UNITED STATES FLEET 
UNITED STATES NAVAL FORCES, GERMANY 
TECHNICAL SECTION (MEDICAL) 
Room 124, EUCOM HDQTRS. , 
APO 737 1 
File: P 3-l(b) 
Serial; 224-Med. 
26 February 1948 
From; Assistant Technical Officer (Medical), 
U.S. Naval Forces, Germany. 
To: Chief of Bureau of Medicine, ' •; 
:(Atth: Chiof, -Publications Division). 
Via: (1) Technical Officer, U.S. Naval Forces, Germany. 
(2) Chief* of Naval Operations (Op-32-F2). 
Subject: Report of Third Conference of the Medical 
Consultants to the Wehrmacht - Forwarding of 
translation of. 
Reference; (a) Letter P 3-l(b) Serial 207 dated 2 January 
1948 from Head, Medical Section, Office of Naval 
Advisor, OMGUS. 
(b) Letter p 3-1(b) Serial 206 dated 2 January 
1948 from Head, Medical Section, Office of Naval 
Advisor, OMGUS. 
Enclosure: (A) Subject Translation (Project I, Folios V,VI) 
1. Due to its bulk, Enclosure A will be forwarded under 
separate cover direct to each of the below listed recipients 
of a copy of this letter. 
2. This is a continuation of Project I of this 
section, parts of which have been forwarded previously by 
references a and b. 
3. To avoid inconsistencies in the make up of the 
bound material these folios have been issued under the 
heading Medical Section, Naval Technical Unit, Europe altho 
administrative reorganizations have changed the designation 
to Medical Section, Office of Naval Advisor, OLGUS and 
more recently as noted at the heading of this letter. 
4. The reserve supply of these folios is limited. It 
will be forwarded to Bureau of Medicine and Surgery, 
Publications Division on a Government Bill of Lading. 
Requests for additional copies or further distribution should 
be addressed to that office. x 
HARRY if. ALVIS, 
Commander, Medical Corps, 
U. S. Navy. 
cc: 
ONA, OMGUS 
CNO (0p-32-F2) 
BUMED (Publications Div.) 
BUTTED (Research Div.) 
BUMED (Professional Div.) 
BUMED (Prev, Med. Div.) 
N.M.R.I. Bethesda 
Naval Med. School, Bethesda 
Dept, of Army, Gen. 
Med. Intell. Sect. 
Dept, of Air Force, Air Surg. 
Med, Intell. Sect. 
U.S. public Health Serv. 
Off. of Surg. Gen. 
U.S. Army Medical Library 
U.S. Dept. Commerce, 
Off. Tech, Info. 151 
VII. 
PROCEEDINGS OF THE CONSUL T ANT S 1 
COMMITTEE ON 
INTERNAL MEDICINE. 
Translation prepared by; 
Office of Military Government for Germany (U» S. ) 
Office of Naval Advisor 
Medical Section Treatment of carriers of diphtheria bacilli 
(See Section VI, Article 9/ 
Ridding carriers of intestinal protozpa 
(See Section VI Article 107 
Threat of malaria for the German population 
(See Section VI, Article ’ ~ 
Treatment of gunshot wounds with sulfonamides 
(See Section II, Article 6) 
Treatment of post-diphtheritic paralyses with 
vaccinoMnalarifl 
(See Section XI, Article 6) 
Pathology of injuries caused by inoculation 
(See Section VIII, 'Article 3T" 
Possibilities of calling up men suffering from ulcer 
for active service* 
Oberstabsarzt (Major, MC.) Prof. STEIN 
Diseases of the stomach are a part of the complex of 
complaints that impairs efficiency and fithess for service 
most. A good soldier will as a rule not report himself 
ill on account of moderate or vague troubles immediately, 
but a large number of men with stomach diseases are in- 
clined to consult the doctor early. The medical officers 
in the field are not in a position to carry out the nec- 
essary examinations. Besides,the diagnosis cannot always 
be made with the required reliability in the field hospitals. 
Even if a diagnosis is made there, the available medical 
attention often cannot effect complete healing; So a stream 
of men with disorders of the stomach flows backwards, and 
durihg periods of important military operations, considerate 
numbers of them reach home hospitals. If today it is 
properly demanded on principle that a greater number of 
the sick, including those with infectious diseases, should, 
whenever possible, be retained near their.units, or in the 
army group area, this demand applies all the more for men 
with stomach trouble, in so far as military conditions will 
allow. It-is a characteristic of stomach complaints, that 
they must be. cured within a definite limit of time and the 
patient must be restored to efficiency. The longer the 
period of medical treatment, the less will be the chances 
of sending the patient back to his unit in a state of ef- 
ficiency. The crisis may occur from the 6th to the 8th 
week approximately. But this critical limit will be ex- 
ceeded the more easily, the farther the patient is removed 
from his unit and the more frequently he is sent from 
hospital to hospital. 
As to our fundamental view of the nature and significan- 
ce of stomach diseases, particularly in war time, I de not 
think it justified to make a difference on principle bet- 
ween patients with a proven ulcer and patients with in- 
flammatory, secretory and spastic disorders without an ulcer. As regards diagnosis of course, this does not change the 
necessity for an exact examination in every single case. 
Both groups have in common the changed reaction of vegeta~ 
We functions,■ These may be uniform or multiform and'com- 
plicated or even hidden. It is not within the scope of 
my task to describe these functional disorders, but in 
forming an opinion of men with stomach diseases the follow- 
ing considerations are important; 
1* The more severe and multiform the vegetative 
functional disorders are, the more will the temper and be- 
havior of the individual be changed. The trend of the de- 
velopment is always towards loss of energy and force of will 
and towards an unsocial attitude and it is this process 
that impedes the patient's guidance and treatment more than 
do circumscribed functional disorders and a circumscribed 
anatomical defect. 
2# The general vegetative functional disorders will 
precede the development of local changes and also the de- 
velopment of peptic or duodenal ulcers. Even before the 
war, we were- able to demonstrate in some cases requiring 
observation for other reasons that the beginning of gastriti 
and ulcer are preceded by gradually developing disorders of 
general vegetative functions. This could ;be shown particu*- 
laaiy clearly in case of the development of hypotonic con- 
ditions combined with bradycardia. 
3. During the last few years and even before the 
war, functional disorders within the vegetative nervous 
system were increasing amongst most of the European nations. 
This steady increase suggests that also an increase of 
intestinal disorders may be connected with it;, but it could 
not yet be settled statistically, whether this is the case. 
At all events, an increase of intestinal disorders strictly 
speaking has not been proved safely so far. In any case, 
in tackling the problem of intestinal diseases one must con- 
sider the fact that major vegetative functional disorders 
have been increasing. The possibility of calling up men 
with intestinal diseases for active service in wartime is 
now chiefly dependent on therapeutic principles and their 
observation. It is probably due to repeated and radical 
changes in the concepts concerning origin and nature of 
intestinal diseases and the still prevailing inexactness 
in forming an opinion concerning these diseases that in 
hardly„any other medical field have so many suggestions 
of treatment - partly contradictory - been made. 
applies to the operative field as well as to 
therapeutics. There are vast numbers of dietetic suggestions 
alone, from a strict Sippy-diet to unrestricted nutrition 
according to MEULENGRACHT. Everjr expert in the treatment 
of men suffering from stomach diseases will agree with me, 
that it is not so decisive whether one or the other diet 
is selected if the term diet is understood to mean not much 
more than the kind of nutrition. In this sense, diet is 
not decisive at all. It is quite another matter if diet 
is understood to mean a strict regulation of the whole way 
of life and all potentialities of the entire personality in 
the sense of the ancient hippocratic dietetics. This is Indeed decisive, and the chief thing is here the adaption 
to the respective state of the organ, function, and per- 
sonality. Two principles, which retain their unchanged 
importance in all fields of medical treatment, the principle 
of putting^at rest and the principle of exercise, must be 
fully considered here also. It is a fundamental error to 
believe that, through prolonged confinement to bed, the 
diseased organ may be put to rest especially well or even 
that the vegetative functional disorders and the attitude 
of^the entire personality may be favorably influenced. 
This is incompatible with the physiological facts and ideas 
as well as with our knowledge and experience as regards the 
temper of men suffering from ulcer. For about 10 years 
I have made it a fixed rule to confine to bed all men 
suffering from intestinal diseases, special complications 
expected, for the shortest possible period, i.e. to re- 
place absolute rest by exercise, increasing the strain 
gradually. Of course, every man afflicted with ulcer 
required absolute rest during the first few days. Par- 
ticularly so if? in order to spare the diseased mucous 
membranes, a brief but most strict tea and gruel diet is 
prescirbed during the first few days. In most uncom- 
plicated cases, one can even after a few days carry out 
exercise-therapy with active and passive exercises, with 
massage and other adequate measures. In most cases, this 
can be done even after about seven days. A treatment, 
partly of rest, partly of exercise will be gradually trans- 
formed into therapeutic training with the aim of attaining 
a normal tonic regulation, particularly in the field of 
blood circulation and the highest possible capacity for 
undergoing a certain strain. Without setting definite 
limits, the steps of treatment by exercise with a strict 
division of the day, will proceed to routine military 
exercises. Hospital treatment of patients with stomach 
diseases must aim at sending back to their units the lar- 
gest possible number of these men in a condition of ab- 
solute fitness for service, and everv hospital is natur- 
ally bound to prove this fitness for service during their 
stay at the hospital. At the same time, this will be for 
the patient himself the best conviction of the success of 
the treatment, of his restoration and his actual fitness 
for military service. I, however, must emphasize the fact, 
thatj as long experience has shown me, a treatment with 
confinement to bed for many weeks makes the patient feel 
more and more ill, has a bad influence on the spastic ap- 
pearances and by no means removes atony and general lack 
of energy, but on the contrary, increases it and makes 
it work. In many cases, the typical features of a change 
of character in our patients suffering from ulcer will 
develop only during the long treatment with rest, lack of 
occupation, and boredom. Hospital wards with patients 
suffering from intestinal diseases, who are left to their 
own resources without any activity whatever, are, as 
general experience shows, hot-beds of ill humor and further 
despondency and bad soldierly conduct. Only by keeping 
the patient occupied increasingly, sensibly and S3rstem- 
atically, can one succeed by strict military guidance 
and by sympathizing with the personal troubles of every 
single patient, in leading him, who is changed by disease, back to a normal condition by restoring his lost self-con- 
fidence and by strengthening his faith in his own efficiency, 
it is a generally acknowledged fact fully confirmed in the 
last, as well as in the present war, that, in mobile war- 
fare, men with stomach trouble present no, or only a negli- 
gible, problem. Also our numerous follou-up histories show 
clearly that many men suffering from ulcer were capable of 
uncomplainingly enduring immense hardships without diffi- 
culties. At the same time, this is a corroboration of 
If*. BERGMANN’s statement, which he made on the strength of 
his experiences in the first World War: "Without special 
food or any other dietetic precaution, it was especially 
the ulcer complaints that ceased among the combatants, andd 
many a man suffering from ulcer felt well only then, whereas 
ulcer and gastritis reappeared in the offices and overheated 
rooms". I consider it an important fact that the combat 
group with its own strict common laws and its unalterable 
obligations is the community, into whichihe patient with 
Intestinal trouble, whose social sense is difficult to 
rouse, may be introduced most easily and naturally* For 
this reason, I have been demanding from the fyery beginning 
whereever I had some influence on the treatment and judge- 
ment of men with stomach diseases, that after successful 
treatment, the largest possible number of them should be 
discharged from the service or sent back to the front. Our 
fairly accurate follow-up of men with intestinal diseases 
time shows that an occupation in formations not 
operating at the front or employment in the home country 
and civilian trade, such as armament factories, is in no 
way better suited to relieve the lot of the pauients, to 
reduce complaints or to limit the number of relapses. 
In a special hospital for men with intestinal diseases, 
the first one established in this war, 60 - 70 per cent 
of the patients treated there, were sent back to their 
units as fit for active service or as fit for garrison 
duty in the field, if they were afflicted with further 
defects. Preliminary statistics listing 1500 patients 
who passed through this special hospital within 13 months, 
show that 70 per cent were still in active service in their 
units one year after their discharge. In about 50 per cent 
of them, ulcer had been positively ascertained roentgeno- 
logically or gastroscopically. The time being too short, 
the abundant material, particularly the numerous and 
valuable follow-up histories, could not be thoroughly 
evaluated, I am sorry to say. This much may, however, 
be safely said that it is quite possible to send back to 
their units a conslteable number of the patients suffering 
from stomach diseases, owing to the rigid treatment brief- 
ly outlined in its principles and to keep them fit for 
active service for a long time. I do consider this pro- 
cedure not only as possible but even as absolutely nec- 
essary for medical as well,as military reasons* If this 
demand is complied with everywhere as strictly as possible, 
the idea that stomach diseases are not necessarily^grave and 
are not at all liable to lead to unfitness for active ser- 
vice j will probably prevail also with the Army. In the 
run, this will also have a favorable influence on the fund- 
amental attitude and original situation of the men suffer- 
ing from intestinal trouble. A report of my collaborator Dr. BERG - to whom we are 
also obliged for drawing up the Heidelberg statistics - 
which was recently submitted to me, shows clearly that 
conditions were quite similar in a formation where the 
army surgeon has been working without interruption with 
his unit ever was first formed. Out’of the men 
described as suffering from intestinal diseases only a 
little less than 50 per cent remained with the unit lor 
returned to it, and these do full duty, oven under the 
hardest conditions of the Russian winter and of the fiercest 
fighting at the Eastern front, and they complain rarely 
or not at all. Though it may seem surprising to us, still 
they have changed their dispositions by getting accustomed 
to permanent hardships and so overcame the disease. 
Now it goes without saying that a certain number of 
men suffering from stomach diseases cannot be used for 
military service from the first. These include the 
following groups: 1. all men with stomach diseases who 
have suffered a heavy loss of blood, 2, all patients 
who have suffered a perforation, 3* all patients with 
extensive stenosis-symptoms or with considerable in- 
convenience of digestion due to mechanical causes; 4, 
all patients who have undergone operations on the stomach. 
These groups will always include a comparatively small 
number of particularly efficient soldiers or men with 
special training who are, for this reason, more or less 
indispensable to their units. These men should of course 
also be sent back to their units, in spite of certain 
dangers and in spite of the of having a relapse. 
In my opinion the only real difficulty in judging them prop- 
erly exists in another group viz. the patients advanced 
in years, amongfet who recurrences were often found and 
whose mental attitude cannot be improved while the ulcer 
is healing. These should be discharged, too, but only 
after severe judgement and thorough treatment in a special 
hospital. 
It is necessary, however, that all authorities re- 
sponsible should have the same views on these things, 
and the possibilities of employment £jf the patients 
suffering from ulcer and intestinal diseases should be 
judged by the same rules. This apolies to the surgeon 
who has to decidd on the employment of these men as well 
as to the sufgdbhsSupervising the treatment and particularly 
to the army medical officer. Now as ever, the 
task rests with the army surgeon who, in cooperation with 
the commanding officer, must endeavour to save the patient 
for the military community. -2* „ Possibilities of calling up rfien suffering from ulcer 
for military service* 
Oberfeldarzt (Lt. Col., MC.) Prof. KATSCH 
Only recently a -surgeon whom I esteem highly, told me 
that we internists hardly ever find simple formulae for 
things. This can be explained I dare say, not so much by 
a lack of resolution on the part of the internist*; as by 
the fact that the living process of diseases is as many 
sided as the constitution of man. As regards the possibil- 
ity of calling up men suffering from ulcer for military 
seivice, it dannot be reduced to a simple formula, either. 
In endavouring to find a simple and prompt solution, 
we may by no means declare unfit for service all men with 
positively diagnosed ulcers of the stomach or duodenum. 
This does not come into question, because there are too 
many men suffering from ulcer and because it has been 
proved meanwhile that many of them make excellent soldiers - 
at least long enough to make it worthwhile. Though I dare 
say it is generally recognized that military service in 
war time is often injurious to ulcer oatients on the one 
hand by the military diet, on the other hand by the physical 
and psychic strain, I think it right to begin this treatis by 
stating that an ulcer condition will not, as a rule or 
inevitably get worse under war-conditions and by doing 
military duty in ' the home country. There are men 
suffering from ulcer who feel better in war than ln~peace• 
I know a farmer whom I have been treating for years 
because of his duodenal ulcer positively proven by X-rays. 
He had to undergo medical treatment every year. From the 
time he was called up for military service, he has been 
quite well nor has he been sensitive as regards his diet 
any longer. I explain this, at least partly, by the fact, 
that, as a soldier he feels in his proper element, whereas 
before, through special conditions, he wasted away through 
bother with the authorities. Meanwhile, his wife succeeds 
in dealing with the same authorities much more adroitly. 
There is a bank clerk who conscientiously managed 
a deposit bank and was troubled all the time by his ulcer. 
As a soldier, he is as fit as a fiddle,now commands a front- 
line battalion as* a major in the reserve and, by taking 
slight precautions in diet, has never had to interrupt his 
duties by hospital treatment. 
There is a young man wanting to be a soldier at any 
price. As he has a duodenal ulcer with stenosis, he has 
been three times declared unfit for service by the medical 
examiners. He consulted me asking whether I could help 
him to do something against the decision of the recruiting 
commission. Considering the findings, I had to refuse. 
In the end, however, he managed to become a He 
managed to get through the period of fundamental training 
and has beenma soldier on the Eastern front for 2 years* 
I exchange letters with him, because I am interested in 
the case. Twice he needed hospital treatment for a few 
weeks. Apart from he sticks it out and his superiors 
seem to think much of him. There is a veteran of the World War I with chronic 
ulcer and fairly serious stenosis. He had made up his mind 
to take part in the Polish campaign and sticks it out from 
first to last, has had meanwhile a recurrence of complaints 
which he overcomes by eating moderately of the military diet 
and by getting milk now and then, a bottle of which he keeps, 
as a rule, in his belongings. 
There are two aviators of the Greifswald training wing 
whose ulcers I have known of positively from prewar times. 
I met them again in Greece, whence they were flying very 
trying long range engagements to Africa. Yet they stuck 
to this tiring duty though they had a bad time while doing 
so. It was a terrific strain upon them, and I am bound to 
say that such longrange flights as d?ve bombers are partic- 
ularly wearing for men suffering from ulcer. 
These examples, to which myself and everybody else 
present might add many others, do not apply to the majority 
of the men suffering from ulcer, but still a considerable 
number who are excellent soldiers with or even without com- 
plaints and who we cannot do without. Enthusiasm for mill* 
ttriy life, general aptitude for it, sense of duty and good 
comradeship are all motives having an influence, sometimes 
even a decisive influence for the possiblity of calling them 
up for military/ service. I should like to mention here that, 
according to a report of Professor v. SALAMANCA (Madrid), 
the ulcers of a number of his patients were cured in the 
Bolshevist community jail, certainly not by the jail-diet 
but, according to our Spanish colleague, by their political 
enthusiasm. 
This effective enthusiams can not be expected of every- 
body nc& can~it be created by suggestion, this reason, 
the other radical solution of the problem, viz. to declare 
on principle all men suffering from ulcer as fit for service 
is impractical too. This would lead to an overcrowding of 
the hospitals and would deprive the war industries of more 
or less valuable workers while their fitness for military 
duty is very dubious* Unfortunately one finds out again 
and again that men who have been discharged as unfit for 
military service because of serious organic ulcer findings 
with complications by a decision in a special hospital, are 
enlisted again as fit for military service by the Army 
Recruiting Offices some time later. After a short time, they 
are in the hospital again, are once more thoroughly examined, 
X-rayed, judged, and discharged as unfit for military service, 
and yet they are inducted again another examination, i 
I found such a perfectly absurd procedure up to seven times 
with the same man. Some means ought to be found to prevent 
it. Certain men suffering from ulcer will be of no use 
as soldiers, that fact is indisputable. 
,rWe must make a differentiation concerning the kind of 
assignment as regards the possibility of enlisting men 
suffering from ulcer for military service, and this differ- 
entiation is not without some difficulties, considering the 
nature and multiformity of this still strange^disease. It 
requires surgeons not only expert in the special judgement 
of the particular stomach findings, who not only know roentgen 159 
findings but also grasp the functional and rhythmical peculiar 
ities of the single ulcer case and, in addition to that, 
understand and, if necessary, know how to influence the 
personality of the individual ulcer patient. Even though 
all^special internists here present have observed the most 
varied experiences and different kinds of ulcer patients 
in' war, if all know the alarming contrast that civilian 
ulcer patients feel no more pain after a few days of hospital 
treatment although it-rts true, they are not cured, but where- 
as such a remarkable number of ulcer patients in military 
hospitals complain of pain even after a treatment of many 
weeks - for which reason some declare the entire ulcer 
disease to be mere neurosis, though they are absolutely 
wrong - I, unlike many of you, am in a position to make 
a particular'personal contribution to our problem, since 
I was an expert in ulcer conditions even in the past war. 
I may call to your minds that I took an active part in the 
clinical research work which led, before World War I, to 
the publications of my master BERGMANN about ulcer dia- 
gnosis and ulcer pathogenesis and that particularly the first 
internists1 debate of 50 proven cases of duodenal ulcer 
were then published by me conjointly with WESTPHAL under 
the title which has just now become topical again of ’’Neu- 
rotic Duodenal UlcerWhile the knowledge of the frequency 
of ulcers and their characteristic complaints had by no means 
spread generally during the years of World War I, I took part 
in that war with a fair knowledge of "the ulcer disease and 
its complications and with a deep interest in it - two years 
and a half as an army surgeon in an infantry regiment, then 
one year in a general hospital in the home country, then 
again in a front-hospital where I was in charge of 300 beds 
for patients with internal diseases. Also that time there 
were vast numbers of men Suffering from ulcer, and partic- 
ularly~at the front. I v/ill not discuss the rather intricate 
question whether there is today a somewhat higher pecentage 
of the population suffering from ulcer than before, as it 
might appear. But this much is certain; the ulcer patients 
in this war are psychologically i~quite a different 
dition "from those of the last war. I mention the following 
reasons? 
1• Ulcer is now diagnosed much better and much more 
reliably (roentgeno-diagnostic I) in the hospitals, or the 
patients even bring with them a positive diagnosis from 
pre-war consultation. When, in 1914 or 1915, I sent an 
ulcer patient to a hospital during a critical stage of his 
complaints, he would return a few weeks afterwards to his 
unit diagnosis ’’gastric catarrh” ’’cured”. Mean- 
while he would feel well, the critical stage of his com- 
plaints had passed, he would think no more of his^stomach 
and would at all events put up with slight remaining dis- 
comfort. Today, on the other hand, the positive diagnosis 
’’ulcer” invariably arouses strong and alarming ideas. A 
young soldier, unconcerned before, will think his health 
ruined, the head of a family who had learned from some un- 
known sources that suffering from ulcers is wearisome and 
may recur at any time, that hemorrhages and dangerous com- 
plications may occur, that some assert that it often causes 
cancer,will become despondent and worry about his health. If he is but of a hypochondriacal disposition, his complaints 
will be made worse by autosuggestion, and an injurious hypo- 
chondriacal circle will arise. Any fits of depression will 
also be heightened by the explicit ulcer diagnosis, partic- 
ularly since it is one of the peculiarities of army medical 
consultations that the patient often cannot speak as freely 
as he will in civil life. Whatever your opinions afe con- 
cerning the problems of ulcer pathogenesis, there is no 
doubt today that the vegetative system and its centers in 
the brain stem affect the function of the healthy as well 
as the diseased stomach psychically, motively, affectively 
and motorially. One of the most important functions of 
the control centers, of which we now know much more than 
before, is to contribute to an effective diversion of 
morbid organic processes or to bringing them back to a 
normal state. For psychological reasons, this normalizing 
function of the control centers may sometimes fail. This 
may delay, may even prevent healing, and above all the re- 
moval of the ulcer symptomatic crisis, which is a kind of 
serious vegetative disorder. The individual level of 
acidity in a healthy stomach is also regulated centrally, 
e.g. it may be changed by pervitin. The psychogenic 
"irritant juice" (Zuendsaft) and psychogenic vomiting 
of men with healthy stomachs have been known for a long 
time. It would be strange if the pathological stomach 
function could, not be influenced by the center too, in 
a suitable as well as unsuitable way. I appeal therefore 
to the specialist in charge of the patient to tone down 
the suggestive force of the blunt organic diagnosis by an 
’enlightening talk. 
2. Contrary to the situation given in the last war, 
today, in peace time conditions, many or most experts agree 
that it is appropriate to prescribe to ulcer patients a 
certain precautionary diet for as long as possible, even 
Tor' years. This is the point of view of v. BERGMANN, KALK 
MATISSON, HEINANEN and many others. I too share this 
opinion. An ulcer patient who has suffered from an 
attack in peace time is familar with that. It is obliged 
now to put up with army diet all of a sudden, which re- 
sults in a seemingly insoluble contradiction. Voluntary 
breaks of the dietary will also occur in peace time, but 
they do not count; compulsory, involuntary ones are re- 
corded and they will certainly come. The doctor himself 
is put in a difficult position by this contradiction. In 
my opinion, he must not take it too easy. He is often 
obliged to make clear this contradiction, to advise the 
patient how to make the Best of the army diet, to grant 
him certain dietetic alleviations, and he must finally 
assert with a certain Vigour that war has its own laws 
and is. not always conducive to a man*s health* 
3. ' One more circumstance affecting the present 
situation of the ulcer patients results from the general 
judgement as to the value of men needing special diet• 
The general interest in problems of nutrition has justly 
increased considerably, involving plso lack of discrimin- 
ation and abuses. In any case, need of special diet is 
thought important and calls for sympathy. The man who has flat feet or nasal stenosis or a narrow thorax will also 
have difficulties as a soldier* He will not find, however, 
that sympathy of which a man needing a special diet is sure 
today* Such judgements of value will change* During the 
last war, many men used to protest noisily that they had 
suffered a nervous breakdown. Many were all too ready to 
do so. Nowadays, this is but reluctantly heard or told, 
though the psychic strain put on men in the present war 
is certainly tremendous. 
The result is that todr.v the ulcer diagnoses are made 
more frequently, more reliably and more easily, but that 
questions of employing men for various duties as a whole, 
nave become more difficult and absolutely demand the 
surgeon*s‘ special eTforts» For this is the inference 
rhat must' be drawn and not the other, viz. that we try 
and put the clock hack by entirely giving up roentgen 
diagnoses and any accurate diagnosis whatsoever. One 
must agree with GUTZEIT who rejects in his last circular 
letter the suggestion made by some side or other, of re- 
fraining from roentgen-examinations of ulcer patients. 
And if I mentioned before that a patient with uncomplicated 
ulcer his crisis of complaints even when 
diagnosed as "stomach catarrh", this does not apply also to 
stomachs with grave organic changes, in particular not 
to ulcer cases with complications (hour-glass formations, 
considerable shrinkihgs of the lesser curvature, stenoses 
of the pylorus and of the duedenum, operated stomachs). 
By means of the X-ray examination they are ascertained 
much faster and are, since unfit for military service, em- 
ployed in some civilian occupation. Roentgen-examinaiions, 
even repeated ones, are also useful for finding correct- 
ions and for the estimating a claimed aggravation as a 
result of military service. It should only be prevented 
that every patient is repeatedly examined by means of 
rpenten-rays in every hospital (for^many a patient passes 
through many hospitals). Exaggerations in this "respect 
partly reach such a point that X*ray damage is to be 
feared. Nowadays, valuable material is wasted without 
any medical profit. Of course, it is awkward to lay down 
fixed rules as to how many times a patient may be ex- 
amined by X-rays. I only propose, for guidance, one 
roentgen-examination each at the beginning and at the 
end of a course of treatment. Thus, with two courses 
of treatment per annum, altogether four X-ray examinations 
every 12 months may be adequate. (Findings to be entered 
into the paybook). 
If I have particularly emphasized the psychological 
situation of the ulcer patient of'&crday, it was because 
apart from certain rudimentary findings, roentgen-examin- 
ations alone do not provide the basis for a decision as 
to whether men suffering from an ulcer may be called up 
for military service* On the one hand surgeons knowing 
nothing about roentgen examinations themselves, on the 
other certain one-sided experts of roentgenology, are 
inclined to overvalue the roentgenogram for practical 
purposes* This must be strongly opposed. As regards 
the possibility of making a large number of ulcer patients 
fit for service that will be worth while in the majority of cases it is not only the kind of finding that it depends 
on, noj? only on the kind of occupation to which an ulcer 
patient may be assigned on the strength of his military 
training and other aptitudes and on the conditions given, 
noj? only on the ability of the patient to stick it out 
and to avert the most serious harm which ability can and 
must be furthered also by the doctor!s advice and partic- 
ularly by the assistance of the army surgeons, noj? only 
on a certain understanding of the superiors, - but also on 
an appreciation of the ulcer patient!s personality. It 
is important to ascertain whether he is afflicted with, or 
constantly troubled by an ulcer, whether instincts of self- 
protection and hypochondriacal fear for his health are 
stronger than the will and endeavour to do his duty in war, 
to stick it through out of a sense of duty and comradeship 
and how and by what means the personal attitude of the indi- 
vidual can be influenced. 
This appreciation and the attempt to exert some in- 
fluence cannot always be realized very quickly. Even if 
one is against long stays at hospitals - which we all are - 
it must be admitted that an appreciation like that just 
demanded by me cannot always be adequately realized within 
5 days - as desired in the directions - particularly not if, 
for instance, large numbers of men suffering from intestinal 
trouble are simultaneously sent to a special ward for stomach 
diseases or stomach observation. Cases, in which rudimentary 
findings of complications do not establish the patient as ‘ 
unfit for military service from the start, will require for 
a proper judgement first an attempt at therapeutics and 
the observation of the patient during his treatment. 
Nor should I like you to assume that, in comparison 
with psychological appreciation, I think little of the 
findings. Apart from the complications mentioned, to which 
frequent bleedings and violent participation of the pancreas 
may be added as not ascertainable by roentgen rays, it is 
certain that besides the morphological pathology the funct- 
ional pathology of these patients is of enormous importance* 
The extent of an ulcer site is no criterion of its capacity 
of involution. The latter will only result from a thera- 
peutic trial. Even moderate stenoses may be 
capable of involution, at least as regards their functional 
effect, since the time of evacuation can be normalized. 
Moreover, above all, the character of recurrences, the 
crises of complaints, which certainly cannot be understood 
by the morphological stomach findings alone, are of decisive 
importance. With not a few ulcer patients the crisis of 
complaints will set in as controlled by destiny, as it 
were, rhythmically, partly seasonally. We do not yet 
understand why this should be so, but we know that it is. 
With some patients the crisis of complaints will set in 
even during a limited diet and without particular outward 
or inward strain. Others are manifestly dependent on 
violations of diet, and again, with others, nervous or 
physogenic effects are the initiating factors, Troubles 
of this kind are not only aversion to service at the front 
or hypochondria (one would wrong many ulcer patientsgin 
assuming this as the description of a definite or uniform ulcer psyche, which was discussed as a caricature 
not borne out by real life) but also haste* great weariness, 
hardships of every description, excessive psychic demands 
must be considered* The chief thing is to recognize and 
to appreciate the character of the complaint crisis and 
the initiating factors prevailing with the individual ulcer- 
patient* Of course, the number of recurrences do matter, 
too* They may also classify a soldier as unfit for military 
service* On the other hand, many patients, in particular 
those suffering from duodenal ulcer, even With two complaint 
crises a year, requiring 4 to 6 weeks of hospital treatment 
each time, are often excellent soldiers during the remaining 
40 weeks of the year; they do not even mind the military 
diet; they may be considered for active service* 
Others with a certain permanent sensitiv as to 
diet may also be retained with their units with slight 
dietary concessions* I tried this myself very success- 
fully as an army surgeon during the last war and have often 
heard of similar cases now* As soon as a unit is at rest 
or in a permanent position, this is possible; during an 
advancet general enthusiasm also neutralizes the need for 
a special diet. It is remarkable how different matters 
are with different dnits as to granting slight dietary 
variations though the units are in the same situation. 
The same applies to the convalescent companies in the 
home country. We know the attitude of many commanding 
officers who wish to have to do only with healthy men, 
but this cannot be accomplished in a total Here the 
army surgeon must carry his point and must ’'be really 
interested in problems of nutrition and diet. For this 
purpose he must of course know something about diet* It 
is often to be seen, even in hospitals, that this is not 
the case* Army bread, well baked handled in the right 
way and not too new, is by no means so harmful to the 
ulcer patient as is supposed over and over again* Never- 
theless, there are some ulcer patients who can be kept 
free from complaint only by the simple measure of being 
allowed white bread. On the other hand, speaking of bread, 
it is important in what quantities it is consumed* Bread 
eaten plentifully or bolted which absorbs gastric juice 
like a sponge without being properly digested is often 
injur&us to a man suffering from duodenal ulcer* On the 
other hand, it would be particularly appropriate to re- 
place the usual morning coffee by porridge or buckwheat 
froats for men with intestinal trouble, which, in exchange 
or coffee which has no nutritive value at all,is a good 
extra ration for breakfast even for soldiers free of 
stomach trouble* I strongly recommend that such cereal 
groats or a soup should be provided at least for men 
nubding special diets, if possible, in all units* 
The army,surgeon should also not hesitate to use 
.small doses of atropine, which distinctly contributes, 
with many a’ patient, to keep him in a condition free 
from complaints,which was obtained in a hospital. 
In hospitals*the dietary should again and again be 
carefully examined and criticized. It must not be too 
monotonous since this would provoke violations; it must not be made too rich, lest a return to normal diet should 
lose its attraction. On the other hand, the observation 
of diet in the hospitals must be strictly enforced. What 
is the good of a diet if the patient may walk about in the 
town and partake of their morning pint and, on Sunday 
afternoon, the attentive Ladies Societies will distribute 
heaps of cake, including the men with stomach trouble. 
Strict diet must be replaced by more generous diet 
while' still at the hospital. Direct transition from strict 
limited diet to the regular army diet has many avoidable 
and disappointing reverses in its wake, which also dis- 
courages the patient himself. During the treatment of men 
suffering from stomach-troubles, prohibition of smoking 
is necessary and must be strictly enforced. 
As the General Instructions Army Manual 209 of 1942 
are excellent, not many detailed proposals need be made 
if only their contents were better regarded and observed I 
I certainly consider bed-rest at the beginning of the 
treatment more important than the instructions give it 
credit. I have a most sincere respect for occupational 
therapy, but I am sure it is unsuitable during the first 
4 weeks of an ulce.r-treatment in a hospital. Patients with 
slight complaints for whom it would be suitable may remain 
with their units. If it possibly can be managed? ulcer 
treatment should be made in field- or front-hospitals, 
where the front spirit prevails and where there is a chance 
of returning to the old unit and to the old pals. In 
hospjtals in the home country questions of unfitness for 
military service and of disability caused by military 
service are in the air, and the reserve battalion offers 
but little attraction. Examination 'r’ith a gastroscope 
may be very useful in judging to what extent the whole 
stomach is inflamed, but is to be considered only where 
a doctor is available who is well versed in this technique 
and has some experience in evaluation. 
