks of pain in case of concussions. 
3. Algogenic and algophobio akinesis, as well as fear of 
concussions. Expectation-anxiety, even if you come near 
to the bed. 4« Pain attacks of protopathic character 
caused by tactile and thermal stimuli in the painzone, in 
rare cases also pain in the symmetrical part of the unin- 
jured extremity (alloparalgia), 5» Synesthesialgia (that 
means a condition in which a stimulus produces pain on the 
affected side but no sensation or even a pleasant one on 
the normal side of the body) tactile and thermic stimuli 
on any part of the body may cause pain in the affected area. 
6, Pain attacks by sensory stimuli as for instance glaring 
light, but especially noise, tumult. 7. Xerosalgia, better 
called trachyalgia, that means provoking pains by the feeling 
of dryness, of rough material, by touching or by being 
touched with dry fingers, by the weight of the bed linen, by 
putting on rough socks, by touching paper, - all these may 
cause pain in the affected area. 8. Hygromania, that means 
moistening the painful extremities, as well as parts of the 
skin far away from the wound. Such patients wear moist ban- 
dages on hands and feet, they moisten their fingers with a 
wet sponge for preventing xerosalgia. The same is attained 
by oiling the hands and feet, and wearing rubber gloves. 
Phobia to all dry and rough material. Patients are not able 
to watch other people put on rough socks, or scrub their hands, 
9. Sympsychalgia, that means transposing psychic occurrences 
into pain attacks in the injured zone. Even the thinking 
of grief and joy starts pains. 10. All 13 cases were healed 
abruptly by removing the stellate ganglion and thoracic 
ganglions I and II, or by the removal of the lumbar ganglion 
II and the sacral ganglion II with their attached sympathetic 
nerves. The operation was done by Oberstabsarzt (Major, MG.) 
Dr. Hand LEHMANN, Vienna. The oldest cases have been free 
from pains for 3 years. 
It is to be requested that the diagnosis causalgia be 
used only for a well defined syndrome. About the therapy 
and the mechanism of this disease, no agreement was possible. 
Burning pains caused by traumatic neuritis, neuralgia, and 
phantom pains by sympathectomy, cannot be cured. 
The grotesque behavior of the causalgia patients and 
their phobias occasionally causes their being mistaken as 
hysterics. But after the operation these patients bear 
the burning pains with the greatest tranquillity of mind, 
behave neither hysterically, "neurotically", nor as "pain- 
hyperpathics", whenever contractures and stiffness which have 
arisen during the disease are freed. 190 
Indications for operation: As soon as the diagnosis is 
firmly established and the patients themselves feel their 
condition is intolerable. Otherwise there is danger of 
morphinism and in case of neurologic failures irreparable 
contractures and atrophies. 
In case of the 13 patients referred to neither the re- 
moval of the projectile of a shell splinter, nor exterior 
and interior neurolysis, epidural injections, vitamin B, 
vaccineurine, cobratoxine, vaso-dilatoric remedies, insulin, 
galvanization and short waves were able to cure or to stop 
its further progress. 
As a result of the Vienna experience it is not pertinent 
that the relative deficiency of vitamin B caused by war 
nutrition is the cause of causalgia, as has been supposed. 
For, 8 of the 13 cases have been wounded in the time from 
1 to 21 September 1939 and were affected within a few days 
and weeks with a completely developed causalgia. A relative 
vitamin B deficiency cannot be assumed during this period, 
3. Stabsarzt (Captain, MG.) Prof. Carl SCHNEIDER 
After having eliminated all neurological contractures 
and those caused by surgical operations, there are other 
persistent psychogenic contractures and curious forms, which 
evidently are related to causalgia. Their symptoms are: 
curious distorted cramped position, scissors-hand, swan’s 
neck, hands held like dog-paws, prolonged athetoid positions, 
grotesque stretched and bent contractures. The positions 
cannot be accomplished by means of the free will. They 
ordinarily correspond to the typo of distribution of the 
nerves. The tonus is elastic, and pliant. The contracture 
may even persist during the sleep and in deep narcosis. 
Symptoms similar to causalgia may be observed, distinct 
vegetative phenomena are especially characteristic: serious 
vasomotor deficiencies, uniform red or cyanotic change of 
the color of the hand, pronounced cold of the extremities, 
shiny skin; brittleness, change of color, cessation of 
growth of the nails; serious deficiencies of sweat secretion, 
permanent hyperhydrosis, and also increased growth of the 
hair. Almost always it is the question of partial lesions 
of the nerves without any abnormal reaction to electric 
stimulation. In consequence of an interruption of the 
stellate ganglion relaxation of the contractions takes 
place. 4» Stabsarzt (Captain, MC.) Dozent ZENKER 
The most suitable treatxment of the common type of 
causalgia as well as of the local one consists in the iso- 
lated elimination of the sympathetic supply of the injured 
extremity by way of extirpation or alcoholization of the 
stellate ganglion and the thoracic ganglion II, or of the 
lumbar and sacral nerves bundle. In the hospital of 
KIRSCHNER, 37 patients with causalgia were treated pre- 
ferentially by alcoholization of the sympathicus, as re- 
commended by PHILIPPIDSS, instead of the more energetic 
sympathectomy, The necessity of an interruption of the 
sympathetic nerves by novocain as a trial for the clarifi- 
cation of the diagnosis and estimating the prospects of suc- 
cess is emphasized. All patients with causalgia or with 
causalgia-like symptoms should be brought as early as possible 
to a hospital department with special experience in this 
field. A film showing the technique of alcoholization of 
the sympathicus was demonstrated* 
E* Punishable acts associated with drunkness. 
Military-medical expert opinion concerning alcoholism* 
Oberstabsarzt (Major, MC.) Prof. MUELLER-HESS 
and Qberstabsarzt (Major, MC.) ROMviEHEY 
63 cases of punishable acts due to alcoholism have 
been medically examined since the beginning of the war in 
the University Institute for Forensic and Criminal Medicine. 
17 of these acts occurred at the front and 46 in the home 
territory. Besides the offences against military discipline 
and pronounced brutalities there was a striking number of 
pervert acts (21). The pervert acts did not take place 
between soldiers of the same rank, but between superiors 
and such subordinated soldiers as were assigned to them for 
special services (personal orderlies, chauffers, etc.). 
Desertion, the punishable act particular to military service 
(that is unauthorized absense) occurred in only 3 cases 
immediately after intoxication. In most cases it was the 
question of chronic drunkards or of moody creatures and 
depressed discontented psychopaths, in whom the abnormality 
of character was the primary cause and the momentary alcohol 
consumption only the cooperating cause. Among them most 
were found to be previous offenders (the group of lesser 
value and the morally deficient). While in some cases co- 
operation of alcohol could be excluded on the whole, in the 
majority of the cases, a more or less severe influence of 
alcohol was to be observed (giddiness to complete drunken- 
ness). But the real intoxication states were equally fre- 
quent (simple drunkenness or complete drunkenness and ab- 
normal or pathological intoxication - the so-called ”p.R.” 
which moans "pathologischer Rausch”), Among the cases of 
complete drunkenness acts of subordination, brutality and 
pervert acts were of the same frequency. In cases of patho- 
logical drunkenness brutalities were predominant. Only in 3 cases was congenital or acquired injury (psychopathy, 
chronic dipsomania, trauma of the brain) established as 
the basis of a pathological drunkenness. Far more fre- 
quent were abnormal alcoholic reactions derived from exo- 
geneous causes, (i.e. physical overstrain or exhaustion, 
overwhelming emotional events, as well as unaccustomed or 
unfit sorts of alcohols which were unfit for drinking pur- 
poses such as selfmade brandies etc.) in cases of other- 
wise physically and mentally healthy persons and even in 
soldiers of much value. 
Since the abolition of paragraph 151 of the "MStGB" 
(military penal code) intoxication by drunkenness during 
and out of service is subject to disciplinary (company) 
punishment, whenever no punishable action has occurred or 
in certain cases (i.e. motor-car-accidents) no essential 
harm has been done. The soldier is warned against the use 
of alcohol by pertinent orders and laws (paragraphs 49,2 
and 141 of the military penal code), which point out the 
dangers of excessive consumption of alcohol as well as by 
the instruction leaflet; War and Alcohol. Therefore every 
soldier acts carelessly according to the opinion of the 
General Court Martial of the Reich, who intoxicates himself. 
Maintenance of discipline requires the enlargement of this 
idea of carelessness as much as possible. Paragraph 330a 
of the penal code will not be applied as a rule, only in case 
a pathologic intoxication occurs for the first time. But 
also in these cases the judge tries to arrive at a punishment 
by considering thoroughly the general life-experience of the 
delinquent. Intoxication intentionally caused is punished 
now, as in former times, according to the principle of the 
actio libera in causa (an act of the free will) in war times; 
if occasion arises according to paragraph 5 KSSOV (Under- 
mining the Army). If measures according to paragraph 42a 
penal code are applicable, a soldier’s removal into a hos- 
pital but not to an asylum for drunkards is indicated. 
Directions for the activity of military medical con- 
sultant experts in case of punishable acts due 
to drunkenness. 
I. In a considerable percentage worthy soldiers of 
previous good reputation may come in conflict with the law 
in consequence of the particular conditions of service with 
the Army in war, caused by: 
a. physical overstrain, exhaustion, 
b. infectious diseases, 
c. mental strain in consequence of impressive 
occurrences at the front or of difficulties 
of personal or official nature at the front 
or at home, caused by war conditions, 
d. increased impulse to consume alcohol by the 
influence of comrades or by more frequent 
access, as for instance in the occupied 
territories. II* Abnormal reactions which only the medical expert 
is able to consider in an objective manner occur relatively 
often in war in case of acute drunkenness, 
III* Cooperation with a medical officer with special 
knowledge in this field is to be requested repeatedly and 
urgently in case of the disciplinary and judiciary con- 
sideration of punishable acts committed while intoxicated. 
IV. In this way it will be possible to consider the 
subjective aspect of the act caused by acute intoxications 
appropriately in order to employ the soldiers efficiently 
at a suitable place by a more detailed consideration of 
their personality and in spite of acknowledging that they 
deserve punishment. 
V. If the military medical expert is requested to 
define his attitude regarding the question of carelessness 
in the sense of paragraph 330a of the penal Code of the 
Reich he is obliged to examine this question with particular 
care considering the interests of discipline. 
VI. While the determination of blood alcohol in the 
clinical evaluation of acute drunkenness will furnish less 
significant and decisive evidence, on the other hand the 
same examination, considering the consumed quantity of al- 
cohol, may be very important in case of considering the 
question of carelessness. Therefore the blood alcohol ex- 
amination should be performed not only in case of motor-car 
and airplane accidents but still more often than before in 
cases of acts concerning brutality, perversion or desertion. 
VII. Forensic experience also shows that the pronounced 
chornic drunkards cannot be kept with the troops in the long 
run. With the interest of maintenance of discipline it is 
therefore proposed to continue the education experiments 
with the troops for not too long a time but to consider the 
same measures as for psychopaths (i.e. special departments, 
discharge). 
VIII. If measures of safeguarding or correction are con- 
sidered necessary, transfer to a medical establishment is 
recommended corresponding to paragraph 42b of Reich Penal 
Code. The proposal of confinement in a drunkard*s asylum 
corresponding to paragraph 42o is not considered appropriate. XIV. 
PROCEEDINGS OF THE CONSULTANTS 1 
COMMITTEE ON PHARMACOLOGY 
Translation prepared by: 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section Pharmacological findings in injurj.es due to cold 
See Section II, Articles 6-7 
1. Chemical warfare problems. 
Oberstabsarzt (Major, MC.) Prof, WIHTH 
We have been in war for three years and six months and 
chemical weapons have so far not been used in practice 
apart from some insignificant events which are of no practic- 
al importance, such as the use of the so-called "Lost*" - 
mines by the Poles in the area of the Jaslo-Bridge. The 
conclusion that chemical weapons will not be used at all in 
this war would be wrong. 
* A substance for chemical warfare with the name of 
its inventors: LOMMEL and STEINKOPF, which is also 
marked as the so-called "Gelbkreuz" - Yellow Cross - 
and has the following chemical formula: Cl. CH2»CH2*S< 
CH2*CH2*C1 that is Di (Chlorineethyl) sulfide, known 
commonly as Mustard gas. 
All German preventive measures are therefore of great 
practical importance; above all the organization and intro- 
duction of preventive measures and medical precautions 
against gas-poisoning. In this connection it is important 
to cooperate in the prevention of such circumstances an are 
suitable to bring about an unpreparedness in case of gas- 
attacks; This means the regular maintenance of all gas- 
masks and gas-blankets, (called "Gasplanen" a piece of can- 
vas soaked with a chemical substance for protection against 
"Lost" when sprayed from air planes); in addition to this 
every loss of gas-masks or gas-blankets as well as any in- 
appropriate use has to be avoided carefully. 
It must be assumed, that the use of chemical weapons 
by the enemy will come as a surprise. This is the principle 
of a decisive success. If preventive measures are not suf- 
ficiently prepared, this will cause damage to the individual 
soldier and possibly serious damage for the public. The 
cooperation of all medical officers is indispensable in this 
connection. 
Question: Against what agents must we protect our- 
selves'? Which chemical agent is the enemy likely to use? 
What are the newer medical points of view? 
"Lostgroup" (Group of the skin injuring, ground-con- 
taminating chemical agents). 
There have been a series of grave injuries by "Lost" 
in the years 1941/42; e.g.; 
1. Destruction of a captured Russian aerial bomb by 
means of shooting by ordnance sergeants. "Lost" sprayed 
over neck and back. Immediate decontamination. Death 
after 9 days, (local skin injuries, death probably by 
absorption). 2. A man was hit by a spray of "Lost" between gas 
mask and gas hood, quick decontamination, severe 
local injuries of the head, neck and chest. Death 
after 8 days (death by absorption). 
3. Explosion. 34 persons were injured by "Lost", 
among them 7 oases with fatal result (death after 5 
hours, 12 hours up to 10 days). (Cause of death: 
Absorption with extensive local injuries in some 
cases.) 
4. Injury of 19 men driving on a truck on which 
Russian "Lost" ammunition had been hauled previously. 
Skin injuries particularly on the buttocks. 2 men 
dead after 28 days. 
Numerous injuries have occurred under the most dif- 
ferent circumstances, e.g. destruction or removal of 
captured chemical ammunition. Also in these cases tne 
fatal termination is often not explainable by the extent 
of local injuries but is rather due to injuries by ab- 
sorption. Even during World War I, HEUBNER, MJNT3CH and 
SLIKA have pointed to the effect of "Lost" on metabolism. 
But by far too little attention has been paid to the in- 
juries of the white blood corpuscles by absorption, which 
may easily be observed and diagnosed clinically. The 
appearance of an increasing leucopenia is a remarkable 
symptom, a disease which frequently ends fatally and in 
which the leukocyte values may be as low as 300 and less. 
My collaborator DREWS has reported this leucopenia for the 
first time as observed in cats. According to my own ob- 
servations at the "Institut fuer Pharmakologie und Wohr- 
toxikologie der M. A." (Institute for pharmacology and 
military toxicology of the German military academy) it 
occurs particularly as a sequel to the influence of higher 
doses of "Lost" and also of "Nitrogen-Lost"^(see below), 
and less by the influence of arsenical chemical warfare 
agents. It has been confirmed by LANGE and POSTED in 
clinical cases. 
The most striking clinical symptom of "Lost" poison- 
ing by absorption is the failure of circulation. I remind 
you of the fact that in the pathological anatomical picture 
of "Lost" casualties, SCHUERMANN has found remote effects, 
especially capillary injuries of the spleen, liver and 
suprarenal glands, as consequences of a general collapse 
of the circulation. (A therapy of continuous intravenous 
drip and blood transfusions has been found to be useful.) 
It is estimated that the fatal quantity by absorption 
of these chemical warfare agents is about 1-2 grams. In 
order that these 1-2 grams by absorbed, it is necessary 
that a considerably higher quantity of chemical warfare 
agents come in contact with the human body. In general, 
the absorption of such quantities is possible only by means 
of a strong spray of chemical warfare agents (immediately 
near an exploding container with chemical warfare agents or 
by means of dense vapor emanating from an air plane), but 
only in the rarest cases when troops are making their way 
through a contaminated territory; lesions of skin, eyes and 
lungs occur most frequently under these circumstances. Even in spite of quickest decontamination of the skin, 
practical experiences have revealed that "Lost" injuries 
are not completely avoidable whenever greater quantities 
of these chemical warfare agents are involved. No efforts 
should, however, be spared to decontaminate the skin as 
quickly as possible; clothing will be taken off if contamina- 
ted, By this at least it is possible to diminish the degree 
of the injuries. 
Among th prophylactic measures the skin decontaminating 
agents are of the greatest importance, as is known, the 
troops are provided with "Losantin" tablets for skin decon- 
tamination. ("Losantin" is the name for a special form of 
a water-soluble chloride of lime, manufactured by I.G.Farben). 
In spite of their good effect against "Lost" there are the 
following disadvantages in medication: the necessity of 
having water available makes difficulties in the preparation 
of the paste, especially when the tablet has become hard, the 
determination of the right amount of rubbing this paste upon 
the skin, the necessity of removing the paste from the skin 
after exactly 10 minutes, non-applicability of this paste on 
sensitive skin, or a skin already reddened by the influence 
of chemical warfare agents. 