In conclusion, I wish to declare emphatically that 
men without military training, in whom reliable civilian 
doctors ascertained grave findings and who have been suf- 
fering from recurrences for a long time, should not be 
drafted for initial training by any means while they are 
just suffering from a complaint crisis. Lastly, as re- 
gards the problem of calling up dubious cases for service 
and those ulcer patients whose disease is suspected of be- 
ing largely neurotic, I wlshbto raise again the question 
of forming companlesgconsisting only of men with stomach 
trouble and to propose that men having had some experience 
in attempts of that kind, should join in the discussion. 
Discussions 
MARK: The procedure of taking care of men with in- 
testinal troubles within the army corps district is generally 
as follows: The stomach observation hospital of every 
medical unit will decide, 1. whether the patient with 
gastro-intestinal disease should be discharged as unfit for military service; 2. whether further treatment 
should be oa3P2ied out in the first hospital; whether 
the patient should be sent to the hospital for stomach 
diseases which two medical units have in common# Fol* 
treatment in the latter hospital, usuall}*- younger soldiers, 
mainly with more severe vegetative dystonia but otherwise 
a good bearing (often not having nicotine-stained fingers), 
are to be taken into consideration. Because of the air 
situation in the West, the hospital was temporarily ac- 
commodated in a ward for slightly ill patients. The treat- 
ment consisted first in about a fortnight of bed-rest and 
a fortifying diet with strictly controlled prohibition of 
nicotine. After a fortnight, all patients except those 
with large stomach ulcers, began occupational therapy con- 
sisting in an hour (11 to 12 a,->in.) of physical exercise 
(callisthenics, handball, football) with a further increase 
in the diet. As a rule, no aggravations were reported after 
the sport. From 18 October 1940 to 28 April 19435 1037 
patients with stomach trouble were discharged. About one 
third of these (22 per cent) were fit for service in the 
field while about another third fit for garrison 
service at home, that is a total of 66.8 per cent were fit 
for military service. Of those taken ill for the first 
time, 42 per cent were discharged as fit for service at 
the front. The average duration of treatment amounted 
to 54 days. 211 inquiries concerning those discharged as 
fit for frontline service or for garrison service in the 
home country or in the field a year after their discharge 
from the hospital, showed 59 per cent fit for service 
without, and 33 per cent with intervening hospital treat- 
ment. Thus, approximately 92 per cent of them have re- 
mained with the Army as fit for military service. 3 per 
cent of the remaining 8 per cent were killed in action. 
This seems to prove that a sensible addition of physical 
therapeutics to stomach treatment answers well. 
Directions concerning the possibility of calling up 
men su?fering from’ulcer for military service. 
As regards the problem to what extent ulcer patients 
are fit for military service, the lecturers and the Con- 
sultants* Committee agreed that no simple formula can 
be found, owing to the many-sidedness of the course of 
the disease and the diversity of constitutions. 
Formerly, as also in the last war, frequency of the 
disease was underestimated, because it was not recognized. 
If, besides, many have an impression, that in war its 
frequency and violence have somewhat increased among 
soldiers and civilians this is traced back to the in- 
crease of vegetative nervous troubles. 
Though the concept of ulcer disease as a mere neurosis 
is rejected and even more the attempt recently made to 
describe a uniform "ulcer psyche”, the vegetative and 
regulatory, and consequently also the psychic, influences 
oh origin, form, course, healing, and delay of healing are 
thought x;o be very important. The psychological situation 
of the ulcer patient is different from that in the last war: through the alarming terra "ulcer” this diagnosis now being 
so positive by means of X-rays; through the instruction 
to always adhere to a certain diet given to the patient 
in peace time; through the general judgement with regard 
to men needing special diet. These psychological effects 
impairing fitness for military service must be reduced 
ty medical enlightenment. Fitness for service depends 
partly on the comprehension of an influence on the patient's 
personality, so it also depends on the surgeon* 
Also in the treatment of a symptomatic crisis which 
begins with a strict and careful diet, usually lasting 
several weeks in a hospital (in the vicinity of the front 
if possible) with bed*-rest afid atropine, prohibition of 
smoking and of pass-privileges for all serious cases 
proved necessary and is considered as being most effective* 
Psychological guidance, suitable occupation, later on 
occupational therapy, and exercise are required; the latter 
also because of their favorable influence on the vegetative 
tonus. 
As soon as the symptomatic crisis has passed, many 
ulcer patients are fit for front-service* They are-those 
without extensive anatomical changes of the stomach, with- 
out delayed emptying, who are not sensitive diet in the 
intervals between their rare symptomatic crises. Even if 
military service in wartime involves unfavorable influences 
on the ulcer disease through military diet and hard physical 
and psychic strain, it is not true that ulcer diseases 
necessari ly are aggravated by military service* There arc 
even patients who feel better in war than in peace. Others 
may be employed as fit for garrison service in the field 
or in the. home country with slight concessions as to diet. 
Among as many units as possible, it should be enforced as 
the least yet very effective dietetic modification that 
gruel instead of coffee be allowed for breakfast. On the 
other hand, patients with considerable anatomical changes 
of the stomach ascertained by a roentogram made by an ex- 
pert (hour-glass-stomach, heavy shrinking of the lesser 
curvature, stenosis of the pylorus or buibus, state after 
a stomach operation) and those who have suffered from a 
perforation or severe hemorrhage or have experienced 
frequent symptomatic flare-up for years, should not be 
called up for military service. If suen findings are stated 
after careful, medically satisfactory examinations at a 
hospital, including examinations by means of X-rays, these 
soldiers should be discharged as unfit for military service 
without any delay by long stays at hospitals* Exceptions 
may be granted: to officers, professional soldiers in 
particularly important positions, to skilled specialists, 
lastly those whose official functions permit a careful 
dietary.  Postdysenterlc intestinal diseases* 
Oberstabsarzt (Major, MC.) Prof, 3T0ERNEH 
The percentage of postdysenterlc intestinal diseases 
cannot be estimated even approximately* The figures are 
doubtless lower than those put down in the literature 
after the last war (up to 12 per cent). 
A clinical differentiation between chronic dysentery 
and the proper postdysenterlc diseases presents some dif- 
ficulties, since the tracing of specific causative organism 
in chronic dysentery yields only doubtful results and the 
agglutination tests often fail also with postdysenterlc 
symptoms. The opinion that chronic dysentery results 
directly from the acute form of the disease while post- 
dysenteric diseases will appear after a short or long 
period of latency does not conform with actual findings. 
The complete healing 6f specific infection cannot be 
positively determined clinically, bacteriologically, or 
serologically. This uncertainty of differentiation sup- 
ports the endeavour of many clinicians to include colitis 
gravis with the clinical picture of dysentery. Two types 
of course stand out among these postdysenterlc diseases: 
1. The dyspeptic (or functional) for and 2. the inflammatory 
form. All the numerous subdivisions made in post-war timer 
may be placed easily in these two groups. The slight as 
well as the severe types of course of acute dysentery lead 
to extensive permanent changes of the gastric juice secretion 
as a kind of subacidity, more frequently of achylia. In 
most cases, toxic injuries may be supposed to be the chief 
cause while gastritis is less responsible for it. Never- 
theless in 40 per cent of the treated cases, a hypertrophic 
gastritis could be ascertained gastroscopically. The clin- 
ical picture of the dyspeptic form is often complicated by 
enteritic phases in consequence of a simultaneously changed 
enteric secretion, which may be termed a toxic "gastro- 
enteritis". A pancreas-hypercholia as an anatomical funct- 
ional disorder may occur at the same time. 
The most important and most lingering results of 
dysentery are the chronic catarrhs of the large intestine! 
If these catarrhs continue and the bacilli test remains 
negative, postdysenteric disease may be properly supposed. 
Localization Is typical to a certain extent: the lower 
intestines are particularly liable to it. disease 
is protracted, however, retrograde entero-colitides will 
set in. Together with the dyspeptic symptoms of the 
stomach and of the pancreas, they complicate the varied 
clinical picture. 
By means of rectoscbpy in the first place, then by 
roentgen-contrast-enemata, it is possible to obtain inform- 
ation to a large extent concerning the inflamed part and 
the nature of the disease of the large intestine. Usihg 
contrast media disorders of the filling through formation 
of spasms are seldom observed, disorders of discharge, 
rapid evacuation because of increased motility and high 
mucus-percentage of the mucous membrane of the large in- 
testine are more frequent; 40 per cent of the cases show retarded evacuation because of weakness of the tonus or, 
on the contrary, formation of spasms. The changes of the 
contour vayy as regards catarrhal, ulcerous, or atrophic 
changes of the mucous membrane. 
The different varieties of postdysenteric diseases 
cause the multiform clinical pictures, from simple allergy 
of the intestines or uncomplicated dyspepsia to ulcerous 
colitis, as well as the mixed forms; a healing of defects 
results but very rarely in strictures and stenoses. Hemorr- 
hage of the intestines and perforations also occur rarely. 
Examination by X-rays reveals a duodenal or gastric 
ulcer in a remarkably high percentage of these postdysenteric 
disorders. Amongst our own patients 33 per cent were afflict- 
ed with ulcer. In the search for the ultimate causes of these 
findings, toxaemic envolvement of the organs is not likely 
to give a satisfactory explanation of the way in which the 
disorders originate. The assumption of the same cause for 
all the seemingly different mahlf©stations of postdysenteric 
diseases suggests a decisive influence of constitutional 
factors. This is confirmed by constant signs of hyper- 
sensitivity of the parasympathicus* 
The question of the prognosis of these postdysenteric 
disorders cannot yet be answered satisfactorily, consider- 
ing the brief span of the present war. The progress of 
the postdisenteric diseases is generally very violent. 
The concept of healing must be estimated with great caution. 
Relapses arc frequent, serious general injuries are always 
possible in the progress of the chronic toxin effect. 
During symptomatic treatment, diet treatment must be 
considered first. The value of an apple-diet has been 
proven also with these postdysenteric diseases. More heed 
should be paid to the frequent use of milk-casein and to 
the bactericidal effect of yoghurt (fermented milk). 
Specific therapeutics have failed, on the whole. 
Medicinal therapeutics should not emphasize astringents and 
adsorbents too much. The sulfonamides have proved partic- 
ularly efficient during these postdysenteric diseases. 
Enterovioform, too, seems to have a favorable influence 
as a disinfectant. One may try using mutaflor against 
dysbacteriosis. Torantil has no effedt. Injections of 
Progynon resulted in subjective improvement. Therapy 
with the cortex of the suprarenal glands appears appropriate, 
particularly with cachectic patients. Vitamin therapy as 
well as transfusion of blood answer the purpose of sub- 
stitution and alterative therapy. Local therapy must^con- 
sider that the inflamed mucous membrane is a most delicate 
orgahnreacting to every strong stimulant with spastic con- 
traction. Small retention enemas, however, have a favorable 
effect. Bathing of the intestines has proved efficacious 
beyond expectation. They seem to create better resorption 
conditions in the large intestine. As regards surgical 
treatment, no sufficient personal experience has been avail- 
able as yet. Discussion: 
HOFF; A large number of the postdysenteric intestinal 
disorders are the consequence of an unreasonable diet con- 
sisting of a monotonous pap-diet, continued too long. Thus 
it frequently happens that famine-conditions arise with 
famine-diarrhea, desiccation or edemas. In the case of 
postdysenteric diarrhea, first a treatment similar to that 
of acute dysentery with castor oil and tea for two days is 
suitable, then a rapid progress to a diet containing calories 
and vitamins. Achyloses and disorders of the external 
Pancreatic secretion are very important amongst postdysenteric 
inuestina 1 ~dTsorders. In this case hydrochloric acid, such 
as Encynorm and ferment compounds such as Pancreon, Gombicym 
and Festal will prove efficient. Sodium chldride treatment, 
the great importance of which I already pointed out at the 
beginning of the Polish campaign, is recommended here once 
more, but only for such cases as are actually desiccated 
and deficient in sodium chloride. In cases of edemas, this 
therapy is of course contra-indicated. I should like, in 
particular, to point out a symptom not rarely remaining 
after dysentery, the "hydrant-stools". Men, who may other- 
wise feel quite well, are in this case attacked by sudden 
watery defecations at certain periods. Against this dis- 
order a drug which has proved efficient for me, for the 
knowledge of which I am indebted to the homeopathic doctor 
STIEGELE. This is podophyllin D 4, three times 5 drops 
per day, each to be taken 15 minutes before meals. Though 
I generally do not hold with homeopathy, I recommend this 
drug because of favorable personal experience, Following 
the principle that, in therapeutics, the good should be 
taken wherever it is found. At times, we also successfully 
combined podophyllin with Allisatin, a garlic-carbon pre- 
paration. The ulcerous postdysenteric intestinal disorders 
occupy an exceptional position. Here the attempt at alter- 
ative therapy is appropriate. If autovaccine is recommended 
Today ,"iJc is, in my opinion, because of non-specific alter- 
ative effect that is of importance. For the same purpose, 
transfusions of blood are enthusiastically■recommended. 
Even a fever treatment, such as by Pyrifer, may have ex- 
cellent results with ulcerous postdysenteric colitis. 
BECKMANN: In Military District V, cases of chronic 
dysentery and postdysenteric disorders are sent to a special 
hospital with a particular possibility of a careful diet. 
(Heservehospital Gundelsheim). Dietetic treatment is 
decisive. Sulfonamides also prove effective, even if no 
genuine recurrence is involved. Alterative therapy, e.g. 
with Sufrogel, has satisfactory results with pyknics, but 
fails with leptosomes. Luicym and Gombicym are desirable. 
Directions concerning postdysenteric intestinal 
disorders• 
The frequency of bacillary dysentery in the past 
phases of the war resulted in an increased number of cases 
of postdysenteric colonic disorders. It is difficult to 
differentiate these postdysenteric disorders from chronic 
dysentery, since the cessation of specific infection can be positively ascertained neither clinically nor bacterioligic- 
ally nor serologically. All parts of the intestinal tract 
may be involved in these postdysenteric disorders owing to 
a functional disorder of the digestive glands or an in- 
flammatory change of the mucous membrane. As cause of the 
origin of these symptoms a toxic injury.by dysentery toxin 
must be chiefly considered, while primary invasion of germs 
exciting dysentery is less important. 
In the clinical picture, two forms of progress stand 
out: 
1# The dyspeptic (functional) form, mainly due to 
disorders of the digestive glands 5 
2. The inflammatory form, affecting chiefly the 
colon, bulTwliich may also affect all other intestinal 
parts. The pure forms of these basic types are rare, 
their mingling is more frequent. 
Clinical manifestations of the postdysenteric diseases* 
a. A high percentage of the slight as well as 
the serious cases of dysentery result in permanent 
changes of gastric .juice secretion or hypacidity, 
more frequently of a histamine-refractory achylia. 
These disorders of secretion are often connected 
with a pancreas-hypocholia and with a disorder of 
the intestinal glands, changed in the same way. 
The often (40 per cent) existing gastritis and the 
frequent catarrhal involvement of the small in- 
testine results in the picture of toxic "gastro- 
enteritis”, which need not differ from the other 
etiology. The acid intestinal catarrh of ferment- 
ation is more frequent than putrescent dyspepsia. 
b. The most important and most lasting conse- 
quences of dysentery are the chronic catarrh of 
the large intestine, the localization of which is 
typical to a certain degree; the lower intestinal 
parts are chiefly affected. Attendant or retro- 
gressive entero-colitides are, however, frequent. 
Obstipation (spastic irritation) is clinically 
often replaced by diarrhea-*, which rnaj7, be of a 
more or less inflammatory character in the stool 
picture. Rectoscopy is as important as the con- 
tour outline shown by means of roentgen-contrast- 
eneraa, in order to ascertain the extent of the 
disease of the large intestine and to differentiate 
catarrhal, ulcerous, and atrophic changes of the 
mucous membrane. 
c. With a certain number of patients, clinial 
examinationrreveals duodenal or gastric ulcer, 
which may be relatively recent. For all these seemingly different manifestations of 
disease the decisive influence of the same constitutional 
factors must be supposed above all (vegetative* neurodysergia, 
lymphatism). 
In stating a prognosis, the persistent course of these 
postdysenteric disorders must at least be emphasized* Any 
opinion concerning "healing" must be estimated vith great 
caution* Relapses through unsuitable diet are frequent, 
structures and stenoses as well as hemorrhages and perfor- 
ations, are rare* A pernicious anemia may occur# 
The best prophylaxis is a thorough treatment of the 
acute dysentery with injections of massive doses of sul- 
fonamides, even if disorders of the gastric secretion can 
probably not always be avoided# 
As regards therapy# dietetic treatment is to be con- 
sidered most. The value of the apple-diet has been proven 
also in the case^of dysenteric disorders# The frequent 
use of milk-casein and the bactericidal effect of yoghurt 
must be taken into consideration. Hydrochloric acid (Afi'idol- 
pepsln) and ferment preparations (Festal, Pancreas-Dispert, 
Gombicym etc.) should be administered in sufficiently large 
doses# Specific therapy has failed. Medicinal therapy 
should not attach too great importance to astringents and 
adsorbents# Also with this groups of disorders the sul- 
fonamides have proved particularly effective# Enterovioform 
seems to have a beneficial influence too. Therapy of the 
cortex of the suprarenal gland are Indicated particularly 
with cachectic patients, the same applies to vitamin- 
therapy. The value of a blood transfusion (preserved serum) 
as a means of substitution and alterative therapy is un- 
questionable, particularly as regards the ulcerous forms. 
Stimulation therapy may be tried (Pyrifer, milk etc.). As 
to local therapy it must be taken into account that the 
inflammatory mucous membrane is a most delicate organ re- 
acting with spastic contractions on any strong stimulation. 
Small retention enemas (olive oil, camomile-tea, cermatol- 
gel) have a beneficial effect on catarrh of the rectum. 
Bathing of the intestines with a sufficient Quantity of 
common salt, used with caution, has proved excellent. It 
creates favorable conditions for resorption for the large 
intestine. On the whole, attention must be paid to a 
satisfactory fluid-supply per os, in cachectic cases in 
the form of infusions. To reduce the intestinal tonus and 
to fight tenesmus, small doses of atropine and papararine 
will as a rule be sufficient. Opium is contra-indicated. 
The surgical indication of appendix-fistula, cecostomy 
and anus praeter naturalis is given only if all internal 
measures are vathout result. On the whole we have so 
little positive experience of the therapy of these dis- 
orders that it is advisable to sum up these cases under 
special heads. 4. Volhynla fever/ 
Oberstabsarzt (Manor, MC.) Prof, SCHULTEN 
The basis for this report is, besides my own ex- 
perience, a general inquiry among the surgeons of two 
armies, which included a group of about 400 000 soldiers. 
In the winter 1941/42 and in the first half of 1942, 
the disease was exceedingly frequent, up to 10 per cent 
of the total strength of the units being afflicted with 
it. This year the rate has been considerably lower so 
far* The reasons for this are the milder winter, the 
troops being less exhausted, immunization from last year, 
and the men’s being less afflicted with lice. The last 
reason is certainly the most Important, 
The accurate number of patients cannot be ascertained; 
even if they consult the surgeon and are sent to medical 
units, the greater number of them are diagnosed erroneously 
at first. We even do not know which symptom complexes 
should be called Volhynia fever. 
The most important symptoms besides headaches are 
attacks of fever with occasional elevations of temperature 
or waves of about 5 days duration and tibia aching. The 
elevations of temperature may occasionally be slight, in 
some cases, there is probably no fever at all. In other 
cases, a rise of temperature occurs only at first, lasting 
for one or two days, which thmvanished with all other 
symptoms of the disease. lastly there are cases showing 
uniform subfebrility either from the very beginning or 
only in the later stages. 
Besides the characteristic tibia aching, which are, 
however, by no means limited to the 5 days or fever, 
aches often set in also in the thighs,Sn the below or above 
the elbow. In other cases, aching is felt rather in the 
joints or in the muscles of the limbs or of the trunk. 
These complaints increase mainly at night, often also 
during the elevation of fever, they frequently decrease 
when the patient moves. 
The limb aches as well as the rhythmical fever may 
be absent in certain cases. If neither symptom exists, 
which is often the case, the disease is to be diagnosed 
merely for epidemiological reasons. 
Infection most certainly is caused chiefly by lice, 
but it is possible that bugs occasionally spread the 
disease too. 
The recognition of the way in which the infection 
occurs is rendered more difficult by our not knowing the 
duration of incubation. According to observations of single 
cases, a duration of the incubation between 6 and 50 days 
is probable. 173 
It is not known why the disease should be so rare in 
peace time, though men may be afflicted with lice, too, and 
why it hardly ever afflicts Russians. A particular dis- 
position due to age certainly does not exist, perhaps older 
men are Infected somewhat more easily than younger ones. 
It is still uncertain, whether the often existing 
changes of the respiratory organs and of the colon belong 
to the clinical picture or whether they are to be con- 
sidered as special complications. 
The spleen is rarely so large that it becomes palpable, 
but splenic dullness is often increased or the splenic 
region is hypersensitive. 
The changes of the blood (leukocytosis, lymphocytosis, 
monocytosis, eosinophilia. etc.) described again and again 
as characteristic, are nor so regular as to be of any dia- 
gnostic value. 
The blood sedimentation rate is usually a little ac- 
celerated, yet normal and considerably accerlerated rates 
do occur. 
While major neurological events occur rather seldom, 
slighter and transitory disorders are to be found quite 
frequently, In most cases they affect sensitivity'(pares- 
thesias, hyperesthesias, hypesthesias, disorders of the 
sensations of heat or pain, neuralgia in the ischial region 
or the intercostal regions) to a lesser degree motor dis- 
orders of the tendon reflexes, transitory paralyses, ex- 
cessive feebleness, ataxia, changes of the tonus. Besides 
also of irritation and events in the sensory field 
(light-allergy, disorder of hearing) and vegetative changes 
(perspiration, vasomotor disorders, palpitation of the heart, 
etc.) occur. Finally, insomnia plaintiveness and slight 
depressions are also observed. All these changes indicate 
besides neuritic, central disorders in addition. They are 
located chiefly in the thalamus. It has even been suspected 
that the aching in the bones and muscles originally depend 
on the center. 
A causal treatment has not been possible as yet; sul- 
fonamides. atabrine, salvarsan, and quinine had no effect. 
Symptomatically, the usual antineuralgics as well as moist, 
cool poultices bring relief. 
Most patients are healed in a few days or weeks. Some 
symptoms, such as, above all, head- and limb aches, as well 
as the neurological and psychic events may persist much 
longer. In addition to these, a very trying tachycardia 
will occur frequently, which is in most cases probably 
founded on disturbed nerve regulation. It is by no means 
rare that in this year, men were afflicted with Volhynia 
fever who also suffered from it the previous year. We do not 
know? as yet, whether these are cases of late recurrences or 
were due to reinfections. The other symptoms of men suffering 
from Volhynia fever are often incorrectly regarded as purely 
psychogenic,on the other hand, they evidently may often be 
suppressed largely bv determination. 5• Concerning epidemiology and differential diagnosis of 
the Volnynia fever. 
Stabsarzt (Captain, MC.) Dozent K. SCHULZE 
Volhynia fever is a typical epidemic disease of war. 
The causative agent, the rickettsia quintana. belongs to 
the group of the rickettsia pediculi from which it can be 
distinguished neither morphologically nor serologica lly. 
The rickettsia quintana or pediculi is not only a 
harmless saprophyte of the louse, but may also be termed 
a normal parasite or symbiant of the human organism, a 
fact which is confirmed by its propagation and its appear- 
ance in the circulating blood of man during disorders of 
various descriptions. 
Under conditions unknown to us, this normal apathogenic 
form may assume qualities causing fast spreading epidemics 
through the medium of the louse in passing from man to louse 
and from louse to man. 
A useful diagnosis may be obtained only by the WERNER 
test, the performance of which is limited to special in- 
stitutions (Research Institute for Typhus at Lemberg) be- 
cause of the difficulty of keeping louse cultures available. 
The experiments to facilitate the diagnosis through 
methods of agglutination, have yielded no useful results 
as yet. 
it is not possible to trace the germs in the blood by 
means of thick smears and GIEMSAfs staining method see 
Army Manual 209/2 # 102. 
In typical cases the diagnosis is easy. Unfortunately 
the disease d6es not show a classical course with the greater 
number of patients, so that mistakes are quite possible. 
It is precarious to trust only to the patients state- 
ments in dubious cases, since, owing to the frequency of 
this disease, the complaints are better known amongst the 
laity than is desirable under the given circumstances. In 
order to prevent, beyond this, Volhynia fever from becoming 
a collective term like influenza, all clinical-serological 
and bacteriological means available must be used. Volhynia 
fever is often mistaken for sepsis, tuberculosis, pernicious 
anemia, and lymphogranuloma. Relapsing fever and malaria 
may also give rise to mistakes, as well as typhoid and 
paratyphoid diseases; also the typhoid form of tularemia 
should be mentioned. Russian headache fever will not last 
long in most cases or is accompanied, in its more serious 
cases, by paralyses which fomno part of the clinical pict- 
ure of 5 days1 fever (Volhynia fever). 
I have never observed that it was mistaken for socodu, 
the latter disease being rare. A test series has proved 
the usefulness of the WERNER test. With clinically entire- 
ly healthy persons who never lived in environments infected with lice, the results were negative. With persons clinic- 
allY positively ill, the rickettsia quintan? could be demon- 
strated in every case. Sick and wounded persons who were 
treated for other reasons (icterus, nephritis, bullet wounds, 
etc.) who had lived, however, in environments heavily in- 
fected with lice for a long time, showed in 86 per cent 
positive results. 
Continual observations showed that the negative findings 
were consistent. On the other hand it could be proved, how- 
ever, that, up to 300 days after the disease has been over- 
come, the rickettsia quintana can still be demonstrated in 
the circulating blood. 
As a result it is pointed out; 
1# The necessity of a useful diagnostic method 
(agglutination)5 
2. the urgency of removing the rickettsia from the 
blood as quickly as possible,' whichjconsidering the 
mild progress of the seems more important 
than the treatment itself. 
Volhyni? fever leaves behind no permanent immunity. ■ 
It is possible to be afflicted with it several times. Ex- 
perience from laboratories shows that reinfection will occur 
only after a long stay in environments free from lice. For 
this reason, one should endavour, in order to prevent a 
second infection, to preserve the protective or defensive 
mechanisms formed at the time of the clinical disease by 
appropriate measures, such as administering material con- 
taining quintana by inunction. 
Discussion concerning Volhynia fever 
HAUER; I wish to make a short suggestion concerning 
therapy. In the home hospitals, Volhynia fever is a puzzle, 
as no therapeutic progress can be obtained. We-have applied 
in vain the whole gamut of therapeutic remedies9 which Mr. 
SCHULTEN mentioned just now. On the other hand we have been 
using gold for two months, evidently most successfully, with 
all our iH patients afflicted with Volhynia fever. It is 
remarkable how neuralgic complaints are often reported spon- 
taneously as alleviated even after the first injection, and 
how- rapidly the w/hole state of health improves. Even 
patients who have been ill for a long time demand that 
another injection should be given thhm soon, as their state 
was so much improved. The fever seems to be influenced 
equally beneficially. I am sorry to say we have only 
early cases of the disease available. We are using auro- 
detoxin exclusively, starting alw/ays with the smallest dose 
(0.01), then increasing it gradually up to 0.1 and more. 
At present, we are shortening the interval of injections. 
It was a striking fact that some patients, even after the 
smallest dose, reacted with irritation of the skin, slight 
opalescence in the urine, and exhaustion, which is but rarely 
observed during the treatment of arthritis with gold-compounds 176 
for^instance, In these cases, we waited till these symptoms 
of irritation subsided and then continued gold-therapy. 
The success seems encouraging, in particular since we have 
had no failures as yet. For this reason, I wish to suggest 
a re-examination of the subject. 
CRAMER: Volhynia fever takes a mild course with hardly 
any exceptions, and leads to no serious complications or 
secondary disease. My observations in the reserve hospital 
of Military District XX showed, above all, that it is nearly 
always unnecessary to evacuate the patients suffering from 
Volhynia fever from field or base hospitals back to home 
hospitals. This would only prolong the duration of hospital- 
treatment, Clinical healing may at least be attained in a 
field hospital too. As regards differential diagnosis, it 
must be mentioned that in the majority of cases, there is 
no 5 days’ rhythm of the fever, but slight rises of temper- 
ature with irregular rhythm are much more frequent. If a 
man is suspected of having Volhynia fever, it is advisable 
to check his temperature at frequent intervals, as otherwise 
sudden changes of temperature might be overlooked. In case 
of Volhynia fever, slight entero-colitides with a certain 
rhythm will often occur, sometimes with subfebrile temper- 
atures, as GUTZEIT too was able to ascertain during an in- 
spection of the reserve hospitals of Military District XX. 
Only in few cases is the spleen palpable without doubt or 
enlarged to percussion. As far as my experience goes, 
Volhynia fever leads to no serious complications. I never 
was able to observe such serious cases as REUTER, for in- 
stance, describes, particularly not the cardiac complications 
of the form of myocarditis as described by him. In more 
than 300 cases, only in one case could signs of myocarditis 
be ascertained clinically or in the electrocardiogram. Cases 
sent to me diagnosed as Volhynia fever and field-nephritis 
particularly from base hospitals have been increasing re- 
cently. Only in two cases could a field nephritis be posi- 
tively ascertained, in the other two cases, a febrile albumin- 
uria or infectious-toxic influences were involved, sometimes 
with slight cylindruria and an increased number of erythro- 
cytes. These symptoms on the part of the kidneys subsided 
with no specific measures being taken in the first few days. 
In these cases no increase of urinary substances or a de- 
rangement of the renal function were ever ascertained. 
As regards the treatment of Volhynia fever, I wish 
to state that one can manage with very few medicaments. 
To alleviate the pain, pyramidon or novalgin (preferably 
intravenously) may be used after subsidence of the acute 
stage. Early getting out of bed and treatment with baths 
followed by active exercise as soon as possible. The 
neuralgiform pain is by no means increased by getting out 
of bed, in most cases it is even alleviated. At the sug- 
gestion of GUTZEIT, I have been consistently making ray 
convalescent patients do exercises for some time in the 
form of cross-country marches, which has yielded excellent 
results. Above all, it shows what one can expect from a 
convalescent by that time, and how far he will be fit for 
service after his hospital treatment. Careful observation 
and strict medical control go without saying. Mr. SCHULTEN 
mentioned that the term "Volhynia fever" is, strictly speaking, not justified at all and that, for this reason, 
he considered the term "Neuralgic fever" equally justified 
for the time being, I am of the same opinion, since the 
complaints of Volhynia fever are actually localized in the 
nervous system with hardly any exception, in the form of 
neuralgias (intercostal neuralgias, ischialgias, etc.) 
and genuine neuritides. I saw myself two neuritides of 
the arm-plexus with Volhynia fever with pareses and a 
neuritis of the left ischiac nerve, also twice a pareses 
fasciales (unilateral). In no case could I observe any 
symptoms of encephalitis. 
SCHTJLTEN: Hardly any differential diagnosis is so 
difficult as that between Volhynia fever and internal 
tularemia, which in our region practically occurs only 
as thoracic tularemia. Though I observed some 100 cases 
of both diseases, I cannot help stating again and again 
that to discriminate between them in any single case nay 
be difficult or at first impossible. Common to both states 
are a sudden onset with fever and violent aches in the 
forehead and the head, exhaustion, weakness, aches in the 
back and limbs, heart-complaints during reconvalescence. 
Also the gnawing tibia pains which we once thought character- 
istic of Volhynia fever, occur in the same form with tularemia 
In most cases of this disease, there will be additional cough- 
ing and aches behind the sternum after a few days. But 
Volhynia fever, too, is not rarely accompanied by pain in 
the chest, the trouble occurring now more in the muscles, 
now more in the heart. If a roentgen apparatus is avail- 
able, swellings of the hilus glands with the characteristic 
radiation of dark streaks in one lobe of the lungs can be 
ascertained in the case of thoracic tularemia. In the case 
of tularemia, the fever will continue high longer and more 
continuously, as a rule, but any other types of fever, 5 
days* rhythm included, may also occur. As a matter of 
course in this differential diagnosis the specific skin 
and serum reactions for tularemia must always be used. 
But two to three weeks will often elapse before a clear 
positive result is available. It will remain a biologic 
puzzle why two diseases due to entirely different agents 
and evidently also vastly different pathogenetically may 
produce clinical pictures resembling each other so^extra- 
ordinarily as is the case here. The wrong diagnosis^of 
field nephritis in the case of Volhynia fever is obviously 
due to a coincidence of albuminuria, back aches, and the 
mask-like face (though without proper edema). 
Information leaflet. 
The Volhynia fever. 
The Volhynia fever (known also as 5 day fever, trench 
fever or neuralgic fever, WERNEH-HIS-disease) is a disease 
usually distinguished by periodical fever and chills and 
a neuralgic rheumatic syndrome, which in World War I occurred 
frequently first at the Eastern front and has been examined 
more closely since that time. Cadsative agent: The agent is the Rickettsia Volhynica 
sive quintana. It lives as a parasite in the louse and 
grows exclusively on the surface of the epithelium, not 
like the rickettsia prowazeki, the agent of typhus, which 
grows within the cells. A direct microscopic proof of its 
presence in the circulating blood has not yet been possible, 
even indirect proof can be obtained only by means of the 
WERNER test. The WERNER test consists of having healthy 
lice suck blood from persons suspected of the disease and 
in tracing the rickettsia in the intestines of the louse 
after about 1 week. The carrying out of this measure is 
limited to special institutions and therefore is immaterial 
for practical purposes. A practically useful serological 
proof of Volhynia fever has not yet been developed; for 
this reason it is no use sending blood test to hygienic 
bacteriologic testing-stations for a diagnosis of Volhynia 
fever. For scientific purposes, an agglutination test of 
rickettsias is made in the Institute for the Research of 
Typhus and Virus Infections at 45 Siegfriedstrasse, Lemberg. 
Epidemiology: Typically a war disease. Practically 
the only carrier is the louse. Infection through men will 
not occur apart from blood transfusion. The disease leaves 
behind no permanent immunity. By its tendency to spread 
epidemically, the tactical preparedness of the troops may 
be considerably impaired. The spread depends on the degree 
of the infestation by lice, the climax of the disease- 
curve therefore generally lies in the colder season. 