This situation necessitated the development of a skin 
decontaminating agent immediately ready for use. In colla- 
boration with Dr. BOESS of my institute, a skin decontaminat- 
ing-jolly was developed by which the above mentioned dis- 
advantages were eliminated. It is immediately ready for use, 
the presence of water is not necessary, it may be applied by 
rubbing in more energetically, it is also applicable on 
sensitive skin, it is not necessary to wash it off after 10 
minutes but may be washed off even after several hours. 
This skin decontaminating agent is known as skin^decon- 
taminating jelly and is introduced instead of "Losantin". 
The ointment is taken along in pocket-containers just as 
the decontaminating agents for weapons. These pocket con- 
tainers are of a different color and have a different clos- 
ing mechanism so they may easily be identified. The pocket 
container is in a protective container, together with cellu- 
lose-tampons. 
The skin decontaminating jelly is still quite stable at 
50° Celsius, it becomes solid at very low temperature, and 
on thawing it regains its former consistency. At very low 
temperatures the jelly container should be carried in the 
trouser pocket. The effect of this agent is similar to that 
of "Losantin". 
If diluted 1:1 with water it is possible to perform 
also a complete body decontamination with the skin decon- 
taminating jelly, which is hardly possible with "Losantin" 
paste, It is known that spap solutions have proved satis- 
factory in body decontamination. Furthermore non-irritating 
cleaning agents as Satina, Praecutan and especially the MS- 
soap are suitable for body decontamination. Their principal 
value lies in the emulsifying and cleansing effect. But as 
far as "Lost" is concerned these agents have scarcely any 
greater chemical decontaminating effect than pure water. It 
is possible to increase the effect by the addition of oxidiz- 
ing agents. If an early removal of the uniform and decontamination 
of the skin has not been possible, it is necessary to per- 
form a complete skin-decontamination even as long as 2 - 3 
hours after the contamination, as drops of the chemical 
agent retained on the uniform might affect the skin even 
hours afterwards. 
The problem of providing a second set of clothes and 
the organization of the decontamination of the clothes is 
only briefly mentioned. 
The body decontamination is rendered more difficult in 
a certain manner if viscous, sticky kinds of "Lost” are used, 
such as have been found several times with our enemies. The 
performance of the decontaminating measures is described in 
the revised edition of the ”H.Dv. 396, M.Dv. # 316, L.Dv.95If. 
(Army Manual # 396, Navy Manual # 316, Airforce Manual ft 95.) 
On this occasion we should like to call your attention to 
these kinds of "Losts" containing arsenic compounds e.g. 
Lewisite (with the chemical formula: Cl.CH: CH.AS.CI2, 
Chlorine Ovinylarsine-dichloride). More recently such kinds 
of "Losts” have been captured again from the enemy e.g. in 
the territory of the Caucasus. Spraying equipment also found 
in this territory point to the intention of the enemy to 
spray those mixtures from air planes especially against 
living targets. The course of the injuries can bo essentially 
changed by the use of such arsenic containing mixtures. In 
these cases, even within 1 hour, most serious edema may occur 
on the affected skin. Decontamination of the skin in the same 
manner as with common "Lost” is indicated. The same thing 
is true with regard to the decontamination of the body with 
soap preparations in case the so-called "Stickstoff-Lost" 
(Nitrogen-Lost) is used. It is the practically odorless 
Trichlorine-triethylamine ((C1.CH2*CH2)3«N) , an agent which 
has become known in the last years. 
With regard to injuries caused by inhalation and their 
therapy, we point to the "Vetivazulen" a synthetic, very 
precious, oil of camomile, which has proved good against 
injuries due to inhalation of "Lost" or "Nitrogen-Lost". 
Diluted with liquid paraffine 1:1000, this remedy is in- 
haled, in a vaporized form by a dry inhaling apparatus. 
At the eastern front several Russian medical papers 
have been captured, which reveal that the Russians have 
scientifically studied intensively a nettle substance, the 
Phosgenoximo. This substance is solid in a chemically pure 
state, but fluid in the impure state, and causes an intensive 
nettle effect immediately after being dropped on the skin, 
combined with burning and violent pains, formation of wheals, 
developing later on into necrosis. We are here in the 
presence of a skin irritant with an immediate effect, which 
furthermore has a considerable percutaneous absorptive effect 
in which the splitting off of hydrocyanic acid-like compounds 
in the blood play an important role. The decontamination of 
the skin is particularly difficult, as the effect occurs 
extraordinarily quickly. According to the experiences made 
hitherto a skin decontamination is possible only by the imme- 
diate use of a 5% solution of caustic ammonia. Decisive in 
the protection against this weapon is the use of gas-blankets 
and gas-masks in due time. 199 
In connection with the skin irritant materials yellow 
phosphorus may be pointed out which is often used in this 
war as an incendiary agent in different forms. 
The principal task for the troops and the physician 
consists in trying to remove the phosphorus from the skin as 
completely as possible. For this purpose, first of all 
the burning phosphorus on the skin has to bo extinguished. 
According to the investigation results of my institute this 
is performed in a most efficient way by the spreading of 
oils (paraffinum liquidum, lubricating oils, diesel oil, 
weapon oils) on the affected spots of the skin. Moreover 
it has proved very good to clean the wound on the skin with 
a solution of sodium bicarbonate with addition of a small 
quantity of hydrogen peroxide. This also causes an excellent 
alleviation of pain. After the extinction of the burning 
and the removal of the residual phosphorus as completely 
as possible from the skin, an ordinary treatment for burns 
(scalds) will follow. 
The phosgene-group has not lost its importance. An 
old controversial question will be settled by stating that 
morphine or Eucodal may be given in small doses (0.005) as 
sedative remedies. 
It is known that phosgene and also chlorine in small 
quantities, shoot out from burning smoke candles. The 
latter are harmless in the open air, but dangerous in closed 
rooms. Several accidents have demonstrated this. 
In the field of nose and throat irritants, French 
generators wore found in 1940 with a filling of Adamsite, 
that is; Diphenylamine-arsinechloride: (HN.(G^H^) 
which had an extraordinary contaminating effect over a very 
largo area (many kilometers). The only first aid remedy 
developed until now by the medical services has been the 
smelling-tube wrapped in fabric with a filling of chloro- 
form-alcohol-other-ammonia which has been introduced among 
the troops. 
In the beginning we have pointed out the absorptive 
properties of "Lost". We are under the impression that 
the agents effective by absorption will play a more im- 
portant part in chemical warfare of the future than they 
have in ttfc« past. 
Hydrocyanic acid as well as chlorinecyanide which 
are supposed to have been introduced by the Russians as 
chemical warfare agents, may be cited as examples. The 
use of hydrocyanic acid in World War I by the French proved 
to be a failure. Nevertheless wo have found with the 
Russians special plans for the use of hydrocyanic acid 
according to which it seems probable that this rapidly 
effective poison may be used as an effective chemical war- 
fare agent. It is astonishing, what extraordinary high 
protection against hydrocyanic acid is guaranteed by the 
Russian filter elements in the respirator. 200 
As a further example we mention the arseniuretted 
hydrogen, which under the effect of the humidity of the 
air is split off of a granular substance. High concentra- 
tions in the terrain are made possible by the use of the 
product, which in a lingering manner can cause a great ef- 
fect. In the first place there are injuries of the blood 
corpuscles (diminishing of the resistence of the erythro- 
cytes* later on hemolysis and anemia). The formation of 
methemoglobin is observed. A more or loss serious state of 
anoxemia is the result. Hematuria is at first followed by 
increasing retention of urine finally amounting to complete 
anuria. To the picture of symptoms of the poisoning by 
arseniuretted hydrogen belong also vomiting, diarrhea, 
colic-like pains of the abdomen, injuries of the liver and 
jaundice. In severe cases death occurs after a long period 
of unconsciousness, sometimes after convulsions. If arseni- 
uretted hydrogen is used by the enemy in very small quantities 
a differentiation from epidemic jaundice would be of clinical 
importance. In these cases the blood picture gives a re- 
liable differential diagnosis, besides the evaluation of the 
general circumstances. The principal treatment consists in 
combatting the anoxemia (transfusion of arterial blood, if 
necessary supply of oxygen) as well as the maintenance of 
diuresis (copious supply of water, derivatives of purine, 
i.e. theobromine-sodium-salicylate). Moreover it is import- 
ant to protect the liver by supplying glucose and insulin, 
as well as preventing weakness of the circulation by means 
of analeptic remedies. 
Finally our point is discussed which in the further 
development of the war may become important, namely chemical 
warfare in hot climates. The opinion is widely spread, 
that the use of chemical weapons in hot climates is of no 
use. lust the contrary is the case. It is just the hot 
climate, which offers ideal condition for the efficient 
use, particularly of the "Lost” group. This is demonstrated 
clearly by the experiences of the Italiens during the war 
in Abyssinia and of the Spaniards in the war against the 
Hifcabylees. The soldiers wear lighter uniforms in hot 
countries, they are therefore especially susceptible to 
spread chemical agents. The warm skin is particularly 
susceptible to chemical warfare agents. It is imperative 
to develop at the right time measures of antigas-defense 
in the hot countries and to include antigas-defense facilities 
in all medical projects. 
Discussion; 
GRAWITZ: Points to the urgent necessity of instructing 
the medical officers so as to avoid all possibilities of 
surprise in the use of chemical warfare agents. 2. Cooperation of the consultant pharmacologist and the 
fliQdical officers for chemical warfare problems 
for the protection against enemy preparations 
for chemical warfareT 
Stabsarzt (Captain, MC.) Prof. GIRNDT 
Uninterrupted reconnaissance with regard to the pre- 
parations of the enemy and his possibilities for chemical 
warfare is an urgent requirement, in order to frustrate sur- 
prises regarding the possible use of chemical warfare agents 
by the enemy and to find adequate defensive measures in due 
time. 
Reference is made to reports and personal experiences 
and it is discussed in which way and with which aim the 
cooperation of the consulting pharmacologist and the medical 
officers for problems of chemical warfare should strive for 
the proper checking of the Soviet Russian preparations for 
chemical warfare. 
It is indispensable that the consulting pharmacologist 
and the gas medical officer cooperate in the reconnaissance 
of chemical warfare research institutes and chemical armament 
factories, this cooperation may evun be of the utmost im- 
portance under certain circumstances, as it might afford 
opportunities to investigate the effect of chemical warfare 
agents. It is hardly possible for officers who are not 
conversant with toxicological and clinical problems to 
realize the importance these investigations may have for 
the appropriate service. 
3. Now experiences in air-raid defense medical service 
and the problems of the air-raid warden Tn 
case gas is used. 
Oberstabsarzt (Major, MC.t of the Police) KRAEFFT 
The serious air raids on the home front beginning in 
spring 1942, have required an increased activity of the 
air-raid medical service, much more than in the past two 
years. Although the principles of this activity did not 
essentially change, it has become necessary, more so than 
formerly, to have a well organized but nevertheless flexible 
leadership emanating from the loader of the air-raid medical 
service. As he is overseeing the entire situation at all 
times, he will have to direct the activity of all air-raid 
medical units, and ho must know exactly, what reserves from 
other places will be at his disposal. 
The formation of emergency squads for the first urgent- 
ly necessary help, which take care of the evacuation and have 
the possibility to request necessary reinforcements has 
proved good. The efficiency of the air-raid medical units 
is thus guaranteed. A slow removal of rubbish is necessary 
with regard to the still living people buried under the stonesc 
Burst water- or gaspipes and burning ruins are an aggravating 
condition. The air-raid protection rescue posts must also be in a 
position to admit patients in case of acute diseases and for 
deliveries. It is the most important task to diagnose the 
disease as quickly as possible, to judge about the transport- 
ability and the possibility for treatment. Only life saving 
operations will be permitted. Non-medical problems must be 
kept away from the physician. Persons deprived of their 
homos should be forwarded at once. I’he most important types 
of injuries are trauma and contusions of the body cavities 
and of the limbs as well as injuries of the eyes. There are 
also injuries of the eyes caused by vapors which lead to 
irritations of the conjunctiva, injuries of the epithelium 
of the cornea and formation of abscesses. Burns of^every 
degree oven to carbonisation have occurred increasingly. 
Tannin together with morphium has proved good. 
The most frequent causes of death were: lack of oxygen, 
suffocation by nitrose and carbon dioxide (CO2) gases, 
crushings, piercings through the body cavities and freezings, 
frost bites. 
The guarantee of a sufficient supply of water in case of 
a breakdown of the water mains and the possibility of re- 
filling water containers by means of fire hoses, the supply 
of electric current for the use of emergency lamps even in 
case of a breakdown of the emergency generator and further- 
more the uninterrupted function of the emergency ventilation 
are all essential for the smooth performance of the numerous 
duties of the air-raid first aid stations. This latter is 
imperative even if no chemical agents are used, because 
otherwise the air in the rooms would become intolerable in 
a very short time by the presence of many people. 
There must be available a sufficient number of ambulances 
especially in case hospitals are hit, or if only their win- 
dow panes are broken. This means an evacuation of hundreds 
of patients in the shortest time. 
The medical supplies on the whole have always been 
adequate, the civilians also could be provided with sufficient 
drugs. To be certain that there is no shortage of beds, 
auxiliary hospitals must be available. 
In case of the use of chemical warfare agents there 
must be available: gas-sentries, consultant chemists, 
official physicians and veterinary officers besides the 
cordon of sentries and protection forces of the police. 
It is important for the air-raid protection physicians 
to be able to recognize the type of the chemical warfare 
agent very quickly so they may perform a proper typo of 
decontamination of the patients. Cooperation with the war 
gas examination laboratories as well as with the operating 
decontamination groups must at all times be maintained. On 
principle everything must be decontaminated that may possibly 
have been in contact with war gas. It is essential to pro- 
vide gas-free paths in order to bring the population from 
the air-raid shelters to a safe district. Besides the gas- 
masks of the population there are also gas cradles ana baby 
gas-jackets in order to perform a safe transport of all per- 
sons. 4. Poisoning in war. 
Oberstarzt (Colonel, MG.) Prof. FLURY 
It is said, that war does not create now diseases, 
this statement requires a certain restriction, at least with 
respect to poisoning. Broadly speaking, the poisonings in 
war are much the same as in peacetime. But the far reach- 
ing changes in all conditions of life and the progressive 
development of war technique involve more numerous and more 
diverse dangers. In addition to this, there are completely 
now dangers to health and life peculiar to the conditions of 
war. 
In case of pathological disturbances or even mysterious 
cases of death, the physician must also take the presence of 
chemical agents into consideration. This is of particular 
importance in wartime. War-toxicology has to study closely 
every case of chemical injury in the broadest sense of the 
term. Therefore all chemical materials come into the scope 
of their activity, even such materials which usually arc 
not considered as poisons, i.e. the host of all chemicals 
which are used in every day life and in the professions, 
liable to affect the productive power and efficiency of 
the soldiers. 
Among the poisons carbon monoxide ranges first also 
in wartime. This poison is especially dangerous in closed 
rooms, also in the cars of trains and other public means of 
conveyance, such as ambulances, in airplanes, ships, and 
in exceptional cases even in the open air. A survey of the 
great variety of possibilities is hardly feasible. The 
first symptoms of gas poisoning are of particular importance, 
that is to say the "mild" cases, which are generally not 
recognized and which affect the perception, power of judge- 
ment, sense of equilibrium and strength of will, thus diminish- 
ing production and safety especially under strenuous con- 
ditions. 
Poisoning by carbon monoxide if sem from the toxico- 
logical point of view is the predominant problem as regards 
motorization. Apart from the exhaust-gases, chiefly con- 
sisting of carbon monoxide, there are serious other dangers 
which, under certain circumstances may prove injurious to 
health; propellants, gasoline, Diesel-oils, and special 
substances, i.e. anti-knock-mediums, even the anti-freeze 
compounds contained in the radiators (glycol, methylalcohol), 
but not alone the chemicals themselves, also the products 
of vaporization, transformation, decomposition and combustion. 
Lead-tetraethyl and its products of combustion have 
an important part in these problems. The lead-problems 
have not yet been solved satisfactorily. 
Furthermore an important, but little known chapter of 
military toxicology comprises all that is understood under 
the collective term of "oils". The industry uses numerous 
products which have similar features as oil; lubricating- 
oils, gliding-oils, cooling-oils, drilling-oils, propellant- 
oils,- burning- and heating-oils, hardening-oils, penetrating- 
oils and so on. Considering the enormous use and the im- portanoe of these products all problems relating to hygienic 
and toxicological evaluation have not yet been studied close- 
ly enough. The Armed Forces also consume enormous quantities 
of them. In the armament industry these products lead above 
all to injuries of the skin, the so-called "Oelkraetzo" 
(oil scabies), to the war-oil dermatitis and similar disturb- 
ances which have often proved to be hazardous to the worker 
thus causing losses of production. Also certain flamethrower- 
oils are irritating to the skin and mucous membranes. Under 
certain circumstances, i.e. in naval warfare, large quantities 
of oils are swallowed and serious diseases may occur in con- 
sequence, even fatal termination. 
It is not the purpose of this lecture to discuss the 
chemical warfare agents. With the exception of the sensational 
first cases at Jaslo in Poland, which was instructive in many 
regards, and the occasional use of irritants and "Lost" con- 
taining training ammunition by our adversaries chemical war- 
fare agents have not been used in this war. 
In spite of this there have occurred a remarkable number 
of injuries by war gases. In a great part the victims were 
civilians, in rare cases personnel of the Armed Forces. The 
containers with chemical warfare agents left behind by our 
adversaries in many places in Poland, Russia, the Baltic 
Countries have been opened and emptied, often in ignorance 
of their contents and often in an unskilled manner. Thus 
hundreds of casualties, even a number of fatalities, have 
occurred. Most often "Lost" was erroneously considered as 
oil, Kerosin, Carbolineun, motor-fuels and such things and 
was used accordingly. 
The injuries by other chemical warfare agents, above 
all by smoke producing agents and incendary agents are also 
numerous. The development of artificial smoko in closed rooms 
has often led to fatalities. Phosphorus causes combined in- 
juries by burns and cauterization, sometimes also to absorptive 
poisonings including injuries of the liver. A few oases of 
injuries caused by chemicals used in flares or other signal 
material etc., have become known. Poisonings by high ex- 
plosives are relatively rare at the front, in contrast to 
their frequency and gravity in the ammunition factories at 
home. 
Also poisonings due to medicinal remedies are not rare. 
There are in the first place the injuries caused by Sal- 
varsan, by sera and the so-called indicental-effects of 
remedies, i.e. of the sulfonamides, furthermore the results 
of a confusion of remedies. Here are to be mentioned es- 
pecially the erroneous injections of benzine instead of 
vaccines. This leads to a very severe local tissue necrosis. 
Carbontetrachloride has caused much mischief, as well as 
the agents provided for air-raid protection, for the de- 
fense against war-gas and decontamination, i.e, chlorine 
of lime, Losantin, and similar products. 
The war-poisonings include many injuries which threaten 
the soldier in the combat zone and the occupied countries. 
The numerous modern war-gas dangers are especially encountered 
in industrial districts, in destroyed industrial plants or in 
chemical factories. Great quantities of poisons for delousing, 
disinfestation, and pest-combatting are needed. Injuries by poisonous snakes, scorpions, and poisonous 
spiders and other insects, have been observed in the south- 
east. 
A£Long the poisonings caused by food and similar dis- 
eases the following are worthwhile mentioning; the ac- 
cumulated cases of trichinosis, the mass poisonings by 
bacteria, poisoning by tinned food (zinc), then the poison- 
ings by mushrooms-, by "wild-growing-vegetables", by poison- 
ous berries such as belladonna, crow-berries, etc* Im- 
portant in these days is the hazard from materials injurious 
to health which are intended as or used as a substitute for 
fat, as for instance technical oils, gun-oils, weapon-oils, 
torpedo-oils. Ortho-tricresyl-phosphate, an odorless and 
tasteless oil, is probably ".the most hazardous material of 
all. It has caused numerous diseases in the Armed Forces 
and in workmen. The effect is characterized by a typical 
latent period. Often only after several weeks a sudden 
motor, ataxia and painful polyneuritis appear. Glycol has 
caused serious, also lethal, poisonings when erroneously 
used or intended as a substitute for sugar. Furthermore 
one must consider possible poisonings of water, i.o. by 
acts of sabotage (arsenic, strychnine, potassium cyanide, 
corpses of animals). The danger of a subsoil water poison- 
ing may arise from leaky containers of lead-benzine. 
The great problems alcohol and tobacco can be mentioned 
only briefly. Excessive - consumption of alcohol has done 
much mischief in the first years,of the war. Also fatal 
cases due to abuse of alcohol have, become known. Numerous 
are the poisonings by "alcohol-substitutes", methylalcohol, 
carbontetrachloride and similar things‘such as benzine, 
alcohol containing and alcohol-like products:such as hair 
and mouth tonics, solid-alcohol, antifreeze agents, lead- 
tetraethyl, consumed as "strawberry liquor". Not rare are 
poisonings by "tobacco-substitutes" such as woodruff, 
golden rain (cytisus laburnum) and other poisonous,plants. 
Already by this brief.review it is shown how extensive, 
manifold and varied are the tasks of military toxicology, 
Many chemical injuries remain unclear. This is last but 
not least due to the fact that there is often 
of the necessity of a diagnosis, so that the possibility of 
poisoning is not thought of at all. The diagnosis has the 
same meaning to the physician as the evaluation of the 
strategic situation has to the leader of troops. It 
constitutes the basis for all further que^ions and proclems. 
Suitable therapeutic measures cannot be instituted nor is 
an effective performance of measures for prevention and pre- 
caution possible without a clear and correct diagnosis. 
All measures for the prevention of injuries must be based 
on knowledge and experience, to be disseminated further 
by appropriate information and instructions. This applies 
to the chemical dangers and injuries as well as to the 
military problems. Discussion; 
HEUBNER; Mustard oil causes a serious irritation of 
the skin only if retained in place by the clothes. 
EICHLER; Fatalities and poisonings caused by hydro- 
cyanic acid used for delousing are mentioned. CO2 (carbon- 
dioxide) poisonings caused by cooling waste gas in hot water 
heaters. 
BUSCH; C02 poisonings caused by make shift heating 
devices in automobiles is mentioned. 
PLESSER; Poisoning caused by gases of explosions in 
cases of bomb hits on board ship* 
LENDIE; A typical course of poisoning under field 
conditions, i.e. carbontetrachloride, methylalcohol, It 
is proposed to introduce the obligation to report cases of 
poisoning. The same proposal is made by LOESER. 
$. Accidents with fire-extinguishers. 
Flottenarzt (Captain, MG., Navy) FFLESSER 
Accidents with hand fire extinguishers of the 
Tetra type were not infrequently reported. Therefore strict 
safety measures have been issued especially for extinguishers 
when used in closed rooms. Nevertheless we still meet with 
surprises. This is illustrated by the following examplu-s 
which actually happened in the Navy* 
1. Mass poisoning by "Ardexin" in a dockyard; 14 men 
fell sick, 2 of them to fatal termination when repairing used 
Ardex fire extinguishers. Course; After a latent period 
of several hours, suddenly headache developed, giddiness, 
cyanosis, cramps, after J to 2 hours with death in coma and 
collapse of the circulation. Medical help often comes too 
late, because of the sudden onset of the poisoning after a 
latent period which lasts many hours. Postmortem findings; 
Obstruction in the internal organs, increased content of 
fluid in the lungs, petechiae in the brain. 
2. Repairs on Ardex-fire-extinguishers on board were 
performed with gas masks. The following night during an 
air raid when wearing the same masks sudden cramps occurred 
followed up by unconsciousness and cyanosis. Soon after 
this death occurred. Postmortem findings: hemorrhagic focal 
pneumonia. The examination revealed that the active charcoal 
charged with "Ardexin" vapor is able to free great quantities 
of vapor, especially when hot air is allowed to circulate 
through it. 
3. By improper use of a Tetra-extinguisher in an a.A. 
gun post. 3 men dead, 1 seriously injured. Postmortem find- 
ings: same as in suffocation. Peripheral weakness of the 
circulation was observed in the survivors. 4* An "Ardex" extinguisher was demolished during a 
battle on a cruiser by a 20.3 centimeters hit. 17 cases of 
poisoning: pains of the eyes with moderate conjunctivitis 
to loosening of the conjunctiva and formation of abscesses. 
After J-1 hour pungent feeling in the throat, labored 
breath and thoracic pains. After a further 1-2 hours cough, 
sometimes with foamy bloody sputum, headache, nausea, some- 
times with vomiting and violent pains in the stomach. Be- 
sides this after 6 to 9 hours 14 patients exhibited itsching 
irritations, dark red colored erythemae, moreover in the 
region of this erythema formation of big blisters. The de- 
veloped blisters showed great similarity with blisters of 
"Gelbkreuz" (Lost), as is demonstrated by the pictures. 
Similar effects are often observed by firemen who get drops 
of the blocking fluid on their shoes when working at the 
remote water-level-control device. The skin-active component 
in all cases has been ethylene bromide. The simple wetting 
of the skin with ethylen-bromide does not lead to injuries, 
because of its high volatility. If, however, the clothes 
are wet, a longer effect is created on the skin, and a 
penetration into the tissues becomes possible because of 
the property of this material to dissolve the lipoids of 
the skin. The described injuries of the skin occur only in 
these cases according to the experiences hitherto made. 
"Ardexin" contains besides this substance methylbromide in 
equal parts which causes the above mentioned injuries of the 
respiratory system. 
6. The pharmacological view-point on drug-therapy. 
Oberarzt (1st Lieut., MG.) Prof. KOLL 
It is clear that our main interest must be devoted to 
those conditions which cause the highest rate of losses in 
troops, such as the wounds and the epidemic infectious dis- 
eases. Poisonings hold a special place because as we know 
from experience they offer difficulties to most surgeons 
and under certain conditions may occur in great numbers. 
The alleviation of severe pain is achieved in^almost 
any case by morphium, Eucodal or SEE, but in the field 
the narcotic effects of these remedies represent disad- 
vantages under certain circumstances. Therefore it has 
been attempted to replace the narcotic morphine effects by 
centrally exciting drugs with the same analgesic properties. 
Following the experiments in animals, carried through ac- 
cording to the method of KOLL in the Pharmacological In- 
stitute in Danzig by order of the Medical Inspectorate of 
the Army, trials were made with injections of a combination 
Of morphine 0.002 and pervitin 0.0075 in some wounded soldiers. 
This remedy has so far fully come up to expectation. Often 
the narcotic effect of the morphine prevails for avout 1 
hour, thereafter the patients are awake, alort and active 
for about 6 hours with a marked freedom from pain. At first 
only evacuation under unfavorable conditions (sitting or 
active help by the wounded) was considered as an indication 
for its use. Further indications are being examined. Especially in the evacuation of wounded in winter time, this 
combination might prove satisfactory in order to prevent in- 
juries due to cold, as the wounded do not become apathic 
under its effect. 
According to my observations the local wound treatment 
with sulfonamides by Marfanil-Prontalbin powder does not 
take place under conditions which allow these substances to 
become fully effective (in the majority of the existing 
technics of application), as the powder usually does not 
reach all the wound-pockets and is washed out by blood and 
wound secretions. The small residual remnant is absorbed 
too quickly. Changes aiming at an increase of concentration 
and duration of the effect are suggested and will be tested 
by experiment. 
Moreover observations have been communicated concerning 
the part played by hypo-or anacidity of the stomach in con- 
sequence of climatic factors regarding the origin of many 
enteritides, and about the good prophylactic or curing effect 
by use of hydrochloric acid or Acidol, (a remedy splitting 
off hydrochloric acid). Furthermore methylaloohol poisoning 
was discussed as well as new promising therapeutic experi- 
ments regarding this poisoning. 
Discussion: 
JANSSEN: Considered the combination morphine-pervitin 
favorably, while EICHHOLZ maintains that there is no need 
for a combination of morphine-pervitin in addition to the 
already existing morphine ampouls and pervitin tablets. 
RICHTER: Raised the question about accumulative danger 
by repeated use of pervitin. This question was answered by 
KOLL in the negative with regard to the special indication. 
ZIPF: Pointed out the increased danger of addiction. 
Morphine-caffein was suggested. 
WEESE: Referred to devices for the application of 
powder for the treatment of wounds with sulfonamides. 
JANSSEN: Pointed out to the difficulty of the evalua- 
tion of the success. 
KONZETT: Discussed the antipyretic effect of sulfona- 
mides. 
LOESER: Discussed the treatment of visual disturbances 
after consumption of methylalcohol with retrobulbar in- 
jections of atrapine. 
KROEBER: Reported successful results with Acidol-Pepsin 
in cases of acute enteritis. 7* Problems of medical equipment from the pharmacological 
' aspect 
Stabsarzt (Captain, MG.) Prof. LENDLE 
As a result of the inquiries about the drug therapy 
in field hospitals of the front line medical units, on 
the occasion of mutual visits with the consulting inter- 
nist, Prof. SYLLA, proposals wore made for the improve- 
ment of the assortment of remedies in the set A, C and D 
of the medical equipment. 210 
XV i 
PROCEEDINGS OF THE CONSULTANTS 1 
COMMITTEE ON PHARMACY 
AND FOOD CHEMISTRY 
Translation prepared by; 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section 1» Physical and chemical analysis and purification of 
drinking water" 
Oberfeldapotheker (Lt. Col., Pharm. Corps) 
Dr. GEMEIEHARDT 
By determining certain substances dissolved in the 
water the chemical physical analysis indicates if a con- 
tamination of the water has occurred. Furthermore it re- 
veals the quantities and the kind of salts dissolved in 
the water • Poisonous substances which the water may con- 
tain or have been brought deliberately into it, may be 
detected exactly only by chemical analysis. On the basis 
of the results of the chemical and physical analysis it is 
possible to issue directives concerning the necessity of 
a water purification. The troop medical equipment includes 
devices (field pack-filter apparatus, water purifier etc.) 
which may be used to sterilize or purify the drinking water. 
It is also possible to perform makeshift sterilizations 
or purifications of drinking water by filtering with or 
without previous addition of precipitating agents of various 
kinds (AI2(SO/^)3 - sulfate of aluminum; Ca(0H>2 - calcium 
hydroxide or slaked lime, etc.) as well as by the carbon sus- 
pension procedure. Complete elimination of salt may be ob- 
tained only safely by distillation. The use of base acid 
shifting methods and electric-osmotic devices are for the 
time being dependent on stationary plants because of the 
variable composition of the different waters. The elimination 
of poisons (i.e. chemical warfare agents) is achieved with 
certainty by a slow filtering through active carbon (prin- 
ciple of the purification filter for water contaminated by 
chemical agents). The chemical control is not only necessary 
for all water purification methods but also in case of 
chlorinating water for the purpose of sterilization. 
2. Experiences with the supply of drinking water for the 
troops. 
SS-Untersturmfuehrer (2nd Lieut., Elite Guard) 
QERSTEIN 
The motorized drinking water unit developed by the 
"Hygienic Institute of the "Waffen-SS" (Combat SS-units) 
was described. The problem of water purification is to be 
solved by a combination of several procedures working on 
different principles, so as to guarantee a safe purification 
of water which doos not respond to our particular system 
of purification. 
Coarse impurities and suspended matter is kept out 
by a threefold device formed by textures of willow, jute, 
and fine wire instead of the usual inlet filter basket which 
is kept afloat in the upper water layers by a float. The impure water is then conveyed by a pump mounted 
on a truck through two filters connected in series con- 
taining diatomacious earth, active carbon, sodium aluminate 
and "Caporit" (a chloride of lime with the physical property 
to disperse readily in powder form) as purifying agents. 
After passing the second filter the water has normally less 
than 100 germs per cubic centimeter. 
An additional ceramic filter is used only in case of 
particularly unfavorable water conditions or in case that 
no purifying agents are available. 
The water, after having passed the twin filters, ob- 
tained from the filter or the ceramic filter is then con- 
veyed into tanks in which Q;5 grams "Caporit" is added 
per 500 liters, and after 15 minutes of reaction it is con- 
veyed by a second pump through a carbon filter, whereby 
excesses of chlorine and musty or muddy smell or tastes 
are eliminated. The pure water is stored and distributed 
in heatable tank trucks of 2500 liters capacity, part of 
which can be transformed by a "Seltomat" installation into 
a soda water or lemonade. The capacity was 500 bottles per 
truck and day* The water purification plant is mounted on 
a 3*5 ton truck and covered with tarpaulins. Its capacity 
is 25 - 35 cubic meters daily. The quantity of purifying 
material amounts to 10 - 15 kilograms per 24 hours. 
Difficulties which may arise if the water contains 
slimy algae or other substances are hoped to be overcome 
by precipitating with milk of lime or caustic lime. 
The hitherto gathered experiences with these installa- 
tions will be published for the general benefit. 
The following additional reports were made in line 
with the objectives of this section of the Consultants* 
Committee. 
Water-supply in North African theater of operation. 
Stabsarzt (Captain, MC.) Dr. GOEPEERT 
After an introduction about the climatology and the 
different sources of water in Northern Africa, a survey 
concerning the employment of the pharmaceutical chemist 
of the Army is given regarding the organization of water 
supply for the "North African Armored Army", with particular 
consideration of the activity of the experts concerned with 
the discovery and exploitation of new water wells. At the 
present time an apparatus for water analysis particularly 
built for use in North Africa for water analysis of the 
spot is being tried out. Reports about the experiences made 
with this apparatus and about the activity of the recently 
formed battalion for water supply with an independent chemist 
on its staff have not yet been received. Equipment for chemical water analysis. 
Stabsapotheker (Captain, Pharm. Corps) Dr. 
LEHMANN. 
The revision of the water analysis apparatus, of the 
small box with reagents and of box # 8 of the chemical 
field laboratory which is subdivided into three boxes was 
discussed. Further supplements for the detection of chemic- 
al warfare agents and for liquid fuel analysis are proposed. 
The equipment for water purification. 
Oberstabsapotheker (Major, Pharm. Corps) 
Dr. WILLECKE 
Important factors in the development of a portable 
water purification apparatus for the Field Army are: 
1. Efficiency of the apparatus and simplicity of 
operation. 