The period of incubation varies from 4 to 60 days. 
Clinical picture and course! Extremely changeable. 
The following kinds of courses of the fever are observed? 
1. 5 days1 fever (rises of temperature lasting 
than 36 hours, alternating with 4 to 6 days free fren 
fever. The fever curves may be so low that they 
scarcely exceed the normal, and so brief than they 
are not observed if the temperature is measured only 
twice a day (about 30 per cent of the cases )* 
2. Undulant fever in a rhythm of approximately 1 wo 
3* Uniform subfebrillty often lasting several week.' 
4. Brief, continued fevei usually not very high, 
without other symptoms of typhoid, the term 
being inappropriate for this reason. 
5. Brief rise of temperature (abortive form). 
6. Combinations of the different types of fever are 
possible. 
Arranged according to their frequency, there are the 
following complaints! headaches, particularly above the 
eyes, neuralgic pain in the limbs especially in the lower 
extremities, above all in the legs below the knee, often felt as gnawing pain within the tibiae, often in the thighs, 
lower arms, arms above the elbows as well as in the joints. 
No objective changes are to be found in the aching parts. 
Contrary to other diseases of the joints there are, above 
all. no hematomas, and the pain will be alleviated by 
moving# The pain increases mostly at night, often with 
rising temperature. There are frequent back-aches, aches 
at the costal arch and in the stomach, which may cause the 
erroneous diagnosis of appendicitis or nethrollthiasis* 
Comparatively frequent are slight and transitory neu- 
rologic affections particularly of the reversible kind 
(paresthesias, hyper- and hypaesthetic zones, disorders 
of the sensation of cold and pain, independent of the dis- 
tribution of peripheral nerves). 
Rarer are disorders in the motor field, reflex-dis- 
orders, transitory paralyses, (occasionally are also ob- 
served? defective hearing, photophobia, aphasia). Psychic- 
ally, the patients are occasionally changed, showing a 
certain plaintiveness with fits of depression# 
The spleen is sometimes palpable, often enlarged to 
percussion and sensitive to pressure in most cases# 
The blood picture is of no use for a differential 
diagnosis, a leukocytosis, monocytosis and eosinophilia 
are often observed, in very rare cases also a moderate 
anemia# 
The sedimentation rate is slightly accelerated in most 
cases. 
In the beginning often a certain bradycardia, which, 
in its course, will often turn suddenly into a persistent 
and pernicious tachycardia, impairing the patient-s ef- 
ficiency to a certain degree. Serious disorders of the 
circulation and of the heart, or electrocardiographic 
changes are rarely observed. 
Exanthemas resembling typhus are seldom observed. 
Heavy perspiration is often seen. 
Catarrhal complaints do not belong to the clinical 
picture of Volhynia fever. 
Clinical course: Most cases are completely healed 
within a few Weeks. In some cases, the clinical picture 
is protracted through months with long intervals free from 
symptoms. 
Differential diagnosis? 
1. Recurrent fever and malaria are to be distinguished 
by the microscopic findings. 
2. Typhoid, paratyphoid. BANG!s disease, and tularem:’r 
are to be differentiated by the clinical course and 
agglutination tests. 3* Influenza: this disease usually shows more 
symptoms connected with the respiratory tract, which 
are missing in the case of Volhynia fever. 
4. Particularly in the cases taking a subfebrile 
course, one must suppose tuberculosis, sepsis, linger- 
ing endocarditis, and lymphogranuloma. 
5. In the case of the so-called Russian headache 
fever, headaches are usually more violent. Other 
symptoms, especially pains in the limbs do not occur 
in this case. 
Treatment: Symptomatically antineuralglcs; in partic- 
ular. novalgin administered intramuscularly or intravenous! 
yielded occasionally favorable results. Antipyretics yield 
generally no effect. Of no use are the sulfonamides known 
as yet, quinine, atabrine, and neosalvarsan. 
Preventive measures and prophylaxis! The disease wil 
set in.the more frequently the greater the plague of lice? 
delousing will prevent it. As regards the necessary meas r 
consult Army Manual 194 (Regulations for Decontamination 
and Sterilization), 209/XIX information leaflet on the 
possibilities of delousing, 209/2 # 100 information leaflet 
on typhus and MArmy Hygiene in Wintern (only for the use 
of the Armed Forces). 
6» Concerning Rickettsias - Demonstration in the blood, 
arid in the cerebrospinal fluid in case of 
Volhynia fever (V# F.T~^ 
Stabsarzt (Captain, MC.) UNGER 
Considering the most varied clinical picture of 
Volhynia fever, it is often difficult to establish a 
diagnosis even clinically. The surgeon who knows the 
different types and symptoms of the disease will often 
diagnose it as such with high probability after a short 
observation. But even he will endavour again and again 
to verify the diagnosis by a distinct method of examin- 
ation. As a matter of fact, such methods do exist. Thus, 
the serological proof by agglutination is possible, for 
which the use of cultures of rickettsia volhynica are re- 
quired. Pursuant to another method, lice are planted on 
the patient, in the stomachs of which the agents can be 
traced after a couple of days. Both methods of examin- 
ation. however, can be carried out only in special in- 
stitutions and are not generally available* 
On the alert for another method, there were severeJ 
times discovered in the literature (both in that of the 
first World War and that of the second) statements pur- 
porting that, in the blood of Volhynia fever patients, 
there were observed forms appearing as tiny double balls, which were pointed out as findings characteristic of 
Volhynia fever and considered as the agents# Other author- 
ities, however, refuse to acknowledge these elements as 
specific, arguing that it is impossible to distinguish then 
from small grains of other origin. 
In order to verify these observations, we have been 
doing large-scale systematic research work since August 
194-2, on the strength of which we are now in a position 
to assert that rickettsiae can be positively traced direct 
microscopically both in the blood and in the cerebrospinal 
fluid. Analyzing thousands of ’’thick smears” and streak 
preparations of the blood of patients whose clinical sympter 
made one suspect Volhynia feVer, in more than 600 preparatir 
there we found elements showing the peculiar manifold ferns 
of the rickettsiae as described and illustrated by DA ROCHA 
LIMA and particularly strikingly by SIKORA in the treatise 
’’Facts concerning morphology of the rickettsiae”. 
It is the very multiformity of rickettsiae which may 
have made other authorities doubt whether it is possible 
to Judge blood-preparations correctly. Besides, if the 
’’thick smear” prepared as usual is stained according to 
GIEMSA, many grain-like forms produced by decomposition 
are to be found resembling sometimes certain forms of 
rickettsiae. The aim of our research work, therefore, 
was to reduce this source of faulty diagnosis to a minimum. 
For this purpose, it is necessary to lay this so-called 
’’thick smear” as thinly as possible on the preparation slid 
in order to render it more transparent. But even more im- 
portant is the staining. After trying several methods we 
now use the CASTANEDA-technique. For the purpose in quest:, 
the original composition is not suitable, since the ”thic 
smear” will often peel off like varnish. If the modified 
staining method is used, however, the preparation will ad- 
here satisfactorily and provide a picture considerably 
more clear than staining according to GIEMSA. The non- 
specific tiny grains etc. obstructing the view of the 
field of vision are absent nearly altogether. On a red 
background the rickettsiae appear in color varying from 
reddish violet to black-blue, and are set off to advantage 
against their surroundings. 
As regards the shape of rickettsiae, they chiefly 
appear as forms resembling diplococci, if the preparations 
are looked at casually. On closer examination, however, 
all forms caused by processes of propagation, as described 
by SIKORA, were ascertained. They are isolated grains, 
small sticks, little barrels, dumb-bell-forms, little rods 
with several grains of chromatin; a chain-like arrangement 
of the single types was also repeatedly observed. In the 
blood streak-preparation, it can be observed that the 
are extracellular; some isolated instances are found with: 
the border of an erythrocyte and these are obvisously ac- 
cumulations. Particulars concerning the ascertained riel 
sia forms cannot be discussed here; it is necessary to 
examine them under the microscope. Examinations have been made in about $00 cases of 
Volhynia fever so far; rickettsiae were ascertained in 
almost each of them, though it was necessary in many cases 
to draw blood several times and to scrutinize the prepar- 
ations thoroughly (as in the examination of Tb-sputum). 
It is remarkable that with some patients the rickettsiae 
appeared only after doses of eubasin had been administered 
(with which, by the way, we observed no therapeutic success 
in any other respect) and then in vast numbers and with 
considerable differences of £ize. Even after the fever 
and the other symptoms of the disease have subsided, they 
may still be occasionally found. 
Recently, rickettsiae could be repeatedly traced also 
in the cerebrospinal fluid of men suffering from Volhynia 
fever. Though the provided positive 
findings, the rickettsiae can be observed particularly 
distinctly in their multiformity, to the light 
background of the preparation in the sediment of the fluid, 
which was examined immediately after being drawn. The 
fluid in which vast numbers of rickettsiae could be as- 
certained in most cases, showed no protein reaction and 
no or only slight increase of the cells; the cultures 
on ordinary media remained sterile. 
In conclusion, the speaker mentions that, also in a 
6ase of typhus, particularly large numbers of rickettsiae 
could be detected in the spinal fluid. 
Discussions 
K. SCHULZE: These findings were reported as early 
as 1916 by JUNGMANN, KUSCHINSKI and TOEPFEH, but they 
were disproved afterwards and considered as misinterpreta- 
tions, particularly by the treatises of DA ROCHA LIMA. 
No therapeutic effects freeing the blood quickly 
from rickettsiae could be obtained either by quinine or 
atabrine, plasmochin, sulfonamides or by convalescentsf 
serum. 
EYER: Pathogenetic rickettsiae for humane do exist 
in the blood, since they may be traced in it by tests on 
animals. As experience has shown, their concentration in 
the blood is slight; conditions do not differ at all from 
those of other infectious diseases, which are never as- 
certained directly but rather indirectly by cultures. 
Certain as it is that rickettsiae can be traced in the 
blood, particularly in the leukocyte-sediment, occasion- 
ally also by staining, the method as a whole is uncertain, 
owing to the irregularity of the findings on the one hand 
and the uncharacteristic morphology caused by strong symt 
of involution, on the other band. So it may be gathered 
that, though certain forms may occasionally be observed ■' 
the blood preparation, which might even resemble ricketto 
such grain-findings, which were well-known already to 
ROCHA LIMA, must not be made the startihg point for form- 
ing a diagnosis, since they may be interpreted in many 
ways • Conjointly with Prof. NAUCK, Hamburg, I have examined 
some microscopic preparations submitted by UNGER, but could 
not convince myself that the forms represented with modified 
CASTANEDA-staining were actually rickettsiae. Neither In 
form nor in size did they resemble genuine rickettsiae; 
I think it less important, whether such forms traceable in 
the blood or fluid are at times actually rickettsiae or not, 
but it is a fact of practical importance that a reliable 
diagnosis cannot be formed on the strength of stained blond- 
er fluid preparations in any case. 
7* Experience with typhoid and paratyphoid, 
Qberstabsarzt (Ma.ior,MC •) Prof, WESTPHAL 
A typhus epidemic of moderate seriousness is reported 
on, which reigned approximately from September to December 
1942 among the 6th Army in the region of the bend of the 
Don and in the wedge of attack towards the Volga at Stalin- 
grad. 
Paratyphoid B there amounted to 10 per cent, para- 
typhoid A was less frequent. Infection occurred in many 
places, probably starting from carriers of bacilli among 
the Russian civilian population, transmitted by the close 
contact with them and, owing to the scanty water-supply in 
the steppe. Within the Stalingrad area, typhus occurred 
only on a small scale. On the whole, 1 per cent 
of the Army, approximately, were afflited with it. 
In the overwhelming majority of cases, men regularly 
vaccinated wore afflicted with typhoid. Those cases parti” 
took a graver course than typhoid among the vaccinated 
soldiers in the first World War. Only with one fourth 
of the patients was the clinical picture a light one, wit] 
one half it was moderately serious and with the last fourth 
it was quite serious. At the hospitals for serious cases 
mortality averaged about 10 per cent among all the patients, 
including the light cases and the often unrecognized cases- 
5 to 6 per cent. The following complications were frequent; 
In most cases the diagnosis was not difficult, because 
of the well-known symptoms, even the diazo reaction was in 
75 per cent of the cases positive in spite of previous 
vaccination. The examination for leukopenia and anislnophi'' 
was particularly advantageous to a quick establishment of 
the diagnosis. For external reasons, the bacteriological 
diagnosis could be established only to a certain degree. 
Here the safest method was a tracing .of the typhus-bacilli 
in the blood or in the cystic bile. The difficulties in 
interpreting the GRUBER-WIDAL-reaction after previous vac- 
cination and if other infectious diseases existed are de- 
scribed. The frequency of mixed infections with dysentery 
or diphtheria and the infrequent infections in the hospit- .< 
are pointed out. Both general and medicinal therapy are discussed, and, 
finally the question is raised, whether this relative ac- 
cumulation of typhoid among vaccinated persons in the 
steppe-regions of southeastern European Russia nay be 
caused by particularly toxic strains of bacilli which 
possibly might be suitable also for the production of a 
vaccine affording better protection in those regions. 
Experience with typhoid and paratyphoid, particularly 
t'HeTr courseTn >fimnunlzedn individuals'* 
Stabsarzt (Captain. MC.) Prof. SCHOEWE. 
The experience, on which my report is based, is founded 
on observations made in a region of the Eastern Front, whic 
is situated to the west of the large bend of the, Don and tw 
the south of the lower Don and Sal, where typhoid is ender 
amongst the civilian population. 
In the latter part r-f summer and fall of 1942, no 
particular accumulation among the Russian population could 
be ascertained except in an endemic area in the district 
around Schutow on the railway-line Salsk-htalingrad. A 
medical officer with a small detachment was ordered there 
by the 4th Armoured Army to localize it. On the other ha..d 
typhoid had been gradually increasing among the troops sir... 
the latter part of the summer of 1942. Most cases appearc*. 
sporadically in the single units. Slight endemic outbreaks 
were observed among a repair company on the lower Don with 
5 cases, among an assault boat detachment on the southern 
railway-line outside of Stalingrad with 22 cases, among a 
field training regiment at Tschoretz and among the persona 
of the D.C.G.S.-section of Army Group Don with 14 patients 
The latter belonged to the group of paratyphoid B. A serir 
epidemic sot in among the Service at Millerowo; of 
the section numbering about 170 men, 78 were afflicted wlti 
typhoid. 
As regards the source of infection, nothing positive 
could be ascertained in the individual cases. In the case 
of the smaller epidemics among the Staff Don, paratyphoid 
B bacilli were eventually cultured from the tap-water of th 
billets and from the water of the river Don, but no in- 
creased incidence of paratyphoid B in the city of Rostow 
was observed later on. Among the Labor Service section 
of Rostow K 1/210 at Millerowo, conditions wore quite diff 
ent; consumption of raw skimmed milk had probably caused 
the infection there. An inspection of the local dairy 
showed that the Russian civilian population, who as you 
know, keep a cow per family, delivered the milk in small 
quantities in a vessel chosen themselves, such as a p 
or a bottle, even a jug. All these single quantities wer; 
poured into a large-tub, the contents of which were sub- 
sequently churned. If you had seen the state of the bottle 185 
brought along and the filthiness of the deliverers of that 
milk you would be convinced that that milk poured together 
contained masses of germs of every description* There 
could be no doubt about it that both the skimmed milk and 
the butter contained all sorts of germs, including typhoid 
and paratyphoid bacilli. Only at very few large dairies 
in this region was the milk pasteurized before it was 
churned. At the small dairies in the open country, the 
hygienic conditions were sometimes even worse* I ascribe 
the appearance, even the sporadic cases of typhoid and 
paratyphoid among our troops, largely to the consumption 
of raw butter, which was a welcome additional ration, con- 
sidering the difficulties of suppljr. For the rest, the 
troops were so disciplined hygienica.lly that they scarcely 
consumed raw liquids and the milk-epidemics among the Labor 
Service, therefore, happened but once* 
Before entering into particulars of symptomatology and 
progress, I must of course point out the evident fact, that 
all our observations, apart from one tragic exception known 
to me, concern vaccinated persons. This exceptional case 
was a female technical assistant of a field laboratory, 
who had never been vaccinated before, was afflicted with 
typhoid in September 1942 and died after a long illness. 
In the autopsy 7 intestinal perforations could be demonstrrtt 
Owing to the experience gained in the first For Id Far, 
the number and also the gravity of typhoid cases are, as 
you know, said to have positively decreased after vaccination 
had been introduced. SCHOTTMUELLER discusses, therefore, 
typhoid of the ’’vaccinated persons” only in a small chapter 
of the 2nd edition of the Manual for Internists* In the 
3rd edition of the same manual, STAEHELIN discusses the same 
subject womewhat more reservedly. Our experience founded 
on the observation of about 2000 cases is a twofold one. 
As regards the problem of susceptibility to typhoid 
infection, the above mentioned milk-epidemic- among the 
Labor Service section who had been ’’immunized” for the first 
time 6 months before with a morbidity of about 40 per cent, 
might be interpreted as proving that there is no practical 
difference from other kinds of typhoid infections in peace 
time, e.g. by ice-cream with a sick rate from 25 to 35 per 
cent. On the other hand, the more common sporadic occurence 
of typhoid in that infested region suggests that, among non- 
immunized troops, major or minor epidemics caused by the 
consumption of other food stuffs, should have set in more 
frequently. lifter consumption of the equally infected butt 
for instance, not one epidemic was observed* For this 
reason, the assumption seems justified that, owing to inmr 
ation, the typhoid bacilli are unable to get a foothold in 
the body. Only in case of ingestion of massive doses or 
strong virulence of the agents will the infection occur. 
A third factor also plays an important part in the origin 
of the disease, viz. the lowered power of individual re- 
sistance, which favors the susceptibility to the infection. 
It is this very lowering of the capacity of resistance that 
seems to be chiefly responsible for the outbreak and program ' 
of the typhoid epidemics among the RAD (Labor Service). In the vast majority of typhoid cases, the course 
was perfectly classical. The temperature rising grad ually, 
sometimes rapidly, with subsequent continued fever lasting 
a fortnight on the average, was very characteristic, com- 
pared with a relative bradycardia of about 90; a look at 
the fever-curve was often sufficient to establish a dia- 
gnosis* The spleen was swollen in almost every case. 
Eruption of roseolae could be observed in just as many cases 
as in peace time, viz. in about three fourths, certainly 
not^only in a fifth, assorts for immunized persons 
during the last war. Diazo reaction also was positive in 
about 70 to 80 per cent of the cases, as compared to 20 
per cent in the last war. Subjectively, the patients 
particularly complained of headaches, rheumatism, and a 
certain numbness; in the critical stage of the disease, 
the latter would increase to a somnolence lasting for days 
or weeks. 
The eosinophilic leukocytes, which were almost re- 
gularly found in 1 to 3 per cent of the cases even during 
the initial stage of the disease, behaved in no regular 
way. On the other hand, the r duction of the number of 
leukocytes, at first normal, to values of leukopenia down 
to 3000, with attendent relative lymphocytosis proved a 
fairly constant symptom of diagnostic value. Even in case 
of rather extensive broncho-pneumonic processes, the number 
of the white blood corpuscles seldom exceeded 10 000; only 
a shifting to the left could then be ascertained besides 
the lymphocytosis. In serious cases, anemia would develop 
as a rule sometimes attaining haemoglobin-values as low as 
to 40 per cent. In one case the picture of anaplastic 
anemia was observed. 
Here also the complications reve chiefly inflammation 
of the respiratory organs. In most cases the patients 
were admitted to the hospital with a tracheitis or a bronch- 
itis. Additional broncho-pneumonic foci sometimes over- 
lapped so much that the impression of a labor pneumonia 
arose clinically which caused diagnostic mistakes. Per- 
sistent hoarseness often gave rise to the suspicion of a 
perichondritis laryngea. While the bones, and also the 
kidneys and the urinary tract were but rarely affected, we 
occasionally observed changes in the neurologic findings; 
sometimes during the initial stage of the disease, the 
absence of epigastric reflexes, unilaterally intensified 
patellar reflexes and at times even a positive Babinski, 
probably as a symptom of a spinal meningitis, could be 
ascertained. As regards form and freouency, the cerebral 
symptons correspond to the descriptions in the text-bocks. 
A remarkable fact deserving to be particularly em- 
phasized is that intestinal hemorrhages occurred but very 
rarely; though this statement refers only to macroscopic 
proof, but it tallies with the autopsy findings, which 
revealed large tumors or perforations only in exceptional 
cases. Among 50 men of the Labor Service affected by the 
disease in the Millerowo epidemic the stool of only two 
contained blood. The frequency of recurrences fell by no means short 
of the peace time rate; if the latter is stated by GUHSCII- 
MANN to be from 6 to 12 per cent, war time cases exceed 
this figure by many times, rising to 20 to 30 per cent in 
our district. At times, the continued fever dropped to 
subfebrile temperatures for 1 to 2 days, with a fever wave 
almost as high and as long following immediately# This 
so-called supplement differed from the genuine recurrence 
as follows: In case of the latter, after a longer inter- 
val free from fever, all symptoms of the disease may recur 
with the rise of temperature, such as enlargement of the 
spleen, positive diazo test, roseolae etc# In many cases, 
the recurrences had a more serious course than the original 
disease# In the case of a nurse, the second recurrence, 
which set in after many weeks, caused the most serious 
clinical picture# 
This frequency of recurrences of war typhoid depends 
probably on the special conditions in the field# Above 
all, transportation seems to have some Influence on it. 
After the second week, transportation furthers the oc- 
currence of complications, particularly of the lungs, 
and of recurrences, which may be attributed to the trans- 
portation may occur even 2 to 3 weeks after defervescence. 
Transportation is tolerated best while still in the initial 
stage of the disease; thus, I saw patients in the second 
week of illness with high fever walk from the improvised 
hospital train to the hospital without any serious effect 
on the later course observed by us. 
The invrlvement of people of different ages approximate- 
ly corresponds to peace time experience. Of 298 new patients 
in a hospital for infectious diseases, the proportion of the 
age group from 18 to 22 years wac 32 per cent, but the 
proportion of the following 4 groups up to the age group 
of 40 were only 16, 14, 22 and 11 per cent respectively, 
though, as regards age, the troops are not composed re- 
cording to this percentage# This shows that juveniles rrc 
particularly liable to the disease. 
It is always difficult to form an opinion on the 
prognosis. Only subjectively, the impression prevailed 
that the seriousness of typhoid fever which occurred last 
year in the south of the Eastern Front did not fall short 
of peace time conditions; the description of the course 
of the disease and of the frequency of recurrences, should 
also have shown as much. The prognosis was particularly 
observed by the decrease of resistence inevitable in the 
field under unfavorable climatic and strategic conditions. 
The Labor Service sections were particularly affected by 
this# Thus, in the case of the Millerowo epidemic the 
disease took an exceedingly serious course from the very 
beginning# 80 per cent of the men were benumbed (lethar^^', 
partly even delirious; somnolence continued for some wer1 < 
even after defervescence. The death rate was accordingly 
high; of the 78 men, 12 died, viz. 15.4 per cent. Of the 
158 soldiers treated at the same hospital, only 9 died, viz* 5.7 per cent. A similar situation occurred in the 
case of the 22 patients of the field training regiment 
a 614, who, having got safely through the advance as 
Labor Service men in the field, were taken over by the 
Armed Forces in October 1942 and fell ill in November* 
5 of them died, whereas only 7 of the other 276 patients 
treated at the same hospital died. Among the Roumanians, 
who were sent to the hospitals in a state of complete ex- 
haustion during the retreat, the death rate was equally 
high. On the whole, the death-rate at the single bespit?Is 
varies between 4 and 10 per cent, but these figures are 
particular use, since the patients sent to the rear 
medical institutions were sifted previously* 
In the vast majority of the cases with fatal issue, 
the cause of death were pulmonary complications* Death 
by intestinal perforation was rare; e.g* among 5 deaths 
which occurred at a base hospital from June 1942 tc April 
1943, no perforation was observed. At another hospital 
for infectious diseases two perforations were found among 
18 autopsies, and twice, hemorrhages were supposed to hove 
been the cause of death. 
Among the cases afflicted with paratyphoid, para- 
typhoid B was predemonant. In most cases, it began with 
diarrhea, which, in some exceptional cases, developed to 
such a degree that cholera had to be taken into consider- 
ation. The course of the fever was characterized partly 
by a brief continuous fever, partly only from the very 
beginning by remittent fever in the sense of a question- 
able disease. The other symptoms, too, had developed loss 
pronounced than in the case of abdominal typhoid. After 
all, the fever-curve with attendant relative bradycardia, 
leukopenia, and often positive diazo reaction afforded, 
besides the clinical impression, sufficient clues to the 
diagnosis* Subjectively, the patients had hardly any 
complaints, the initial diarrhea excepted. No f-tal 
case was reported to men, but the frequency of recurrences 
was little less than that of abdominal typhoid* 
Paratyphoid A occurred more frequently than in 
Central Europe; its proportion of the total numbers of 
paratyphoid cases may be estimated at 1/4 to 1/3, approx- 
imately* As regards the gravity of the clinical picture, 
it was between abdominal typhoid and paratyphoid B. Its 
fever curve resembles moie that of the former* On the 
other hand, diarrhea and vomiting could often be found from 
the onset here also. Recurrences occurred almost as 
frequently as with typhoid, one patient had the second 
recurrence after nearly three months* But here also, 
not one fatal case has been reported to me* 
Since the diagnosis of paratyphoid cases is mainly 
based on bacteriological results, something may be said 
here about diagnoses. If STAEHELIN writes; "Today the 
diagnosis of typhoid will be established in the laboratory", 
this statement is by no means appropriate for conditions 
in the field, particularly not for abdominal typhoid. I mentioned the classical course of the fever- and pulse 
curves, and also the pronounced signs of the other symptoms 
before, so that, with a few exceptions, the diagnosis could 
be established on the strength of the clinical picture 
alone# Of course, there are abortive cases where clinical 
symptoms may fail, such as the case of a surgeon-ensign 
with brief rise of temperature recurring three times and 
without considerable complaints; but also in this case, 
leukopenia of 5000 and a positive diazo test indicated 
typhoid disease. Broadly speaking, a bacteriological 
examination will bear out and specify the general clinical 
diagnosis of typhoid. 
In this connection, it must bo mentioned that the 
bacteriological results were seldom uniform and. leave 
many problems unsolved. It wTas for instance a striking 
fact with paratyphoid A particularly but also with other 
varieties, that though bacilli had been traced, in the 
blood or in the stool, the WIDAL reaction remained negative 
even after weeks. The field conditions may be responsible 
for the fact that tracing the bacilli in the blood was only 
partially successful, although SCHOTTMUELLEH was already 
struck by it during the last war and ascribed this phenomenon 
to protective vaccination. The existence of a vaccinal 
titer and the increase of it even by non-specific infections 
produces a situation so that a WIDAL reaction of 1:400, 
made but once, is of no diagnostic value. Only the rise 
of it is of diagnostic importance. Hence it follows that 
blood must be sent in for agglutination rather frequently. 
So one can manage to settle many obscure cases bacterio- 
logically, particularly if the intervals between the single 
analyses are not too long. We have observed that several 
agglutinations repeated at short intervals resulted in 
one high titer, whereas the WIDAL reaction was negative 
4 to 5 days before and afterwards. 
As regards treatment, nothing essentially new can 
be said. The quality of attendance is and will remain 
decisive. I could not completely convince myself of any 
excellent effect of the sulfonamides on pulmonary com- 
plications; on the contrary, it was pretty certain that 
if sulfonamide-therapy had no effect on an ostensible 
pneumonia, the latter was probably only a complication 
of a typhoid disease. 
In summary: The susceptibility to typhoid and para- 
typhoid in the infected area was apparently reduced despite 
smaller endemic outbreaks and greater numbers of sporadic 
cases. Protective immunization probably manifested itself 
in a reduced cbility of the typhoid bacilli to get a foot- 
hold. If typhoid had once set in with "immunized” persons 
the gravity of the clinical picture did not differ from 
that of peace time during the last fall. It was a re- 
markable fact, however, that intestinal hemorrhages were 
very rare and that intestinal perforations as a cause of 
death were ascertained onl3r in exceptional cases. The 
behavior of the eosinophilic leukocytes was variable, they 
were hardly ever missing. The frequency of recurrences far exceeded the peace time rate, it is probably caused 
by the special conditions in the field. The WIDAL re- 
action may be used only with a titer higher than 1:400. 
Since the bacilli test as well as agglutination failed 
in many cases, the clinical picture is still decisive 
for diagnosis under field conditions. 
Discussion of typhoid and paratyphoid. 
GUTZEIT: In the search for the causes of the degree 
of gravity of infectious diseases and of typhoid in par- 
ticular, much more allowance must bo made for the epidemic- 
logical peculiarity. The "decrease of resistance" for the 
serious course of a disease has become a catchword mere 
and more. Asked in confidence what he meant by decrease 
°f resistance, the individual surgeon certainly would 
often be at a loss as to what to say; every one means 
something different by it. During the fall of 1942, 
typhoid was comparatively more frequent than in the pre- 
ceding year, despite the same vaccination, not only in 
the south but on the whole Eastern Front, In the south 
of the Eastern Front all epidemic diseases have for years 
been more numerous and the clinical pictures more serious* 
The causes are still largely unknown. It cannot depend 
on the patients’ resistence. During an epidemic in Paris 
in 1941, the vaccination made during the period of in- 
cubation had a most beneficial effect on the ravity of 
the disease. Thus, no negative phase set in. This is 
important for future outbreaks of diseases. Stabsarzt 
(Captain, MC.) Prof, HOERING should report on his experience 
with fever-therapy. 
HOERING; In the Italian, English and also German 
(NETOUSEK) literature, intravenous vaccine-treatment is 
often recommended; it has been emphasized that it is im- 
portant for eventual success to bring about a shaking 
chill. At a base hospital in the Crimea, corresponding 
experiments with non-specific shock-treatment (with Py- 
rifer) could be made, which were completely successful 
(critical defervescence) r ith patients at every stage 
of typhoid in more than three fourths of 50 selected 
cases (demonstration of the fever-curves). For this 
therapy, the patients must not be too feeble. To obtain 
a complete effect, 2 to 3 injections with increasing 
doses (up to a severe chill) are sometimes necessary. 
Isolated recurrences will occur also with persons thus 
freed from fever. Even if a treatment with sulfonamides 
has on the whole no effect on typhoid, diarrheas in the 
amphibolic stage may sometimes be promptly removed by it. 
In earlier stages, a temporary lowering of temperature 
is all that may be expected from the sulfonamides. 
UHLENHUT; Typhoid in Russia spread among the^troops 
in the same way as during World"'War I. when infection 
could be traced back to the endemically Infected indigenous 
population of Belgium and Northern France. It is partic- 
ularly the bacilli carriers that are the original cause 
of endemic typhoid distribution and effect wider spreading 
through direct or indirect contact (infection of food stuffs). During trench-war in World War I (Med. Clinic 1915,6), I 
thoroughly examined the indigenous population of the places 
behind the front for bacilli carriers, and isolated then, 
as we had been instructed by Robert KOCH during organized 
typhoid fighting in the south-west of the German Reich 
(assembly areai). In the course of the organized campaign 
against typhoid in Alsace and Lorraine, they were isolated 
during the mobilization. Dangerous sources of infection 
were eliminated in this way. But this is no radical remeck 
under war conditions. Unfortunately, chemotherapeutic 
healing of the bacilli carriers could not be managed as 
yet in spite of extensive research made bv my and my 
collaborators. At the instance of His Excellency SCHJER*- 
NING, a reward of 20 000 Reichsmark had been offered even 
before the World War. The curing of the bacilli carriers 
is the beginning and the end of* typhoid control. By means 
of chemotherapy, typhoid itself might be attacked by elimin 
ating bacilli carriers. The same applies to paratyphoid, 
with which it is true, not only the patient or bacilli 
carrier must be taken into account as an infection source 
(UHLENHUT, Med. Clinic 1934, 24). The sulfonamides have 
had no effects as yet, whilst, in case of dysentery, re- 
markably beneficial results were recently obtained with 
Cibazol, etc* Protective vaccination against typhoid 
affords no absolute protection. The high virulence of 
the Russian strains will perhaps sometimes break through 
the immunity. The highest possible numbers of such highly 
virulent strains ought to be used for vaccine preparation. 
In the bacteriological diagnosis of typhoid the (Blutgalle) 
blood and bile are positive in nearly, 90 to 100 per cent in 
the fifth week. The surgeons must be reminded of that 
again and again, since in peace time they often were not 
yet properly acquainted with typhoid. Even under field 
conditions, the method is quite simple and decisive. Here 
it must be remembered that in numerous cases, typhoid can- 
not be safely diagnosed clinically at all, as it may take 
a course with the most varied clinical pictures (influenza 
e t c *) • 
9» Postdlphtheritlc disorders: treatment, .judgement 
of fitness for service., later possibilities 
of calling up for military service~ 
Obersta.bsarzt (Major, MC.) Prof* SCHOEN 
Postdiphtheritic disorders - only these, not the 
acute stage of the disease will be discussed here - are 
practically limited to disorders of the circulation and 
of the nervous system, with myocarditis and polyneutitis 
predominant in the clinical picture. The local specific- 
ally diphtheritic changes in the respiratory tract seldom 
cause late postdiphtheritic diseases; the same applies to 
the attendant hemorrhagic symptoms of serious diphtheria, 
to parenchymal disorders of the liver and other 
The suprarenal gland is perhaps affected in the acute cir- 
culation collapse of toxic diphtheria. Only diphtheritic nephrosis^may occasionally outlast acute diphtheria for 
a short time, sometimes combined with hematuria, owing 
to parenchymal bleedings. The prognosis is always favor- 
a ble . 
By far the most frequent and most important post- 
diphtheritic disease is nyyoca.rditis♦ Pathologico-anatom- 
ically, it is a primarily toxic injury to the myocardium 
with degenerative changes of the muscle fibrils (myolysis 
with vacuolar degeneration with deposites of hyalin), an 
edema with particular affinity to the conduction system 
and affecting large areas of the myocardium. This diffuse 
heart disorder chieftly affects the left ventricle, par- 
ticularly the apex and the middle layer of the myocardium, 
accounts for the acute danger of heart failure. In its 
further progress, secondary perivascular and interstitial 
infiltrations of round cells and finally thin callouses 
replacing the destroyed tissue will form. Diphtheritic 
endocarditis with subsequent valvular defect is very rare. 
The development of diphtheritic myocardial injuries 
can be observed only in the electro-cardiogram. Early 
injuries can be ascertained in the first week," at times 
even on the third day (derivation of the pectoral wall 
according to NEHB). The earlier and graver the change, 
the more serious will be the prognosis. If death occurs 
within the first two weeks it is caused by heart-failure 
in most cases. In order to judge the late consequences 
in non-fatal cases, it is necessary to follow the progress 
of the myocarditis closely. 
As in the case of many infections, tachycardia of the 
sinus (irregular) will set in first, which is combined with 
functional disorders of the circulation (3T-deformation); 
these will disappear with the tachycardia. If a myocarditis 
develops, any injuries possible may occur, often in com- 
binations; every part of the heart may be affected. 
is no typical electrocardiogram for diphtheria. Prolongations 
of PQ, flattening or negativity of the secondary oscillation, 
ST-deformation are observed most frequently. Fluttering and 
fibrillation of the auricle are rare; intraventricular dis-' 
orders of the conduction system, abnormal stimulation, 
extrasystole, change of rhythm with contraction of several 
stimulation-centers are often observed. Crural and branch 
blocks have not so unfavorable a prognosis as is often sup- 
posed; on the other hand, a complete a-v dissociation in 
case of bradycardia is considered unfavorable, which I 
could confirm in four cases. The rapid change in the 
electro-cardiographic picture (caused by temporary anatom- 
ical symptoms) and the possibility of complete disappearance 
of even grave EKG-changes are characteristic. In order 
to show this clearly for future judgement, I show some series 
of typical findings, demonstrating, at the same time, the 
most important changes of the electrocardiogram in case 
of diphtheria (demonstration). First the usual picture of a flattening of the T- 
deflection with gradual retrograde change to the normal, 
in this case remarkably slow, since in the case of this 
nurse, diphtheria was diagnosed and treated only in an 
advanced stage. A grave case of diphtheria showed grave 
changes with retardation of conduction and ST-deformation, 
which will disappear completely in some two months, be- 
sides polyneuritis. The third case with WILSON-block had 
a still graver progress, later branch-block with extensive 
involution within one month afterwards. On the tenth day 
a transitory a-v dissociation was ascertained, which was 
overcome. After a grave failure of the circulation on the 
20th day, the electrocardiogram showed considerable im- 
provement. Another clinical picture showed a late Injury 
with bi- and trigeminal extrasystolos• The difficulty 
of forming a prognosis on the basis of the•electrocardiogram 
is showd by two fatal cases, in which days, even hours 
before death by heart failure occurred, the EKG showed 
only slight cases, and in which most serious disorders de- 
veloped suddenly. In case of late injuries, such rapid 
aggravations are not to be expected. 
The frequency of demonstrable EKG-changes depends on 
the gravity of the epidemic. Provided that regular con- 
trol is exercised, we find them in the majority of our 
cases* They are predominantly slight transitory changes 
with flattening of T, downward deflection of ST or PQ- 
prolongation, which should be regarded as prognostically 
favorable and complete capable of involution, after the 
second week of illness. The time necessary for that can- 
not be foreseen, but is usually limited to a few weeks 
with absolute rest. Even our grave cases showed, with 
hardly any exceptions, a normal EKG again within three 
months. 
If there are clinical symptoms of myocarditis com- 
pletely absent, the judgement must tee founded on the EKG, 
Disorders of rhythm and grave functional disorders of the 
circulation manifest themselves of course. Continuous 
control by the EKG will prevent overestimating slight de- 
viations in the EKG, as it indicates an active process by 
the change of findings. It is also required for the 
therapeutic control, which must consist in absolute rest, 
if possible, till the EKG is normal. Even in the case of 
mild diphtheria, EKG-control is required, before the 
patient gets out of bed, since overlooking a myocarditis, 
even a slight one, - not yet completely healed - and 
permitting premature strain, at least impairs convalescence 
considerably. In this respect, nothing can match the EKG. 
The temporal development of myocarditic postdiphtherit-5 e 
disorders varies but is usually rapid and limited-to a few 
weeks. Particularly the hearts of juveniles will, as a 
rule, recover complete functional efficiency. ROSTOSKI 
in Dresden followed up the fate of 1371 surviving diphtherir 
cases with EKG-changes, during the years 1935-1938*# The 
majority, 55.5 per cent, showed a normal EKG agah within 
4 to 6 weeks. The other 6ll cases showed late defects, usually prolongation of PQ, changes of T and ST. particularly 
in lead 3? whose diagnostic value is partly dubious* Three 
years later, 19 cases (less than 4 per cent) still showed 
slight changes, but all were fully occupied with labor duties 
and were feeling well; 1 year afterwards, only 7 cases had 
not yet quite recovered. Only some negligible few out of 
vast numbers remain, as demonstrated, and even these are 
clinically healthy and completely fit for work* 
As soon as the first few weeks are over, the prognosis 
of diphtheritic myocarditis is distinctly favorable, and 
even in case of the rarer delayed disappearance of the EFG- 
changes, complete recovery can nearly always be expected, 
even if only after many months. I have the impression that 
a delay of healing is still more restricted by a strict 
rest-cure, Remaining slight abnormalities in the electro- 
cardiogram must of course not be overestimated; in doubtful 
cases the total clinical picture and cautious functional 
strain will decide. On the other hand, the question arises, 
to what degree a functional heart-disorder will remain, even 
if the EKG is normal. In case of immediately preceding grave 
disorders, this must be expected for a limited period; in 
case of lighter ones, the fitness for work will be ascertained 
by carefully regulated functional strain (UHLENBRUCK)• As 
a rule, complete restoration will occur usually within a 
remarkably short time; exceptions will be found particularly 
in the cases of patients of advanced age, who need a com- 
paratively long time for functional restoration. 
The periphery of the circulation is comparatively rarely 
affected by late postdiphtheritic disorders, irregularity 
of blood-distribution occurs during convalescence as in 
other infectious diseases and disappears with systematic 
training. Though postdiphtheritic hypertonia was occasion- 
ally observed with children, I did not find it with adults. 
Nor do hypotonic disorders of regulation play any important 
part if the heart is sound. The most important thing is the 
evaluation of the heart. 
As regards the evaluation by the army surgeon, the 
following conclusions are to be drawns 
1. The frequency of diphtheritic myocarditis requires 
regular control means of the electrocardiogram even 
in lighter cases (at the latest before the patient 
first out of bed (3 to 4 weeks after his falling 
ill)). Patients suffering from myocarditis need strict 
bed-rest, at times for a long period.- If necessary, 
drugs for stimulating the circulation, particularly 
small doses of strophantin, should be administered. 
2* The vast majority of the EKG-changes as symptoms 
of myocarditis are slight and subside within 4 to 6 
weeks after the patient has fallen ill, i.e. at the 
time when he is allowed to get out of bed also on the 
strength of the rest of the clinical course. 3* Judgement of fitness for military service after 
diphtheria without complications: after recovery 
"fit for general service" (kv) without limitation. 
In case of demonstrated myocarditis, a certain pre- 
caution is recommended even after clinical healing 
and normalized EKG. 
a. Light diphtheria with slight EKG-changes and 
rapid recovery will result in complete fitness 
for general service (kv) after the end of a 4 to 6 
weeks1 treatment and a recuperative leave* This 
will be the case in the majority of cases. 
b. After grave diphtheria the circulation must 
be strained only gradually, even after normaliz- 
ation of the EKG and clinical healing, and that the 
more cautiously, the longer the disease lasted. 
It is recommended to decide on "fit for garrison 
duty at home" (GvH) for three months, first with 
indoor-service, then systematic training, control 
by the EKG, afterwards "fit for general service 
(kv) if the efficiency is satisfactory* 
4* A remaining change in the EKG after clinical heal- 
ing, which does not disappear after about three months 
of hospital treatment and is connected with reduced 
efficiency, will according to its gravity, have to 
be judged as "fit for garrison duty at home" with 
cautious training, or better as "transitory discharge", 
further control within 3 to 6 months and upon dis- 
appearance redrafting as "fit for garrison duty at 
home", later on as "fit for general service"* 
5* Only very few cases who have recovered from grave 
diphtheria and grave myocarditis, and who have te- 
tained a permanent defect, particularly elderljr men, 
are to be discharged from military service with or 
without some degree of disability* Even here, a 
further control after 6 to 12 months is necessary and 
will often render redrafting possible. It is not 
necessary to continue hospital treatment too long 
beyond the period of active myocarditis* Cures at 
bathing resorts for heart diseases are not recommended 
if the EKG-changes continue, and may be dispensed 
with after healing. The opinion about grave diphtheria 
cases is often also decided by an attendant neuritis 
in addition to myocarditis. 
Obvious postdiphthcritic paralyses as late consequences 
are easy to judge. The frequent isolated pareses of the 
soft palate and of accommodation will disappear soon, as 
a rule* Extensive deglutition-paralyses with involvement 
of the pharynx must be treated at a hospital till they 
disappear, as there is danger of a deglutition pneumonia. 
In case of grave polyneuritis, the duration of the treatment 
will be chiefly decided by the peripheral paralyses* If acute danger of a paralysis of the respiratory 
muscles in case of highly serious polyneuritis and the not 
very rare cases of LANDRY*s paralysis is overcome, the 
prognosis of postdiphtheritic paralyses is absolutely 
favorable, though there are vast differences in the duration 
of complete healing. In the therapeutic respect, the dis- 
appearance of paralyses cannot be considerably influenced 
by the usual remedies though itis of some Importance to 
stimulate the muscles by physical therapy* Whence it 
follows^that hospital treatment has certain limits. irhen 
paralysis has disappeared so far that the patient can 
take care of himself, it is possible to send him to a 
suitable home till he recovers his full capability of 
motion. After disappearance of the paralyses, courses 
of medical treatments may be taken into consideration as 
transition to "garrison duty at home" in order to increase 
the efficiency faster b' means of hygienic gymnastics and 
training. After a limited period, full fitness for 
general service rill often be attained; over-exertion 
and influences of cold are still to be avoided for a 
long time, 
Postdiphtheritic paralyses may set in 60 days and 
even later after the beginning of diphtheria. Till this 
period has elapsed hard exertions, soakings and injuries 
by cold, abuse of alcohol are to be avoided as far as 
possible in order to prevent it. If a light diphtheria 
is soon treated with serum, the danger of a polyneuritis 
is slight and. almost negligible. This danger is consider- 
ably greater in cases where diphtheria was neither diagnosed 
nor treated. Serious cases will be treated long enough 
to render a late polyneuritis after discharge improbable; 
particular preventive measures are, therefore, not re- 
quired. 
Most important for avoiding diphtheria sequelae is 
an early clinical diagnosis and immediate serum-therapy 
in sufficient, but not excessive, doses and repeated ad- 
ministration of serum, as long as considerable membrane 
exists* The second important measure is complete rest 
till the acute symptoms have subsided, particularly a 
possibly existing myocarditis. Thus, the period of the 
inevitable unfitness of diphtheria patients for military 
service may be shortened. The disability as regards bodily 
injuries suffered during military service are nearly al- 
ways prevented by the treatment, considering that the 
prognosis of the diphtheria sequelae is remarkably favor- 
able despite the seriousness and danger in the beginning, 
making allowance for the fatal cases. IQ*. Consequences of diphtheria, treatment, and .judgement 
or the fitness for military service* 
Oberstarzt (Colonel, MC.) Prof. UHLENBRIJCK 
Diphtheria has always been spoken of without any 
exact definition of the form of diphtheria, and yet it 
is of the utmost Importance to make a differentiation. 
•A classification, made by ESCHERICH and improved by 
SECKEL, and used at the clinical hospital of KLEINSCHMIDT, 
is founded on the working hypothesis, that the different 
progress of diphtheria is strongly influenced by the re- 
action of the macro-organism, in particular by the state 
of allergy. Localized diphtheria is, in clinical respects, 
diphtheria locally limited to tonsils, nose, and larynx; 
wound diphtheria may be included in this group. It would 
correspond to the normal manner of reaction. Spreading 
diphtheria corresponds to the abnormal reaction. It may 
bo subdivided: without croup, with croup, and with broncho- 
pnounonia. The third form is toxic diphtheria with an 
allergic reaction of the body, the symptoms of *-hich are 
the susceptibility to edema and hemorrhage. Diphtheria 
is called pretoxic, if the edema is limited to the sur- 
roundings of the affected tonsil, with a clinical picture 
often much resembling peri-tonsillar abscess; toxic 
diphtheria of the first degree, if the edema spreads be- 
low the angle of the jaw as far as the middle of the neck; 
toxic diphtheria of the second degree, if the edema spreads 
to the clavicular cavity; toxic diphtheria of the third 
degree, if the edema extends beyond the clavicular cavity, 
often as far as the mammilla. The fatal cases with serious 
insufficiency of the circulation are termed hypertoxic 
diphtheria. Besides, this scheme should, for the records 
of disease, list the carriers as suchf They are usually 
subdivided into carriers of incubation bacilli (one must 
be careful with this division, sihee an overlooked diph- 
theria of the nose will often be considered as an ostensible 
carrier of bacilli) and carriers of contact bacilli (i.e. 
cases with positive findings of bacilli, without being ill 
themselves), and into carriers of convalescence bacilli 
(i.e. permanent carriers). Statistics including 951 cases 
of SECKEL1s at KLEINSCHMIDT1s hospital show that this 
aspect of diphtheria from the working hypothesis of allergy 
is particularly important because of a differentiation 
between the non-toxic and toxic cases# Among 532 cases 
of localized tonsillar diphtheria, there was nc case with 
any disorder of the circulation, no case with paralyses, 
no fatal case. Progressive diphtheria in the cases ac- 
companied by croup showed 7*5 per cent disorders of the 
circulation, 3*5 per cert paralyses, 16.8 per cent fatal 
cases,’ all of the fatal cases being due to pneumonia. 
The cases without croup showed extrasystoles in about 
10 per cent, 4.2 per cent paralyses, 4.2 per cent fatal 
cases. These figures rise rapidly in the cases of toxic 
diphtheria. Pretoxic diphtheria has 26 per cent disorders 
of the circulation, 20.8 per cent paralyses, but no fatal 
cases. In case of toxic diphtheria of the third degree, 
there occurred 97*3 per cent disorders of the circulation, 
76.7 per cent paralyses, 60.3 per cent lethal cases. Though 
I recommend a more exact differentiation of the diphtheritic cases based on their widely differing clinical picture and 
regard the above mentioned classification as the most suit- 
able, the other point of view of the micro-organism in 
comparison to the reaction of the macro-organism (patient) 
must hot be overlooked. There are serious and mild epidemics 
of diphtheria, and there are different opinions as to 
whether the type gravis, the type intermedius, and the 
type mitis actually do determine the serious or mild course 
of diphtheria. I am sorry to say that in the Mediterranean 
area, we were not in a position to make this differentiation. 
Otherwise you would think the mitis-type by far the most 
frequent in those countries, where, as you know, diphtheria 
is particularly frequent. The Airforce hospital at Athens 
reports among 195 cases of diphtheria only 5 per cent toxic 
diphtheria and no fatal cases. The hospital at Catania 
had only one fatal case among 16? cases, at Trappani one 
fatal case among 48 cases, at Ragusa no fatal case among 
about 20 cases, at Rome no fatal case among 13 cases. In 
Germany, the mortality of diphtheria epidemics at the 
military or civilian hospitals will amount, as a rule, to 
at least 4 per cent even after the serum period, occasion- 
ally it even rose to 10 per cent. Diphtheria in Greece 
and Italy may therefore be called extraordinarily mild in 
this war* Tunis seems to be a certain exceptions I ob- 
served 4 fatal cases of diphtheria there within a short 
time. From the hospitals mentioned above the patients 
were discharged as fit for service after an average treat- 
ment of about 40 days. 
I wish to make some remarks about the duration of the 
course of diphtheria. As for myocarditis, it is known, 
to set in generally about the 8th or 9th day, the second 
and third weeks of the illness being the critical stage. 
5 to 6 weeks later, myocarditis will disappear if it has 
not been fatal. One may safely say that the prognosis 
generally is the worse, the earlier the pathological 
electrocardiogram appears. I demonstrate a case (treated 
by Oberarzt (1st Lt., MG.) Dozent Dr. SCHAEFER), the 
electrocardiograms of which I was in a position to observe. 
It showed a positive involvement of the myocardium, as 
early as the second day, which did not disappear until 
after 6 months. The second case, too, shows an involve- 
ment of the myocardium on the fifth day which disappeared 
only after almost 6 months. Diphtheritic myocarditis, 
therefore, must be expected to last rather a long time. 
As regards fitness for service the classification may 
perhaps be formulated thus: to recover his fitness for 
service, the patient meeds about the same time that the 
myocarditis took for its course according to the EK'G- 
findings. The great danger of diphtheria in its early 
stage is collapse. Danger of collapse will exist during 
the first few days until the second week has elapsed, 
later on, only in case of an attendant serious myocarditis. 
In the case of toxic diphtheria, anotherv.critical stage 
with danger of collapse will set in when the patients get 
out of bed in the 5th or the 6th week. Tachycardia will 
appear from the second to the third week and it has a 
favorable prognosis. Hrre too the time when the patient 
is allowed to get out of bed is a second critical stage. Frequencies of the pulse about 120 and more are frequently 
observed for weeks afterwards, When the patient gets out 
of bed. The appearance of early paralyses is during the 
third and fourth week. It is usually the soft palate and 
the abcommodation that will be affected; the period of late 
paralyses lasts ftxr. the sixth to the ninth week. After the ninth week, 
the danger or paralyses may generally ue regarded as over- 
come, even in toxic cases. If the kidney is involved in 
the forms of an invariably mild nephrosis, this will occur 
from the second to the fourth week. The bacilli findings 
will usually be negative during the fourth or fifth week 
even in serious cases, after the eighth week we speak of 
them as permanent carriers. A survey, which the reserve- 
hospital Koeln-Hohenlied was kind enough to place at my 
disposal, showed that among 32 cases predominantly of 
toxic diphtheria, wh?ch required prolonged hospitalization, 
in the seventh week 11 cases still had a myocardial de- 
fect, 3 cases required further treatment because of para- 
lyses, 5 cases because of persistent positive bacilli 
findings, 14 cases because of postdiphtheritic lability 
of the circulation. 
As for evaluating the irregularities of the circulation 
in^cases of diphtheria, the electrocardiogram should be 
chiefly consulted since it is absolutely indispensable for 
an accurate diagnostic explanation. I an sorry to say that 
under war conditions this is very often impractical. Im- 
provements are urgently desired in this matter. A rough 
diagnosis of diphtheritic myocarditis may be arrived at in 
many cases, it is true, from pallor, cyanosis, disposition 
to collapse, vomiting, enlargement of the liver, enlargement 
of the area of cardiac-dullness, shifting of the cardiac 
apex beat to the left. 
Again speaking of evaluating the electrocardiogram of 
diphtheria patients, early disorders of auricular functions, 
enlargement of the auricular appendages, P-wave turning 
negative, change of the original place of stimulation, 
even auricular fibrillation have been observed. Early dis- 
orders are always myocarditic, the later ones, in my opinion, 
are often caused by a vegetative disorder of regulation. 
During states of exhaustion of aviators, I very often ob- 
served the change of the original seat of stimulation in the 
auricle, though there was no reason to suspect a myocardial 
injury. In many cases, deficient sensitivity of the vagus, 
allergy of the sympathicus are the causes and not a myo- 
cardial defect. Prolongation of the conduction time between 
auricle and ventricle is frequent and often temporary. If 
it persists, the EKG must be kept under control, and the 
patient requires careful treatment, chiefly bed-rest. If 
these disorders do not disappear in the course of several 
weeks, though the time of transition becomes normal through 
physical strain, the remaining myocardial defect is slight, 
the patient fit for garrison duty at home, in light cases 
even for general service. If the disorder of conduction 
in its early stage leads to a complete a-v block, the pro- 
gnosis frequently is fatal, with the mortality of these 
cases exceeding 90 per cent. Femoral block and incomplete 
bilateral femoral block (arborization block) have a mortality 200 
rate of 50 to 60 per cent* High doses of atropine with 
small doses of strophantin proved most efficacious in 
those cases. W-block and M-block will occur, also a change 
of the block from a left block to a right block and vice 
versa, which might be explained by a change of the inter- 
stitial edemas. Absolute (permanent) slight deflections 
of the EKG are bad prognostically, they are considered pre- 
mortal. Even slight variations in the QRS-complex. light 
forms of interventricular block are frequent. In these 
cases, it will be sufficient to keep the patient under ob- 
servation, and to ascertain bv means of continual EKG- 
control that either the deflection disappears or remains 
constant and thus'*isno longer a symptom of an active myo- 
carditis. On the whole, with a diphtheritic heart, the 
most important fundamental thing is the continual observ- 
ation! with the EKG. Only when the EKG is absolutely con- 
stant, may the patient be discharged from the hospital; 
as long as it is still changing, there is an active myo- 
carditic process and the patient is to be confined to bed. 
It is not necessary to treat these cases with strophantin, 
provided there exists no dilatation of the heart. Remain- 
ing slight deflections in the QRS-complex should be judged 
as cicatricial changes; their overestimation is warned 
against. The majority of the cases with alight formation 
of deflections in the rising side of R or in the S-de- 
flection are fit for general service again six months 
later, as the myocardium has completely recovered by that 
time, and the remaining slight scar is but an irrelevant 
defect. These cases will often pass their whole lives 
under the diagnosis of myocardial defect and may be some- 
times treated with strophantin, which is absolutely use- 
less. Besides these disorders of conduction or defects of 
the stimulation system, there is a second groups the 
change of the ST-wave and the final variation. Curves, with 
right or left auricular preponderance are remarkably fre- 
quent and usually disappear. Coronary forms of the EKG 
with arched ST-deflections and negativity of the final 
waves occur. They are prognostically more favorable than 
disturbances of conduction. It cannot always be decided 
whether they are toxic diminutions of stimuli in the inner 
ventricular wall or genuine coronary defects. Complaints 
of angina pectoris do occur sometimes. Typical pictures 
similar to the case of coronary infarct occur and may cor- 
respond anatomically to wider foci of necrosis within the 
myocardium. Slight upward and downward deflections of the 
ST-wave are observed rather often; if they are not more than 
one millimeter, they are irrelevant, even if they are 
permanent. For the coronary forms of diphtheritic defects 
of the heart, strophantin-therapy is the treatment of choice. 
The extrasysroles are of less importance. Ventricular 
extrasystoles of different origins indicate a form of myo- 
carditis prognostically favorable in most cases. In the 
late stage, the exercise EKG may often reveal a latent 
myocardial defect caused by this form of extrasystole. 
Also elongation of the QT-wave may Indicate a myocardial 
defect. To conclude, in the late stage, measurement of the 
QRS-complex with a lead from the chest-wall and a fast-re- 
volving cylinder is important at times, such as SCHELLONG and SCHWINGEL undertook. In a test at random of 22 cases 
of predominantly toxic diphtheria in the seventh week, I 
discovered five times a positive shortening of the QHS, 
interval within the normal range of variation; in 14 cases 
the change was less than two sigma; in three cases, a 
pathological elongation could be proven. Among the same 
patients, five still had a remaining myocardial defect; 
four had slight changes of the EKG, which could be con- 
sidered only as irrelevant defeats. In the exercise-EKG 
four cases failed, and one must take care not to consider 
a decrease of the final variation after exercise in leads 
I and II as a pathological reaction. On the other hand 
I should consider a perceptible downward deflection of the 
ST-wave in lead II after exercise, as well as the appearance 
of frequent extrasystoles to be important. All the same, 
the fact must be pointed out that T in leads I and. II will 
often remain flat for a considerable time and rise to its 
normal height only weeks and months later. These flat T- 
forms after diphtheria indicate therefore a heart that has 
not yet recovered its complete efficiency. It is very 
difficult to evaluate the labile circulation of the toxic 
diphtheria case after rising from bed, i.e. in about the 
sixth or seventh week. In SCHELLONG’s test of regulation, 
only two of 22 cases showed a hypotonic reaction with dis- 
position to collapse, 11 cases reacted normally. 9 cases 
showed a disposition to hypertonic reaction. Altogether 
these cases with pcstdiphtheritic disposition of the circu- 
lation are "basedowified" (basedoid)? but they have no in- 
creased basal metabolism. Such patients with their permanent 
disposition to acceleration of the pulse should, not be kept 
in an hospital longer than eight weeks. They are not fit 
for duty in any arm of the service as yet it is true, but 
they are inclined to psychic superlmpcsitlons and must be 
occupied, careful training being the best way* As a rule, 
they must be Judged as fit for garrison duty at home for 
another 2 to 3 months. 
I should like to add some remark on the size of the 
heart. Large numbers of young men have an extraordinarily 
large heart today, and the frequent statement of diphtheria 
in the anamnesis might induce one to consider diphtheria 
as the cause. This is certainly not the case, hut it must 
be considered that athletic training has considerably in- 
creased nowadays, that many people ride their bicycles to 
the places where they work, that many have to work hard 
in armament factories, and thus I am of the opinion, that 
all those large hearts have been occasioned by sports and 
ork. The well-known tables of heart size, compiled by 
MORITZ and DIETLEN, probably would not prove correct today, 
the measurements of today probably being higher* Of course, 
exceptions are hearts which become large and flabby during 
diphtheria, which are recognized as flabby, changeable hearts 
even in the roentenogram and kymogram and which, in the 
course of some weeks, will be reduced to their normal size. 
This ability of diphtheritic defective hearts to reduce to 
the norm must be emphasized again. In contrast with articu- 
lar rheumatism, the diphtheritic heart in its acute stage 
may possibly be in serious danger, sudden death by heart failure through toxic myocardiac paralysis may occur, 
whereas the heart of a patient afflicted with rheumatism 
is not imperiled at all during the first few weeks* But 
if diphtheritic myocarditis is not fatal, it will practic- 
ally always be completely healed, and persistend defects 
are very rare. Quite in contrast; with this, a patient 
afflicted with rheumatism is threatened by development of 
late cardiac complications, in particular by defects of the 
cardiac valves which never occurs in the case of diphtheria. 
In conclusion of my report, which need not consider 
paralyses, as they were dealt with before, I should like 
to point out that also for the (typographical 
scramble in German text) the safest remedy for 
preventing irregularities of the circulation is adequate 
serum-treatment, particularly in toxic cases* But if we 
add the cases with irregularities of the circulation, I 
mention for instance the cases of the reserve-hospital 
at fcoeln-Hohenlind (ward-surgeon, Dozent Dr* SCHAEFER), 
a number of whose cases I am familiar with, and who kindly 
placed the reports at my disposal. Of 279 cases of last 
year only 48, i.e. 5.8 per cent, were dismissed as tempor- 
arily fit for garrison duty at home* Mortality amounted 
to 12 cases, that is 4*3 per cent. 219 cases, that is about 
90 per cent, could be sent back to their units as fit for 
active service. 
Directions concerning consequences of diphtheria: 
treatment, decision on fitness for military 
service, possibilities of service later. 
1* For clinical purposes, a differentiation should, 
be aimed at between 
a. local diphtheria (pharyngeal, nasal, laryngeal, 
wound-diphtheria), 
b. progressive diphtheria (without croup, with 
croup, and bronchial diphtheria), 
c* toxic diphtheria, marked by edema of the 
mucous membrane and the outside of the neck and 
serious effect on the general state of health. 
Serious toxic diphtheria may cause death within 
a few" day's and cannot be influenced therapeutically 
(hypertoxic form). The statistics show that the toxic 
forms2 in particular, lead to serious involvement of 
the circulatory and nervous system. 
2* Diphtheria passed without complications will heal 
without leaving behind’”any bad con so quinces*. After 4 
to 6 weeks of mild course and early administration of 
serum, complete fitness for active service can be ex- 
pected • 3* The late diphtheritic sequelae of importance for 
evaluation are myocarditis and polyneuritis* Both are 
frequent complications of moderate and serious diph- 
theria, but may also occur with the mild forms, es- 
pecially if they are not adequately treated* 
4* The most efficient protection against diphtheritic 
sequelae is early diagnosis, and if the clinical find- 
ings are clear, immediate serum-treatment, Thick must 
be repeated two days later, if considerable membrane 
is still observed then* For mild and moderate forms 
doses of 6 to 12000 units are indicated# For serious 
cases up to a total of 20 000 units (more only in 
exceptional cases) are recommended* 
5* The defects of circulation are: 
a. early collapse of toxic diphtheria in the 
first two weeks, 
b. myocardial defects in their various, mostly 
rapidly changing forms of appearance, such as pro- 
gnostically favorable tachycardias and extra- 
systoles, changes of late waves and coronary 
disorders, delays of conduction and blocks which 
are most serious disorders. Total a-v block is 
considered to be highly unfavorable, 
c. late irregularity of the circulation with 
disposition to collapse, tacEycardlas, hypertonic 
reactions• 
6. For a favorable progress of myocarditis, strictest 
bed-rest is of fundamental importance until the acute 
inflammation has subsided, or better, until the electro- 
cardiogram has returned to normal, since myocarditis 
may take completely latent clinical course, electro- 
cardiographic examination, if available, should be made 
before the patients are permitted out of bed. Under 
field conditions, this ideal is not practical. In 
case of severe myocarditis, bleeding of the nose, 
vomiting, periglandular, edemas, apathy or deliria, 
swelling of the liver, cyanosis or striking pallor, 
enlargement of the heart, arrhythmias, and lowering 
of the blood pressure indicate irregularity of the 
circulation. As long as changes of the EKG occur 
which must be repeatedly observed the process must be 
considered as active. Upon symptoms of decompensation, 
intravenous injections of strophantin once or twice a 
day. i milligram each time are indicated* If necessary, 
medicines against collapse in appropriate doses are 
recommended. 
The proper treatment of postdIphtheritic _ir ar- 
ities of the circulation during the later weeks of 
convalescence is a carefully supervised treatment by 
exercise (no heart remedies). ?• The restoration of fitness for militarjr service 
requires, besides clinical healing, the disappearance 
of EKG-changes. Patients having suffered a myocarditis 
should be judged cautiously but not anxiously* Small 
irregularities in the EKG must not be thought too im- 
portant if they are constantly present^ 
Myocarditis, if not fatal in its acute stage, 
should be judged absolutely favorable in its later 
prognosis; permanent persisting disorders are rare. 
The period necessary for complete healing of myocarditis 
varies between several weeks and 3 to 6 months, some- 
times even more. To attain complete fitness for active 
service when the EKG-changes have subsided, as a rule, 
takes about the same time that the myocarditis lasted. 
During this time, the decision fit for garrison duty 
at home and fit for labor duties (for a certain period}, 
according to the severity of the case, may be considered 
Regular expert examination by EKG are necessary. As 
soon as the condition has become stationary, the patierr. 
may be discharged from the hospital* Spa treatment 
after that is seldom Indicated; it is strictly contra- 
indicated in cases of active myocarditis* 
8* The following nerve defects are to be observed; 
a. early paralyses in the 2nd or 3rd week 
(soft palate, oculomotorius (accomodation), 
b. late paralyses from the 5th to the 9th week 
(pharyngeal muscles peripheral motor paralyses, 
ascending Landry forms)* 
9* If the danger of paralysis of the respiratory 
muscles has subsided, postdiphtheritic paralyses are 
prognostically favorable even if they last a long timed 
In the case of deglutition paralyses, there is danger 
of aspiration pneumonia. There are only slight thera- 
peutic possibilities to accelerate the disappearance 
of the paralyses. Strychnine (3 milligrams a day 
subcutaneously) may be tried; the administration of 
vitamin B (B^9 B2) is controversial. In cases with a 
poor tendency to heal (vaccino-malaria) fever therapy 
may be applied but only in specially selected hospitals 
and by surgeons who are experts in this field (control 
of the circulation!). If the patient has satisfactory 
conditions at home, the treatment at the hospital may 
be finished as soon as the patient has recovered suf- 
ficient mobility. The patient should be discharged 
as fit for labor duties with re-examination 6 months 
afterwards proceeding as in a case of "permanently 
unfit for military service". Only when the paralyses 
have disappeared, healing treatment with gymnastics 
and systematic training as a transition to garrison 
duty at home and later on general military service, is 
to be recommended. 10. Pay attention to the following further sequelae 
of diphtherias 
a. nephrosis 2nd to 5th ¥/eek, 
b. diphtheria recurrence 3rd to 7th week, only 
in cases not treated with serum, 
c. associated involvement of the accessory 
sinuses and formation of abscesses (retrotonsillar 
abscess, mixed infections by streptococci). 
11. When diphtheria is healed? no conseouences of 
bodily injury sustained on active service will exist, 
as a rule. 
By order of the army medical inspector, a conference 
on hepatitis epidemiea was held during the meeting, from 
which the following report" by hOhMEN and" the TnformatIona 1 
pamphlet oh HepatTtis7 which resulted from the discussion, 
are published. 
Concerning the etiology of hepatitis epidemics. 
Stabsarzt (Captain, MC.) Dozent DOHMEN 
Starting from the consideration that, in case of 
hepatitis epidemica, the process of disease must take place 
within the liver and that if this process is caused by an 
agent, the latter must be accumulated there, we took small 
particles of the liver from a living man by a hepatic 
puncture made by Dr. VOEGT. We inoculated these particles 
on various species of animals and on chicken embryos. In 
the course of these examinations, it was found that white 
mice fell ill upon application of human hepatic material 
and showed, besides pulmonary changes, consistent changes 
of the liver. Among 16 hepatic punctures we thus attained 
positive results - which will be described later - in 13 
animal tests, and have kept 7 strains for a long time, one 
of them up to the present day, that is nearly for a year. 
On an average, the passages amount to from 12 to 32, with the 
oldest strain the 37th animal passage .has been attained. 
The observations described in the following are based on 
the results and observations gathered after the inoculation 
of 1900 white mice. After inoculation of the starting 
material gained by hepatic puncture, the animals were first 
afflicted with changes of the lungs, liver and spleen after 
an average incubation period of 14 to 21 days# The pulmonary 
changes, which were at first thought to be bronchopneumonia, 
consist of brownish-red changes of the size varying from 
dots to pin heads, partly even to lobes and which, patholo- 
gico-anatomically, turned out to be hemorrhages. A constant enlargement of the liver and the spleen was found, e.g. 
the spleen may swell to 8 times its normal size. In the 
area of the liver, there are often observed, besides an 
enlargement of the organ, multiple whitish foci discernible 
under the capsule. No icterus can be observed in the 
animal. Besides those in the lungs, hemorrhages were at 
times observed in other places, too. We think ourselves 
justified to consider these hemorrhages as a result of 
hemorrhagic diatheses. Under the microscope, the hepatic 
changes appear mainly as changes of the minor vessels, 
which extended to their maximum, are often filled with an 
albuminous, amorphous substance, in the lumen of which 
numerous desquamated' endothelia cells are to be seen. 