2. Size of the apparatus. 
3* Type of filtration and the problem of supply of 
the filtration material. The different types of 
equipment introduced to certain units of the 
Armed Forces making use of either layers of 
asbestos, cellulose, active carbon and chlorine 
or with diatomacious earth, were compared with 
each other and considered critically. The results 
of the chemo-bacteriological analysis have proved 
by now, that the water purification apparatus 
adopted by the Army, functioning on the principle 
of filter layers, has not yet been surpassed as to 
simplicity, capacity, and accuracy in the prepara- 
tion of completely satisfactory drinking water. 
A purification apparatus especially designed for 
brackish or sea-water was mentioned and the functioning 
and the employment of* these apparatuses demonstrated. 
The activity of the chemical laboratories of the Field Army. 
Oberapotheker (1st Lieut., Pharm. Corps) 
Dr. HOFFMANN 
The activity of the chemical laboratories, which in- 
cludes the testing of chemicals, food, poisons, chemical 
warfare agents, and physiologioo-chemical tests, is out- 
lined. The equipment available for this purpose (chemical 
field laboratory, war-gas protection laboratory, physiologioo- 
chemical analytical equipment) and its possibilities for 
use were explained. Proposals were made, which were based 
on the available experience with the view of completing the 
equipment, particularly that of physiologioo-chemical ana- 
lysis. In addition to the examinations of food and physio- 
logico-chemical examinations, which were done on a particular-, ly grand scale, examinations of captured material, of pro- 
ducts of the indigenous industries and the operational con- 
trol related thereto was described. Special stress is laid 
upon the analysis of potable water, for the preparation of 
soda-water, for boilers and for building purposes. 
The activity of the chemical stations in occupied and home 
' territories, 
Stabsapotheker (Captain, Pharmi Corps) Dr. LIDDlvER 
After a brief outline of the historical development 
of the chemical equipment of the Armed Forces within the 
German medical organization which included in its staffs 
from the very beginning the post of the army pharmacist 
besides the physician, (hygienist)* The army pharmacist 
is particularly qualified in all problems concerning the 
chemical examination of food, drugs and the very diverse 
chores of the army pharmacists in army test stations. The 
various problems in the chemo-analytical field were tnen 
discussed in detail. Experiences gained in the routine 
examination of food, in the examination of chemical war- 
fare agents and the important cooperation as advisors in 
chemo-teohnieal matters and in many other services of the 
Armed Forces, were discussed to round out the picture of 
the important role of the chemical test stations. 
Examination of food. 
Oberfeldapotheker (Lt. Col., pharm. Corps) 
Dr. DILEER 
It is the principal task of the civilian chemical 
stations or offices to check on food hazardous to health, 
falsified, imitated or improperly labelled. In addition 
to this the analysis stations of the Army have to check 
on quality, price and the possibility of storing and further 
supply. With a view to demonstrate how a specific scheme in 
the appraisal of quality is worked out, the method of check- 
ing the quality of "Sauerkraut" was illustrated in detail. 
Standards will be formulated as soon as possible in the 
Pharmaceutical Institute of the Army for all kinds of food. 
In this connection it is urgently required that the chemical 
analysis stations of the Armed Forces place their experiences 
at the disposal of the Pharmaceutical Institute of the Army. 
Pecularities of the Russian sanitary equipment. 
Oberstabsapotheker (Major, Pharm. Corps) 
Prof. Dr. UNGERER 
Among others the following items were discussed: 
1. The chemical heat cushion, the contents of which 
consist of fillings of technical iron with an addition of 
either 5% cuprichloride or ammoniumchloride and produces 
a temperature increasing to 100° C., on moistening it with 
water. This heat is maintained for several hours. The thermo-chemical process is explained; it is shown that 
cupriacetate or oupriphosphate are to be preferred. The 
danger of inflammability of the heat-cushion containing 
ammoniumchloridG if exposed to humidity was pointed out. 
2. Agents for sterilization. Soap "K" is a soft 
soap, containingr$0% Di-xanthogene. Properties and pro- 
duction are discussed, and details given for a quantitative 
analysis. The details will be published in another place. 
"Seifensolventpaste" (soap solvent paste) contains 60% 
benzol II, emulsified with 30% sodium-naphthenate and 10% 
water to make a jelly. Dust DFA is a dusting powder con- 
taining 25% diphenylamine and V5% talcum. Dust SK consists 
of 10% tetrachlorine-cyclohexane and 90% talcum. 
3. In contrast to the German filter for water con- 
taminated with warfare agents, the Russian filter contains 
an active carbon with 10% colloidal ironoxide in ordei to 
bind the arsenic compounds4 
4. Water sterilization tablets ("Banthozid”) contain 
2-3 milligrams of active chlorine in the form of an organic 
sulfone chloramine. 
5. Anti-gas packs represent a practical arrangement 
of skin-decontaminating agents (dichlbfamine in alcohol or 
carbon tetrachloride), preventive agents and dressing 
material. 
Details are given by the Institute for Military 
Pharmacy of the Military Medical Academy. 
Winter hazards for medical supplies and preventive measures. 
Stabspotheker (Captain, Pharm. Corps) Dr. KOCH; 
and Oberstabsapotneker (Major, Pharm. Corps) 
Dr. PREUSS 
The following items must be particularly protected 
against winter hazards: 
a. Drugs. 
Containers with aqua destillata, blood substitutes, 
disinfecting agents; ampoules of Novocain (with or without 
additions), Prontosil, Solvochin, oaffein sodium salicylate, 
Morphine, Gardiazole, Sympatol, Suprarenine, calcium glu- 
conate; sera and vaccination materials, reagents for urine-, 
water- and chemical warfare agent analyses; emulsions, 
boroglycerine-lanoline, lubricant media, as well as plasters. 
b% Rubber materials. 
c. Instruments. 
All kinds of instruments for water purification. 
A series of proposals in order to prevent hazards to 
medical supplies was made. Problems of medical equipment from the pharmaceutical 
point of view. 
Oberstabsapotheker (Major, Pharm. Corps) Dr. UNGER 
and Oberstabsapotheker {Maj or, Pharm.Corps) 
Dr. MAISS 
The supply and further development of the field medical 
equipment is being influenced at present in a decisive manner 
by the difficulties in the supply of raw materials and by 
the limited possibilities of manufacture. It is the special 
task of the pharmaceutical chemist of the Armed Forces, next 
to the medical officer to cooperate in tho perfection of the 
technical equipment and field medical equipment, as he is 
supposed to be an expert in all questions concerning raw 
material and supply, as well as in all problems concerning 
medicaments, dressing material and appliances for dressing. 
All sorts of simplifications and standardizations of tho 
types of technical equipment and of the field medical equip- 
ment are to be striven for by all means. In all new de- 
velopments in the medical field special consideration must 
be given to the possibility of using the existing items. XVI* 
PROCEEDINGS OF THE CONSULTANTS * 
COMMITTEE ON 
FORENSIC MEDICINE 
Translation prepared by: 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section Punishable acts associated with drunkenness, 
(See Section XIII,"Article S) 
Ammunition, violating International Law. 
Oberfeldarzt (Lt. Col,, MG.) Dozent PANNING 
The principle will be strictly adhered to that the 
discovery of the use of dumdum ammunition, regardless of tir 
development of other weapons, will give rise to rigorous 
retaliations* The evaluation of wounds and projectiles is 
incumbent on the surgeons. It must be noted that the 
surgeons (v.BRUNS) have had an eminent part in the develop- 
ment and terminology of the stipulations of the Hague 
Convention. 
The stipulations of the Hague Convention of 1899, 
article 3, ban "any projectiles which extend or deform 
readily in the human body, as for instance projectiles 
with a hard envelope that does not entirely wrap up the 
inner core or which is provided with slits”. The Hague 
Convention on Continental Warfare of 1907 bans projectiles 
that cause unnecessarily painful injuries. 
These stipulations are not limited to the partly en- 
veloped projectiles mentioned here as an example, but they 
likewise include the explosive projectiles of the infantry 
with explosive charge, (Examples: Soviet explosive and 
incendiary projectiles, British explosive and incendiary 
projectiles). Furthermore, among others are included - 
in contrast to the opinion of KIRSCHNER, THOELE, - the 
massive projectiles, having absolutely the same effect as 
dumdums, which are similar to the French "balle sectionnee" 
(sectioned bullet), they extend in the body, producing a 
large wound, because of their cumulative pressure forming 
a wedge-shaped, tapering block of tissue-fibres. 
The bending and considerable deformation of the lead 
of the bullet on the partly enveloped projectile cause a 
very serious and large wound. 
In each single case it is difficult to ascertain the 
demarcations of the wounds, caused by percussion shells and 
in case of riochetes or serious bone damage. The formation 
of lead contaminated cavities, as described by PERTHES, may 
also be caused by explosive ammunition. The fissures at 
the spot where the dumdum entered as described by v. BRUNS, 
are probably due to the decomposition of the anatomic pre- 
parations. According to recent experiments carried out by 
THOELE and by myself and according to hunting experiences 
with partly enveloped projectiles a ragged wound of entry 
is not observed. 
The wedge-shaped widening of the woundbed in case of 
a small wound of entry possibly a bit larger than the missile, 
as well as certain findings about injuries due to projectiles 
lodging in the body are characteristic. The findings about the wound of themselves are never 
solely conclusive. 
The so-called "Mantelsplnne" (spider-shaped casing) a 
remnant of the bullet envelope, which THOELE considers as 
convincing evidence of dumdum and which is characterized 
by an intact or almost intact base and outwardly^bent loir"] 
tudinal shreds, may however originate also from intact poi 
bulleots. This was proven by my own experiments by inter- 
cepting bullets including all fragments in sawdust. Con- 
trary to THOELE1s conception, a reperoussive movement of t 
lead-core, caused by the counter-pressure of the resistance 
of the target, and thereby damaging the base of the bullet, 
does not take place. On the contrary the specifically 
heavier lead will protrude at the impact, A defective point 
of the bullet may cause the protrusion of the lead and show 
the same effect as the partly enveloped projectile, tearing 
up the envelope in the shape of a spider. 
The use of dumdum may only be ascertained positively 
either if the findings of the wound confirm it, or if the 
spider-shaped envelope reveals no traces of a previous im- 
pact that could have caused a damage of the bullet point. 
Examples of such projectiles, being damaged before 
hitting the body, were then shown, as for ins ha.- ce the rear 
fragment of a French groove-bullet (type: l’b'32xv) that war. 
brokefn at the fastening groove and defor .v towards the 
spider-shaped envelope, as well as a So/Ao S-bullet (ordr.i - , 
pointed S.A.A.), bent by a secondary part of the project!. a, 
to the shape of a mushroom which was overlapped by a fro. U. 
shred o£ the envelope. Furthermore a Soviet tracer pro- 
jectile was presented which showed characteristic ueformat; c 
in that the shell body containing the tracer substance too., 
the shape of a mushroom and the shape of a spider; sharp 
contours revealed an impact on a hard intermediate target. 
The special design of these Soviet 3m star shell tracers 
excludes their possible use as partly enveloped projectile. 
(no lead at rear of the projectile). Then a spidershaped 
envelope of a Soviet S-bullet was presented, which had undo, 
gone a deformation owing to a previous impact as was shown 
by the presence of cloth fibres under the bent envelope. 
Finally some rare findings about bullets lodged in the 
body could be presented bearing clear cut evidence of the 
use of dumdum, namely parts of bullets extracted from the 
body, with clearly recognizable edges of the pointed hole of 
partly enveloped bullets, according to the onaracteristics 
as established by KIRSCIiEER. These conditions especially 
prevailed in one case, concerning a fragment of a French 
hollow, pointed bullet, called "ball© de stand", meaning 
a rifle range bullet which is used, according to v.BUTLaR- 
ELBERBERG, by the French for executions because of its 
intense impact. In an experiment on animals it could be 
demonstrated how a frontal edge fragment of an English double- 
core bullet (Mk VII with aluminum in front and lead-core be- 
hind) had been broken off by the mechanism, existing on the 
English Lee-Enfield rifle, the so-called lever-hole of the 
retaining spring of the magazine. Eerefrom, characteristic 
notches are often formed next to the fracture margin. 220 
The following discussions were also held by this group 
of the Consultants’ Committee: 
Self-inflicted mutilation by gunshot and other mechanical 
influence. 
Obexstabsarzt {Major} MC.) Professor MUELLER 
The speaker reported about his own examinations, con- 
cerning in particular the problem of the close range gun- 
shot and the proof of close range gunshot by the spots on 
the skin where the bulxet entered by microscopic examination 
and micro-chemical examination with the dithizon-reaction. 
Besides the dithizon-reaction intra-red photography of the 
clothing and equipment is recommended which, however, does 
not furnish any clues if the clothing is fully soaked with 
blood. It is not valid on the boots. The dithazon-reaction 
is always reliable. A soaking of textiles with leaded 
gasoline does not result in any important increase of the 
precipitation amount in the dithizon-reaction. 
The effects of the tracer ammunition have been under- 
study. No special features have been observed in case of 
normal penetration of the projectile. In case of gunshots 
with tarnished projectiles, lodging in the body, the wound- 
channel appears granulated by black masses and burn cavities 
are formed. W'e furthermore observed amorphous foreign 
substances and globules of coagulated A slight 
dithizon-reaction is found within the burned area. Magnesium 
is traceable. 
Discussion: 
PLANNING: The smoke of the Soviet tracer projectiles 
(see leaftlet) contains barium, which being an element that 
does not occur in the human body, can always be ascertained 
by spectrographic examination in spite of powder smoke. 
same is true with regard to strontium contained in the 
ammunition of the Western Forces, The lead, proven by 
dithizon, which is effective in the smoke of tracer ammu- 
nition, originates from the lead-coating of the case of the 
tracer substance. Magnesium also is a constituent part of 
the tracer substance, but spectrographically is of no use, 
as it occurs normally in the human body. 
The organization of the forensic-medical service in the 
theater Q? operations*! 
Oberfeldarzt (Lt. Col., MC.) Dozent PLANNING 
Notification of the plan of operation. Experiences concerning forensic-medical service in front- 
Y^nes t -- -- - * - 
Stabsarzt (Captain, MC.) Prof. BUHTZ and 
Stabsarzt (Captain; MC.T~TrofV SCHNEIDER 
Both point out the necessity that information con- 
cerning the tasks of the Consulting Forensic-physician 
should be addressed to all commands, particularly to the 
General Court Martial (Ic). Sufficient transportation 
should be made available; trucks will be best for Eastern 
conditions. 
Organization of the forensic-medical serviee_in the homeland. 
Oberfeldarzt (Lt. Col., MC.) Dozent PLANNING 
The text of a formal agreement with experts of forensic 
medicine about extrajudicial autopsies for the Armed Forces 
and concerning the appointment of experts by the judicial 
department of the German Army for forensic sections to the 
subordinate tribunals under the authority of the German 
Army. 
The forensic-medical investigation on Soviet violations 
of International Law. " 
Stabsarzt (Captain, MC.) Prof. Dr, BUHTZ 
115 exhumations and autopsies have been made from 
28 August to 21 October 1941, along with thorough examina- 
tion of eye-witnesses and troop physicians about Russian 
violations of International Law. In numerous cases torture 
of German soldiers of the Army and the Airforce, who had 
been taken prisoners of war, wounded or not, was undoubted- 
ly proven, in particular rifle stock-hits and numerous 
stab marics on soldiers, gunshots that did not originate in 
combat but from torture and murder, a combination of bayonet- 
stabbing, hitting and close shots on"defenseless prisoners, 
proved by the course of the bullet through the trunk and arm, 
gunshots into the eyes or into the mouth opened crying for 
help, gunshots into prison-cells, furthermore shooting in 
the neck, while standing with hands up, clearly prove the 
deliberate violation of International Law, Acts of par- 
ticular brutality, such as injuries of the genitals, stabbing, 
or shooting into the eyes, spiteful fettering, furthermore 
tortures by repeated stabbing or hitting, shooting and 
stabbing on one and the same person were found. The viola- 
tions of International Lav; committed on PW’s and forcibly 
landed German airmen are to be considered as the top of 
brutality. They were frightfully tormented and then murdered. 
The time and frequent occurrence of brutalities in certain 
areas as well as the particular type of torture applied, 
prove that these procedures are carried through systematic- 
ally and cannot be considered as illegal actions of single 
subordinate units. 222 
Search of evidence of Soviet violations of Internationa1 Law. 
Dozent SPECHT 
These investigations concern in the first place torture- 
cellars of the NKVD in Baltin States in Russia as well as 
methods of tortures and arson employed by the Soviets and 
on the other hand to the terrifying activity of Russian 
sabotage groups and spies who had been dropped from airplan ,< 
in the rearward areas of the German Army,4 Hitherto unknown 
torture-cellars were discovered at Duenaburg. Among other- 
discoveries, scalps were found in the prison-cells at Pleskau. 
which proved in a particularly drastic manner the brutal 
tendency of the Russians, The limit of brutality in these 
tortures consisted in tearing off fingernails of prisoners 
(at Duenaburg), We were able to get hold of the equipment 
of a group of Partisans dropped at Staraja Russa. The 
chemical and scientific examination of the sabotage explosiv-. 
and incendiary material and mines pointed to the important 
tasks assigned to these Soviet gangs, A complete set of 
captured sabotage material made it possible to judge the 
brutal methods which were systematically applied by the 
enemy. (75 pictures) 
The problem of self-inflicted injuries. 