KupferTs star-shaped cells of the liver have distinctly 
multiplied. The hepatic epithelium has also changed. Be- 
sides approximately normal cells, there are others with 
considerable changes of the cytoplasm and of the nucleus. 
The nuclei may be stained with difficulty, they are pyknotic 
and dissolved into single grains, the cytoplasm is clarified 
particularly at the rim of the cell, and hydropic to an ex- 
tent that it often remains discernible only in little cloud.- 
around the nucleus. This enlargement of single cells or 
hepatic cells enlarged in groups will result in a more or 
less intense dissociation of the hepatic cells. and in a 
destruction of the streaky structure of the liver cells. 
These changes have been described by Stabsarzt (Captain, 
MC.) Dr. VOEGT as primary capillaritis with secondary 
hepatosis after hepatic punctures on patients* In those 
livers in which whitish dotted changes can be ascertained 
macroscopically, one observes, histologically, in addition 
to that, the pictures of multiple hepatic necroses, as we 
know them from acute yellow hepatic atrophy. The time of 
incubation, beginning with 2 to 3 weeks, was reduced to 3 
to 6 days in the following passages through animals. After 
the expiration of this time, the animals show brief symptoms 
of disease, and almost all of them die. By macerating the 
lungs and liver, one succeeds in producing the same clinical 
and anatomical changes in some passages. The animals will 
fall ill after the administration by subcutaneous, intra- 
pulmonary, intracerebral, and intraperitoneal injections. 
The same changes can be continued by means of filtrates 
disinfected by passing through unglazed procelain candle 
or Leiz filters. In this case EERKEFELD filters N are 
still easily passed. Among the first two strains isolated 
in June 1942, the human starting material was not only in- 
oculated in the animals but also on embryo chicken-eggs. 
After that one only observed an increased vascular injection 
in the region of the allantois, but otherwise no cloudiness 
whatever. Contrary to the inoculation of duodenal juice 
of hepatitic patients carried out by SIEDE and LUTZ at 
BUERGER’s hospital in Leipzig, the embryo does not die 
after the inoculation. After the 4th passage on chickens, 
the animal tests were resumed once; here also the animals 
fell ill and died, showing pathologico-anatomically the 
same macroscopic and microscopic organic changes as the 
animals on which the starting material had been inoculated 
directly. Meanwhile, one more inoculation from the 8th 
passage through animals was made on the chicken embryo, 
inoculated again on the animal after the first passage, and had been carried on in six animal passages so far. Here 
also the same changes as in all other animals could be 
observed. After these experiments, the material was gup# 
posed to be a filtrable~Virus« Then, hn experiment was 
made to determine the identity of the virus by means of 
the neutralization test. The starting material were 
organ sample of typically diseased animals, which were 
mixed with the serum bf men who had already recovered 
from hepatitis and were left, together with the serum, 
in the incubator for some two hours. In another experi- 
ment, the serum of soldiers of the Eastern Front was used. 
Demonstration of curves. Thus it is shown that the serum 
of men recovering from hepatitis contains against 
the infectious animal material, but that the normal serum 
of the soldiers of the Eastern Front is not free from them, 
either. The reason for this phenomenon might be a passive 
immunity of the soldiers of the Eastern Front; For further 
clarification of the matter, tests are being made with 
the serum of children, who certain!}?" have not had hepatites, 
but no useful result is available as yet. These neutral- 
ization tests were made on 252 animals# All of them took 
the same course and showed that through the human serum a 
neutralization of the virus material rakes place so that it 
is in a position to reduce the mortality in the animal 
test quite considerably. That a living agent is involved 
in these tests is shown by the fact that one succeeds in pro- 
ducing, in the passages again and again the same changes 
leading to pictures of acute yellow hepatic atrophy, 
filtering the infectious agent through unglazed porcelain 
candle filters, in cultivating it within the chicken embryo, 
and in producing the same changes as described above in 
tests of replanting the agent in the animal. As further 
examinations showed, the living agent has a distinct thermo- 
lability. It will become ineffective at incubator-temper- 
atures for 3 to 4 hours, while according to our observations 
made so far, it will rerain its effectiveness for more than 
a fortnight in a frozen state. 
It seems improbable that the virus just described is 
the same as the already known broncho-pneumonic virus cf 
the mouse, as described by GOENNERT and as the strains ”1 bft 
and MGreifswaldM as described by HERZBERG and GROSS, since 
GOENNERT did not discover any morbid changes in the region 
of the liver and besideb, both the virus described by 
GOENNERT and the two strains desbribed by HERZBERG and 
GROSS may be transferred, according to a personal communi- 
cation from HERZBERG, only by intrapulmonal application, 
but not, like ours, by subcutaneous, intraperitonoal, or 
intracerebral inoculation. Whether the virus is in some 
w?ay responsible for the death of chicken embryos by in- 
oculation of duodenal juice on the chicken allantois as 
observed by SIEDE and LUTZ, cannot be definitely decided, 
as no animal passages have been mentioned by these authors. 
It seems improbable anyhow', since, according to the treatises 
of the authors mentioned, the embryos die after application 
of the test material, w'hereas the lives of our ambrjros are 
preserved. The experiments of transferring the virus on 
canaries, as reported by BUERGER during the last meeting 
of the Berlin Medical Society, cannot be evaluated as yet 
either. In summary it can be said: By inoculation of human 
liver, which was obtained by puncture of hepatitis patients, 
it was possible to produce changes 13 times in 16 animal 
tests, by the consequences of which nearly every animal 
died. In these cases, histological changes could be as- 
certained which showed clinical pictures up to acute 
yellow hepatic atrophy. If the material is inoculated 
on the animal, a period of incubation will pass before 
the disease becomes manifest. As it could be managed to 
continue the material up to the 37th passage so far, a 
living agent must be involved. It can be transferred to 
the chicken embryo, and, starting from this material, the 
same changes can be produced again in the animal. On the 
other hand, also after direct inoculation of the hepatic 
material of hepatitis patients on the chicken embryo and 
subsequent transference in the animal, the same changes may 
be produced in the animal test as if the animal is directly 
inoculated, £he transferred material is filtrable and 
thermolabile. All these facts suggest a living agent of 
virus nature. It is not identical with the well-known viruses 
of mice. Since the hepatic material of hepatitis patients 
was used as a starting material and animals in all passages 
were afflicted with hepatic changes, it may be supposed 
that the virus in question might be the agent of the human 
hepatitis epidemica. Even if a series of decisive observ- 
ations have already been made, absolutely conclusive proof 
is still lacking. It is to be hoped that the tests still 
going on or begun will bring a definitive settlement '~f 
these problems. 
Instructional pamphlet: 
Epidemic jaundice, 
(Hepatitis contagiosa sive epidemica), 
1, Hepatitis epidemica is an infectious 
appearing in large and small epidemics, but also in indi- 
vidual cases. The frequency of the disease is dependent 
on the Reason. They usually begin in July, reach their 
climax in October/November, and subside from January to 
March, It is a controversial point up to the present 
day whether hepatitis epidemica is identical with the 
sporadically occurring so-called "icterus catarrhalis" 
or simplex. In the majority of cases, it does not differ 
in its clinical picture from the so-called icterus catarrh- 
all s* 
2, Agent. The agent of hepatitis epidemica is 
still unknown. It is probably a virus. All agents known 
to us as yet have no etiological importance. The contagious- 
ness of hepatitis epidemica is proved and is evidently very 
great. 3* Route of infection* Infection will occur both 
at the beginning of the acute icteric stage of illness 
and - predominantly - in the prelcteric stage. Besides 
an infection by little*'drops and smearing, infection may 
also occur through food and water, through inanimate ob- 
jects, and healthy carriers of bacteria* Children and 
youths are afflicted particularly easily* External cir- 
cumstances (previous infections, hardships, hunger) may 
favor the outbreak of the disease by reducing the power 
of resistances 
4# Immunity, Having got over a hepatitis epidemics 
seems to confer immunity for life or at least for many 
years# A second affliction occurs only quite rarely. 
5• Period of incubation. The period of incubation 
is 3 to 5 weeks, but may also be longer or shorter# 
6. Clinical picture, 
a• Forms of the disease. 
In a number of cases, acute febrile onset with head- 
aches, anorexia, dyspeptic troubles or 1 involvement 
of the upper respiratory passages are observed# Occasionally 
an initial shaking chill with most serious faint feeling 
and aches in the region of the liver is observed# In a 
number of cases with violent prodromes accompanied by fever, 
the initial stage is followed by an interval free from 
fever with comparative well-being, Which is Tollowed by the 
third (icteric) stage, occasionally with brief increase of 
intestinal symptoms, but usually with disappearance of 
all subjective manifestations. 
In other cases, initial non-characteristic symptoms 
without fever are to be observed instead of those violent 
onsets# These patients will often complain of lack of 
appetite, sense of fullness, sometimes abdominal pains, 
and a more or less pronounced exhaustion# At times, the 
icterus is preceded by a short or long period of diarrhea. 
In other cases again, the icteric stage does not appear. 
Thus, the disease, for which the symptoms of the' first 
stage have become most important now, will often not be 
recognized and will be diagnosed as influenza or intestinal 
trouble# 
The icterus may also occur without any prodromes what- 
ever, so that it is sometimes not the patient, but his 
companions that first notice the disease. 
b• Particular results of examination. 
Icterus. which can be ascertained first in the sclerae, 
will grow more intense within the first few7 days, is colored 
at first canary, then dirty-yellow to yellowish-red, and 
assumes a greenish tinge only w/hen it takes a severe and 
protracted course# At first, the liver is always enlarged 
and often is also sensitive to pressure. In the majority 
of the cases, a swollen spleen is also to be found. In the 
urine, urobilin, urobilinogen, sometimes acetone, and, in the cases afflicted with severe icterus, always bilirubin 
are to be found. In other cases again albuminuria of 
slight degree, occasionally with some erythrocytes, leuko- 
cytes and cylinders, is to be observed in the sediment. 
In the icteric stage, the blood picture shows normal or 
subnormal numbers of leukocytes; there is often a shift 
to the left of the granulocytes with a relative increase 
of lymphocytes and monocytes and high normal values of the 
eosinophiles, often rising, during the further course of 
the disease, to a marked eosinophilia. In the beginning^the 
sedimentation rate is usually slightly accelerated and will 
’continue to increase until the third week* The sedimentation 
of the blood corpuscles does not exclude hepatitis contagiosa. 
7# Course of the disease . The disease will take a 
different course in different places, both as regards the 
clinical picture and the severity of the symptoms. Mild 
cases will be cured even within one or two weeks; moderate 
cases will take 4 to 6 weeks before they are healed* On the 
other hand, severe cases may continue in the icteric stage 
for months* In quite isolated cases, transitions to acute 
or subacute yellow hepatic atrophy or to hepatic cirrhosis 
were observed. Recurrences after icterus had already sub- 
sided will occur more frequently. Too early chilling, 
dietetic and physical strain will cause recurrences, but 
even bed-rest and special diet cannot always prevent them. 
They often delay and complicate the disease considerably. 
Besides typical icteric forms, also anicteric forms of course 
occur, as mentioned above, which are usually treated ambula- 
tcrSfer without proper diagnosis as ’’grippal infection” or 
’’gastro-intestinal catarrh”. Convalescence is often character- 
ized by a remarkable weakening of resistance to other in- 
fections* 
8. Differential diagnosis. Discrimination from Well’s 
disease isreasy (anamnesis, usually by the acute beginnings 
with a shaking chill and high fever,^aches^in the calves, 
albuminuria and hematuria, often serious disorders of the 
renal functions, even uremia, high acceleration of sediment- 
ation rate, leukocytosis, liability to collapse, weakness 
of the Mud fever seldom shows an icterus, but 
nearly always exanthemata, while hepatitis epidemica is 
accompanied by exanthemata only rarely and then usually as 
urticaria with itching. The possibility of pseudo-icterus 
after intense atabrine-treatment, in which the sclerae 
get no yellow coloring, and of an icterus as attendant 
symptoms of severe infectious diseases (malaria, black- 
water fever, pneumonia, paratyphoid, sepsis, etc.) limst be 
considered. 
9. Pathologico-anatomical findings« in pathologico- 
anatomical respects, there appears an inflammation of the 
mesenchymal part of the liver - capillaritis - with evident 
secondary hepatosis. No serious inflammation occurs in 
the icteric stage. In the cross-striped skeletal muscles, 
miliary necroses are to be found. 10* Treatment* In order to prevent serious sequelae 
and to restore the patients to health more quickly, it is 
necessary to give- them a thorough treatment, 
a. General and medininal treatment. Till the 
icterus subsides, strict bed-rest must be mainained. usually 
for 3 to 4 weeks, with consideration of the sedimentation 
rate, increase of weight, and disappearance of swellings 
of liver and sploen. In case of disorders of gastric-juice 
secretion, prescribing hydrochloric acid and. pepsin must not 
be omitted. Analgetics, narfcotics, and sleeping drugs (par- 
ticularly barbituric acids) should be administered, but only 
in small doses or better not at all, because of their hepatm 
tropic effect. Medicaments to stimulate choleresis and dis- 
infection of the bile are unnecessary, the tea mentioned 
below excepted. 
Not only in the beginning, but for the whole duration 
of the treatment, particular attention must be paid to the 
activity of the jntestines, since the liver may be affected 
"By processes of f ermentation and putrefaction, with toxin- 
resorptjon,abused by atony and insufficient exercise. In 
the beginning, pirgatives (2 to 3 tablespoons castor oil 
or 1 to 2 tablets of castor rhei or twice an hour 0.3 calomel 
with addition of podophyllin, e.g. in form of cholagognes) 
are suitable, even if diarrheas exist. If constipation 
occurs in the further course of the disease, Karlsbad-salt 
and bitter water will prove efficacious. Adrenal cortical 
extracts have a beneficial influence on the intestines by 
their tonic effect by retarding the resorption of toxins, 
but theT may be dispensed with in most cases. 
If the icterus is persistent, duodenal rinsing with 
300 cubic centimeters 10 per cent solution of magnesium- 
sulphate has a beneficial effect. Moderate and continuous 
application of heat (electric pad, Priessnitz bandage, 
thermophore, cataplasms etc.) is not only felt as agreeable, 
but evidently has, like short-wave diathermy, when care- 
fully applied, a beneficial influence by improving the 
blood-supply of the liver. Liability to hemorrhage, which 
often exists in the case of an intense icterus, may be 
successfully opposed by injections and peroral administration 
of vitamin K. Particularly in the case of protracted ill- 
ness, vitamins C and B should be parenterally (resorption!) 
administered. As for brief icterus, additional administering 
of insulin to grape-sugar therapy is unnecessary, I dare say. 
By biopsy of the liver, we know that the liver is not 
deficient in glycogen in the acute stage of 
icterus. Irritating itching of the skin may be alleviated 
b37‘ embrocations of vinegar-water or menthol, possibly also 
Of mitigal. Semibaths of 35° to 40° Celsius, too, have a 
beneficial effect. 
In cholecystography, caution is recommended*for some 
time after the parachymarous icterus is overcome, while it 
must not be made during or shortly after the disease (up- 
to 2 months). In times of accumulated occurrences of hepatitis epi- 
demica, powerful hepatntropic medicaments (such as Salvarsan, 
mercury, phosphorus, etc.) must always be administered with 
caution. 
b. Dietetic treatment. After a few initial 
days of hunger - uncooked food - (apple-diet) or juice- 
diet, the patients receive chiefly soluble carbohydrates 
(gruel, porridge, puddings), besides fruit and jam and 
gradually vegetables and potatoes which are easy to digest. 
If there exists no acholia nor hypercholia, fat may be 
given early in the form of butter in small quantities, or 
of egg yolk. Animal protein in the form of meat should be 
given with caution, it should be added to the diet only if 
the icterus has distinctly decreased and the whole clinical 
picture has generally improved. For this reason, protein 
should be given but in a form that is easy to digest, pre- 
ferably as milk and curds. Cabbage, legumes, inferior fats 
and fresh bread will prove Indigestible for a long time. 
Slices of stale bread, cole toast will often render super- 
fluous the prescription of white bread. A sufficient supply 
of liquids in the form of fruit-juices, hot lemon-juice, 
caraway, peppermint, and camomille-tea must be provided. 
All forms of alcohol must be strictly prohibited for a long 
time. If the initial diet is rich in carbohydrates, the 
supply of grape sugar may be dispensed with. It should be 
provided only in serious cases. Also continuous intravenous 
drip-infusions (10 per cent) and injections (30 per cent) 
of grape-sugar solution may be administered. In very 
serious cases resistent to therapy, drop-enemas with a 
duodenal catheter, placed in the stomach or duodenum, which 
is introduced preferably through the nose, with 4 to 6 
liters of 5 to 8 per cent grape sugar solution with an 
addition 5f 1 per cent sodium chloride have had a most 
beneficial effect. They are made several days in succession. 
c. Use of medicinal springs. Spa treatments 
at Karlsbad, Mergentheim, etc. are indicated only with 
diseases which have become chronic and leading to permanent 
injuries to the liver, and then only for a limited time 
(4 weeks). In all other cases they are unnecessary. 
11. Isolation and measures of organization. Since 
infection occurs chiefly in the pre*icteipTc~stage- and the 
latter is diagnosed only in exceptional cases, isolation 
will be too late in most cases. For this reason, it has 
proven unnecessary. The vast numbers of patients suffer- 
ing from jaundice at the same season makes it advisable 
for mere reasons of simplification, to unite the hepatitis 
patients in particular hospital ward's,' rooms,' etc." and 
later on in hospitals' for convalescents. Hospitals for 
convalescents have, above all, the purpose of receiving 
men with mild diseases and thus to keep them near the front. 
Besides long transport, particularly under unfavorable 
climatic conditions, are harmful to hepatitis patients and 
result in long unfitness for military service. 12• Making of reports, In the sick reports of the 
units (Army Manual 21, part II, form 2) and in the sick 
reports of the hospitals (Army Manual 21, part II, form 4) 
every case of hepatitis is to be entered in disease group 
I under number 12. During periods of accumulated occurrence 
jaundice is to be considered as hepatitis epidemica, if it 
cannot be clearly traced to other causes, such as stone ob- 
struction, hemolytic icterus etc. 
13• Evaluation by the Army Surgeon. Every icterus 
is to be considered as a more or less serious parenchymal 
injury of the liver, therefore, it must be thoroughly treated 
at a hospital. The vast majority of the cases (about 90 
per cent), however, will lead to restitutio ad integrum 
comparatively soon* But icterus is only a symptom, after 
the disappearance of which the hepatic injury nay continue 
to exist. In case of premature physical and dietetic strain, 
remaining injuries may lead to chronic injuries of the liver. 
For this reason, swellings of the liver and of the spleen 
urobilinuria, acceleration of the blood sedimentation rate, 
also ability to tolerate the normal diet and physical strain 
ought to have disappeared, before military duty is resumed. 
But isolated enlargement of the liver, urobilinuria, slight 
acceleration of the sedimentation rate as well as slight 
increase of the values of serum-bilirubin and positive 
Takata-Ara reaction, which may often be ascertained long 
after icterus has disappeared, must not lead to a hospital 
treatment protracted for weeks and months, yet such patients 
ought to remain under medical observation (at homes for con- 
valescents or in the field sick bays). If the remaining 
consequences have become stationary and the general con- 
dition of health permits a discharge from the hospital, it 
should not be delayed, as increasing physical strain with 
light military duties (fit for garrison duty at home) may 
have a beneficial influence upon the restorative processes 
of the liver - the blood supply of the liver being improved - 
and an unnecessarily long stay at the hospital will not 
infrequently lead to additional hospital infections (weak- 
ness of resistance), which are again injurious to the liver. 
If there are doubts as to whether remaining disorders will 
heal completely, discharge as ,ffit for garrison duty at home" 
with re-examination at a hospital 3 months afterwards is 
recommended. The latter is advised particularly with re- 
curring diseases. Serious chronic hepatic injuries (hepatic 
cirrhoses) are to be judged as "unfit for military service”. 
Patients who have got over a serious hepatitis, but with 
some disorders still remaining, ought to be exempted from 
duty in regions with difficult food supply and particularly 
unfavorable climatic conditions (South-East and South). VIII. 
PROCEEDINGS OF THE CONSULTANTS1 
COMMITTEE ON PATHOLOGY 
Translation prepared by: 
Office of Military Government for Germany (U* S. ) 
Office of Naval Advisor 
Medical Section Injuries after treatment with sulfonamides. 
(See Section II, Articles 7 - 9) 
Inflammatory diseases of the central nervous system. 
Tbee Section XI, ArticTe 
Calling up for military service of men having 
injuries due to cold. 
(See Section II, Article 12) 
1* Legal status of soldiers having malignant tumors 
in view of the question of line of duty 
injuries. 
Oberstarzt (Colonel, MC.) Privy Councillor 
TFoTessdr 1ER5T 
Concerning the question to what extent body injuries 
received in service are connected with the manifestation 
of malignant tutors, the current theories concerning the 
formation of tumors were discussed critically* None of 
them are without the assumption of a particular predis- 
position* Besides, the directions elaborated until now 
concerning the relation of trauma with the formation of 
tumors - the question of the severitjr of the trauma, the 
local and temporal conditions and the so-called border- 
line cases - were criticized. The difficulties arising 
in the judgement of the time required for a malignant 
tumor to grow and to destroy life were discussed* We 
generally take a sceptical view as regards the significance 
of acute isolated traumas for the formation of malignant 
tumors* We admit that a trauma may further the predis- 
position to the formation of tumors existing in particular 
cases* Chronic irritations or injuries are more closely 
related to the formation of a malignant tumor, particular- 
ly to carcinomas. In this process, not only the duration 
and intensity of the irritation, but also the particular 
kind of irritant is important,. Pointing out the fateful 
character of ulcer one must not altogether ignore the in- 
fluence of material factors. But their significance is 
the less, the more certain predispositions are present. 
Besides, the question of the progress of an already exist- 
ing ulcer as a result of trauma or by a local or general 
disease was discussed. Also the question of the signif- 
icance of general preconditions for the formation and 
aggravation of malignant tumors was considered* The quest- 
ion of acknowledging how far body injuries received in 
service are due to delay of the necessary medical treat- 
ment of a tumor was discussed. Lastly, the connection of 
body injuries received in service and malignant tumors was 
illustrate* by examples of some frequent malignant tumors 
of certain organs • the brain* the bones, the lungs, the 
rectum, the skin, and the testicles. 
It was regretted that the decisions arrived at from 
the purely scientific point of view are often not under- 
stood by the people and are thought of as being inconsider- 
ate of the people. The opinion that all tumors which manifested themselves during the war must after all depend, 
eventually, on the various influences of military service, 
is met with the statement that there are no scientific 
foundations whatever for such a conception. In forming 
an opinion, we medical men must stick to these foundations. 
It is important, that above all the surgeon in charge is 
fully conscious of his responsibility and forms no rash, 
insufficiently founded diagnoses, raising hopes in the 
patient that will not be fulfilled and that will shake 
the people*s confidence in science and in the doctors. 
Discussion: 
GRUBER: Consultants opinions concerning the legal 
status of soldiers with body injuries received in service 
often led to the statement that malignant tumors were re- 
cognized in time, that, however, - instead of intervening 
during the stage of probable operability, the surgeon had 
the patient discharged from military service, go that* 
during the lengthy term of the procedure of discharge, the 
propitious period for intervention v?as missed. In my 
opinion, it must be a rule also for the military surgeon 
to find at once the means for treatment after diagnosing 
a tumor probably operable or which may be beneficially in- 
fluenced by some other method. 
I wish to corroborate the large numbers of carcinomas 
of the stomach arising from ulcers among the specimen sent 
in by renowned stomach operators (surgeons). As a matter of 
fact, the proportion of ulcers of the stomach to carcinoma 
arising from ulcers is the same now as thirty years ago. 
SIEGMUND* As far as I dan see, the question of acknow- 
ledging body injuries received in service in case of tumors 
takes a similar turn as that of lymphogranulomatosis, which 
was discussed during the last meeting. It seems absolutely 
necessary to me to discriminate between scientific opinion 
and that influenced by sodial policy. The pathologist must 
be guided by strictly scientific rules, according to Privy 
Councillor BORST’s instruction, which deserve complete ap- 
proval. Consideration of war conditions to a large extent 
should be subject to particular instructions and regulations. 
Within our field of work, trauma is related to a more rapid 
progress in cases of seminomas and melanoblastomas than else- 
where. Carcinomatous ulcers will be ascertained more easily 
and frequently in patients to be operated on than in corpses 
for autopsy. 
GRUBER: I wish to make a suggestion to the Medical 
Inspectorate: the Veterans’ Administration of the KSDAP 
can be a very beneficial organization, if its officers 
succeed in reconciling the washes of the veterans and their 
families with the biological facts. But it is regrettable 
and contradictory to the efforts of the public health author- 
ities to strengthen the people’s wall for health and effic- 
iency, if arguments of officers of the Veterans* Administration 
raise hopes and expectations in veterans op their families, 
which must be absolutely denied by an. expert surgeon. In complaints against such negative medical opinions it was 
pointed out that the people felt differently* The scien- 
tist asked to state his opinion must consider the questions 
as they are put to him, which are founded on the re- 
gulations of the particular laws. He must not accommodate 
non-professional feeling outside the limits of these re- 
gulations. If allowance is to be made for this feeling, 
the legal regulations for the possibilities of taking care 
of veterans must first be altered. 
RUEHE: Points out that forming an opinion on the 
question of body injuries received in service in cases of 
malignant tumors is unsatisfactory on the whole, as too 
little is known as yet of the original or aggravating re- 
lations of the influences of military service to the form- 
ation of malignant tumors. Therefore the practical needs 
must be considered in drawing up directives. Special con- 
ditions of militarv service, which may also lead to the 
ackowledgement of body injuries received in service, do 
not only exist, if a disease is ascertained or treated too 
late owing to war conditions, but also if a wrong diagnosis 
is formed or a wrong treatment is undertaken. So-called 
Popular opinion is often at variance medical opinion 
and so renders the surgeon’s task more difficult. Sven if 
this is humanly understandable, scientific medical knowledge 
cannot be changed for that purpose. 
In the evaluation of this discussion the following 
Instructions for the evaluation of the question of 
body injuries received in servic_e in_ cases of 
malignant tumor’s 
were drawn up. 
Experiences in the fihal evaluation necessitate the 
drawing up of general instructions for judging the question 
of bod}?- injuries received in service in cases of malignant 
tumors. These instructions are not meant to be a formula 
to be applied mechanically, but each single case must be 
judged individually, according to circumstances and expert 
findings# 
In the first place, the difficulties in the judgement 
of the question of body injuries received in service arise 
from the fact that the problem of tumors still involves 
many unsolved questions. Besides, sufficiently numerous 
instances, statistically confirmed, for the judgement of 
the question of the actual interdependence of the formation 
or decisive aggravation of an ulcerous disease and character- 
istic influences of military service on it are still lacking. 
Medical experience, particularly from the first World 
War, positively showed, that no increase of malignant tumors 
occurred through military service* In only a few^special 
cases was a genuine interdependence between body injuries 
received in service and the formation or aggravation of 
tumors assumed as probable. For this reason, in the judgement of the question of 
body injuries received in service in cases of malignant 
tumors, the same principles generally recognized by scien- 
tists apply as is the case in civil processes# Of course, 
in military cases, the law concerning financial and other 
aid provided for regular soldiers on their return to civil- 
ian life and the law concerning financial and other aid 
provided for discharged soldiers must be consulted# Those 
regulations differ in many respects from the legal bases 
for civilian judgement# They are sometimes worded less 
strictly# For Instance, the simple probability of an 
original connection for the question of the formation or 
aggravation of a tumor will do for acknowledging body in- 
juries received in military service# 
The question whether an earlier detection of the 
ulcerous disease was prevented by the special circumstances 
of military service, must be particularly examined in 
every individual case. 
On principle, the importance of so-called irritants 
blamed for the development or aggravation of tumors 
should be examined most carefully. Acute irritants, such 
as isolated traumas, are but rarely responsible for the 
formation of tumors# Chronic irritants of a certain kind 
which, experience shows, may cause a formation of tumor 
more frequently, are of but slight significance in the 
Army# 
As long as the regulations now valid are in force, 
It is the duty of medical men to judge the question of 
body injuries received in service only from the scientific 
point of view. 
2# Pathology of injuries caused by Salvarsan• 
Stabsarzt (Captain# MC.) PETERS 
Just as in the last World War and during^the post-war 
period, still today considerable numbers of disagreeable 
incidents in treating syphilis with Salvarsan occur. It 
is, above all, involvement of the central nervous system 
that occurs more frequently. 
Clinical symptomatology (headaches, giddiness, vomiting, 
numbness) indicates a general increase of pressure within 
the skull# The pathologist accordingly finds an increase 
of volume of the brain caused by an edema# Edema is the 
cardinal symptom of cerebral injuries caused "fey Salvarsan. 
In the cortex and medulla, there is a diffuse or focal 
loosening of the basic tissue due to edematous infiltration. 
A hypoxydosis caused by this will soon lead to injuries 
of the nerve-cells and the medullary sheaths# Hemorrhages, 
which were always thought particularly significant^in former 
reports, are of secondary importance as regards clinical symptomatology and fatal outcome. They occur, principally, 
in those parts of the medullary layer of the cerebral 
hemispheres and of the cerebral horns which are close to 
the ventricels, located symmetrically in the internal 
capsule, in the pons cerebelli and in both cerebellar 
p^dunc1es• This localization is to a certain extent char- 
acteristic of injuries caused by Salvarsan. Because of 
rne hypoxydosis caused bv the edema and Hemorrhages, com- 
plete and incomplete necroses will develop later on in 
the cortex and marrow, with corresponding reactive symptoms 
in the neuroglia and the glia. Independent of the cortical 
injury caused by the edema, isolated necroses limited to 
the vessles are observed, which may be related to cerebellar 
disorders of the circulation preceding epileptic fits. The 
edema and the hemorrhages depend on a change of permeability 
of the vessles. The increased permeability of the vascular 
walls may be the consequence of a effect of Salvarsan 
on the endothelium of the vascular walls. On the other hand, 
animal tests made by RICKER and KNAPE show that Salvarsan 
acts as an irritant on the vascular nerves# Thus, after 
use of Salvarsan, a narrowing and, finally an enlargement 
of the vessels with prestasis and stafeis will ensue# A 
resulting hypoxydosis may also cause functional disorders 
of the endothelium of the vascular walls in the form of 
an increased permeability of the membrane# 
Numerically, second place was held by injuries to 
the skin caused bv Salvarsan (dermatitis)# To the same 
extent, the hematopoietic system (agranulocytosis, aplastic 
anemia, panmyelophthisis) and the liver (acute and subacute 
hepatic atrophy) were affected. 
The changes in the central nervous system and in the 
skin are doubtless caused by Salvarsan* Injuries to the 
hematopoietic system and to the liver may be caused both 
by lues alone and by Salvarsan. 
The assumption of a toxic effect is sufficient for an 
explanation of the changes observed in the different organs. 
All the same, numerous clinical observations and also some 
available cases as well as the anatomical substratum of 
available cases do not exclude a possibility that the in- 
juries caused by Salvarsan may occasionally be due to an- 
tigen-antibody reaction, i.e. to an allergic process# 
As a cause of the frequent occurrences of injuries 
due to Salvarsan, the lack of surgeons sufficiently trained 
in this field, the changed diet, and accumulated occurrences 
of hepatic injuries (hepatitis infectiosa sine ictero) are 
mentioned. 
Discussion? 
LAUGHEi The question of the influence of climatic 
conditions was raised by BENECKE, because no further in- 
juries were observed in the South-East when the place of 
treatment was transferred from Athens to Belgrade. The 
curve of frequency can only be judged if the total number 
of the cases treated is known. As experience shows, the 
numbers of men with venereal diseases will decrease in 
winter, as a rule. STAEMMLER: In the region of Breslau, we observe^ 
both in the Army and among the civilian population, in- 
juries to the liver and to the hematopoietic system much 
more frequently than injuries to the brain. I should 
like to be informed whether in the different districts 
of consultants the injuries to the different organs are 
proportioned differently. 
OSTERTAG: The frequency of injuries caused by Sal- 
varsan in this war corresponds to the frequency after the 
first World War. The observations (Pathological Institu- 
tion of the Charit£) often mention high doses of Salvarsan, 
it is true, but these injuries caused by Salvarsan oc- 
curred in the period of accumulated hepatic injuries. 
According to my observations, the question of the frequen- 
cy of cerebral injuries must be answered in this way that 
the liver is always affected first and cerebral injuries 
occur only after the liver has failed. Among the injuries 
caused by Salvarsan 20 years ago, no involvement of the 
bone marrow and no agranulocytosis were known, but a re- 
examination of old preparations proves clearly that these 
also existed at that time. 
BOEHNE; No particular* * accumulation of fatal cases 
caused by Salvarsan occurred at the central sector of the 
Eastern Front. Technical mistakes in performing the in- 
jection were pointed out, such as intravenous injection 
of bismogenol with subsequent fat embolism and brain pur- 
pura. 
NEUHAUS; Within our Army sector on the Eastern Front, 
fatal cases caused by Salvarsan have been insignificant as 
yet. Amongst the fatal cases caused by Salvarsan, which 
I autopsied in peace time in the district of North-West 
Germany, hepatic changes predominant and were partic- 
ularly more distinct than cerebral changes. 
SIEGMUND: No discussion is necessary on the fact 
that the cerebral changes are a result of local disorders 
of blood supply, and take a course up to stasis by way of 
peristatic processes, with and without plasma- and erythro- 
diapedesis. To what extent it is the anoxia that causes 
the permeability of the vascular walls, cannot be safely 
said as yet either for Salvarsan or for other factors ef- 
fective etiologically in corresponding disorders of blood 
supply. The most urgent question is, why these disorders 
of the circulation occur above all in the brain and only 
occasionally in other places. In this connection, the re- 
marks of OSTERTAG are particularly interesting; the in- 
juries caused by Salvarsan are in the final aialysis con- 
sequences of (relative) overdoses with weakened resistance 
of the patient# 
KLINGE: It is pointed out that in the USA, during 
and after the World War, a temporary increase of fatal 
cases caused by Salvarsan was observed, but the increased 
effect, which was assumed could not be accounted for. NOREMaNN; The injuries caused by Salvarsan, which 
were observed when the drug was put to the test at Magde- 
burg, also occurred above all in the brain. At that time, 
large doses were given. 
KOCH: In three fatal cases of Salvarsan which were 
autopsied it has been determined that overdosage was no 
factor. The cerebral changes were more imnressive because 
of the seriousness of the serous inflammation which has led 
moie to actual local accumulations of plasma alongside the 
vessels than to hemorrhages. 