Qberfeldarzt (Lt, Col,, MC. ) Doz .t PARKING 
We are glad to say that very few instances of self- 
mutilations have been reported in the German Army whereas 
the enemy, according to intercepted restricted information • 
intended for the instruction of military forensic examiners, 
revealed considerably higher figures, namely: increase of 
the courtmartial of self-mutilators by 90between January 
and May 1942; in some regions the increase went up to 9 
times. Absolute figures are available for a certain Soviet 
Infantry-division (the number was mentioned) which reported 
more than 50 cases within a very short period of time. In 
one division 39 self-mutilators were court-martialed in one 
day. 223 
XVII. 
VARIOUS LECTURES IN 
— 
THE FIELD OF HYGIENE 
Translation prepared by: 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section 1. Geomorphological analysis as an element of fighting 
epidemics. 
Oberstarzt (Colonel, MC.) Prof, RODENWALDT 
Within Chinese culture, geomantic ideas have been ex- 
pressed for thousands of years in order to determine pro- 
pitiousness or unpropitiousness of the locality. Their 
symbol is the Fung-Schui and the 8 Pat-kwa. In the 
Greek-Roman culture, too, there was hygienic action based 
on the strength of geomorphological facts. But even there 
ideas of magic were predominant, such as we find in the 
measures taken against malaria epidemics at Selinunt by 
Empedokles, 
Modern epidemiology must consider the multiformity 
of the causes, so it is obligated to solve the problems 
of why epidemics are often dependent on a certain behavior 
of the soil, why they proceed in a certain direction and 
sometimes in strange ways. An important task, which is 
being worked on at present, is the cartographical survey 
of epidemic spreading. The object of this work is to com- 
pletely discover the various causes of these epidemics. 
In this work, one cannot do without an analysis of the soil, 
of its statics and dynamics. 
Examples for epidemic conditions requiring an ex- 
planation are the limitation of paratyphi’ * B to the 
temperate climate, of paratyphoid A to countries with warm 
climates, of paratyphoid C to the Near East, the regional 
dependence of hepatitis epidemica, the irregular distri- 
bution of tetanus and gas gangrene infections. 
The lecture includes the method of geomorphological 
analysis as demonstrated by the example of malaria. 
This analysis is simple if malaria caused by human 
work is concerned, such as the creation of artificial 
breeding places for the anopheles by inappropriate work 
on cultural structures {construction of railroads, dams, 
etc.). In order to avoid such mistakes, hygienists must 
be in close cooperation with the technicians. Analysis of 
natural situations with the aim of finding out whether 
they are alterable or inalterable is discussed in the 
example of coast-malaria, and that in its dependence on 
the situation created by the so-called displacement of 
the coast. By cooperation of surf and drill,' 'the sea 
shifts every particle of sand and thus the whole sand-mass 
of the coast in the direction of the drift. If surf and 
drift are stronger than the impetus of the rivers running 
down from the land, these are shifted along the coast in 
the form of lagoons and their mouths are closed permanent- 
ly or temporarily. - Deforestation of the mountains causes 
the sharp contrast at the heads of the rivers, large floods 
and later almost completely running dry. This is the fault 
of man, too. These situations are illustrated by humorous 
examples from the coast of East Prussia (Haffs - fresh water 
lakes) and from the tropical zones (Dutch India), Pictures 
of Crete demonstrate the mechanism of coast-displacement. 
By aid of them, the possibility or impossibility of effect- 
ing a change by keeping the river-mouth open was discussed. Examples from Crete and Greece were demonstrated in pictures, 
in which some success was obtained, and in part of which 
there was no possibility of changing the dangerous situation. 
Two of these examples concern situations known from the 
Herakles myth, the Lernaean and Stymphalie swamp of the 
Peloponnes, which the lecturer was in a position to analyse 
some months ago. Finally, it was shown by the example of 
the Seraju-delta, a region of Java infested with filaria 
malayi and elephantiasis, how a complete causality of the 
epidemics could be established by geomorphological analysis 
even in a complicated situation. 
2. Practical results of predicting epidemics. 
SS-Untersturmfuehrer (2nd Lieut., Elite Guard) 
Dr. ZIEZOLD 
The prediction of epidemics is based on the experience 
that the spreading of an infectious disease is a natural 
process with its own laws. If these laws are sufficiently 
well known, fairly precise predictions can be established 
even in advance as to the probable development of the 
epidemics in the subsequent period. 
1. Epidemic waves recur every year .t the same time. 
The number of patients first affected by'meningitis will 
rise particularly high in April. Gases of typhoid fever 
will be most frequent in the beginning of September, cases 
of poliomyelitis in the middle of September. As a rule, 
the peak of the scarlet fever wave will be reached at the 
end of October, of diphtheria at the end of November. 
These times will be regular with a limit of 2 - 3 weeks, in 
case of meningitis 4 weeks, 
2. Also the amplitudes, that is the height of the 
annual waves, are remarkably constant. At the period of 
the highest morbidity, there are regularly twice as many 
cases of scarlet fever as in the less active season. With 
diphtheria, the numbers of cases rise every year at the 
time of its peak to 2 - 2j times as much, with paratyphoid 
to 6 - 10 times, with poliomyelitis to 10 - 20 times the 
lowest level, 
3. As for the inner structure of the epidemic waves, 
we know the following: All intermediate states between 
maximum and minimum of the epidemic waves are related to 
each other according to natural laws. The number of fresh 
cases depends on the number of the immediately preceding 
fresh cases and on another factor fluctuating like a sinus- 
curve. The logarithms of the sick rate, therefore, practic- 
ally follow a sinus-curve. 
4. Besides the seasonal waves, the "season-rhythms” 
of the epidemics, even a regular rhythm of several years 
can be observed with some infectious diseases-. With typhoid, 
we are at present again on the ascending phase of a wave of 
about thirty years. With diphtheria, the peak of a wave of 
also about thirty years will soon be arrived at. The number 
of scarlet fever cases fluctuated in a rhythm of about 8 
years till 1936; at the end of 1940, a new wave set in, which 
is shorter and whose peak has evidently been passed in the 
spring of 1942. These four regularities of the course of epidemic 
diseases are so pronounced that they can he made the basis 
of a prediction. With them, one can predict the probable 
course of the epidemic waves normally to be expected. This 
is the course occurring if the regularities observed pre- 
viously continue. Deviations of the prediction at once In- 
dicate extraordinary tendencies, so tney are no less import j 
than a really correct prediction. Thus, the prediction 
provides a normal measure of the quantitative Judgement of 
epidemiological reports. In a systematic observation of 
the causes of these deviations even more valuable knowledge 
of the causalities of the epidemic course might be revealed. 
On the other hand, every progress in recognition of the 
causalities will render the perfection of the epidemic 
prediction possible. Examples illustrated by slides were 
shown, on the one hand for the regularities of the epidemic 
waves and on the other hand for characteristic deviations 
vfrom the normal course. The subject of ’’epidemic prediction” 
is discussed in more detail in a treatise by the author 
published in 1943 in the Zeitschrift f. Hygiene und In- 
fektionskrankheiten. 
3, New bioclimatic apparatuses and experience with them 
in Southern Russia. 
SS-Obersturmfuehrer (1st Lieut., Elite Guard) 
Dozent SCHARLAU 
The special problems of bioclimatology have led to the 
development of special bioclimatic measuring units and 
measuring instruments permitting one to grasp the summary 
effect of certain climatic elements according to their order 
of importance. In this field, a detailed discussion of the 
question was held as to how the coincidental effect of 
moisture and heat acts on the human organism and how this 
climatic coupling of factors might be exactly determined 
by measurements and expressed in figures. In the literature, 
a series of so-called ’’curves of sultriness” have been 
published, which show the difference between a sultry room 
and a comfortable room. Of the limits of sultriness ex- 
perimentally and arithmetically deduced, the so-called 
Lancaster-Castens-curve, also used by HUGE in his work on 
the problem of sultriness, may be called at present the 
one which is best Justified, This limit of sultriness 
coincides almost exactly with the vapor-pressure curve of 
14.08 mm, Hg. This coincidence can by no means be accidental, 
but must be regarded as a proof that the regulatory adaption 
of the human body to the moisture-heat conditions of his 
climatic environment takes place according to physical laws, 
i.e, that the feeling of sultriness may be called a function 
of the vapor-pressure. This results in the possibility of 
expressing the amount of sultriness in simple figures. If 
a certain hygrothermic pair of values lies beyond the limit 
of sultriness, the amount of the feeling of sultriness can 
be determined either by the extent of the excessive tempera- 
ture or by the corresponding deviation of the percentage of 227 
the relative humidity. The difference of temperature has 
turned out to be best suited for that. The difference of 
temperature may be calculated either by aid of a table or 
determined graphically; for this purpose, the so-called 
"hygrothermic curve-picture" has been developed. 
The practical application of the difference of tempera- 
ture led to the construction of a special thermometer, the 
so-called "thermometer of sultriness". This is an ordinary 
thermometer with a double scale. On the left half of the 
scale, there is the usual subdivision in C°, but on the 
right half of the scale, the limit temperatures are indie.teg 
i.e, the temperatures by which, in case of coupling with 
the coordinated values of the relative humidity, the limit 
of sultriness is determined. 
The same principle-is the basis of the development of 
a self-recording writer, which delineates the hygrothermic 
values in continuous curves on a strip of paper. The 
recording pen is coupled by a special mechanism of trans- 
mission with both a hair hygrometer and with a thermometer, 
and is thus directed by both. This climatologic recorder- 
may be used also for automatic regulation of air-condition- 
ings. 
These statements on the measuring-unit and measuring- 
instruments for the feeling of sultriness fr ve been com- 
pleted by practical experience from Southern Russia. The 
hygrothermic measurements made there proved the usefulness 
of the scale of sultriness and furthermore gave important 
information concerning the temporal occurrences of periods 
of sultriness and the regional distribution of zones of 
sultriness. Ror this reason, they are, in addition to that, 
very valuable for fixing the limits of zones of danger- 
caused by the climate. 
4. Medical .cartography and con.trol of epidemics. 
Oberstarzt (Colonel, MC.) Prof. 3EISS 
A preliminary condition of work on medical cartography 
is the knowledge and understanding of the two elements in- 
volved, viz. of medical and of geographical medicine 
briefly called geomedicine. F6rr the development oi medical 
geography, whicE~ls based on medical topography and goes 
back to the times of Hippocrates, there are a good many 
interesting documents, which are unfortunately not yet com- 
pletely employed for practical and theoretical evaluation 
for the tasks of modern hygiene. While working cooperatively 
with the geographer, the geologist, and the cartographer, 
the hygienist will often be surprised, what concealed or 
unknown sources are to be found there. The-same applies 
to the medical geography of other countries, in which un- 
evaluated material has often been kept, even for decades. This fact applies particularly to medical topography, whicn 
developed above all in Germany in the course of the 18th 
century. The Hygienic Institute of Berlin University has 
prepared for years detailed work on the importance and 
collection of medical topography. 
The Russians based their research work on the classic- 
al medical dissertation of K.E.v,BAERS about the Estonians 
(Dorpat 1814), who followed the German example and did 
excellent work. They received fresh stimulation by the 
expansion of Russia towards Central Asia and the Ear East. 
World War I and the decisive importance of the Caucasus 
in the war with Turkey were particularly important. Numoroi 
quite detailed topographies provided with maps of the 
Tiflis Army District, which were drafted by Russian medical 
officers, bear the date of that time. The strategically 
most important regions of the Caucasus are there described 
in detail with regard to their military geographical and 
thus military hygienic importance. According to the 
sources available to me, the Soviets have continued to 
draw such topographies with special consideration of malaria 
in the Caucasus. Considering the inexorable thoroughness, 
with which they work on all these military affairs, the 
tables of contents alone promise valuable contributions 
to the medical topography of the Caucasus in general, and 
of malaria in particular. 
Let us pass to medical geography’, h is either com- 
posed of different medical topographies of single localities 
or regions, or it comprises■the total medical-geographical 
representation of a country, of continents, or of the 
world. Such a medical geography is in most cases a kind 
of ’’snapshot of the diseases of a region” of a geographical 
unitTj the single stages of which" are represented in various 
kinds of development, which quite frequently may also in- 
volve a healthy region in the vicinity. In all events, 
border-regions already play a part which can be recognized 
as an obstacle against an infectious disease or as a medical 
geographical boundary against an endemic form of disease, 
according to the circumstances whether traveling or station- 
ary diseases of parasitic or non-parasitic kind are involved. 
If we consider the cartographical methods, according 
to which the individual scientists wished to fix their re- 
sults and to render them intelligible geographically, we 
only find extraordinarily primitive conceptions, which do 
not at all arrive at the methods usual with geographers, 
nor do they stand a comparison. Both the cartographer and 
the hygienist have missed the medico-geographical map so 
far, and there are but slight attempts in the course of a 
century to create a medical cartography. The development 
of the idea and method of geomedicine gave a strong impetus 
to medical cartography. When I suggested that at that time 
(1931), I demanded geomedical maps and atlases in addition 
to geomedical methods and a prognosis as one of the principal 
tasks of geomedicine, which is just as dynamic as geopolitics. 229 
Geomedical research work has two preliminary con- 
ditions ; 
1. Knowledge of geographical, facts of the region 
which is to be examined geomedically, i.e. its 
boundaries, the shape of its surface and ground con- 
ditions, the history of its ground, its earthquake- 
zones, general climate and special local climatic 
conditions, community of life and cultural landscape, 
city landscapes etc.; 
2. Knowledge of the medical and medico-historic 
events in that region. 
Thus, geomedicine is that part of medical science that 
deals with the exploration of spatial and temporal relations 
of the courses of diseases to processes of the earth, 
HAUSHOFER and his school have occupied themselves 
for years with the theoretical and practical aspects of a 
dynamic map. They have developed their own methods of re- 
presenting geopolitical processes and movement; but in ad- 
dition German geographers have recently engaged in examin- 
ing the possibility of a "dynamic map" critically and 
methodically. The difficulties of representation often lie 
rather in tm subject than in the method of its represcntatio: 
Both, however, cannot be separated, because the processes in 
time and space must be represented by plares in the dynamic 
map oT“geopolitics as well as of There are no 
difficulties if we wish to represent the present state Of 
extension of a disease in a geographical unit, which has 
already passed or changes only slowly. Matters are changed 
if we wish to chart the movement of epidemics. Herein, we 
have successfully used the method of isodates, which had 
never been used before. 
These geomedical methods are not said to be perfect. 
Just the opposite. They are only in the beginning of their 
development, for they allow a good many other valuable.com- 
binations, such as inclusion of the density of population, 
of botanical and zoological geography, particularly of the 
propagation of animals transferring diseases and their 
food-areas, furthermore, the immensely important geological 
condition of the ground. In addition to that, there is 
the change of the landscape effected by man in times of 
war and peace and by nature; or the slow origin of shifts 
of the coast, of swamps, of the rise and fall of the water 
table, be it caused by man’s hand or the hard efforts of 
nature. All these factors may change a region of health 
into a region of disease, and thus once more change the 
map. 
For this reason, the medical map becomes a prognostic 
instrument in the hand of the hygienist, if he reads it 
with cool brains and practiced criticism. If he does not 
do so, but tries to read things into the map that do not 
exist, if he does not consider the bacteriological, diag- 
nostic, and clinical epidemiological facts, he behaves like 
a fortune-teller, for geomedical methods of the diagnostic 
and prognostic map must not be used separately but only in 
closest relation to each other. 230 
5. The sanitary situation in some regions of Africa, as 
seen from the point of view 6f the miTitary 
hygienist, 
Flottenarzt (Captain, MC., Navy) Prof. ZSCHUKE 
The following report refers to French and Spanish 
Morocco and to the territories of the African Western Coast 
from Sierra Leone to the mouth of the Campo-river, a region 
extending over subtropical and tropical zones, contains 
deserts, savannas and virgin forests, and shelters inhabit: nf ; , 
who vary widely as regards their level of civilization, their 
standard of living, their manners of nutrition and other 
factors decisive for health. 
If I dare all the same to give a general view of the 
total situation within a brief lecture, I do so in the 
hope that personal experience under the present circumstances 
is of same interest despite all incompleteness, all the more 
so, because the official reports of the colonial and mandate- 
governments are sometimes liable to give a false picture of 
the real situation to people who do not know the local con- 
ditions by having viewed them firsthand.. 
This statement particularly applies to the disease of 
most immediate practical importance in Africa, malaria, which 
is of pronounced seasonal character in the north and caused 
by plasmodium vivax and malaria© to a coin ’durable percentage; 
while it appears in the Central African virgin forest as a 
most serious hyperendemic permanent malaria with most violent 
participation of the plasmodium falciparum. Official statis- 
tics cannot properly show its eminent importance, since only 
small numbers of the patients-are treated due to the generally 
insufficient medical treatment, particularly in the regions 
of the virgin forest, and since only minimal parasitological 
records will easily deceive and because of the peculiar con- 
ditions of immunity among negroes. With the western African 
colored men, positive blood-findings may mean a disorder of 
the equilibrium between the tendency of the parasite to in- 
crease and the force of resistance of the body as well as an 
infection-immunity of a high degree in the nature of a pro- 
phylactic premunition (SERGENT), negative blood-findings may 
mean real freedom from germs of the organism as well as 
"parasite-immunity" in the nature of a chronic malaria but 
incompletely suppressed by the body. It is paradoxical, 
therefore, that both findings in a colored man may speak 
both for and against the-presence of the clinical disease. 
For a military hygienist, who has only white soldiers to 
care for, this is of no importance in so far as every carrier 
of parasites is a source of infection for the gnat and thus, 
for practical purposes, every negro may be considered dangerous 
to his white neighbors. Since systematic measures of sani- 
tation in North Western Africa - French Morocco excepted - 
have been limited to some principal cities and ports, a 
European military unit is forced to care for their own pro- 
tection, and that by means of the most conscientious possible 
realization of medicinal prophylactics, of mechanical pro- 
tection from gnats and their own measures for control of the 
gnats. Considerably more of a problem is caring for colored troops, in which one risks breaking the resistance which 
is maintained only by continuous reinfection but which is 
most valuable for efficiency. Generally, one had better- 
wait at first and adapt the extent of control measures to 
the decrease of efficiency or the number of the cases caused 
by malaria. 
Next to malaria, venereal diseases are observed most 
frequently. They, too, are not quite covered by statistics, 
since primitive man, by his most pronounced sense of shame, 
will refrain from consulting a white doctor for a disease 
in the urogenital region. With an average of 8%, syphilis 
holds the second place in the statistics of morbidity, though 
gonorrhea occurs much more frequently. Fur this reason the 
most strict isolation of the European man from colored women 
is not only a demand of racial hygiene, but also of military 
hygiene. Ulcus nolle, lymphogranuloma inguinale, and even 
more, granuloma venereum are of no practical importance be- 
cause of their rarity. Lues, however, has more serious 
sequelae than in the temperate zone, apart from the missing 
metasyphilis. 
Its sister disease, framboesia, is third in frequency. 
It has particular foci and it thus is not uniformly distri- 
buted. Though its share in morbidity may amount to 21$, it 
is no hazard to the efficiency of the troops, Europeans 
will be affected only in exceptional cases - in the Belgian 
Congo, for instance, there was, in 1938, j,.Ju one case of 
framboesia in a European as contrasted to 253,966 medically 
treated cases in colored men. Colored men old enough to 
serve in the Army in most cases have only the symptoms and 
have few spirochetes during the late period, particularly 
on the soles of the feet, which are effectively treated by 
Salvarsan and are much less dangerous to the healthy than 
the raspberry exanthemata of the eruption-period. 
After the end of World War I, encephalitis devastated 
large territories of Western Africa in formidable epidemics; 
at present, there is the following situation: In-the South, 
particularly in Portugese Angola and Spanish Muni, infection 
by trypanosomiasis becomes more and more rare, the course 
milder and milder. The French mandate of Cameroon remained 
helplessly exposed to the epidemics until 1926 because of 
the negligence of its government, until the infection-index 
had increased to 18.7$* The index then dropped to 1.43$ in 
1932 by energetic control. Since that time, the status 
quo has been fairly well stabilized. In Upper Guinea, the 
disease is in progress at some places. In 1936, among 
almost half a million examinations of the blood, 11$ were 
positive in Nigeria, up to 13$ in Haute Volta, and up to 
54$ in French Guinea. Seen as a whole, the danger threaten- 
ing from encephalitis is by no means completely removed, but 
is considerably reduced in comparison to...former times by the 
fact that every case diagnosed in time is certainly 
by Germanin within a few days and that, in addition to this, 
the prophylactic administration of Germanin will prevent any 
positive infection by trypanosoma gambiense for three months. At first sight, the problem of preventing leprosy 
must appear considerably more difficult, since, for the 
greater part of Guinea, we must assume an average infection 
of and have no effective methods neither for treatment 
nor prevention. In spite of that, troops under medical 
care are hardly seriously endangered; though we do not know 
the mode of transfer, we know that transferring will only 
result in case of close contact with leprous men and in 
case of a primitive standard of living, i.e. conditions 
which may be avoided among combat troops. There are addi- 
tional factors, which are still discussed at present, e.g. 
foodstuffs• containing sapotoxin, such as the tare, colocasi" 
antiquorum, which should be eliminated from the army aiet 
for the sake of security. 
The clinical effect of the helminth-infections, toe, 
must not be overestimated despite their enormous frequency, 
because the infection-intensity only exceptionally corresponds 
to the infection-index, so that there are many more worm- 
carriers than worm-patients in Africa, All the same, the 
military surgeon must constantly keep this group of dis- 
eases under control, because there is always the danger 
of epidemic infection where masses of men are concentrated 
under unhygienic conditions. Adequate drinking water supply, 
removal of excrements and garbage and fly-control are urgent 
requirements of military hygiene in Western Africa as well. 
They prevent most effectively infections of the in- 
testinal tract by bacterial agents of the typhoid-para- 
typhoid-dysentery group and of amebic dysentery which was 
properly feared so much formerly. This disease is no longer 
of the nature of an acute epidemic in Lower Guinea; in 1936 
its share of total morbidity amounted only to 0,26$ in 
the Cameroon, and in Lages the percentage of positive 
stool examinations was no higher than This picture 
changes, however,, the farther one goes to the North, Even 
in Northern Nigeria, the percentage of cyst-carriers in- 
creases to 5% and in Morocco serious epidemic courses with 
the loss of numerous lives are observed every year in the 
Fall. This is avoidable if the patients are properly 
treated, but prevention is more difficult and apparently 
not quite successful so far in the North African campaign. 
As regards the diseases publicly dangerous, I refer 
to the reports, though doubtless incomplete, which have 
been submitted to the International Health Office during 
the last two years. According plague is of some 
importance only in French Morocco, but even there, there 
are only 3 eases among every 10 000 inhabitants. The 
decision whether a unit should be systematically protected 
against plague - the best method is an active immunization 
with attenuated bacilli - depends on the kind of their 
engagement and the intensity of their inevitable contact 
with natives. 
As regards yellow fever, the minimal sick rate of the 
last few years must not induce one to shut oneTs eyes to 
the seriousness of the danger. More decisive than morbidity 233 
is the silent infection of the population ascertainable 
by the protective test, which amounts to 30$ and more in 
Northern Nigeria and French 7estern Africa among other- 
regions, It can be assumed that jungle yellow ft>ver has 
spread so much in Western Africa between the 20th degree 
of Northern and the 10th degree of Southern latitude that 
outbreaks of epidemics, i.e. yellow fever in towns, must be 
expected everywhere in case of the importation of non- 
immunized men. Fortunately, a new French method of immu- 
nization with percutaneous and simultaneous application of 
cerebral mouse-virus and cowpox lymph has proved effective. 
Corresponding vaccines are being prepared at the Robert Koch 
Institute and at the Hygienic Institute of the University 
of Strasbourg, 
Typhus in North Africa may appear as the epidemic 
fever transferred by the clothes louse, the endemic or 
murine fever transferred by the rat flea and finally the 
exanthematioal fever transferred by the dog tick. There 
is no cross-immunity; but since the two latter forms 
take a mild course in most cases, immunization only against 
classical typhus is to be considered. The increase of 
morbidity in this year might render such an immunization 
necessary. 
As for the rest, the fighting of rats and their fleas, 
also because of the plague, the fighting sf lice and ticks 
because of the North and Central African elapsing fever is 
recommended. The keeping of dogs is contraindicated because 
they might form a reservoir of the causative agents of 
Kala Azar. 
At last, I wish to mention a disease, the disadvantageous 
effect of which lowers the efficiency of colonial troops as 
has been observed also in this war, although little attention 
has been paid to it: ulcus tropicum. Since etiology is 
probably not uniform and decidedly is not clear and treat- 
ment is disproportionately lengthy, the only remedy available 
so far is the mechanical protection of the place of pre- 
dilection, the leg below the knee, by appropriate dressing 
against injuries and bites of insects, i.e. giving up the 
fashionable shorts and replacing them by gaiters or wide 
trousers, fitting snugly at the ankle, 
I conclude this list, the incompleteness of which I 
.fully admit, with the statement that the sanitary situation 
in the North West African area demands the military hygienist’s 
continuous attention and care, but will hardly confront him 
with emergencies which he cannot overcome with his skill and 
technical means. XVIII. 
NIGHT - VISION: 
PRO BLEMS OF FORENSIC MEDICINE 
Translation prepared by: 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section 1* Comparable experiments with different instruments 
for testing night-vision, 
Marineoberassistenzarzt (Lt, j.g., MC.# Navy) 
F. A. HAMBtJRGSR 
Due to the war, especially due to night-warfare, we 
are confronted with the problem of singling out soldiers 
afflicted with night-blindness, and on the other hand we 
have to care for a selection of men possessing excellent 
night-vision, so they may be trained as night-fighters 
and night-observers for the Airforce and Navy, or as 
commanders of searchlight units. 
In making the selection, due consideration should be 
directed to the most important fact, that the acuity of 
the visual power shifts in a quite unregulated way all 
over the center and the periphery of the retina, depending 
on whether it is day or night. By watching that fluctua- 
tion in various stages of illumination, varying from 1 stilt 
(holding the sheet of paper in sunlight) over 10’° stilb 
(moonlight) to stilb (complete darkness) it will bo 
noticed that the acuity of vision, as in daylight, remains 
normal up to stilb or so, and then decreases rapidly. 
In the dark-adapted eye there is no region whatever of 
topmost visual power as in the light-adapted eye; a twi- 
light scotoma develops in the fovea centralis, and at the 
spot where the highest visual power was located an area spreads 
around the scotoma annularly, the visual acuity of'which varies 
between 0.02 - 0.1 of normal daylight visual power, depend- 
ing on the intensity of the illumination of the test object. 
It is of much significance in practice that the maxi- 
mum acuity in night vision is not attained by central fixa- 
tion as in daylight, but by peripheral fixation. This 
peripheral fixation does not set in automatically in twi- 
light and darkness but it needs some training. By such 
training the visual power can be considerably increased. 
Appropriate methods of training have been worked out in the 
Airforce as well as in the Navy and are in the course of 
application. 
Decisive as to maximum night-vision is the visual 
power and the capability of adaptation inherent to the 
fovea (something about 10~5 to 10’°) and to the peri- 
phery (usually from 10"? downwards). As to the method 
of selection the question arose whether these physiologic- 
ally absolutely separable properties are also quite inde- 
pendent of each other in their distribution in a single 
pair of eyes, or are they in a close correlation. Should 
this be the case an examination of one of them ought to be 
sufficient for an aptitude test. 
Until quite recently only one way to test night- 
vision was available clinically, i.e. by preparing a 
curve of adaptation to darkness. Yet as tnis does not 
take the visual power of the dark-adapted eye into con- 
sideration and besides requires as much as a half hour 
of time towards complete and full adaptation for each sub- 
ject, it is not suited for our purpose. Very appropriate 
however is the nyktometer of and the device to test 
night-vision of NOWAK-WETTHAUEH. 236 
1. The nyktometer is used'to establish a so-called 
initial adaptation curve; it tests the adaptation and de- 
finitive power of the central acuity (vision test at 10~6 
or so), 
2. The night-vision test device is used to determine 
the peripheral acuity of vision in minimum brightness after- 
full adaptation (intensity of illumination 10“9 0r so). 
Both devices may be advantageously used to examine 
a great number of people. Device No. 1 takes 10 minutes 
at the most for examination, which eventually may be re- 
duced to 5 minutes. For device No. 2 the time is 3 
minutes for one subject because the span of time of 30 
minutes is distributed over all the group of the subjects 
(30 - 40). Another advantage in comparison to all other 
methods so far used is, that the results obtained by dif- 
ferent apparatus are comparable to a large degree. This 
applies especially to the second device. 
With the aim of finding out any pcssible correlation, 
130 soldiers were subjected to test with both devices. 
In addition the absolute threshold of perception was tested 
by means of an adaptometer, taking thereby a variety of 
aspects into consideration the nature of which cannot be 
of interest here. The results were: 
1. Immediate adaptation and maximu ■ visual power 
of the fovea are not correlated with the maximum adaptation 
of the peripheral retina. Accordingly, 4 combinations will 
be possible, i.e. good visual power of the fovea and good 
adaptation of the periphery, good visual power of the fovea 
and poor adaptation of the periphery etc. 
2. In order to come to an exact opinion concerning 
acuity of night-vision an examination with both devices 
is necessary. 
3. As a matter of fact, however, this will most 
rarely come into consideration, because in only one fourth 
of all cases, (my results show even lower figures) really 
unobjectionable night-vision acuity is found. Besides, 
the test with both devices takes too much time. 
4. Rather is it advisable to consider the task the 
soldier is to be trained for, before making a choice of the 
device to be used for testing. For instance there are 
duties requiring nothing else but good peripheral vision 
in complete darkness (observer on submarines, with no 
artificial illumination whatever, night observers in the 
aircraft signal service, commanders of searchlight units 
etc.), or other tasks requiring quick and comprehensive 
adaptation of the center of the retina (night-fighters, 
gunnery personnel, chauffers). For the first group, the 
NOWAK WETTHAUER device (2) will come into consideration, 
and the COMBERG device (1) for the latter. 5. An important factor in practice is tire great 
drawback short-sighted people are afflicted with as to 
initial adaptation (central acuity) whereas their peri- 
pheral night-vision power is usually normal. Therefore 
short-sighted people are unfit as commanders of search- 
light detachments, even in the case of a favorable night- 
vision test on device Mo. 2. 
Very important additional factors have to be taken 
into consideration by the oculist, apart from the problem 
of selection. They concern hygienic measures against the 
action of light (protective covers to prevent dazzling, 
the use of adaptation glasses etc,). 
Yet still more important is the problem of increasing 
the visual power. As already mentioned this is a matter 
of training, it may also be achieved by dietary measures 
and medicine (Vitamin A, perhaps also toxic drugs such 
as strychnine). 
The English keep their night-observers and night- 
fighters permanently and fully accustomed to dark adaptation 
by compelling them to stay in dark rooms or to wear adaptation 
glasses. As to whether this is right or wrong must still be 
proved. The process of ciarm adaptation is a reverslule 
chemical reaction which by the change from brightness to 
darkness will rather promote night-vision acuity than 
hamper it. Tests with the nyktometer go., .j some hints in 
that direction, exact evidence allowing on evaluation in 
practice needs still to be furnished, 
2. Forensic medical questions. 
Oberfeldarzt (Lt« Col., MC.) Frof. GUTZEIT 
After inquiring of all the Consultant Internists about 
the subject and after discussing it with the Internists at 
the Second Conference, the opinion was expressed almost 
unanimously that both lymphogranulomatosis and acute leu- 
kemia according to their clinical course have to be con- 
sidered as infectious diseases, the causative agent of 
which as well as the mode of transmission are not known 
as yet. For this reason the internists agree on recogniz- 
ing both diseases as a disability attributable to war- 
service if the first initial symptoms have appeared in war- 
service, The explanation is for one part, that in military 
service the spread of infectious diseases is much more un- 
checked than in civil life, due to overcrowded billets and 
other unhygienic conditions in war service. On the other 
hand not only the contact with diseased persons plays a 
part in the spread of diseases, but carriers of bacteria 
and spreaders may also often be of essential importance. 
As we do not know the causative agent nor the 
transmission we might easily come to a false decision un- 
less recognizing it as a disability attributable to war service in such cases. Taking the general trend in favor 
of disabled persons, which underlies the Armed Forces 
Veteran’s /elfare and Maintenance Act, into consideration, 
it would be contradictory to the sense of that law to 
take any other attitude. 
Moreover lymphogranulomatosis and leukemia admittedly 
may grow worse in war service. Also in peacetime both 
diseases show an acute sudden turn for the worse if ex- 
terior incidents (strain, infection, trauma) have any 
influence. Considering the marked increase in frequency 
of manifest and latent infectious diseases in the Armed 
Forces with simultaneously present physical and psychic 
strain which the patients are subjected to, it can be 
taken for certain that this must result in an aggravation 
of the diseases. Basing non-recognition of disability 
attributable to war service on the ground that merely an 
aggravation of the disease has taken place would require 
in each individual case the furnishing of evidence that 
aggravating factors were not present. 
3. Forensic medical questions. 
Oberfeldarzt (Lt. Col., MC.) Prof. LAUGHS 
Conferring together with the internists could not be 
practised for lack of time. As to the question of dis- 
ability attributable to war service, the pathologists 
agreed in a special conference, that for the time being leu- 
kemia and lymphogranulomatosis should be considered in the 
same way as infectious diseases having unknown causative 
agents or unknown mode of transmission (poliomyelitis). 