LAUCHE: Since injuries caused by Salvarsan have re- 
cently ceased almost altogether, I am of opinion that 
avoidable causes played some part in them. 
3* Concerning pathology of injuries caused by inoculations• 
Oberfeldarzt (Lt. Col.. MC.) Prof. KLINGE 
With the aid of several tables, the lecturer gave a 
survey of the observations in 24 cases, in which death oc- 
curred as a direct or indirect consequence of inoculation. 
The majority of these cases, 16, proved fatdl after nro- 
tective inoculation against typhoid. Among these 16 cases, 
5 were caused by coccal infection of evidently secondary 
nature. Two fatal cases after protective inoculation 
against typhoid were regarded as acute or protracted ana- 
phylactic shock, as has been occasionally observed before 
in the literature after intravenous and subcutaneous pro- 
tective inoculation against typhoid* (ZISKIND and SCHATTEF*- 
BERG). The finding of hepatic typhoid symptoms after in- 
oculation as reported by MEESEN still requires 
research, since it was but rarely observed in autopsies 
among the vast numbers of soldiers examined after inocu- 
lations* According to the lecturer, 5 more cases prove 
that men suffering from organic cardiac diseases, partic- 
ularly coronary stenosis, but also valvular defects, may 
succumb to a fatal attack of angina pectoris through the 
inoculation (1st to 3rd inoculation against typhoid), above 
all? if they have attained or passed the 4th decade of 
their lives. 
In 4 caces, disorders of the circulation were fornd, 
particularly hemorrhagic diatheses, twice affecting the 
intestinal tract, once the meninges. In a fourth case, 
hemorrhages in the brain after recent thrombosis in an 
encephalic angioma were observed. In accordance with the 
observations mentioned in the literature, these disorders of 
the circulation must be explained by the SANABELI-SCHWARTZ* 
MANN-phenomenon. No clear significance of the number and 
temporal succession of inoculations can be ascertained. In 
3 cases, the inoculation against typhoid was immediately 
followed by a thrombosis, twice in a coronary artery? once 
in a cerebral angioma. A pachymeningitis haemorrhagica 
interna was caused in one case 2 days after the 2nd inocu- 
lation by drill with full packs in the sunshine* In a particular case, a coccal phlegmon set in at the site of 
inoculation, but when death occurred, abdominal typhoid 
was ascertained. It appears doubtful whether the opinion 
of the surgeon executing the autopsy, viz. that 
was caused by the inoculation, is correct. 
After vaccination against dysentery and smallpox, 
only secondary ooccal infections were ascertained as causes 
of death by the autopsies. 
The fatal cases after inoculations against diphtheria, 
gas-gangrene, and tetanus were caused by serum injuries; 
these are partly primary sertim sensitivity (idiosyncrasy) 
without previous contact with the serum, partly previous 
sensitization by injecting the serum into the tissue with 
subsequent intravenous injection* 
Discussions 
LAUCHE; Whether the 5 fatal cases of coronary 
sclerosis can have been caused by the inoculation, seems 
doubtful to me,, considering the comparative frequency of 
sudden fatal coronary cases, particularly, as in 2 
death did not occur until 2 or 3 days after the inoculation. 
NORDMANN: As regards the 24 cases reported as injuries 
caused by inoculation in wartime, I think myself Justified 
in remarking that these are but part of the actual cases. 
Some cases are not registered with the chief disease or 
cause of death as being a consequence of injurious inocu- 
lation, but appear under another diagnosis. This will 
probably be the case, if the surgeon who made the autopsy 
was convinced that the injuries caused by inoculation could 
not have been decisive. Therefore it seems advisable to 
complete the list of these cases by making further inquiries 
among the pathologists, who, I dare say, will remember their 
own cases. The relation between coronary sclerosis and an 
injury caused by inoculation may be very loose. Thus, I 
observed a case in which death from coronary sclerosis oc- 
curred a few hours after the patient concerned had been de- 
ferred from the inoculation because of irrelevant complaints. 
GRUBER: I refer to the discussion of possible morpho- 
logical consequences of protective inoculation against 
typhoid, which was held 27 years ago during the meeting of 
war pathologists. Even at that time, certain changes of 
the reticuloendothelium in the lumphatic glands were found. 
Also the subject of coronary sclerosis or of men with cardiac 
injuries and subsequent inoculation was touched upon even 
then* At that time, chiefly death from coronary injuries 
was discussed, which naturally might prove fatal by the ad- 
ditional strain of the consequences of inoculation. 223 
4. Pathological anatomy of tularemia. 
Oberstabsarzt (Major. MC.) Dr. SINGER 
The report on the pathological anatomy of tularemia 
is based on four observations, three of which were sub* 
mitted as autopsy-records, while in one case an autopsy 
was made by ourselves, which could be judged by pathologico* 
anatomical, histological, and bacteriological examinations. 
The observations were arranged under the various forms of 
tularemia according to the classification made by LAUCHE 
at the first conference of medical consultants at the Eastern 
Front* 1942, which does full justice to all pathologico- 
anatomical points of view according to our knowledge of the 
clinical picture so far: 
LAUCHE distinguishes two main groups: 
1. Glandular or bubonic form, which also may be called 
the external glandular form. The primary infection may- 
be observed on the surface of the body (skin, conjunctiva) 
and at the orifices of the body (tonsils, pharyngeal 
mucous membrane), the regional lymnhatic glands being 
affected by it, or, when the place of entrance of the 
agent cannot be recognized any more, as the purely glan- 
dular form. 
2. The internal, intestinal or enteral form, in which, 
too, the involvement of the lymph glands is predominant 
and tie place of entrance of the agent into the respira- 
tory tracts and into the intestinal canal must be de- 
termined mostly by conjecture from the involvement of 
the regional lymph nodes. The generalized form of the 
disease with tubercular necroses in almost all internal 
organs is not yet known well enough to ascribe to it a 
special position no^r. The ulcero-glandular form of 
tularemia is no special group of diseases, but may be 
regarded, along with the external glandular form and in 
the internal intestinal form, as a complicating stage in 
the clinical course, with breaking through to the ex- 
terior and to the interior. 
As regards the frequency of the single groups of the 
disease, there are considerable differences between the state- 
ments of American scientists and the observations on the 
Eastern Front, According to the latest reports (BOGENDOERFER), 
30 per cent are to be considered among the pure glandular 
form, 5*0 per cent among the internal or intestinal form. 
The route of infection by contaminated food apparently plays 
a more important part on the Eastern Front (BOGENDOERFER). 
Considering the still few cases available for examination, 
it is impossible to give a comprehensive description of the 
pathological anatomy and histology of tularemia. Even these 
few observations are still rather unsatisfactory as to their 
judgement. In all four autopsies, the examiners only arrived 
at the diagnosis "probably tularemia", which was based chiefly 
on the positive serological findings? or the peculiarities in 
the anatomical findings (irregularities of the tissue picture) led to differential diagnosis* Among the observations de- 
scribed in detail, one case belonged to the ulcero-glandular 
form with erosion of a larger artery branch, one case to the 
internal or pulmonary form (DOERR), one case to the internal 
intestinal form (HARTMANN), and one case to the internal 
pleuro-pulmonary and intestinal form of tularemia (my own 
personal observation). Of particular interest Tere pene- 
trations of the soaked mesenteric granulomas of lymph nodes 
into the abdominal cavity with ensuing death by peritonitis, 
the formation of peculiar infiltrating tumors in the ileum, 
larger confluent foci of necrosis and granulomas in the fat- 
tissue of the mesentery of the small intestine, particularly 
where the rectal tube is inserted, and the dissemination of 
nodules on the peritoneum. 
The histological results do not differ much from the 
already known findings of former examiners. The granulomas 
of tularemia much resemble tubercles. The cases examined 
by me showed a certain range of variation in the tissue 
constituents of the exuberant granulations, and also the 
tissue necroses often show apparently different forms of 
progress. The inflammatory reaction in the neighborhood 
of the necroses and granulomas is often distinguished by 
more intense histiocytic exuberance and proliferating pro- 
cesses on the vessels, particularly the veins. 
This peculiarity is probably not only dependent on 
the prevailing form of reaction of the organism and its 
tissues, on the virulence of the agent, and on mixed in- 
fection by other bacteria » which does apparently occur 
often - but also on the place where the granuloma developed, 
or was formed by reaction to previous tissue necrosis. I 
still doubt whether these morphological findings are a 
positive characteristic of tularemia. The difficulty of 
diagnostic judgement is illustrated by the fact that I 
was able to prove tubercle bacilli in a culture by ray of 
guinea-pigs from a lymph node at the hilus pulmonis of my 
case, which was granularly changed. For the present, I 
suspect that a latent tuberculosis was activated by the in- 
fection with tularemia. Such disappointing results of ex- 
amination, however, urge one to proceed with the utmost 
caution in the purely morphological outlook on the clinical 
picture. 
Summary: The diagnosis of "tularemia" cannot yet be 
safely formed by pathologico-anatomical and histological 
examinations. In the evaluation of serological test find- 
ings some reserve is advised. 
Discussion: 
LAUCHE; Though we have but inadequate knowledge in 
this field, I proposed to put tularemia on the agenda, as 
tularemia occurs more frequently also in the home country, 
and above all the workers from the East are afflicted with 
it. Thus, I was asked several times to examine cervical 
lymph nodes with the conjectural diagnosis of "tularemia". 225 
In other cases, the histological examination raised the 
suspicion of tularemia, which was sometimes even strength- 
ened by the result of the serological reaction. After all, 
the positive serological finding is no definitive proof, 
for it may have been caused by an infection, which was 
previously overcome. 
Demonstration of a case of evident combination of 
tularemia with tuberculosis in cervical lymph nodes. 
RANDERATH; Demonstrated the clinical pictures of 
patients with oculo- or tonsillo-glandular tularemia. With 
the aid of microphotographs the microscopic changes in the 
lymph nodes are demonstrated. It is believed that a micro- 
scopic diagnosis of tularemia is possible, or, at least, 
an indication of the possibility of existing tularemia may 
be given. 
NOHDMANN: As regards the possibilities of diagnosing 
tularemia from the histologic preparation, I share RANDERATH*s 
optimism. If a tularemia nodule can really not be distin- 
guished from a tubercle, the situation is the same as with 
the differential diagnosis between lues and tuberculosis. 
In the case of tularemia, therefore, the diagnosis should 
be formed particularly by making use of the clinical data. 
I am in a position to supplement SINGER*s lecture by a 
report of one more autopsy. That case too proves that the 
diagnosis of tularemia may be formed from the anatomical 
findings, for I could form it even at the autopsy table, 
though, clinically, the diagnosis of typhus had been formed. 
The patient died after 20 days of a typhoid clinical picture 
and had, at times, a distinct agranulocytosis. This case 
is of particular interest, since the anatomist was here in 
a position to show - for the first time as far as I know - 
a primary tularemic affect in the lungs. There already 
exist excellent cllniccal roentgenograms of such primary 
involvement. Morphologically, our case showed a hepatization 
of the size of a bean with a yellow edge, and micro-anatomic- 
ally, a hepatization with beginning necrosis of the alveolar 
walls. A wall composed of lymphocytes, a Border of fibro- 
cytes, and a beginning carnification formed the surroundings. 
The lymph nodes at the bifurcation and at the corresponding 
side of the trachea showed caseations and suppurations, as 
well as numerous nodules. The mesenteric lymph nodes and 
the cervical lymph nodes were affected to a considerably 
small extent. There were also a few isolated axillary and 
inguinal nodes. Besides, the man had subcutaneous and 
intracutaneous abscesses and tumors. In all infected 
regions gram-positive accumulations of cocci were found. 
The diagnosis of tularemia was confirmed by the animal 
test from the dissected organs. 
RANDERATH; As regards the subdivision of tularemia, 
it is proposed to speak of a tularemic primary complex and 
to differentiate an exterior primary complex (tonsillo- 
glandular, oculo-glandular forms) and an internal tularemic 
primary complex (thoracic and intestinal forms). Besides these, there are lympho-hematogenous forms of general spread 
with specific changes in numerous inner organs, the meninges 
included* The serological reaction does not remain positive 
as long as states in the literature on the subject, 
NEDHAUS: In the region of the Oka (Orel), where 
tularemia is known to be widespread, we could make no 
autopsy of any positive case of tularemia within our Army 
District during the winter-months of 1941/42# In two cases 
sent in for autopsy, which had been diagnosed as tularemia, 
this diagnosis was not confirmed. Both cases had shown a 
positive agglutination titer for tularemia* In one of the 
cases an extensive caseating glandular tuberculosis with a 
proven tubercle bacilli in the caseated glandular parts 
was observed, A histological examination of this case 
yielded the result of typical tuberculous granulation tissue, 
without any peculiarities* 
SIEGMUND; In the southern sector of the Eastern Front, 
tularemia played no part at all in the Army and among the 
population either in 1941 nor in 1942, On the other hand 
the Russians had, in their institutes at Stalino, Kostow, 
and Krasnodar, a number of good macroscopic collection-pre- 
parations, partly in a form corresponding to the hematogenic- 
ally spread tuberculosis of the inner organs* Unfortunately 
we were not permitted to secure this valuable material. 
7 hat did the Russians know concerning the pathology of 
tularemia? 
BOEHNE: Numerous observations of cases of tularemia 
during the winter of 1942/43. No fatal case. No examinations 
of the lymph nodes possible. The epidemic set in with a re- 
markable fatality among rodents, from which the epidemic 
could be predicted. Non-specific positive Widal reaction 
in case of typhus and infection with the titer mounting tip 
to 1:800 also* in the epidemic area. 
\ 
KOEBBRLE: After several excisions, I have observed no 
fistulation following a trial excision of lymph nodes. In 
all cases, a primary complex could be ascertained; usually 
it is true, only after conscientious examination of the 
patients, as the injured place of the skin will often heal 
quickly and is no longer noticeable* On account of the in- 
spection of histological preparations of patients and animals 
from America, and of several cases of tularemia from the 
surroundings of Vienna I am of the opinion that the expert 
acquainted with the histological clinical picture is in a 
position to make the diagnosis of tularemia from the autopsy- 
preparations. 
LAUCHE: I think I am justified in summing up the re- 
sult of this discussion as follows: In cases of tularemia, 
granulomas are observed, which will chiefly affect the 
lymphatic tissue, but also may occur outside it in the con- 
nective tissue and adipose tissue as well as in numerous 
inner organs. The histological picture of the granulomas is char* 
acterized by a central necrosis, which, contrary to tuber- 
culous caseation, usually contains numerous leukocytes and 
nuclear remnants, and often still allows the original 
structure of the tissue, chiefly of the vascular walls, to 
be recognized, although only faintly* By this fact, it has 
a certain resemblance to a gummatous necrosis, though it is 
considerably softer, which is shown by numerous rents and 
cracks in the histological section. Around this necrosis, 
there may be a rather wide and often remarkable regular 
zone of epithelioid cells (fibrocytes), which is usually 
arranged radially# This zone occasionally contains numbers 
of giant cells of the Langhans type. The border between 
the necrosis and the edge of the epithelioid cells is 
often vacuolized in a peculiar way (artefacts originating 
during fixation?). Contrary to tuberculosis, the edge 
of the epithelioid cells is outwardly surrounded, in most 
cases, not by a zone of lymphocytes but often by a very 
hyperemic zone, abundant in vessel?, which in older cases, 
snows the picture of a non-specific granulation-tissue, 
the capillaries of which penetrate into the zone of the 
epithelioid cells. Moreover, contrary to tuberculosis, 
the inflammatory changes extend beyond the region of the 
lymph nodes to the surrounding connective and adipose 
tissue. In this zone, T'hich is also highly hyperemic, as 
a rule, endarterial and periarterial changes are to be 
observed. 
As regards the healing process, we have as yet in- 
sufficient knowledge. Apparently, a gradual "organization" 
of the granulomas will ensue, without encapsulation of the 
connective tissue. 
The differential diagnosis against a secondarily in- 
fected tuberculosis is difficult to form. Occasionally, 
staining of the tubercle bacilli may clarify doubtful 
oases. In my opinion, however, so far most cases can be 
diagnosed only as "probably tularemia". The suspicion 
of tularemia will be confirmed by the quick onset of 
necroses. Of course, this can be judged onl3r if the 
duration of the disease is known. Therefore, it is ne- 
cessary to add precise clinical and historical data when 
material is sent in for examination. If the serological 
examination turns out positive, it may support the histo- 
logical diagnosis. But it must be considered that the 
positive result may have been caused by a former infection 
now subsided. It seems to me important to state that a 
combination of tularemia and tuberculosis especially in 
the cervical lymph nodes, which are examined most frequent- 
ly, is apparently not raree 
I request all gentlemen who have the opportunity 
to make autopsies t)f tularemic cases to preserve and 
send in macroscopic material for the War-Pathological 
Collection. 5. Professor ROESSLE. 
6. Pathological anatomy of the effects of detonations. 
Doctor WERNER 
7* Physical bases of the effects of detonations. 
Stabsarzt (Captain, MC.) DESAGA 
These lectures were not intended for publication. IX. 
PROCEEDINGS OF THE C 0 N 3 U L T A N T S 1 
COMMITTEE ON PHARMACOLOGY 
Translation prepared by: 
Office of Military Government for Germany (U* S* ) 
Office of Naval Advisor 
Medical Section Treatment with sulfonamides* 
(See Section II, Articles S - 10) 
Injuries caused by Salvarsan. 
TSee Section VlII, Article 2) 
1» Consequences of chemical warfare* 
Oberstarzt (Colonel, MC.) Prof* FLURY 
Since the beginning of gas warfare, many erroneous 
ideas have prevailed even to the present day, and oven in 
medical circles. Incurable lingering illness, tuberculosis, 
ulcer, and other serious diseases are said to be the in- 
evitable fate of the victims. Nowadays the terror of gas 
is being revived from wildly exaggerated war-rumors* For 
this reason, increased importance and urgency is to be 
attributed to the enlightening of the people on the real 
state of affairs. In Germany, it was particularly 0. MUNTSCF, 
who undertook this problem. 
What do we know today of the consequences of gas- 
poisoning? What has become known of the fates of the 
victims of gas-war? What can be regarded as certain? 
What remains obscure even now? Tho war-archives and offic- 
ial sources are often still inaccessible. But there is 
available abundant statistical material from various 
countries. In Germany, valuable material has been lost, 
so we have to draw on foreign sources to a large extent. 
It need not be proven in detail that it is the organs 
of respiration that are injured most by the inhalation of 
gas. It is chiefly the respiration system that tho gases 
will attack. 
The organic pulmonary injuries, particularly the 
diminution of the respiratory surface and its significance 
for the later consequences may be somewhat generally over- 
estimated. The injuries to the upper respiratory tract 
and to the lungs by the different groups of gases are 
easily intelligible as regards cause, course, and conse- 
quences and raise no particularly intricate problems. Here, 
the connections are clear and easy to sec. 
The diseases of the nose, of tho accessory sinuses, 
of the larynx, and of the trachea, as manifest them- 
selves particularly with the ,?Yellow-CrossM-group (mustard 
gases), have been observed a thousand times and are well- 
known. In the case of serious injuries to the mucous mem- 
branes of the upper respiratory tract, atrophic changes 
and formation of tumors, particularly in the larynx, will 
predominate. The cases of bronchitis are seldom due to 
the effect of the gases. They are rather consequences of 
bacterial infectionf I am not going to mention here in 
detail the consequences of pulmonary edema and of chronic 
bronchitis with their complications and subsequent effects, 
emphysema, atelectases, bronchiectases, bronchopneumonias, 
diseases of the pleura, formation of empyemas, abscesses, 
pulmonary gangrene, callosities, septic states, and bronchio- 
litis obliterans. According to almost general opinion, pulmonaly com- 
plications are said to be the most frequent and numerous 
ones* This certainly seems to be natural and self-evident, 
but some questions still need further explanation* 
Probably the greatest problem of post-war time con- 
cerned the possibility of pulmonary tuberculosis being a 
sequel of gas-poisoning. In the course of time, the opinion 
underwent considerable changes. 
During the first World War, the opinion was widely 
spread that serious local pulmonary injuries by gases were 
liable to result in tuberculosis to a large extent. 
In post-war time, enormous efforts were made to settle 
this question. A long series of researches and statistical 
inquiries aimed at clearing up the matter, particularly be- 
cause of the problems of pensions and providing for the 
victims* Thus, extensive inquiries were made in the various 
countries,‘on the one hand about men actually or ostensibly 
injured by gases, on the other hand, about veterans suffer- 
ing from pulmonary tuberculosis concerning possible pre- 
vious injuries by gases. The statistics comprise more than 
100 000 cases. Investigations concerning 70 000 gas-cases 
of the Americans and more than 22 000 cases checked by the 
English Veterans1 Administration rank foremost. Thousands 
of those patients were re-examined later on. The result was 
amazings the proportion of men suffering from tuberculosis 
was much lower than expected. Among the 70 000 Americans 
mentioned, chiefly gased by "Lost" (Mustard gas), there were 
but 173 cases of tuberculosis, that Is 0.24 per cent. 
/ 
The possibility of tuberculosis being revived by the 
effects of gases is generally admitted. Many medical men 
are of the opinion that gas-poisoning alone is not sufficient 
to cause tuberculosis and that rather a general predis- 
position or circumstantial conditions are necessary. Among 
men injured by gases, pulmonary tuberculosis does not occur 
more frequently than among the bulk of the war veterans. A 
clinical picture resembling tuberculosis to a large extent, 
but with negative bacilli findings, has been described as 
pseudo-tuberculosis (ACHARD). 
As mentioned before, disorders of respiration (dyspnea) 
are the most conspicuous symptoms. If there are distinct 
injuries to the respiratory organs, these disorders are not 
difficult to explain. On the other hand, the occurrence of 
chronic respiratory trouble is not so easy to understand. 
This applies particularly to the primary cause of shallow. 
rapid respiration, which is observed very often. Several 
theories were formed as to its origin. The possibilities 
of a circuius vitiosus developing are abundant here. One 
could imagine that in consequence of the local injury to 
the respiratory organs by the gas a permanent state is caused, 
which is characterized by lack of oxygen, chronic anoxemia; 
which in its turn is liable to have various consequences 
for the entire organism. Even in the subsequent states, we must ascribe a much 
more important part than has been so far customary to dis- 
orders of the circulation. Apart from complications of 
the lungs, with a vast majority of the patients, disorders 
of the cardiac functions, particularly tachycardia., are 
the chief symptoms# This is regarded over* and over as the 
main symptom of the sequelae. Besides, shortness of breath 
is most frequently observed and usually sets in at night. 
Also in judging late injuries, respiration and circulation 
together must be considered a? an inseparable whole. Ex- 
perience on the part of the Germans at the front and in the 
home country, at ammunition-dumps, chemical factories, even 
scientific institutions showed again and again that, above 
all, functional disorders of the heart and of the nervous 
regulation system will occur after gas-poisonings* But in 
spite of abounding subjective complaints, there are at 
first mostly only few or no objective findings whatever. 
With late injuries of this description, all symptoms of 
respiration due to altitude before adaptation (mountain 
sickness) were observed. Here also, there is a chronic 
lack of oxygen in the blood, a chronic anoxemia. It is 
caused by the rapid shallow respiration of the patient. 
Thus, the lungs are but insufficiently supplied with air. 
This concept is confirmed by the positive, by no means 
temporary successes of the English, who made the patients 
live and particularly sleep in oxygen-chambers for some 
time and arranged small oxygen-tents over their beds# 
In judging the consequences of gas-injuries, two 
notions played an important part in the English and Ameri- 
can Armies: the irritable heart, and the effort syndrome. 
These two diagnoses rank foremost among the cften violent 
late consequences# The irritable heart corresponds, to a 
certain extent, to that of ’’cardiac neurosis", the ”cor 
nervosum"# 
The effort syndrome comprises the changes of pulse 
after a short physical strain, which chiefly consist in 
quick acceleration of the pulse and delayed return to the 
normal rate. 
War gases are not specific heart-poisons; nor is the 
irritable heart to be regarded as a specific cardiac dis- 
ease, particularly not as cardiac insufficiency# Besides, 
it is by no means a specific disease of soldiers# 
Real organic injuries of the heart, however, will also 
occur not infrequently! Myocardial injuries may be caused 
by war gases as w£ll as by other suffocating poison-gases, 
such as carbon monoxide, carbon dioxide, nitrose, sulphur- 
etted hydrogen, carbon bisulfide, prussic acid, etc# (ADEL- 
HEIM, WOHLWILL)• When they arise, they always imply com- 
plications by infection. Sudden late deaths by gas-injuries, 
which were occasionally observed, are to be explained by the 
formation of thromboses with embolism or cardiac infarcts. 
It however, that serious permanent injuries to the 
heart by war gases are not so frequent as is sometimes as- 
sumed. It is not positively proved whether some particular 
war gases, such as Lost (mustard gas), cause particularly 
frequent or particularly severe cardiac injuries# The Injuries to the skin by war gases show a remarkable 
resemblance to certain injuries caused by radiation. The 
formation of pigment by Lost reminds one of the effects of 
light. Common to both are the sensitivitjr and susceptibility 
to injuries of every description, which will often prevail 
for a long time, as well as mechanical traumas and infections 
by cocci. Old scars caused by Lost are said to be highly 
sensitive to changes of the weather* Patients are suscept- 
ible to eczemas, furunculosis and abscess formation, to 
symptoms of hypersensitivity of various kinds , to urticaria, 
dermatitis and vascular injuries; during the healing process 
recurrences, particularly furuncles, will often occur. 
Allergic states of various kinds caused by war gases, 
particularly by Lost and arsenic gases, were frequently 
observed. 
The injuries to the eyes are of a particular interest, 
beyond the general medical one, since they afford a deeper 
insight into the very nature of the effects of war gases and, 
moreover, elucidate the late consequences in a new and sur- 
prising manner. 
In the weak concentrations used in the field, the 
group of the gases irritating the eyes ("White Cross Tear 
Gases") is comparatively harmless, in more concentrated, 
particularly liquid form, however, they may cause serious 
injuries, even the loss of the affected eye. 
The eye is highly sensitive to Lost and analogous gases* 
The serious acute injuries shall not be discussed here. As 
regards late consequences, I make the following remarks: 
Direct involvement of the anterior parts of the organ of 
vision, the lids, the conjunctiva, the cornea causes either 
a temporary inflammation without formation of permanent 
scars or atrophic changes with scar formation. The injured 
cornea too may become the place of entrance of the agents 
of infection. A secondary infection creates further com- 
plications. Chronic inflammations of the conjunctiva with 
states of irritability, photophobia, intensified lachrymation, 
and various disturbances of vision occur most frequently. 
The manifestation of these consequences is furthered by pre- 
vious eye diseases, particularly trachoma* 
Another group of eye-injuries is due to the consequences 
of the resorptive poisonous effect; indirectly through the 
blood, grave disorders of the circulation and not rarely of 
the vessels arise. They manifest themselves chiefly in 
the lower parts. To this group belong the hemorrhages, 
thromboses, ambolisms, injuries to the retina and to the 
choroid, and night blindness. Thromboses of the veins and 
embolism of the central artery have in some single cases 
led to blindness. 
The problem of permanent blindness may be regarded as 
settled today. Here also, the apprehensions much exaggerated 
at first gave way to a more optimistic conception. The 
number of men made blind by war gases is small, they form only an inconsiderable part of the men injured by war 
gases during the World War* Of the 3 000 Germans blinded 
during the first World War, only 8l were injured by war 
gases. But it appears that we must somewhat check our 
optimism also as regards late consequences affecting the 
eye. Here too, we observe a change in judgement. 
The view, expressed particularly often in German 
literature, that serious consequences affecting the eye 
are extraordinarily rare, cannot be supported any longer. 
In any case, it must be modified. Recently, there have 
been continually increasing reports of diseases occurring 
very late and usually taking a serious course, of the so- 
called "recurrences"• 
In numerous reports, cases are described, in which 
renewed diseases of the eye occurred 4, 6, 10, 12, 15, 17 
add even 19 years after the injury caused by Lost during 
the first World War. In many cases, no visible corneal 
injury, particularly no opacity is said to have existed, 
sometimes, however, there has been increased sensitivity 
and predisposition to eye-diseases even before the first 
injury. There were partly infectious processes, partly 
recurrences said to have set in without any visible infec- 
tdon. The following manifcstations are described; keratitis 
kerato-conjunctivitis, corneal opacity, leukoma, corneal 
degeneration, corneal tumors, perforation and panophthalmia. 
Particularly emphasized are peculiar changes of the corneal 
vessels; enlarging (vascular varices, "mustard-gas varices"), 
forms similar to strings of pearls, abnormal vascular form- 
ations, new formation of vessels and vascular germs. The 
conjunctivo-limbal syndrome is said to be caused by de- 
rangement of the alimentary functions of the marginal net- 
work. The most frequent diagnosis is that of "keratitis 
neuroparalytica". It is remarkable that this disease is 
always compared to the injuries caused by X-rays. As with 
the effects of radiation, there is also here, a remarkably 
long period of latency. 
The observation that simultaneously with the late 
consequences affecting the eye recurrences are said to 
occur in other mucous membranes previously injured, par- 
ticularly the bronchia, is of more general importance. 
Besides these the war gases cause various general 
diseases, among them allergic states. 
The effects on metabolism show the characteristics 
of injuries by war gases in a particularly impressive 
way. This applies, above all, to the "Yellow Cross" group. 
Marked loss of weight is one of the regular symptoms 
of the late consequences, caused also by other 
groups. The patients rapidly lose weight, show a pale, 
sallow complexion, also slight formation of edemas and 
their power of resistance is weakened. Marked loss of 
weight is also observed after phosgene and arsenic com- 
pounds. But with the "Yellow Cross" group, the disorders 235 
of metabolism are the most lasting. The organs of digestion 
are nearly always affected. Cases of gastritis are frequent. 
The problems of intestinal tumors and of hepatic injuries 
are still unsolved. 
There is no positive prodf of the occurrence of specific 
metabolic diseases. Genuine diabetes can be no late con- 
sequence* since it depends on the constitution and hereditary 
disposition. Glycosuria, observed after gas-poisoning, 
also after infectious diseases, has nothing to do Tith 
genuine diabetes mellitus. 
The war gases also affect the blood and the blood- 
forming organs. Anemias occur very often. AS also perniciou 
forms will occur after grave poisonings and infections, 
there may be a connection, particularly with Lost and 
arsenic compounds, if sufficiently proven by previous 
history, similar symptoms, and expert findings* 
Let us now turn to the nervous system. In the beginning. 
particularly during the first World War, nervous disorders 
except local effect of irritation were but little heeded, 
though serious effects of war gases are very often connected 
with various disorders of the nervous system, even with long 
unconsciousness. The late consequences will chiefly affect 
the nervous system. In many thousands of re-examinations 
"neurasthenia" was diagnosed. War gases will affect all 
organs of sense and by no means the eye exclusively. Dis- 
orders of the olfactory sense, of the sense of taste, of 
the sense of hearing, of the tactile sensitivity, of the 
equilibrium are often observed. Various cases of neuritis 
are not rare. Distinct neurological symptoms, however, are 
apparently not very frequent. Psychic disorders after in- 
juries caused by war gases are by no means as rare as is 
usually supposed. Depressions, hysterical-hypochondriacal 
states ("gas-neuroses, gas-psychoses") are described above 
all. But in the judgement of nervous symptoms, particularly 
of cerebral and mental diseases after gas-injuries, the 
greatest caution and reserve is recommended. Isolated cases 
of paralysis, parkinsonism, epileptic states and the like 
are known, but they are very rare. Even schizophrenia has 
been associated with previous injuries by war gases. 
Among the unsolved problems, the auestion of permanent 
injuries to the vegetative nervous system by lipoid soluble, 
highly active war gases are not the least• These are pro- 
bably also responsible for disorders of the regulations of 
respiration, circulation, cardiac action, of the extracardial 
cardioneural system, the various injuries to the vascular 
nerves, for loss of tonus in the periphery and centers. 
Lastly, they are supposed to play an important part in 
metabolic disorders. As regards the question of judging, 
I have to say: 
It is often very difficult to answer the question of 
connection, that is whether the disease in question was 
positively or probably caused by a previous war-gas injury. 236 
The main bases are formed by the proven facts, by the record 
of the patient, and by the. results bf the examination. A 
strict critical examination of the data and evidence is 
particularly important here. Just as in any problem of 
providing care following accidents, the primary injury, 
in this case the injury caused by war gases, must be pos- 
itively proved. Secondly, there must be proof that the 
injury was liable, also as regards the various circumstances, 
to cause the subsequent disease or to make a disease al- 
ready existing worse. The kind of injury, the severity of 
the case, e.g. serious pulmonary edema, long unconscious- 
ness. possibly also localization are essential for the 
opinion* Thirdly, the temporary circumstances must be 
known* They must correspond to experience and knowledge 
concerning the occurrence of the late consequences in 
question. The judgement becomes difficult, often absolute- 
ly impossible, if related symptoms are lacking or indistinct 
In this connection the recently observed late injuries to the 
eyes, which will appear even decades afterwards, are sig- 
nificant* On the other hand, it was often ascertained, that 
severe war-gas injuries, e.g. diseases caused by phosgene 
with pulmonary edemas, healed without leaving behind any 
consequences clinically traceable. 
At all events, the greatest caution and reserve seems 
to be imperative in the judgement of all diseases not occur- 
ring until many years after the war or the war-gas injury, 
of diseases depending on predisposition, of rare diseases 
and those of unknown origin. The war-gases Till generally 
cause no new specific forms of disease characteristic of 
them, nor any specific consequences. Nearly all symptoms 
occurring after war-gas injuries may have other causes as 
well. 
In Gorman literature, the enormous difficulties of 
the subject have been pointed out over and over again, par- 
ticularly by 0, MUNTSCH. Even if matters are examined again, 
the principles elaborated by that author in many publications 
retain their validity. Nor have any new particulars been 
found out as regards the subsequent states during the last 
few years. The same applies also to their prevention and 
treatment. With respect to subsequent diseases of long 
duration with their psychic effects, psychiatrical treat- 
ment is of particular importance. 
Discussion: 
Referring to experiences of his own, HEUBNER points 
out the credulity of patients and surgeons with regard 
to a connection of ostensible absorption of a poison and 
a disease. 
WIETH: Points out the difficulty of the problem of 
a connection between the effects of war gases and pulmonary 
tuberculosis. Several times, this question has been the 
subject of inquiries with internists and experts for tuber- 
culosis, but no solution could be found. The connection 
between the effects of war gases (arsenic) and paradentosis 
is oqually doubtful* LENDLE: Asks whether a non-specific susceptibility 
to eczemas will prevail even if there was only one ex- 
posure to Lost, He indicates the operative treatment of 
eye injuries caused by Lost (transplantation of the labial 
mucous membrane), in order to preserve the Vascular supply. 