It is left to the respective expert to state in his report 
the deviation of his personal view from the scientific- 
concept'(leukemia to be a true tumor). In those cases, 
however, where the opinion on the nature of the disease 
is divergent, it shall be controlling in the decision 
which opinion goes in favor of the subject concerned, or 
hi£ next of kin. 239 
ANNEX 
CONFERENCE OF THE CONSULTANTS COMMITTEE 
CONCERNING 
PROBLEMS OF MOUNTAIN PHYSIOLOGY 
4-6 OCTOBER 1942 
3T. JOHANN (TYROL) 
Translation prepared by: 
Office of Military Government for Germany (U, S. ) 
Office of Naval Advisor 
Medical Section 240 
FOREWORD 
by 
Oberfeldarzt (Lt. Col., MC.) Prof, Dr. Dr. LANG 
A conference was held concerning the problems of 
mountain physiology at the Mountain Medical School at 
St. Johann from 4 to 6 October 1942, It was the object 
of this conference to acquaint the participants with 
the results of the research work in this field and to 
find ways and means for a sensible coordination in the 
future to avoid that the same problems be undertaken 
by different headquarters. It is of decisive importance 
that the scientists of the Airforce and of the Army have 
seen their way for a close cooperation. As a matter of 
fact the problems of mountain physiology and aviation 
medicine have many points in common. The influence of 
altitude and temperature is of equal importance for both, 
although the conditions do not fully collide, since the 
plane brings the aviator effortlessly to altitudes which 
mean desperate climbing to the mountaineer* This differ- • 
ence outlines the important problem of mountain physiology, 
namely to further with all means the efficiency of the 
mountain troops who are faced with the hazards of alti- 
tude and temperature and who have to endure a great amount 
of physical and mental strength. 1. Sports and circulation, 
PARADE (Innsbruck) 
The practice of sports and continuous training is 
a prerequisite for the efficiency of troops in the moun- 
tains, The efficiency of the circulation is a very im- 
portant factor in this connection. Two problems were 
given special consideration: 
1. The direct influence of physical strain on the 
circulation; 
2, The effect of long lasting training on the 
circulation. 
The concentration of physical energy preceding the 
actual adventure of the body causes nervous regulations 
which are decisive for adapting the circulation to the 
prospective exertions* The efficiency, properly speak- 
ing, is characterized by sympathicotonia occurring along 
with a general reduction of the stimulus threshold of the 
respiratory centers which results in the well-known in- 
crease of the circulation. The correlation of these pheno- 
mena will be discussed in detail. The importance of the 
"dead point" which is probably due to a temporary over- 
loading of the blood with lactic and carbonic acids is 
pointed out. The deficit in the oxygen pply of the 
body under strain is gradually compensated for at rest. 
Examinations on well trained sportsmen revealed a pro- 
longed tachycardia in 20$ of the individuals as compared 
with 56$ in healthy but untrained persons. The drop in 
alkali reserves is much more evident in untrained than in 
trained persons under the same test conditions. This is 
especially true for the mountaineer. This fact is attri- 
buted to the more complete resynthesis of lactic acid in 
the muscles or reduced formation of lactic acid in trained 
persons. Long lasting training causes a condition of 
parasympathicotonia. The trained person is distinguished 
by a specific economy of the circulation which becomes 
evident for instance by a reduced pulse rate and pulse 
volume and respiratory frequency while at rest. The heart 
of trained persons may remain normal in size or be dis- 
tinctly enlarged (athletic heart). The intensity of the 
training is of a certain influence with regard to the en- 
largement of the heart as is also the predisposition to 
cardiac enlargement and the regulation of the peripheral 
circulation. It is common knowledge that the utilization 
of the oxygen in the muscles - including the heart muscle - 
is more complete during training and thus increases the 
oxygen carrying capacity of the blood. The athletic heart 
is more of an adaptation than a pathologic deformation. 
The particularly pronounced enlargement of the right heart 
in some sportsmen is explained by the forcible respiration 
which is typical in sport. These enlarged athletic hearts 
owing to their reduced pulsation volume are characterized 
by small excursions at rest, and they promptly respond to 
physical strain by large excursions including a large pulse 
volume. In other terms the enlarged right heart immediately 
pumps, as from a reservoir, large quantities of blood into 242 
the lungs which, proves favorable to the momentary require- 
ments of the circulation. The dominating parasympathetic 
condition of the sportsmen is of decisive importance for 
arriving at higher standards of efficiency. The critical 
heart frequency of 180 - 200 for instance is reached con- 
siderably later than in untrained persons. The onset of 
the critical heart frequency has a particularly unfavorable 
influence on the coronary blood circulation and will lead 
to a considerable drop of the pulse volume. 
Discussion: 
LEHMANN: Each type of work requires an adaptation 
of the training, even if switching from a heavier to a 
lighter type. 
2. Heart and lack of oxygen. 
H. SCHWIEGK (Berlin) 
The lack of oxygen is the most frequent and significant 
variation in the physiology of oxygen breathing animals. 
It consists of a decrease in the supply of oxygen and an 
increased consumption of oxygen, two conui ions which are 
both present in case of physical work in tne high mountains. 
The importance of the lack of oxygen for the heart could 
only be explored about 10 years ago when.the electrocardio- 
gram was invented and this permitted the proof of the 
anoxia of the heart muscle and the secondary changes per- 
taining to histology. An increased supply of to the 
heart becomes necessary either as a consequence of an in- 
creased function of the heart or under unchanged working 
conditions, due to an increased heart frequency, decrease 
of oxygen supply caused principally by a decreased coronary 
blood circulation, decrease of saturation of the arterial 
blood, and decrease of the amount of hemoglobin of the blood 
capable of carrying 02# An extensive regulatory mechanism 
guarantees the adaptation of the 02 supply to the actual 
requirements by physiologic processes, especially by varia- 
tions of the coronary blood circulation. Excitation of the 
sympathetics and administration of adrenalin, though dilatat- 
ing the coronaries, cause-a still more important consumption 
of 02 by the heart muscle, so that after all the O2 supply 
will be unfavorably influenced. Excitation of the vagus 
nerve and acetylcholin have a conservation effect. This 
applies, however, only to the physiological conditions and 
normal coronary vessels. In case of coronary sclerosis 
adrenalin will only cause an insufficient coronary dilatation, 
and the vagus excitation may even cause a deleterious de- 
crease of the coronary blood circulation. The lack of O2 
in coronary sclerosis is restricted to the region of the 
heart muscle. It seems that the heart muscle alone is af- 
fected, in the first place by an inadequate supply of O2 
to the heart due to a decrease of the O2 saturation of the 
blood and an increase of heart function. Especially the histologic examinations by BUECHNSR, MESSEN, LUFT, have 
demonstrated, however, that also certain parts of the heart 
namely the inner surface of the left ventricle, the septum, 
and the papillaris muscles are especially endangered. This 
is due to the particular conditions of supply of the vessels 
and the mechanism of blood circulation in the coronary 
vessels* This explains that a general lack of 02 is primari- 
ly manifested as a localized 02 deficiency in certain regiois 
of the heart* The most important aid in diagnosing an 
anoxia of the heart muscle is the EKG. The S-T segment 
and T deflection are particularly decisive in this respect. 
A decrease in the height of the T deflection, isoelectric T, 
negative T and ST depression, and finally a sudden change 
to a pointed positive T and a drop of the ST indicate the 
increasing 02 deficiency of the heart muscle. The corre- 
lation of these changes became clear to a wide extent by 
an evaluation of the EKG after summation of the monophasic 
curves according to SCHUETZ. The insufficient supply of 
02 calls forth a change of the form and amplitude of the 
monophasic curves in the particularly affected regions of 
the heart. It must be borne in mind that the potential 
amplitude of the monophasic curves attains a maximum value 
of about 50 millivolts, that of the summation curves, how- 
ever, only about 1 millivolt. This explains the large 
deviations in the standard EKG corresponding to hardly 
perceptible variations of the monophasic carves in the 
common recording methods. As SCHUETZ po‘ hs out, additional 
monophasic potential variations have to ; taken into con- 
sideration since the regions of the hearc suffering from 
a lack of O2 react in the same way as ordinary injuries. 
The changes of the EKG as described above are not specific 
for a lack of oxygen and similar observations are made in 
case of inflammatory heart diseases. These may, however, 
fit the picture if interpreted either as an impairment 
of the capillary oxygen diffusion or as a disturbed oxy- 
dation process in the changed parts of the ventricular 
muscles due to inflammation. The changes in the EKG 
due to an acute lack of 02 are characterized by transition 
and reversibility. General clinical reasons make it 
appear doubtful whether an acute lack of 02 of the human 
heart is associated with severe histologic changes {hemorr- 
hages, necroses) as is the case in the heart muscle of the 
rabbit as was proved by BUECHNER and his associates. 
3. Suitability for mountaineering. 
BALKE (St. Johann) 
Combat assignments in the high mountains will not 
only require the highest combat efficiency but in addition 
the best physical conditions and climbing experience of 
the soldiers. Already the peacetime mountaineer in his 
climbing tours arrived,not infrequently at his last re- 
sources of physical and mental energy. So it is quite 
obvious that the soldier, who has to contend not alone 
against weather hazards, misanthropic rock and ice and other difficulties but principally against the enemy, must 
be carefully selected. War in the mountains is usually 
waged in small and very small groups. Every man must, 
therefore, come fully up to the high standard with regard 
to physical condition and mountain experience. This moun- 
tain experience includes quite a host of separate quali- 
fications, such as perfection at climbing, evaluation of 
weather hazards (rocks, avalanches, sudden fogs and storms 
etc,) familiarity with the influence of altitude and 
climbers’ disease etc. A well experienced drafting 
committee and special testing equipment under the direction 
of a qualified medical officer can under no circumstances 
be dispensed with in the selection of suitable men. With 
regard to the physical efficiency the judgement of the 
medical officer will be of decisive importancej but as 
to psychological and mental qualities, however, the 
commanding officer of the respective unit should be heard. 
The examination of suitability for mountain troops would 
have to consist of a preliminary recording of the follow- 
ing data: Body height and weight, chest circumference, 
vital capacity, breath holding test (time breath can be 
held on deep inspiration), In the main examination the 
constitutional types, training conditions, and an elaborate 
anamnesis of the candidates will be established (including 
achievements in sports, climbing and skiing) in addition 
to a general and a few special medical examinations bearing 
particularly on the function of the heart nd circulation, 
high altitude fitness tests, physical en . 0y, and resistance 
under oxygen deficiency, skill, sense of equilibration, 
coordination of movements and in connection therewith a 
courage and perseverance test. As a matter of fact these 
examinations will have to be carried through at an appro- 
priate place right in the mountains rather than in a doctor’s 
study and it is particularly important that the medical 
officer supervising these examinations be a mountain 
specialist himself. 
Characteristics of high-mountain fitness. 
1, physical and functional properties: athletic- 
asthenic constitution, well trained, large respiratory 
volumes, perfect function of the heart and circulation with 
typical labor or athletic heart, possibly typical athletic 
bradycardia; good coordination of movements, perfected 
sense of equilibration, skill, and perseverance, 
2, Mental qualities: Interest in the mountains, 
practical and theoretical experience in mountain climb- 
ing, knowledge of important alpin literature, avalanches, 
meteorology, sense of orientation, capability to assume 
responsibility for all kinds of climbing tours, correct 
evaluation of difficulties and possibilities. 
3, Psychological features: Enthusiasm-for the 
mountains, mental energy, will power, courage, calmness, 
ability to make decisions, sense of responsibility, sobriety 
and hardness in the endurance of adverse weather conditions. 245 
Discussion: 
0PITZ: The additional stress on the respiration in 
the high mountains makes a high vital capacity very de- 
sirable. 
ANTHONY: In the Airforce the judgement of the 
medical officer bears only on the physical suitability, 
whereas the final evaluation is incumbent to the command- 
ing officer in collaboration with the field surgeon. High 
altitude tolerance is not synonymous with altitude ef- 
ficiency , 
4. Natural adaptation to high altitudes, 
LUFT (Berlin) 
High altitudes - regardless if attained by mountain 
climbing or by airplane - confronts the human being with 
a hazardous change of the conditions of life. The most 
important factor in the effect of high altitude is the 
decrease of oxygen pressure in the air. In aviation, 
altitudes of more than 10 000 meters can be reached by 
the use of adequate oxygen equipment. If 'he aviator 
penetrates into altitudes in which the 1 >1 pressure is 
less than 1/5 of the pressure on the ground, even the 
respiration of pure oxygen will not suffice for maintaining 
the human forces. Mountain climbers in the Andes and 
Himalayas have furnished the proof that an adaptation to 
the high altitude conditions is possible to an astonish- 
ing degree. An increase of altitude tolerance due to a 
stay in the high mountains means additional altitude, per- 
mitting to penetrate farther into the stratosphere by use 
of the ordinary oxygen equipment, furthermore this gain 
of altitude affords a greater security in case of the inter- 
ruption of the oxygen supply. Investigations carried on 
in research stations in the Alps dealt in the first place 
with the effects on the respiration. An increased aeration 
of the lungs was observed in a series of test persons, in 
some of them the minute volume went up by 35$ above the 
value on the plains. In the course of 5 to 8 days a gain 
of 13 millimeters Hgf could be observed in the alveolar 
oxygen tension. The corresponding reduction of the carbon 
dioxide tension of the lungs clearly revealeu a shifting 
of the blood reaction to the alkaline side, which latter 
caused a decrease of the bicarbonate contents so that the 
normal acid-alkali balance was almost reestablished. The 
increased respiratory functions are particularly obvious 
under acute oxygen deficiency and account for the fact that 
a mixture poor in oxygen similar to the conditions of an 
altitude of 8500 meters could be endured without notable 
difficulty for more than 20 minutes as compared with 5 
minutes on the plains. The adaptation effect of the test 
persons was checiced after their return to the plains and it 
was found t.iat the increased altitude fitness as tested in 
the low pressure chamber and in a mixture poor in oxygen 
lasted for about 4 to 6 weeks. 5. Exchange of gases at high altitudes. 
OPITZ (Berlin) 
The transportation of oxygen from the blood into the 
tissues is exclusively effected by diffusion, that is to 
say it depends on the surface involved and on the differ- 
ence of tension between the two phases. Most striking is 
the fact that tae O2 consumption remains constant under 
O2 deficiency. Only in case of a most severe lack of 
oxygen does a drop of the 02 intake below the so-called 
critical threshold due to an Insufficient pressure of dif- 
fusion occur. This threshold is reached in human beings 
at an arterial oxygen tension of 25 to 28 millimeters or 
less. Rebreathing tests were made (in collaboration with 
F. PALME and R, HESSE) at the Brandenburg-House in the 
Tyrolean Alps (3,280 meters) with the view of determining 
if this critical threshold is shifted to the range of 
lower oxygen pressure by altitude adaptation. The character- 
istic changes of the critical alveolar oxygen pressure re- 
vealed in three test persons that this value was actually 
lowered by almost k millimeters by altitude adaptation. 
Analogous observations were made with the currents generated 
by the action of the brain, at the critical threshold we 
observed waves with a frequency of 2 to 3 Hertz instead of 
the normal 12 Hertz waves; the alveolar Op tension at which 
these critical changes occur is likewise lowered. The 
electrocardiographic examinations lead to an opposite re- 
sult. If a relation is established between the flat de- 
viation of the T-wave in lead II to the alveolar O2 tension 
it can be observed that the flat deviation of T in a period 
of oxygen deficiency is more pronounced in altitude adapted 
persons than in the inhabitants of the plains. The decrease 
of the critical alveolar oxygen tension and the behavior 
of the brain action currents point to the fact that the 
conditions of oxygen diffusion in the central nervous system 
were changed by the altitude adaptation. It is, however, 
uncertain whether this improvement is due to changes in 
the circulation or by special properties of the cells. 
6, Effect of cold, 
BREITNER (Innsbruck) 
A survey is given of modern literature on this sub- 
ject, The experiences gained by the Swiss Captain of the 
Medical Corps (DEBRUNTER) point to the possibility of 
fargoing restitution even over the elapse of several days. 
Apart from cases in which quick amputation is necessary 
the surgical measures should as a rule be conservative. 
In the modern concept two problems stand in the foreground: 
The periarterial sympathectomy is likely to contribute 
considerable to a fargoing subsidence of the effects of 
cold and to a quick demarcation in case of necrosis; Early 
amputation, as advocated among others by von LCSWEN, though 
possibly implying too great a loss of the extremities, elimi- 
nates the hazard of remote effects of the injured tissue on 
adjacent sound areas and late aftermaths in the sense of 
SUDEK* s bone atrophy. 7* Effects of cold, 
LOOS (Innsbruck) 
The speaker dealt principally with the local effects 
of cold from a dermatologic point of view. He spoke at 
some length on the internal and external factors causing 
effects of cold and proposed considering the quickly 
passing alterations due to short exposure to cold, the so- 
called "indifferent reactions to cold" apart from the 
actual injuries due to cold. It can be taken for granted 
that vaso-active histamine-like substances play an im- 
portant part in the vascular disturbances which are a pre- 
dominant factor in the effects of cold. The therapy was 
then briefly outlined. Its main objective is the restora- 
tion of normal circulation, and the substances referred 
to above are of importance in this connection too. Even 
in the prophylaxis against the effects of cold encouraging 
results have been obtained in the treatment of the skin 
with histamine-like preparations, which should give rise 
to systematic examinations in this respect. 
Discussion of reports 6 and 7: 
LUFT: The hazards of cold increase with the altitude. 
Examinations should be carried through to otormine whether 
or not the favorable therapeutic influent of oxygen in 
higher altitudes will also be observed on the plains, 
SCHWIEGK: A sudden warming up in case of a general 
effect of cold might prove hazardous, since the dispro- 
portion between the vascular volume and the circulating 
quantity of blood might cause a collapse. 
ANTHONY: The fear of this collapse is not well 
founded as recent examinations could prove. 
RANKE: Little connection between the consumption of 
alcohol and effects of cold has been observed. Smoking, 
however, creates a specific susceptibility of the respira- 
tory passages to the effect of cold. 
PARADE: Female sexual hormones proved very success- 
ful in case of disturbances of the circulation. Since the 
urine of both males and females contains fernal sexual 
hormonesj these may be considered the effective ingredient 
in the treatment of frozen feet with urine, practiced with 
good success by the inhabitants of the extreme north. A 
vascular dilatation may also be attained by CO2 and excellent 
results of the treatment with carbon dioxide have been ob- 
tained, 
LEHMANN: The production of adrenalin is very high if 
the body is exposed to extreme cold, and this easily ex- 
plains the conditions of exhaustion, 8. Chemical regulation of heat in extreme cold. 
KRAMER (Berlin) 
The chemical regulation of heat as discovered by 
LAVOISIER is divided into two distinctly differentiated 
mechanisms: 1. voluntary and involuntary function of 
the muscles; 2. increased basal metabolism at rest. 
The quantitative aspect of the regulation can only be 
demonstrated to a limited extent. GES3LER found in a 
series of tests of short duration an increase of the 
basal metabolism at rest by as much as 25$ with a slight 
drop of temperature below 18° Celsius. Fluctuations of 
the basal metabolism due to the season showed variations 
in the sensitivity of the heat center, which correspond 
to the curve of the daily average temperature. Tests 
carried through under extreme cold (stay in polar regions, 
high mountains) pointed in the same direction, namely in- 
crease of the basal metabolism with a decrease of external 
temperature. My own tests in a refrigeration chamber on 
normally dressed test persons at temperatures down to 
minus 20° Celsius reveal an increase of the metabolism 
up to 100$, and which, therefore, lies in the range of 
the thyreotoxic increase of metabolism. These increases 
of the metabolism are, however, due to both of the two 
mechanisms mentioned above, for as long as the involuntary 
function of the muscles (trembling) does nol: set in, the 
increase of the metabolism does not excc 25$* The ex- 
tent of the chemical heat regulation duo m-a genuine in- 
crease of the metabolism under extreme cold, which is by 
no means sufficient to maintain the necessary body tempera- 
ture, is striking, 
discussion: 
STRUGHOLD: The question as to sensitivity of definite 
areas of the body with regard to the thermo-regulation is 
raised by this speaker. 
9* Clothing problems, 
RANKE (Berlin) 
The light and heavy winter protective clothing were 
demonstrated. Reference was made to the necessity of de- 
termining the insulating qualities of different clothes, 
which task is incumbent to the physiologists, A suitable 
instrument for these measurements has been developed and 
a picture of this instrument is presented. The results 
confirm the well established observation that the permeabili 
will be the lower, the thicker the air cushion retained 
between two layers of clothing. 10. Practical problems of the protection against cold. 
HILDMANN (St. Johann) 
This consultant reported on his experiences as a 
medical officer gained in the winter campaign 1941/42 in 
a ski battalion in Russia, A maximum protection against 
cold is attained by a honey-comb-like system of air cushion, 
in immediate proximity of the body as is secured for in- 
stance by a double layer of knit underwear. Protective 
overcoats are less effective since the air cushion formed 
by them is not in direct contact with the skin. The use 
of ointments is rarely observed by the troops in a general 
and satisfactory manner, so that reliable observations could 
not be made. The idea of the use of ointments is, that the 
vessels are prevented from their normal reaction to cold 
by virtue of an applied layer of grease. As far as pro- 
phylactic measures are concerned preference should be given 
to those measures which aim at a voluntary or involuntary 
adaptation of the capillaries to cold. 
In the treatment of new local injuries due to cold, 
the vascular spasms which are more impressive than the 
momentary loss of temperature will be relieved best by 
the stimulative effect of alternating hot and cold baths. 
No reaction whatsoever of the vessels is observed in old 
localized injuries due to cold. This is explained a priori 
by the formation of vasodilating substar , in the frozen 
tissue and it was emphasized that the th na-py will have to 
counteract these phenomena. 
A general chilling of the body limits first of all 
the wish to move and to be doing things, associated with 
a certain stiffness of the muscles. These symptoms were 
observed in all men of certain units. A slight and moderate 
degree of chilling may be tolerated for several days. 
After that time excessive thirst, loss of appetite, permanent 
headaches and weariness will set in. Injured soldiers 
are especially prone to injuries by cold in mobile warfare 
in winter time, since the loss of blood, immobilization 
and wound shock constitute additional hazards. As com- 
pared with summer conditions a higher fatality rate is ob- 
served even in case of slight injuries, generally four to 
six days after the injury. Death is due to a failure of 
the circulation which cannot be overcome by the administration 
of drugs. In the treatment of a general chilling preference 
is given to the method of a quick warming up of the body. 
In case of a prolonged stay in the cold without any possi- 
bility of rest and warming up, meals prepared with fat 
meat are not acceptable; the soldiers prefer light soups 
and hospital diet under these conditions. Frequent small 
meals consisting of cookies, biscuits and bread help to 
tolerate the cold. 
Discussion: 
STHUGHOLD: Points out the fact that the hair of 
certain kinds of animals contains air. 250 
ANTHONY: Agents which will counteract both localized 
and general effects of cold will always remain a utopia. 
11* Problems of the metabolism in the high mountains. 
LANG (Berlin) 
In spite of a great many examinations oui knowlc ;dgu 
regarding the metabolism of the basic foodstuffs in the 
high mountains is very limited. 1he tests have been of 
too short a duration to yield reliable results. The in- 
formation received is often contradictory and this is not 
so very surprising if one considers that many factors such 
as the dilution of the air, cold, radiation and strain are 
involved. 
As a critical evaluation of the results gained so 
far on the carbohydrate metabolism in the high mountains 
the following facts seem to be well established: 
1. The carbohydrate tolerance of the human being 
is increased in the high-mountains; 
2. The effect of adrenalin on the .food sugar is 
more pronounced in the mountal.. than on the 
plain; 
3. The (respiratory quotient) on the intake 
of sugar goes up more rapidly in the mountains 
than on the plain. 
It must be assumed that the stored carbo-hydrates of 
the body have become more mobile in high altitudes and thus 
used up easier. The practically highly important question 
of whether or not the carbohydrate stock of the body is de- 
creased in high altitudes remains unsettled. In short tests 
in very thin air a considerable decrease of ttecontents 
of the liver and muscles is regularly observed, which can- 
not be balanced■even by the administration of insulin- 
glucose. It is, possible that the glycogen contents 
will decrease again on a prolonged stay in high altitudes as 
is maintained by SAPEGNO, 
No information at all is available concerning variations 
in fat metabolism in high altitudes. Essential disturbances 
of the protein metabolism were not observed. LOEWY, who 
had an opportunity to examine the urine of 7 members of 
the DYRSNFURTH-Himalaya expedition did not observe any re- 
markable changes of the N-components of the urine. In our 
own experiments, however, certain subtle changes of the 
amino acid metabolism (increased excretion of Imidazol cor- 
puscles, decreased urine N-fraction precipitable by hydra- 
gyrum sulfate) until the body adapted itself to the altitude 
conditions could be proved. The higher the altitude the longer 
the adaptation period. Presumably these slight changes in 251 
the metabolism are due to a temporary disturbance of the 
liver functions, which must also be considered as the 
cause of the porphrinuria occurring until the adaptation 
takes place and which has no connection to the hemoglobin 
metabolism. The reduced process of transformation of 
fructose into glucose further points to a disturbance of 
the liver functions. Disturbances of bile secretion were 
observed too, A certain strain is laid upon the protein 
metabolism by the new formation of hemoglobin. In a test 
carried through on myself, 150 grams of hemoglobin were 
formed in 20 days, that is to say 7.3 grams per day. In 
untrained persons the formation of muscle substance has 
to be considered in addition. 
The question whether or not the total nitrogen meta- 
bolism is increased in the high mountains is of special 
interest. The former tests made in this respect are not 
entirely satisfactory. It is essential, however, to know 
whether the oxygen requirement of the organism is particular- 
ly high just at the time when little oxygen is offered to 
the body. 
Discussion: 
PARADE: The influence of training and ultraviolet 
radiation on the cholesterin level was mentioned by this 
speaker, 
STHUGHOLD: This consultant pointed out the necessity 
of accurate determination of the basal metabolism at high 
altitudes. 
12, Heat regulation in conditions of excessive heat. 
RANKE (Berlin) 
The heat regulations in excessive heat and cold show 
certain parallels and both are of special importance in 
the high mountains, where special attention is due to the 
influence of physical strain. According to the classic 
concept the basal metabolism assumes a minimum value at 
medium temperature, whereas it is observed to be on the 
increase at high or low temperatures. The problem, in 
how far the low outside temperature is compensated by the 
increased metabolism, and what amount of heat is drawn 
off by the ambient cold is discussed in KOENIG'S paper about 
the ”homoiothermal Kernel" and the "poikilothermal shell” 
of the entire organism. According to his theory the with- 
holding of the circulation due to cold is a measure of the 
organism to protect the kernel against cold. Vice versa the 
increased circulation of the skin due to heat facilitates 
the diffusion of the excessive amount of heat. The reflexes 
of the skin viewed from this angle do not suit the purpose 
under all conditions: namely in case of a quick warming over 
causing the circulation of the skin to increase abruptly. Thus the blood of the shell will cool down and have a 
paradoxical cooling effect on the kernel which might 
initiate a hazardous collapse. The kernel supports only 
a limited fluctuation of temperature without serious 
damage; there exists thus a law of time for the heat 
regulation: an excessive heat or cold which may be sup- 
ported for a short whilu will, if continued, cause a 
hazardous increase or fall of temperature of the kernel. 
If, however, the kernel remains homoiothermal, the ambient 
temperature will not exercise an influence on the meta- 
bolism, which fact has been verified by the tests of 
KRAMER. Only on the increase of the temperature of the 
kernel will the well-known disturbances and precursory 
signs of an imminent collapse appear to be associated with 
disturbances of the circulation which can be demonstrated 
by the EKG and which subside on recovery. On the strength 
of clinical tests it could be verified that high external 
temperatures may be tolerated for many hours if the tem- 
perature of the kernel does not rise by more than 0,2 
degrees Celsius and if the pulse rate does not increase 
by more than 10 beats per minute. Objective criteria have 
been established for the so-called ”comfortable feeling”. 
The limits of the "comfortable feeling” conditions may be re- 
presented in a diagram according to M0LLIEH in which the 
temperature and humidity of the air will be the coordinates. 
Discussion; 
LEHMANN; In the adaptation to heat the body produces 
a perspiration of low concentration. It is important that 
small amounts cf liquid be taken in on frequent occasions if 
work is to be performed in heat so as to keep the osmotic 
pressure as stable as possible. The admixture of salt to 
the drinking water is only indicated if the normal adapta- 
tion will not be sufficient. 
LUFT: It was observed that the Arabs in Africa put on 
their burnooses during the Ghibli (very hot wind) presumably 
to reduce the evaporation. 
13. Physicochemical problems of respiration. 
FISCHBECK (Berlin) 
The different stages through which the oxygen has 
to go on its way from the alveoli to the tissue,* includ- 
ing the redox process and tne oxidizing ferments, has been 
so thoroughly investigated that we are in a good position 
to estimate the relative inertia of reaction of the dif- 
ferent stages by comparing their speed of response. These 
investigations afford us a clear picture of the inertia of 
reaction which opposes itself to the flow of oxygen. The 
stage with the greatest resistance will have the most im- 
portanne in case'of oxygen deficiency due to decreasing 
tension. It was furthermore demonstrated in which way the 253 
position and readaption of the chemical equilibrium, the 
diffusion in the membranes and fluids, the speed of the 
blood circulation and other factors act jointly and in- 
fluence the speed of oxygen intake. 
14* The substances affecting blood formation. 
WESTPHAL (Berlin) 
The supply of the organism with oxygen is the main 
problem of physiology of high altitudes; in this connection 
the study of the blood formation viewed from the chemical 
aspect seems to be important. Experiments of WHIPPLE and 
collaborators on anemic dogs have verified that a diet very 
poor in protein will impede the synthesis of the red blood 
pigment; additional intake of protein leads to a new forma- 
tion of hemoglobin (about 1 gram per 7 to 8 grams of food 
protein). The intake of amino acids likewise increased the 
hemoglobin values by 23 to 30?£. Examinations on anemic dogs 
with radioactive iron revealed that this element which is 
responsible for the oxygen carrying function of hemoglobin 
was rapidly resorbed and used for the formation of new ery- 
throcytes . 
Little is known about the initiating .•chanism as 
viewed from the chemical aspect. Whereas the effective 
substances in a pathologically changed blood forming system 
(anemias) were given much attention from a chemical point 
of view only a few findings seem to point to an implication 
of specific ingredients in the normal physiologic formation 
of blood. Specific substances (hemopoietin) were observed 
in the serum of rabbits after venesections which caused an 
increase in the number of erythrocytes in other normal 
rabbits (CARNOT and DEFLANDRE 1906); the presence of these 
substances was also proven in the marrow extracts of animals 
which were made anemic. Later on the hemopoietins were 
also found in guinea pigs and rabbits which had gone through 
breathing tests under oxygen deficiency (low pressure chamber) 
(MUELLER 1912, F0ER3TER 1924). The hemopoietins also occur 
in human beings in case of an oxygen deficiency; SCHWARTZER 
and LOESCHKE 1940 were successful in proving them in the 
blood of the umbilical cord of a one week old baby. Recent 
tests on human beings revealed that a short stimulus caused 
by oxygen deficiency will be sufficient to increase the 
number of erythrocytes in the sense of an altitude adaptation; 
the test persons in question were breathing repeatedly for 
several minutes with interruptions of several days a gas 
mixture poor in oxygen (BRUEHL and HANISCH*1942). 
The exact location of the hemopoietin formation is not 
known. The spleen, if it plays a part therein, will certain- 
ly not be the only organ, since the hemopoietic substance 
was also found in spleenectomized rabbits. The blocking of 
the RES (reticulo-endothelial-system), howevery prevented 
the formation of hemopoietin as well as the increase of ery- 
throcytes and hemoglobin under high altitude conditions (LOEWY 1934)* The removal of the thyroid gland and thymus 
jeopardized the accelerated blood regeneration following 
the administration of hemopoietin; if in addition to these 
two organs the spleen was extirpated the response to the 
administration of hemopoietin was reestablished. Histo- 
logic examination revealed tiiat these effects act in the 
bone marrow (ASHER and NAKAO 1925), The latest research 
work confirmed an increased function of the erythropoietic 
tissue of bone marrow due to extracts of thymus (de CANDIA 
1942). 
The examinations of hemopoietins made so far had only 
an informative character. The question whether or not the 
normal physiologic new formation of blood is regulated by 
specific substances or if non-specific decomposition pro- 
ducts of blood play a part therein still remains to be 
clarified by more systematic examinations. 
Discussion: 
PARADE: Do specific hemopoietins really exist or is 
the hemopoietic effect started by vegetative or hormonic 
regulations? 
LEHMANN: Inquired after the real origin of the hemo- 
poietins , 
BALKE: Reports on his experiments with hemopoietins 
at the Mountain Medical School, 
15 > The measurement of physical efficiency, 
LEHMANN (Dortmund) 
An^'exact measurement of that kind is only possible witn 
regard to a definite form of work. The results then ob- 
tained will, beside the individual differences, be rather 
heterogenous according to which organ under most strain is 
used for this purpose. If the efficiency is measured up 
to the limit of exhaustion, the determination of the latter 
will be very subjective. Therefore, a series of objective 
measuring methods has been developed based on the amount 
of work performed with a regular intermission for recovery 
ventilation until a predetermined pulse rate or minute 
volume is attained. The values are then given in terms 
of the product of pulse rate and blood pressure aiaplitudo. 
With the above mentioned method in whi ch the amount of-work 
is adapted individually to the strength of the muscles, so 
that the time elapsing until the limit value is reached in- 
dicates directly the respective degree of efficiency, it 
was possible to demonstrate the influence of drugs and 
nutrition on efficiency. The fluctuations of efficiency due 
to the influence of physiologic factors in the course of the 
day are called efficiency conditions. The conditions are 
characterized by the adrenalin load of the bloodplasma as 
determined by LEHMANN and MICHAELIS. 255 
Discussion: 
TROJA: The limit value of an amplitude frequency pro- 
duct of 10 000 as used by LEHMANN will not always suffice 
for well trained mountaineers who in many instances reach 
that value in the first minute. 
16. Tiie efficiency of the mountain soIdier. 
CREMER (St. Johann) 
Since the problem of fatigue - objective definition 
of the term and causes - has not yet been solved in a 
satisfactory manner so far. It seems to be indicated to 
deal first with the reverse: efficiency. The maintenance 
and the increase of efficiency in the mountains appear as 
the most important tasks of the mountain physiologists. 
First of all the definition of "efficiency" is explained, 
and the organ and organic systemson which the efficiency 
depends were reviewed. The enumeration of all the internal 
and external factors of influence on efficiency lead to 
the question as to how the efficiency could be increased 
artificially. After a discussion on the efficiency stimu- 
lating drugs the nutritive problems in the mountains were 
brought up. A special mountain diet - 1 w weight, high 
nutritive value, quick preparation - has been developed. 
This diet will for the time being only be issued in case 
of special missions of mountain troops but after the war it 
might be available for all mountaineers as an ideal diet. 
This report will possibly be published in full in 
May 1943 in the K1inishe Wochenschrift,