ORZECKOFSKIs The late consequences affecting the 
eye are probably injuries of combination. "To get accustop.ec111 
to "Blue Cross" gases is rather a tachyphylactic reaction. 
The difference of dyspnoea from tachypnoea is significant 
for the treatment with C^. 
SOBERING: In a patient injured by Lost, who was not 
primarily treated, double vision and temporary paralysis 
of the ocular nerve sot in 4 to 5 weeks afterwards. The 
connection is obscure. 
WERNER: A permanent late consequence of injuries 
caused by Lost is the often occurring diergy, which is 
accompanied by a violent cutaneous edema in the face and 
limbs and by violent eosinophilia. 
-GREMELSt Points out the importance of the administra- 
tion of sufficient oxygen after the effect of war gases 
injurIcUS to the lungs. Morbidity by tuberculosis after 
the effect of war-gases injurious to the lungs, which 
amounts to 3 to 4 per cent, appears to be loss than the 
morbidity by tuberculosis among the civilian population. 
Directions concerning the sequelae of injuries 
caused by war gases. 
As regards the sequelae, the following can generally 
be observed: Most injuries caused by war gases will heal 
completely or leave a scar. Only a comparatively small 
number of them will leave behind late injuries. Contrary 
to wounds, complete invalidity is extraordinarily rare with 
them. 
The sequelae in Question and known until the present 
may be divided into two large groups. On the one hand, 
there is a series of clinical pictures frequently occur- 
ring immediately after injuries caused by war gases, where 
the connections are clear and easily understood and there- 
fore generally acknovdedged. On the other hand, there 
are large numbers of most variable diseases, in which 
the connections are more or less doubtful and which are 
therefore disputed. 
Today, the principal sequelae generally acknowledged 
have been thoroughly investigated clinically and scienti- 
fically. After the inhalation of war gases, three types 
of late sequelae are generally In the first 
group, the diseases of the organs of respiration, above all 
chronic bronchitis and emphysema, rank foremost. The second 
group comprises disorders of circulation, chiefly so-called functional diseases, such as cardiac neurosis and extra- 
cardiac disorders of regulation. Disorders of the heart 
and of the circulation arc more frequent than was formerly 
supposed. As a rule, they are only visible during function- 
al strain. The third group of symptoms consists of permanent 
states of disease which manifest themselves chiefly in the 
nervous system ? nd are generally referred to as "neurasthmir 
Tn the literature, now one group, now the other is mentioned 
as the most frequent or most important sequela# This con- 
tradiction is probably due to the different time of judge- 
ment. The respiratory tract is injured first; infections 
and other complications ensue, thus gradually producing 
disorders of the circulation. Lastly, various general 
injuries are observed as sequelae of a chronic deficiency 
of oxygen; above all, functional disorders within the 
whole nervous system, and disorders of blood-supply and 
nutrition of varied description# If war gases affecting 
also the skin and the eves are involved, there appear, 
of course, additional late injuries to these organs. 
Besides the typical forms of,disease mentioned, which 
set in with a certain regularity, there are other possibil- 
ities, accidental disturbances, atypical sccuelae as it 
were, to be reckoned with. Above 711,'" the sccuelae of 
vascular injuries, hemorrhages, thromboses, embolism, 
belong to this group. More rare accidents of that kind 
are for instance gangrene of the extremities, sudden 
blindness by a closing of the central vessels of the eye, 
otitis media, perforation of the tympanum or the nasal 
septum, unexpected late deaths due to apoplexy. Pulmonary 
tuberculosis, too, belongs to the sequelae. It is, how- 
ever, not more frequent with soldiers injured by gas warfare 
than among other participants of the war. The greatest 
reserve is necessary, particularly if ostensible late in- 
juries do not manifest themselves until long after the 
injury caused by the gas, that is many years after the 
war; particularly also if rarer diseases are concerned 
or such diseases the origins of which are not knwon at 
all or only imperfectly. The same applies to all diseases 
depending on a particular predisposition. So, the data con- 
cerning connections with injuries caused by war gases are 
very doubful, partly absolutely obscure, with cerebral 
and mental diseases, with metabolic disorders such as 
diabetes, with dental and oral diseases, such as para#* 
dentosis, with malignant new formations such as bronchial 
carcinoma, gastric carcinoma, skin carcinoma and with 
diseases of the excretory organs, chiefly the kidneys. 
A moot question is also the connection with the frequent 
diseases of the organs of digestion, particularly gastric 
tumor; besides hepatic atrophy, diseases of the blood and 
rare diseases of the skin. The majority of the veterans 
afflicted with these late diseases are rare individual 
cases concerning which no generalization can be made. 
Hardly ever could it be positively ascertained whether 
the diseases were really sequelae of war gas injuries. 
Sequelae must be judged with great caution, since war 
gases nay eventually affect any organ of the body and 
any function. All the same, the number of the diseases which are to be recognized as late sequelae must be re- 
stricted as much as possible* It is essential for the 
judgement that a primary injury caused by war gases is 
positively determined* Then this primary injury must 
hat>e been liable, considering the circumstances, to cause 
the disorder in question* Related symptoms must be re- 
quired on principle* Difficulties may arise here by the 
very striking observations recently made, according to 
which recurrences affecting the eye, particular!}7, corneal 
injuries, may occur very late, even after many years, even 
decades* One must bear in mind that this is no isolated 
symptom limited to the organ of vision, but that similar 
’’relapses” may possibly occur with other organs as well. 
Without thorough knowledge and great experience in 
the special subject, any safe judgement of these conse- 
quences is hardly possible. Even if during the last few 
years, nothing absolutely new has become known as regards 
the particular subsequent states, it is urgently desired 
that the experience available sn far should be collected 
and adequately utilized by a central authority. 
The different war gases of the groups of phosgene 
and Lost not differ very much as regards the sequelae 
after inhalation. All the same, there ate generally certain 
differences as to the violence, the local extent and the 
temporal course of the late sequelae* According to pre- 
vailing opinion, is by no means uncantested, the 
most severe sequelae are caused by the ’’Yellow Cross” 
gases, it is also with these that healing takes the 
longest. Lewisite and similar compounds of arsenic are 
supposed to range between the groups of phosgene and Lost* 
The treatment of late sequelae in men injured by war 
gases is generally the same as that of corresponding dis- 
eases from other causes. The task of the surgeon does not 
end with the healing of the acute poisoning, such as the 
pulmonary edema and its primary effects* A particularly 
important task is that of strengthening the patient!s will 
to work, his capability for work, and his will to recover, 
principally by influencing the entire personality. It is 
just with the prolonged subsequent diseases with their 
psychic effects that the psychic treatment must not be 
neglected. The remaining therapeutic possibilities arc 
various. Here, a large field opens to medical activity* 
Here also, the approved physical, dietetic, climatic, and 
medicinal methods, if necessary surgical intervention, 
are to be considered. The chief aim remains the complete 
recovery of the patient, •‘•t is attained more frequently 
with war gas injuries than with many other war-injuries. 
Mt will be possible to attain it more easily in the future 
than during the first World War. Today,#the surgeon is 
assisted by much new knowledge and experience, and not 
least of all by a much wider foundation in the judgement 
of latd eequolae» 2. Toxicology of explosives. 
Professor HEUBNER 
I. General. 
It is known sufficiently well that most of the modern 
explosives are compounds of nitric acid, either aromatic 
nitro compounds which are formed by the release of hydroxyl 
from nitric acid and of hydrogen from tho bonzel-nuclcus, 
or nitric esters of multivalent alcohols, which are formed 
by tho release of hydrogen from nitric acid and of hydroxyl 
from alcohol. During the last few years, particular 
attention and research work has been paid to the following 
compounds: metadinitre-benzol, trinitrotoluol, dinitr^- 
anisol, hoxanitro-diphenylamine, hexogen, dinitroglycol, 
and dinitrodiglycol. The first four arc aromatic 
compounds and solid substances, the last two are nitric 
acid esters and oily liquids such as nitroglycerine. 
Hexogen, as a nitramine, has a particular chemical char* 
acter, but essentially it is more nea.rlv related to the 
derivatives of nitrobonzcl than the esters; it is a 
solid substance, too. 
These explosives are often used not in their pure 
forms, but mixed with each other or with other non-poison- 
ous substances. 
II* Dinltrobenzol* 
As is known from the last war, the simplest of the 
mentioned nitro compounds* that is dinitrobenzol. is 
of the most practical importance, viz. it is particularly 
liable to cause poisonings. For this reason, poisoning 
with this substance has been recently studied most. It 
is considerably more poisonous than mononitrcbenzol, but 
also more poisonous than fcMnitrobenzol. Its volatility 
is so great that its vapors are easily inhaled under the 
conditions of the manufacturing and filling works and that 
even the higher temperatures of slimmer considerably increase 
the danger of poisoning. On principle, a difference must 
be made between an acute and a chronic poisoning, though 
there are virtually all kinds of transitions and mutual 
relations* 
A. The most remarkable symptom of acute poison- 
ing is the formation of hemiglobin (methemoglobin), which 
manifests itself objectively in a cyanotic coloring of the 
skin and the mucous membranes with a gray tinge, subjective- 
ly in weariness, weakness, headaches, and similar general 
disorders. 
In m-dinitrobenzol, the effect of methemoglobin is 
more lasting than in any other nitro compound examined in 
this respect; for this reason, a cyanosis once set in will 
abate comparatively slow, that is only after some days. 
Danger to life by anoxemia will only occur if more than 
60 per cent of the hemoglobin has been changed into metheme- 
globin. B. A second symptom, which nay occur even in 
a single, that is acute poisoning, but which becomes vir- 
tually important only after repeated doses, is the formation 
of Heinz-b~dies. They are demonstrated best by so-called 
"vital staining” with Nile blue or brilliant cresyl blue, 
but can be recognized alsd in the unstained object. These 
formations were often called "hemoglobinomic inner corpuscles 
which is wrong in two respects; the Heinz-bodies arc neither 
inside the erythrocytes nor do they consist chiefly of hemo- 
globin; they are rather products of coagulation in their 
shell* They arc formed within the circulating blood, grow, 
in the course of time from subnicroscopic dimensions to 
larger button-like appendages, change neither the osmotic 
resistance nor the oxygen capacity of the erythrocytes, but 
cause their premature reduction after being absorbed in the 
spleen and the liver; in fatal cases and in the animal 
tests, a good many erythrocytes with Heinz-bodies capable 
of being stained will be found accumulated in large phago- 
cytes of the spleen and the liver. 
This corresponds in the living patient to the appear- 
ance of reticulocytes in the wake of the Heinz-bodies, or, 
in case of a discrepancy between accelerated blood-reduction 
and regeneration, to the development of a hypochromic anemia- 
It is easily understandable that*.this will occur particular! 
in case of the repeated or permanent influence of dinitro- 
bcnzol: for this reason, anemia is the important 
clinical symptom of chronic poisoning* On the other hand, 
there are, of course, also cases of rapid decomposition, 
of the blood with great changes of the red and white blood 
count, pleiochromic icterus, pathological urinary findings 
and late death# 
C* Rare though possible is a third change 
affecting the which is of diagnostic rather than 
prognostic interest; the formation of verdoglobin, an 
oxydation-product of the blood pigment, which is green 
in its pure state; like hemoglobin, it colors the 
and the mucous membranes cyanotic. But its formation is 
usually confined and will never get a decisive influence 
independently besides the two changes mentioned before. 
D. The development of a disturbance of the 
hepatic function is rare, too. It will mostly be dif- 
ficult to differentiate between hepatic symptoms caused 
by blood-decomposition and those caused by direct toxic 
injuries to the organ. As regards tests of the hepatic 
functions1*' it can be stated that, in caso of icteric 
color of the skin, the Takata-Ara test may have a 
positive result. Animal tests rats and dogs by the 
method introduced by FELIX (secretion of the p-oxyphenyl 
pyroracemic acid) yielded variable results: with some of 
the chronically poisoned animals, the quantity of secret- 
ion distinctly rose shortly before their death, but by no 
means in all fatal and never in the earlier stages 
of the poisoning: 242 
E. After imbibing moderate quantities of 
alcoholic beverages, a sudden appearance of symptoms of 
poisoning has often been observed, which was a long time 
considered to be identical with the direct effects of 
dinitrobenzol. Since those symptoms, however, often be- 
came manifest at late hours and at inns, as it is easy to 
understand, the initial symptoms were obviously observed 
but seldom by surgeons or even examined by clinical methods. 
More exact background investigations recently made as well 
as animal tests, however, led a different conception; 
these symptoms are rather effects of the alcohol in a 
changed organism* so that the character of these effects 
is considerably intensified and also changed* After 
of alcohol otherwise harmless, there occur congestions 
of the blood in the head, giddiness and states similar to 
collapse with convulsions; a cyanosis, possibly pre-exist- 
ing, becomes much more apparent, which evidently is to be 
attributed to a disorder of the circulation* This also 
accounts for the fact that these pictures of poisoning 
will generally not occur in the factory, viz. under the 
direct effect of the explosive, but after leaving work, 
even on a holiday etc# 
In animal tests on though not on dogs, this 
picture of poisoning could be reproduced, though with 
individual variations* 
F. The recent experiences in therapy in case 
of poisonings by dinitrobenzol are to the effect that a 
threatening increase of hemoglobin in the blood nay be 
easily checked by methylene blue, and that is most suit- 
ably given by peroral doses of about 5 grans* (Intra- 
venous doses - ten times smaller - may be suitable for 
instance with unconscious patients, but they have only 
a temporary effect and must be repeated, therefore, accord- 
ing to circumstances). In the stage of anoxemia, respir- 
ation is, of course, beneficial, too* 
With the more frequent chronic poisonings, many of 
the recommended and tried remedies did not prove efficacious 
not even iron- or liver-treatment of anemia* Several weeks’ 
leave always proved to be the best remedy* Regular supply 
of Vitamin compounds (ascorbic acid, aneurin) had no 
effect in the animal test, but it seems to increase the 
workers* power of resistance to poisoning* 
III# Trinitrotuluol (tritol). 
This substance is nuch less poisonous than dinitro- 
benzol; according to animal tests, about four tines the 
molar dose is needed to produce the sane quantities rf 
methemoglobin, but even then, the constancy of the formation 
of methemoglobin is considerably shorter; in addition to this, 
the extent of the formation of Heinz-bodies is perceptibly 
smaller* The main reason for this difference is the pre- 
sence of a methyl group at the benzol-nucleus, which delays 
the reduction of the nitro compound to the direct toxic 
compound (or to the majority of such compounds)* (The 
dinitrotolucls are still less poisonous than trinitro- 
toluol* ) This explains why this substance is usually treated 
with much less caution than dinitrobenzol. On the other 
hand, the difference in the effect upon parenchymatous 
organs, particularly the liver, in comparison with dinitro- 
benzol does not seem to be so great as in their effect on 
the blood* At least it was observed that in equal or 
even smaller degrees of cyanosis or anemia, the symptoms 
of a hepatic injury, such as increase of bilirubin in the 
serum, increase of urobilinogen and urobilin in the urine, 
finally also pathological values in the liver function 
test according to FELIX, will occur to a higher percentage 
after handling trinitrotoluol than after handling dinitro- 
benzol* Also serious hepatoses with danger of life by 
acute yellow atrophy were registered much more frequently. 
In tests with rats and dogs, investigations of the 
function according to FELIX also yielded more distinct 
positive results with trinitrotoluol than after dinitro- 
benzol. Besides, determination of blood sugar after 
doses af adrenalin and direct analyses of the hepatic gly- 
cogen of rabbits indicated a hepatic injury. 
The principles mentioned in the therapy of injuries 
caused by dinitrobenzol including the elimination of 
alcohol also apply to the therap?,' of trinitrotoluol. The 
danger to the liver requires a diet rich in carbohydrates 
and sufficient in calories, as well as a rigorous re- 
striction of the drinking of alcohol, also from that 
point of view. 
IV• Dinitroanlsol• 
No disorders caused by this explosive have been 
observed in men as yet, though it proved very interest- 
ing in the animal tests. 
V. Nitro explosives locally irritating« 
In professional-hygienic respects, some nitro ex- 
plosives are remarkable by the fact that they cause local 
irritation, that is to say they cause erythemas, dermatitis, 
also eczemas. To this group belongs a frequent by-pro- 
duct of technical trinitrotoluol: tetranitromethane. 
Other substances of this group are: di- and trinitro- 
anisol, mono- and dinitrochlorbenzol, and lastly, hexa- 
nitrodiphenylamine (hexa). 
VI. Hexogen. 
Hexogen is no derivative of benzol, therefore it 
has a toxicological character of its own, according to 
its different chemical structure. The substance is 
solid, not easily soluble and does not evaporate easily, 
only if Inhaled as dust, rill it cause poisonings. De- 
spite the nitro groups contained in the molecule, no 
pathological changes in the blood are observed, but ex- 
clusively central symptoms; headaches, giddiness, vomiting, 
also stomach aches; these are accompanied by fits of 
sudden fainting, which will set in quite unexpectedly at different times of the day, often out of working hours, 
even when the patient is feeling quite well, and which may 
last from minutes to hours. If the patient was heavily 
exposed, spasmodic fits, at times even delirious fits, 
will occur. 
In the animal test, the most striking picture of 
motor spasms of partly clonic character prevails. These 
spasms may be of the utmost violence and may return for 
many hours (with intervals) after a single 
exposure. Often, injuries and biting of the tongue will 
result. Besides, bradycardia as a consequence of vagus- 
irritation, vomiting, salivation, incontinence of urine 
and defecation* at times hyperglycemia with subsequent 
hypoglycemia are observed. According to the dose, death 
will occur more or less early by central paralysis or 
exhaustion, and without any fixed rule either during a 
spasmodic fit or in an interval between the fits. The 
fits can he suppressed by analeptics (sleeping drugs) as_ 
long as they are effective, or by preventive treatment with 
bromides. 
VII, Nltroglycols^ 
Theoretically and practically a strict discrimination 
must be made between the grrup of aliphatic nitric acid 
esters and the aromatic nitro compounds. In the picture 
of the symptoms of poisoning caused by the former, the 
effect upon the blood, which depends on the nitric acid 
ester, are preserved, it is true, but the effect upon the 
central nervous system, which depends on the aromatic 
nucleus, is completely absent; also with respect to the 
parenchymatous organs, these substances are much less 
dangerous than the derivatives of benzol. There is per- 
haps a connection between this fact and the fact that 
possible changes in the blood of the same extent are more 
easily tolerated and overcome. 
In practice, these esters disturb the physical health 
by an effect, which is limited to and characteristic of them, 
viz* the distension of the vessels, which manifests itself 
in congest ion"'of the blood in the head, headaches, weak- 
ness, and collapse, owing to the lowering of the blood 
pressure. In case of repeated exposure, increased excit- 
ability and sleeplessness were observed, too. 
On principle, every surgeon is familiar with this 
effect by the therapeutic use of nitroglycerine (rather 
glycerol trinitrate). But as a derivative of the tri- 
valent alcohol glycerine, this explosive evaporates so 
little, that no effective amount of it is inhaled in in- 
dustrial technics. On the other hand, the corresponding 
derivative of the bi-valent alcohol glycol, viz. "dinltro- 
glycol" or rather glycol dinitrate, is considerably more 
volatile, so that larger amounts may easily penetrate into 
the body with the inhaled air. Effective amounts of the 
substance also penetrate easily through the skin, as was 
observed, among other things, even during the tests with 
this substance by the resulting effects (headaches, giddi- 
ness, nausea). Taken on the tongue one drop will be suf- 
ficient with most persons to cause these symptoms, with 
subsequent vomiting and weakness in some persons* It is possible to get accustomed to that to a certain 
extent, but not for any length of time* After pauses in 
work (holidays), when work was resumed, the effect was often 
felt more strongly than before. 
On principle, glycol dinitrate can also produce methemo- 
globin and Heinz-bodies at a particularly striking rate 
and freely, as numerous animal tests have shown. The amount 
of methemoglobin is in a stoicheioraetric proportion to the 
dose and does not exceed the monomolecular proportion. 
Heinz-bodies can be traced in the blood even as early as 
20 to 30 minutes after a dose was administered; besides, 
they can be easily preserved even in vitro by this sub- 
stance. An amazing fact is the complete good health of 
the animals while all their erythrocytes carry Heinz-bodies. 
Anemia will occur as a rule, but mostly with a delay, or 
it may even partially disappear at times despite^continuou • 
doses. The prwer of regeneration of the hemopoeitic system 
is evidently not at all impaired, a fact supported also by 
the large number of reticulocytes. 
Mononitroglycol is in every respect much less poison- 
ous than dinitroglycol, which affords quite an interestirg 
parallel to mono- and dinitrobenzol. Despite considerable 
qualitative conformity, is likewise several 
times less poisonous. All the same, this substance also 
will cause in men disturbances similar to those caused by 
the more volatile dinitroglycol. 
By all experiences, including investigations of 
foreign scientists, the impression is strengthened that, 
for the effect of dilating the vessels of the nitric acid 
esters, neither a saponification of the esters nor a re- 
duction to nitrous acid esters is necessary, but that it 
is rather the esters themselves that are effective. 
Discussion; 
FLUEY; In nitro factories, there often occurs violent 
discoloration of the skin and distinct cyanosis in workers 
without any subjective complaints* Report of a fatal case 
after resorption of nitrobenzol through the skin. 
LENDLE: Question, whether nitro compounds may not 
form dark colored substances with hemoglobin and thus 
create the erroneous impression of a more violent cyanosis* 
Experiments made by HEISE towards influencing the amount 
of ascorbic acid in the tissue and the treatment with ascorbic 
which yielded a negative result* are mentioned. 
WIRTH: Mention is made of tests made by PENDL at 
the Institution for Pharmacology and Military Toxicology 
of the Military Medical Academy, even in case of 
fatal poisoning of rats by dinitrobenzol shoved the life- 
preserving effect of oxygen inhalation. 
DIENENMANN: Why is intravenous supply of oxygen 
not used more in Germany? WIRTH: The danger of embolism is too great* In 
case of subcutaneous application, the amount of oxygen 
which can be supplied, is too small. 
GREMELS: Points out the inefficaoy of intravenous 
infusion of oxygen. 
KLIMMER: Are any particulars known about the 
retrograde change of methemoglobin to hemoglobin? 
HEUBNER: As to human beings no experimental re- 
sults are known. Complete retrograde change in poisoned 
rats occurs after 3 to 4 hours, in poisoned cats after 
7 to 8 hours, in human beings Probably after 5 to 6 
hours# 
The theory of KALLNER about a form of cyanosis, which 
is said to be caused by saline linkage of substances like 
acetanilide, etc* to carbhemoglobin, was ex- 
amined by Dr. GAEDE in two ivays: firstly, the most im- 
portant test-tube experiments of KALLNER were repeated, 
but with absolutely negative results. Above all, the 
difference of color described by him was not found 
(depending on the introduction of carbonic acid into the 
blood sample); even a consultation with ICaLLNER by letter 
about particulars of the method did not yield the same 
results. Secondly, blood was drawn with all precaution 
from a number of clinically observed cases of cyanosis and 
this blood was quantitatively as to its contents 
of methemoglobin (hemiglobin), verdoglobin (sulfhemoglobin), 
reduced hemoglobin and total blood-pigment by aid of light- 
absorption in the apparatus of HAVEMANN, and of'oxygen- 
supply in the vanSLYKE-apparatus* In all cases, 20 so 
far, the color of the blood corresponded to that which was 
to be expected according to the analysed composition* We 
therefore have no reason to accept the supposition of^the 
presence of further pigments as proposed by KALLNER, in 
order to explain the cyanoses, but are rather of tne 
opinion that they are always due to reduced hemoglobin, 
methemoglobin, verdoglobin, or a mixture of them® Nothing 
definite can be said as yet with regard to the occurrence 
of verdoglobin (sulfhemoglobin) in workers occupied in the 
manufacture of explosives. But since the occurrence of 
verdoglobin after large acute doses of dinitrobenzol was 
found in animal tests, I think it possible that, Just as 
after chronic use of acetanilide or phenacetin, also after 
the absorption of explosives, there are cases carrying 
verdoglobin in the blood for a long time. As far^as 
know, verdoglobin is never significant for the elimination 
of the blood pigment as a transmitter of oxygen,^but it is 
important for cyanosis, since the pigment, even in much 
less concentrated form, colors the blood very dark* It 
is absorbed much more in hemoglobin than in methemoglobin 
(hemiglobin)- 
Without particular influences, the reduction of 
methemoglobin (hemiglobin) will proceed comparatively 
quickly, that means within a few hours; Of course, this 
does not apply if the poisonous system, which forms metheno- 
globin (hemiglobin), is constant for a long tine, which is 
evidently the case with dinitrobenzol. Therapy with oxygen is useful onlv in case'of in- 
tensive formation of methemoglobin (hemiglobin)* THen, 
however, it is to be recommended; subcutaneous or intra- 
venous injection of oxygen is always insufficient quanti- 
tatively and besides, it is dangerous and must therefore 
be rejected. 
Directions concerning toxicology of explosives. 
1* Choice of workers: 
In factories producing and manufacturing ex- 
plosives, no persons with previous diseases of the 
liver or anemic states, nor drunkards nor pregnant 
women may be employed or, if so, they must be dis- 
charged. 
2* Prevention of the absorption of poisons* 
With substances dangerous in the form of dust 
(hexogen): the explosives must be moistened, etc. 
With volatile substances (such as dinitrobenzol, 
glycoldinitrate): adequate ventilation-system, par- 
ticularly during the hot season? careful control of 
the protective clothing, above all of the protective 
gloves; strict carrying through of the changing of 
clothes before leaving the factory and enforcement 
of bathing. 
3. General measures; 
Avoidance of alcohol. 
Satisfactory general nutrition, if necessary 
the addition of vitamins, particularly C and B^. 
4. Therapy: 
A. Aromatic nitro compounds: 
In case of trouble due to formation of methe- 
moglobin (weakness, headaches, shortness of 
breath under strain): oxygen-respiration (par- 
ticularly if life is endangered); intravenous 
injection of methylene blue (up to 0.5 grams), 
it is advised to administer a subsequent oral 
dose up to 5 grams; if the danger is less imminent, 
the oral dose alone is sufficient; slighter cases 
of cyanosis require no therapy. 
In case of anemia, the usual treatment with 
iron, even liver preparations is usually less 
beneficial than temporary removal from the factory 
(several weeks’ leave). Milder cases need not 
cause incapacity for work. 248 
The usual symptoms will reveal no endangering 
of the liver, as decomposition of the blood nay 
occur* Repeated execution of the Takata-Ara test 
is recommended, and if possible, the function test 
according to FELIX. 
B. With glycoldinitrate and similar substances, 
the main symptom is lowering of the blood pressure 
with giddiness, headaches, and weakness* By ac- 
commodation these symptoms will often be over- 
come. After temporary interruption of work, at 
times even after a Sunday, the complaints at first 
reappear more intensely. Symptomatic therapy 
will be sufficient. 
For further instructions consult "Directions for the 
Protection of Health in the Manufacture of Explosives" and 
the attached instructions for surgeons as elaborated by 
the National Health Office and published in the National 
Labor Bulletin on 20 January 1941 by the National Secre- 
taries for Work and Economy, as,well as decree of Army 
Headquarters (Chief of Army Armament and Commander of the 
Training Army) B 26/2? top secret document V 8 (11/1) 
Nr. 624/42 top secret document of 8 February 1943)* 
3. On the toxicology of explosion- and combustion-gases. 
Flottenarzt (Fleet Surgeon) PFLESSER 
Corresponding to the experience of rrorld War I, ex- 
plosion and combustion gases claimed numerous victims 
among the personnel of the German Navy also in this war. 
Three great catastrophies caused by enemy bombs are 
reported: 
1. A bomb hit on a cruiser which killed 60 and 
wounded 22; 
2. a bomb hit on a battleship which killed 89 and 
wounded ?0; 
3. another bomb hit on a battleship which killed 
114 and wounded about 80. 
Though these three cases, in their particulars, con- 
firm many known facts, they also raise a new problem: in 
cases 1 and 2, many killed men, who had no outward injuries 
whatever, showed a violent cyanosis or discoloring by carbon 
monoxide and always a white or slightly bloody clump of 
foam - of about the size of a fist - at their mouths and 
noses. far as autopsle#'ware made {only In case 1), 
the lungs showed an intense diff\f$o someteat marked 
aapdratio* of *0*1 and dust ft* fs# as t&fc i*nem»st parts 
of the lungs*, lie casppulmp«ary edema was observed 249 
among the surviving persons, after superficial burning or 
scorching, in many cases corrosive crusts of the pharyngeal 
mucous membrane, distinct susceptibility to infection of 
the respiratory organs, bronchopneumonias and bronchitis 
even 1 to 3 days after the injury. 
It was demonstrated that neither the explosion gases 
nor the "impact of air pressure" offer an explanation of 
these findings in dead and surviving men* Rather it is 
highly probable that these are typical consequences of 
injuries to the respiratory tracts and lungs caused by 
heat, which were never observed in this distinct form 
before. The statements of the surviving men seem to 
confirm this theory: an intolerable sensation of heat 
in the lungs with the first breath in the darting flame, 
continued hot pain in the chest, and the feeling that the 
chest had become too narrow. Another confirmation of the 
theory is seen in the following facts: warned by ex- 
perience, the part of the crew held in readiness below deck 
were ordered to put on their gas masks in the future in 
case of alerts. Reason; Protection against heat. Result: 
In compliance with this order, the clinical pictures ob- 
served in cases 1 and 2 were no longer observed in case 3? 
neither with the dead nor the wounded. Another confirm- 
ation of the theory is FISCHER’s observation during dn 
explosion accident1 at a Frankfurt ammunition factory in 
February 1917. (FISCHER and GOLDSCHMIDT: "On changes of 
the respiratory tracts after poisoning by war gas and after 
combustion". Frankfurt Journal for Pathology, Vol. 23? 
Nr. 1) 
In case 3? there are also reported 4 men injured 
nitrose with acute toxic pulmonary edemas, all of them 
with complications (they all had violent leukocytosis 
with another peak on the seventh day, 2 had bronchopneumonia, 
2 collapse, 1 neuritis). Besides, their need of oxygen 
amounting to 156 300 liters within 4 days in spiwe of most 
economical dosage was rather surprising. 
Discussion: 
HEUBNER: Perhaps, the distinct boundary between 
pulmonary edema and bronchopneumonia is explained by the 
boundary between bronchiolus and alveolus, which in one 
case of sufficiently hot air is not reached, in the other 
exceeded* 
EICHLER: Heat need not be ascertainable by measuring 
instruments. Single molecules may retain enormous energies 
and thus hit the alveoli (theory of hitting molecules?) 
FLURY: The question, to what extent carbon monbxide 
travels on a street after an air-raid, depends on quantity, 
time, temperature, local conditions, and wind. Under pres- 
sure, carbon monoxide will easily penetrate into the porous 
earth while it will diffuse from it only very slowly* (Dur- 
ing the first World War, deaths occurred in trenches and 
dug-outs in the porous chalk of the Champagne). 4* Concerning the question of the use of potent drugs 
in The "Armed Forces without control by the 
surgeon,■ 
1st lecture* 
Oberstarzt (Colonel, I,TC») Prof* 17. V/IRTH 
This question represents a practical problem. 
The need of having strong anodynes available with units 
left to their own resources doubtless exists, and that both 
from the point of view of the individual soldier and from 
the point of view of the commanding officer who must see to 
it that the morale of the wounded combatants who are not as 
yet wounded should not be impaired by too loud manifestations 
of pain by the wounded. This applies especially^to the men 
of the armored cars. Here it is chiefly a question of alle- 
viating pain after injuries caused by burning, which has ob- 
tained additional importance by the frequent use of phos- 
phorus incendiary ammunition. Of course, alleviation of pan i 
due to wounds is equally important, though^great loss of 
blood and shock will often render such medicines unnecessary 
at first. Lastly, we are interested in the question raised 
also with regard to a possible use of war gases rapidly 
causing pain« such as the nettle substance ahos_ge 11 ox 1m. In 
This case, not only isolated units, but every individual 
soldier ought to be equipped with an anodyne* 
As regards the practical answering of these questions, 
the Anglo-Saxons have already led the way. Even in 1941/42, 
we found syrettes of morphium in English armored cars capt- 
ured in Africa. Similar to the tubeunic-ampoules known in 
Germany, which are filled with lobelin by the firms Hoffmann 
la Roche and C.H. Boehringer, Niederingelheim. These syrette 
consist of tin, with the hypodermic needle attached to them. 
A sterile injection is possible. Similar syringes of American 
origin were captured on American soldiers in Tunisia. 
Contents• 
English: 
American: 
\ grain (0.0324 grams) "omnopon" 
(total opium-alkaloids) with 
i grain (0.0162 grams) morphine 
grain (0*0324 grams) 
morphine tartrate 
In the German Navy, there is among other medicines 
also morphine for alleviating pain at the disposal of the 
commander of submarines and other small units without a 
surgeon* The same applies, in uarticular cases, to the 
German Airforce as regards the equipment of airplanes. 
Por this reason, we asked the medical authorities of. the 
Navy and the Airforce to state their opinions on the 
problem in question especially as regards practical ex- 
perience* The following questions are therefore to be discussed 
and answered: 
1* Is the equipment of units without surgeons, and 
}.eft to their own resources, with strong medicines, 
chiefly morphine compounds for use of medical per- 
sonnel a. necessary, b. suitable? 
2* Is the equipment of every soldier with strong 
medicines for alleviating pain and preserving efficienc; 
in case of phosgenoxim-effect a. necessary, b. suit- 
able? 
3. Should questions 1 and 2 be answered in the af- 
firmative, the morphine syringe or preparations ad- 
ministered perorally should be considered particularly. 
Discussions 
EICHLEH: For alleviating violent pain, subcutaneous 
injections are necessary. The few ampoules would have to 
be kept under control. 
SCHMIDT: points out the danger of uncontrolled peroral 
doses of opium by the medical corpsman in case of obscure 
pain in the abdomen. 
SOBERING: To prevent misuse and unnecessary use of 
tabloid opiates, it is suggested to use ampoules exclusively 
for equipment of military units* 
BOOK: In the Airforce, the equipment of all small 
units engaged far from a field surgeon, with morphine 
ampoules kept under control has proved very efficient* 
Refers to Navy Manual Nr* 269, page 75, 
par* 18. 
2nd lecture: 
Stabsarzt (Captain. MC.) Prof. ANTHONY 
Summary: 
1, To prevent fatal weariness, pervitin is contained 
in the emergency outfits of the flying personnel and 
has proved beneficial in some cases* 
2. For refreshment during engagements, accessory 
foodstuffs containing caffein are sufficient and are 
generally more suitable than pervitin* Onljr in ex- 
ceptional cases* the surgeon should be authorized to 
distribute pervitin for these purposes* 3. Strong anodynes were repeatedly asked for, but 
not yet added to the emergency-outfits. For these 
purposes, antineuralgic tablets were distributed so 
far. 
4. The demand of appropriate suicidal medicines to 
be used in case of captivity was not complied with. 
5. It is necessary to settle this question uniformly 
and on special lines. 
3rd lecture: 
Marine-Stabsarzt (Lieut»4 MC», Navy) Prof. 
ORZECHOWSKl 
Peacetime medical equipment with strong medicines for 
smaller units of the Navy without medical officers wes 
discussed, and the additional potent drugs in war selected 
for vessels sailing alone were mentioned. No objections 
had been raised to the equipment of naval units without 
medical officers with potent drugs. The long experience 
in this field admits the conclusion that the equipment of 
smaller naval units without medical officers with potent 
drugs is suitable. 
The regulations for the Navy determing the use of 
potent drugs by non-medical men were mentioned. The treat- 
ment of sick sailors by laymen by aid of the book of medical 
advice for submarines was illustrated by a few examples from 
that book. 
The new institution of medical N.C.O.fs with special 
training was discussed. These medical corpsmen may use 
many strong medicines from the medical outfit of the units. 
Experience of one year shows that all so engaged 
have accomplished their task most satisfactorily so far. 
Directions on the questions of using potent drugs 
in units without control by a surgeon. 
1. The equipment of the units left to their own re- 
sources without medical officers (at advanced bases, 
defence posts, smaller naval units) and the equipment 
of armored cars and planes with strong medicines 
(anodynes) for use in case of woundings and burning- 
injuries, is necessary and suitable. 
2. For the purpose mentioned, particularly sub- 
cutaneous Injection of morphine compounds of SEE- 
mixture or adequate efficacious analgetics should be 
taken into consideration. Importance should be 
attached to the preservation of consciousness. 3# If possible, the administration of anodynes 
should be reserved to medical corpsmen especially 
trained for it. 
4. The application of the mentioned strong medicines 
by medical corpsmen for alleviating obscure pain in 
the abdomed should be prohibited# X. 
PROCEEDINGS OF THE CONSULTANTS' 
COMMITTEE ON 
PHARMACY AND FOOD CHEMISTRY 
Translation prepared by: 
Office of Military Government for Germany (U. S* ) 
Office of Naval Advisor 
Medical Section (SURVEY) 
The Consultants1 Committee on Pharmacy and Food Chemistry; 
was concerned with the problems of medical equipment, chemical 
items of field equipment, usefulness of existing materials 
and possibilities for improvement. Those topics were dealt 
with in various discussions by specialists who had gained 
practical experience in daily contact with the respective 
equipment, in such assignments as army pharmacists, corps 
pharmacists, chiefs of chemical laboratories, etc. Several 
contributions were made on important problems of food and 
nutrition. One of the outstanding speakers on this topic 
was Oberfeldarzt (Lt. Col., MC.) Prof. Dr. LANG, who is 
a member of this specialty board, which has coordinated its 
efforts with those of the internists, hygienists and army 
Physiologists. In the field of analytical chemistry dis- 
cussions were devoted to the influence of chemical warfare 
agents on food, their detection and nemoval or preventive 
measures# A further discussion of special interest in war 
time was concerned with technical chemical procedures for 
forensic medicine. Another discussion was devoted to the 
planned rebuilding of the various domestic industries in 
the Eastern territorries and to the most important cultiva- 
tion and collection of wild growing medicinal herbs. (Util- 
ization of glands). 
The different reports and discussions are summarized 
as follows: 
1# Medical equipment. 
Oberfeldapotheker (Lt. Col., Pharm# Corps) 
Dr. FISCHER ' “ 
A couple of recently introduced items pertaining to 
the medical field equipment nor* in use were under discussion 
and proposals rs to their improvement were made'after due* 
consideration of experience made in field units# Among 
others, the following observations were presented# The 
surgical bag of the medical officers is considered too 
heavy and clumsy, a flat canvas bag with carrying straps 
and convenient compartments was proposed. The medical field 
equipment was likewise considered too clumsy, especially in 
mobile warfare# A great part of the equipment was usually 
left behind with the baggage. Efforts should be made to 
reduce set "A" to 2-3 boxes by stowing part of the dressing 
material in medical field packs. 
It was suggested that the system of winding^the in- 
struments in a strip of canvas be replaced by using a plain 
canvas bag and the water barrel be replaced by a sheet metal 
can similar to gasoline cans. 256 
It was considered desirable to include the following 
instruments in set MAM: Blood pressure apparatus, otoscope 
and perhaps an adjustable light source working on 12 Volts, 
15 - 30 Watts? with a light tripod and reflector. The 
following medicaments should be eliminated or reduced in 
quantity: Barbital, morphine, hexamethylenetetramine, 
digipuratum, heat stroke and calomel tablets, solvochine, 
and caffeine-sodium-salicylate ampoules. Consideration 
should also be given to replacing the opium tablets in the 
medical bag by tannalbin tablets. The introduction of the 
following medicaments was recommended; Phanodorm, luminal, 
eleudron and serum preparations with higher contents of 
antitoxics• 
It was recommended that the dressing material in the 
medical units no longer be packed in heavy metal protected 
wooden cases, but in water tight bags similar to laundry 
bags or in plywood crates, wicker baskets or the like. It 
was required to provide a special compartment in these sets 
for the opiates that can be locked by special key# The 
ordinary lock now in use cannot be considered as sufficient 
protection. It is suggested that sets MCn and ,!Dn be pro- 
vided with a larger number of basic medicaments and be made 
more complete by adding the following instruments: A press 
for suppositories, larger mortars and perhaps even a device 
for the making of pills. The demand for a field distilling 
apparatus for the medical companies and field hospitals can 
be satisfied soon. A field distilling apparatus with a 
capacity of 5 liters will be the first model introduced. 
The proposed introduction of a couple of new medicaments 
into sets f,Cft and ffDu is still under discussion. Bequests 
for a greater stock of blood substitutes available in the 
blood-banks are constantly made. A decrease of the quan- 
tity of chloroform (for anaesthesia) in favor of ether rould 
meet actual requirements. An exchange in the quantities of 
various pills would also be advisable; the quantity of 
calomel tablets for instance is abundant, while there are 
relatively too few cardizol tablets. Analgeticae and anti- 
neuralgicae and targesin throat tablets are completely ab- 
sent. The stock of cellulose and cctton at the medical 
companies should be much greater. The proposed minimum 
stock of plaster bandages is in no relation to the actual 
requirements an increase of the stock is imperative. A 
larger cast knife with a wooden handle and a somewhat 
stronger pair of cutters for cutting the plaster casts 
and an adjustable pelvic shelf for the table would be de- 
sirable. The sterilization drums of the field autoclaves 
are not considered sufficient in number, at least 8-10 
drums are required. Set "D" of the equipment is not con- 
sidered suitable for use in field hospitals, because too 
many tablets, liquids and instruments of common use are 
missing. The development of a special set for field hos- 
pitals, subdivided into sets for the surgeon, for the in- 
ternist and for the pharmacy would be desirable. 
The entire equipment of the medical field depots of 
the Army should be overhauled and adapted to the actual 
requirements. It should be borne in mind, that the stock- piling of too large quantities is detrimental to the mobility 
of the field depots. Special care should be given to the 
contral-depots which, according to their important role of 
supplying several field depots, must be enlarged both in 
supplies and in personnel. 
Chemical itoms of field medical equipment* 
Oberstabsapotheker (Major, Pharm. Corps) Dr. MOUCKA 
In t he anti-gas field laboratories the following new 
procedures are worthwhile mentioning: More importance is 
now attached to the examination of aqueous sample extracts, 
chemical proof of Lewisite, the proof of nitrogenous and 
sulfurous compounds in Losr, proof of anthracene oil, and 
the new instructions for cleaning and decontaminating the 
testing Instruments. In the testing instruments for chemical 
weapons the former DS instrument has been replaced by a 
gas indicator. The principal examinations will in the 
future consist of the following steps: The examination of 
the aqueous extract on chemical agents, proof of sulfur 
if Lost is suspected, a simple but strictly a chemical 
method of Lewisite detection and the proof of arsenic com- 
pounds. The new examination equipment consists of two 
cases: 1 case contains instruments and reagents for the 
chief examinations, case 2 contains the gas indicator, a 
device for the drawing of samples and other requisites re- 
quired for urgent examinations in the field. If it is not 
possible to bring case 2 to where it is needed, the gaso 
indicator and test tubes and the other necessary implements 
may be carried in a field pack* 
The supplemented biochemical testing set permits, 
v/ithout changing the working methods, the following addition- 
al special examinations: Colorimetric determination of 
total protein, of serum albumin, of globulin in the blood, 
urine, and in urine the following tests: Colorimetric de- 
termination of indican and xanthoprotein, determination of 
diastase and the diazo reaction. The following additional 
blood examinations may be carried through: Colorimetric 
determination of cholesterine, hemoglobin, creatine and 
creatinine, uric acid, diastase, Takata-Ara test, determin- 
ation of sodium chloride and diastase in the stool* It 
is planned in a later more complete model to add all the 
important instruments for a mane comprch£.&s8y6 examination of 
blood and cerebro-spinal fluid. 
The new cases Nr. 8 a, b and c of the chemical field 
laboratory contain instruments and reagents for the ex- 
amination of water, medicaments and foodstuffs as well as 
for chemotechnical and toxicological examinations. Fuels 
can also be examined as well as metal plating and cloth 
fibers. The chemical field laboratory is still in the 
process of reorganization. The essential problems are 
the source of energy for the burners, incubators and stoves, 
and the light for the optical instruments. It is proposed to provide a gasoline powered generator for this* The 
big incubator will be replaced by a new electric one and 
a small additional incubator for gas heating* An electric 
hot plate working on 120 Volts and lightbulbs for 126 Volts 
will be added* The new cases have a somewhat smaller size 
and permit their being used as laboratory desks with the 
aid of intermediate boards* The number of chemicals has 
been slightly decreased. The containers will be provided 
with more secure closures. The raw fiber determination 
developed by SCHARHER may also be used* A vacuum distilling 
apparatus, a generating vessel for sulphuretted hydrogen 
and other instruments will be added. The hygrometer and 
the nPehaviM as well as,the Westphal balance will be elimi- 
nated. Other instruments will be thoroughly modified. It 
is intended to decrease the number of ready made liquid 
reagents in favor of an increase of the quantities of con- 
centrated acids* A silica compound will be used as an 
exsiccator filling. Dithizon and hydroxylamin will hence- 
forth be used for the determination of small quantities 
of lead, fuchsin, and sodium for the determination of 
methyl alcohol; ferric sulphate for the determination of 
blood sugar according to the method developed by BERTRAND. 
The books will be replaced by more recent publications* 
3* Pharmaceutical practice in the 6th Army* 
Oberfeldapotheker (Lt. Col*. Pharm. Corps) 
Dr. PATZSCH 
As an introduction, reference was made to the numerous 
pharmaceutic-chemical problems the 6th Army encountered 
and mastered in and around Stalingrad. As an example, the 
exceptional hardness of the water was mentioned, which lead 
to a critical situation in the water supply. The different 
phases of combat made frequent movements of the supply 
depots necessary. Only very limited channels of supply 
by air were left open after the encirclement of the main 
body of the army. Frequent Changes of the take off bases 
of the planes were carried through in a minimum of time 
and required quick and strenuous action* These operations 
were carried through without abnormal losses. The free 
loading capacity of the planes allowed only medical supplies 
of 50, 150 or 200 kilograms to be taken aboard* The supplies 
thus available had to be assorted proportionally according 
to the requests received. The average loss rate was ap- 
proximately 15 - 20 per cent* In spite of all these dif- 
ficulties the most urgent demand could at all times be 
satisfied as long as the planes were able to operate* Hpw 
important the requirements were, will be made clear by only 
one example: The number of plaster bandages needed amounted 
to 10 000 pieces per week. An important point is the 
standardization of the packing and crating material used 
for medical supplies to that already adopted in other lines 
of army supply. The replacement of medical equipment offered particular difficulties, the more so, when scattered parts 
of the Army fighting outside Stalingrad were united with 
the Army Group HOLLIDT. In this case, too, the army 
surgeonsdid not ask first for set ,?AM, but for the medical 
box ,f30tf together with a few instruments or a complete 
case of surgical field instruments. In the ultimate re- 
treat the transportation of the bulky material presented 
great difficulties, this is especially true for the paper- 
clothes and it is recommended that the volume of these 
items be reduced by pressing them into a more compact form. 
Qualified personnel to handle the medical equipment was 
not available during the retreat, so it happened that im- 
portant items were taken too far back, which were later 
bitterly needed in the lines. When a landing within the 
fortress of Stalingrad was no longer practicable, re 
fortunately succeeded in dropping a scanty supply by 
parachutes even until the end. The allocation of the 
remaining material of the medical depot at Charcow to the 
Army Group B jeopardized a quick supply to the new 6th 
Army. Hence, there was an acute need of^certain medicaments 
such as dextrose and medicines to be administered in cases 
of disturbances of the circulation. Solutions made of 
’’Dextropur” (powdered grape sugar) which were offered as 
a s bstltute were Rejected. It was then emphasized that 
an optical shop should be attached to the medical depots 
(army group depots and upwards to higher units), also an 
orthopedical shop would be very convenient. The experience 
at Stalingrad again showed that unforeseen situations may 
crop up at any time which require the medical service to 
act on the spur of the moment. 
4, Work and special duties of the corps pharmacist in 
the EasIT 
Stabsapotheker (Captain. Pharm. Corps) Dr, KLEIN 
The cooperation of the medical corps (in the Eastern 
theater) in the supply over long distances^proved very 
satisfactory; its work consisted in gathering up the total 
requirements of medical supply and in creating central 
distribution depots of the corps for the purpose of 
satisfying all demands of the army medical depots and thus 
in the end giving the army surgeon the material needed In 
his daily work* The versatility of the medical companies 
and their!use as small supply units for advanced positions 
should be the most important goal. The new stricter re- 
gulations concerning the exchange of field stretchers 
blankets, especially in case of evacuation by air or hospital 
trains and the provisions qf frost-bite remedies for use 
during evacuation will be welcomed by the troops# The co- 
operation with the gas-warning officers has not.been satis- 
factory as far as gas warfare chemistry and the use of the 
field gas laboratory is concerned. The gas-warning officers 
are in many instances not well.informed necessity of a 
close cooperation with the corps pharmacist# The mess-halls 
and field bakeries are regularly inspected and spot checks 
are made on previous understanding ■with the proper officer. 
The task of the corps pharmacist is still so important today 
that one cannot possibly think of cancelling this position. 260 
5. Reconstruction of the pharmaceutical chemistry and 
~ food' chemistry industry in the EaslT# 
Oberstabsapotheker (Major. Pharm. Corps) 
wrT3h~nmmf—— 
In the northwestern section of the Lake Ilmen district 
there are no factories of importance falling under the scope 
of this section* The neighboring land will also in peace- 
time have to supply the provincial towns* In planning for 
the future it would be wise to consider building distilleries, 
potato starch factories, wood distilling plants, medicinal 
herb gardens, fruit plantations (esp* raspberries and black 
currants). Special care should be devoted to the raising 
of sheep (production of wool fat) and bee-raising. The pro- 
duction of medicinals at Forchow and the collection of wild 
growing medicinal herbs should be encouraged. It should 
be noted that the army pharmacists have done the±± best to 
alleviate the keen lack of medicaments of the Russian civil- 
ian population in the year 1941/42# It was pointed out that 
the utilisation of animal glands (esp. pancreas gland) in 
the rear territories is of the utmost importance# 
6# Food concentrates. 
Oberstabsapotheker (Major. Pharm. Corps#) 
ProF. Dr. UNGERER 
A report was madd on the composition of emergency food 
concentrates® The daily ration of 300 grams contains about 
1?00 calories; it Contains 8-10 per cent of protein calories 
and 68 per cent of fat calories. Additional food with an 
adequate quantity of carbohydrates in the form of bread, 
dried whole grain bread or biscuits is necessary, to give 
the diet more energy food hnd to reduce the too high content 
of fat# The preservation under normal temperature may be 
called good. Captured English food concentrate tablets 
w<3Jghing 2.5 grams each and which were said to contain all 
the necessary ingredients proved to be completely insuf- 
ficient due to the fact that they contain only 9 calories. 
The food pill will always remain beyond realization. 261 
■!Z»— Special forensic and toxicological research. 
Stabsapothekcr (Captain. Pharnu Corps) Dr* MAYER 
A new method of separating alkaloids and other poisons, 
including heavy metals, in solution, from organic substances, 
and their quantitative determination in vomitus, organic 
pulp* etc* has been developed along the lines of electro- 
dialysis in which four osmotic cells and certain electrolytes 
are used. The details and possibilities of this new pro- 
cedure were then discussed; A report on the particularly 
rich experience of a chemical research station was then 
made, it included details on sabotage material for poison- 
ing men and animals, for arson, explosive cartridges etc. 
which were used or surrendered bv partisans* In the dis- 
cussion reference was made of an enemy (English) pamphlet 
giving detailed instructions on how to feign oneself sick 
and unfit for duty and how to use certain chemicals and 
medicaments for the sane purpose. The knowledge of these 
possibilities is very important to the chemical research 
stations for the purpose of determining malingering and 
purposely selfinflicted injuries. 
8« Nutrition problems* 
Oberfeldarzt (Lt. Col.. MC.) Prof« Dr» Dr. LANG 
The physical efficiency of a person requires an intake 
of protein exceeding by far the physiological minimum. Full 
efficiency is attained with a daily intake of 80 - 85 grams. 
Larger doses rather produce an increase of vital energy than 
of actual efficiency* Of still higher importance than the 
biological valence of protein substances is its importance 
as a supplementing substance. Milk protein for instance is 
able to supplement vegetable protein so as to obtain valuable 
nutrition. This was tried out in the feeding of persons 
injured by long continued deprival of food. Individuals 
suffering from hunger edema were given 50 to 55 grams of 
protein per day and soon their N-balance became positive. 
All experiments with artificial fats have been successful. 
A daily consumption of a moderate quantity gave no abnormal 
metabolic products whatsoever. In‘the winter campaigns in 
Russia when the supply of vitamin C dropped far below the 
desirable minimum, no avitaminotic or hypovitaminotic con- 
ditions were recognized. Experiments made in naval stations 
proved that severe cases of scurvy were all right again in 
a very short time after 10 milligrams of ascorbic acid had 
been administered. These experiments and the cases described 
in recent publications show that by far smaller quantities 
of ascorbic acid are required for the maintenance of health 
than was generally supposed. When dealing with nutritive 
values it must be borne in mind that the figures shown in 
the official schedule are by 10 - 15 per cent too high due 
to the decrease in quality of the respective food. If the 
greater part of the required protein is supplied in the form 
of vegetable protein, it must not be overlooked that the list gives the percentage of crude protein and that the effective 
part of pure protein is only about 50 per cent or less of 
this figure. Bread made of finely ground flour is not as 
rich in protein as white bread. The contents of protein 
are higher, indeed, but due to the lowered resorption the 
actual intake of protein is lower than in case of bread 
made of less finely ground flour. The bran contains too 
much phytin and thus forms insoluble calcium saits which 
are difficult to absorb. Thus the consumption of bread 
made of finely ground flour reduces the intake of calcium* 
In the present ration of the soldiers there is a deficiency 
of calcium. Experiments to add calcium to the bread to 
overcome this deficiency are pending. During the dis- 
cussion it was pointed out, that the absorption of vitamin 
B in the case of repeatedly ground flour is worse although 
the quantity available is larger than it is with white flour 
(which is ground fewer times). 
9t Food and chemical warfare agents» 
Oberfeldapotheker (Lt. Col». Pharnu Corps) 
Dr. K. GEMEINHABDT 
The problem of the influence of chemical weapons, their 
detection and prevention and possibilities of decontaminating 
foodstuffs without affecting their usefulness is of special 
importance in case of difficult supply and scarcity. The 
instructions laid down in the Field Manual 395/1 and 396 
and in circular D 1107 were then discussed and commented 
upon. Whereas the influence of gageous and vaporous chemical 
weapons, including Lost vapors, can be eliminated and de- 
odorized mechanically due to the high degree of moisture in- 
herent to foodstuffs and which causes hydrolytic effects 
by simple exposure to the air and sun, this is not the case 
when field poison gas, especially arsenic compounds, are 
being used. The scraping off of the cuter layers of con- 
taminated foodstuffs brings about good results if done 
soon after the contamination. Before and after any treat- 
ment a chemical examination in a field laboratory is 
necessary. This examination does not take much time. It 
is emphasized that no adequate decontamination can be ob- 
tained by cooking, baking, smoking or salting, especially 
if arsenic is involved. 
Special care should be devoted to proper packing and 
piling in boxes and in protected places in order to 
avoid excessive damage. These measures, as well as the pro- 
tective effect of the kinds of packing material were describ- 
ed. Arsenic plays the same role in the contamination of 
water. Gaseous, vaporous chemical warfare agents in- 
cluding Lost are soon dissipated by hydrolytic action; 
The non-dissolved particles of Lost can be eliminated 
mechanically by passing the water through a filter. Arsenic 
on the other hand must be eliminated by a more intricate 
procedure, not more than 50y of arsenic per liter can be tolerated. This could up to the present be achieved only 
by passing the water through an organic charcoal filter 
(principle of the anti-gas field drinking water filter). 
Poisoning of subsoil water with chemical agents ban be 
considered as impossible under normal soil conditions. 
The dilution in the subsoil flow and the chemical and 
physical absorbent action of the soil will sofcn decon- 
taminate the water after flowing a short distance* An 
open well or water hole may, however, easily be poisoned. 
The chemical examination of the potable water must be 
carried through regularly. 
The food chemistry laboratories, anti-gas stations 
and substations placed under the command of the army 
medical inspector are the only competent personnel to 
carry through these examinations with the proper equipment. XI. 
PROCEEDINGS OF THE CONSULTANTS' 
COMMITTEE ON PSYCHIATRY 
Translation prepared by: 
Office of Military Government for Germany (U. S* ) 
Office of Naval Advisor 
Medical Section !• Questions on the classification of psychoneurological 
cases with respect to service incurred disability* 
Oberstabsarzt (Manor. MC.) CHRISTUKAT 
A brief historical review of the policy concerning 
claims after World War I introduced this discussion. In 
the nationalsocialist Germany new liberal regulations (sic) 
considering the welfare of disabled ex-service-men have 
been formulated which are guided by the principle: nAde- 
quate employment instead of pension” and aiming at a re- 
integration of the disabled soldiers into a productive 
and contended life* A few specific cases of neurological 
diseases in which the environmental factor had not been 
duly considered were then discussed at length. It is im- 
perative that the evaluation of each case be based on 
individual findings, and similar cases should not be 
followed. All disabilities, though they are of'an indi- 
genous, hereditary or psychoneurological origin, may to 
some extent be due to environmental factors (combat, 
privation etc.) and may be evaluated from a different 
angle. 
2. Consideration of the list of deficiencies with regard 
to some forensic-psychiatric questions• 
Oberstabsarzt (Major. MG.) Prof. WUTH 
With a view to determining the degree of mental weak- 
ness the office of the army medical inspector has recommended 
to the army recruiting surgeons that a text be dictated to 
those subjects suspected of mental weakness. The^question 
of the suitability of sterilized subjects has definitely 
been decided in the sense that they will be separated from 
the Army and considered unfit for military service. The 
modification of deficiency group 15 of the classification 
of fitness was then commented upon. It is understood that 
the LU category comprises diseases or equivalent pathological 
conditions, whereas delinquents (criminals? homosexual 
subjects etc.) fall under A 15, 3« There is an important 
difference between U 15, 3 and A 15, 3? ahd under no cir- 
cumstances may U 15, 3 be considered a lighter degree of 
A IS-, 3» In accordance with orders, forensic-psychiatric 
diagnoses will be made by qualified psychiatrists only. 
The paragraph 51, 2 penal code (*) is often applied with 
too much Indiscretion and without proper examination to 
determine if paragraph 42, b would not suit the case. It 
is important in this connection to specify that military 
secrecy is an integral part of public security. 
(*) Editor!s Note: Paragraph 51, 2 of the German Penal 
Code concerns mental incompetence; Paragraph 330 etc. 
concerns reduced punishment according to particular 
circumstances, such as temporary insanity etc. Drug-addicts or alcoholics will be classified in 
accordance with the provisions of paragraph 42, b penal 
code because the application of paragraph 42, c would, 
in case of punishment, result in loss of rank and there- 
fore an unintended severity. According to the information 
received from the office of the judge advocate the psy- 
chiatrists will be considered the only qualified personnel 
to give judgement as to the application of paragraph 42 
and 330, a. 
3* Hysteria and simulation* with special consideration 
ol1 psychogenic factors added tip organic injuries» 
Stabsarzt (Captain, MC.) Prof, PANSE 
The overwhelming majority of psychogenic reactions 
are positively characterized by hysteria* I am using the 
term psychogenic because it is more comprehensive and less 
prone to emotional interpretation* The picture of spycho- 
genic reactions has changed* They are less apparent, in 
a larva stage I might say, and are based in many cases on 
an organic deficiency. They are difficult to distinguish 
and therefore particularly dangerous* The proper active 
treatment of psychogenic cases is beyond the scope of 
many a surgeon in that he either does not recognize the 
nature of the disease or he recognizes it and treats it 
inadequately. Even insignificant additional psychogenic 
impairments justify therapeutic measures by the fact that 
often lead to such completely erroneous classifications 
as "fit for garrison duties” and "fit for labor duties"* 
After treatment of 315 cases out of 500 at the army re- 
serve hotel at Ensen by suggestion therapy including the 
use of high galvanic currents, I can now review the re- 
sults which are as followss 52 per cent were again fit 
for active service, 17 per cent fit for garrison duties 
in the field, this means that 2/3 were fit for use in 
combat; 24 per cent were classified as "fit for garrison 
duties at home" because of constitutional or nucleic de- 
ficiencies; 5 per cent were "fit for labor duties" or 
"unfit for military service"; 2 per cent were trans- 
ferred to other hospitals and were suitable for labor 
assignments on an ambulatory outpatient basis* The 
personal background is in all cases a decisive factor 
for the assignment*. Careful evaluation ftill hfclplto pre- 
w&it relapses, which-however- cannot be fully excluded 
to Che particular constitutional conditions, of the 
respective soldiers. Ten of re lapses have feoen re- 
ported, and it is possible that there are- actually more 
than ten* 
In 500 cases we had only one failure and that con- 
cerned an inveterate hysterical pension-hunter with ex- 
perience gathered in W6rld War I. These results will 
clearly demonstrate that successful treatment is possible 
in the majority of cases* Only refractory patients 
should be kept under isolated observation, especially 
if a detrimetal influene on other soldiers is likely 
to be exercised. Much of the success depends on the physician-patient relationship, on an atmosphere of con- 
fidence creating a susceptibility to suggestion* It is 
a matter of fact that most of the psychogenic diseases 
are specific forms of an escape from environmental de- 
pressions* It is psychologically unwise for the patient 
to realize that his condition is due to the above stated 
influence because it would to a large extent jeopardize 
the therapeutic possibilities® The psychogenic patients 
are treated in the same manner as the organic patients 
and are not kept in detached rooms* Mistrust and em- 
bltterment which do anything but further the therapy are 
avoided this way* The borderline between hysterical 
reactions and malingering is often hard to define. V.re 
therefore, apart from a very few drastic cases, do not 
indulge in any attempts of differentiation but we treat 
the cases with energy. The result will be the same. It 
is recommended that suitable surgeons be detailed to 
army hospitals where this therapy is practised. 
Comments upon the above report by Oberfeldarzt 
(Lt. Col/. MC/ Prof, VILLINGER 
The varieties of the described psychogeneous diseases 
have undergone a change so that now 90 per cent of the 
cases are side-affects of organic diseases or injuries 
in the form of fixations, hysterical reactions, such as: 
Pseudo-paralysis, pseudo-contractures, diffuse pains, 
vertigo and fear. A careful medical examination by 
qualified specialists and a psychiatric evaluation of the 
patient is necessary. In any case where the healing 
period exceeds the normal time the possibility of a 
psychogenic component should be contemplated and adequate 
treatment should be applied without hesitancy* In my 
opinion tie neurologist is not consulted often enough.^ 
As a matter of fact, there are many psychogenic cases in 
army hospitals and in the army convalescence units which 
are not treated as such. The therapy must be adapted to 
each case in due consideration of the personal background, 
th& symptomatology and genesis. Provable malingering is 
rather rare. 
Out of 255 neurotics, 39 per cent were discharged 
from the hospital as "fit for active service", 27 per 
cent as "fit for garrison duties in the field" - this 
means that 66 per cent were again fit for use in field 
service* 27 per cent were classified as "fit for garrison 
duties at home", 5 per cent as "fit for labor duties"; 
only 2 per cent proved to be resistant to this therapy 
to such an extent that they had to be isolated. 
In 3 cases disciplinary action was taken because of 
obvious malingering. It is important to keep the neurotics 
in a trustful frame of mind. The electro-shock following 
an adequate hypnotherapy has shown good results even in 
case of intentional opposition to this therapy. This method is, therefore, prone to further development* A 
special labor therapy proved very efficacious in regard 
to discipline and the will to be productive* A weekly 
schedule of labor to be performed in different groups 
according to efficiency is recommended* Utilization 
in armament or other suitable .factories is possible-, 
the working hour's should be gradually extended* 
Directions on hysteria and malingering with special 
conslderailon of psychogenlc factors added to 
organic in.1 uries> (Supplement of the directions 
of tlie Army Maniial page T2£T7~ 
1* The army and hospital surgeons are supposed to 
have full knowledge of the Army Service Manual 209 
and of the Special Instructions dated August 31? 
1932. 
2* Special attention should be paid to psychogenic 
and hysterical disturbances in their incipient stage 
in all sections of army field hospitals* If the 
average time of rehabilitation is considerably ex- 
ceeded in cases of paralysis, gunshot wounds affect- 
ing a nerve, contractures etc*, a neurologist should 
be consulted with a view to establishing differential 
diagnoses of the organic and the psychogenic defects. 
3* The soldiers afflicted with psychogenic or 
hysterical defects will not be evacuated beyond the 
neurological departments of the army field hospitals, 
apart from very exceptional cases and then only 
after hearing the chief of the neurological depart- 
ment or the consultant psychiatrist. 
4* At homo, ail soldiers afflicted with hysterical 
defects which are curable almost without exception 
will under no circumstances be separated as unfit 
for military service, but they will be transferred 
to army hospitals provided for that purpose* 
5* If these soldiers are relieved of their symptoms 
they will be classified according to their consti- 
tutional or organic deficiencies* 
6* The therapy resistant cases will be isolated 
and transferred to special army hospitals or asylums 
in order to prevent detrimental psychological Influence 
on other patients. They will in no case, however, be 
separated from the army as "unfit for service". 
7. The Inspection of these departments in army 
hospitals etc. is incintaait to the consultant psy- 
chiatrists who also have to consider other possibili- 
ties of treatment in other hospitals* 269 
4* Encephalitis* myelitis* polyradiculitis* polyneuritis, 
poliomyelitis, inflammatory diseases of the 
central nervous system. 
Geschwaderarzt (Colonel. MC.* Airforce) Prof* 
PlTTE 
1* Virulent diseases* 
Poliomyelitis occurred in a few instances as an 
after-effect of dysentery, infectious Icterus, typhus 
and vaccinations* This fully conforms with the obser- 
vation that poliomyelitis is often preceded by a non- 
specific infection* The incipient stage of the disease 
and its course as set forth in the reports which came 
to hand to not differ from what has been well known for 
a long time* In the meningeal form which seems to oc- 
cur most frequently only the examination of the cerebro- 
spinal fluid will secure a reliable diagnosis. Cases 
of epidemic encephalitis are rare. Patients in a post- 
encephalitic condition were in a few cases erroneously 
considered as neurotics* The so-called "Russian head- 
aches" observed in the central and southern sections of 
the Eastern Front, manifested by marked increase of 
temperature, must also be considered as a virulent dis- 
ease* 
2* Pan-encephalitis (typhus encephalitis, Japanese 
encephalitis and domestic panencephalitis) is characterized 
by pyramidal and extra-pyramidal symptoms, disturbances 
of the vegetative functions and psychic disturbances* In 
spite of an extensive histological analogy, the above 
mentioned diseases belong to different classes* (The 
Weil-Felix1 reaction for instance reacts positively only 
in case of typhus* 
3* The particular type of encephalomyelitis marked 
by progressive wasting of the marrow occurs usually in 
the parainfectious form* All intermediate phases from 
light paresis, paraesthesia, defective bladder and bowel 
function, involvement of the eyes, to severe^cases of 
spastic-ataxic paralysis, transverse paralysis, hemiplegia, 
tetraplegia etc* occur. The etiology of these diseases 
remains unknown* In the first the patient has what ap- 
pears to be an inconsequential illness which is non- 
specific in type, associated with a variable amount of 
fever, catarrhal infections etc. Encephalomyelitis oc- 
curred- sporadically after prophylactic vaccinations and 
injections of serum. 
4. Mononeuritiss plexus neuritis? and polyneuritis 
cgsjteatf fl»st In the nerye basal ganglia* spinal ganglia •’ dcrsal 
root ganglia without always sparing the peripheral nerves. 
The clinical picture follows the outlined development. It 
is not unusual that poliomyelitis affects the cranial nerves, 
which are, however, only in rare cases primarily invaded. 
Poliomyelitis appears in light cases as a weakness of cer- 
tain muscles, diminished reflexes, increasing in degree and distribution. A few patients have continued fever and 
progressive paralysis of the Landry type even to fatal 
termination. A marked increase in protein is usually ob- 
served in the cerebro-spinal fluid, whereas there is little 
or no lymphocytosis. On the whole, the prognosis in moderate 
cases is favorable and, good care provided, most of the 
cases will show, sometimes after a treatment extending over 
several months, marked improvement or complete recovery. 
This refers to cases with catarrhal, gastro-enteric infections, 
including dysentery, typhoid fever and suppurations in its 
early stage. Only in rare cases is plexusneuritis ob- 
served as an after-effect of injections of serums or pro- 
phylactic typhoid vaccination. At the same time, when a 
higher incidence of neuritic diseases was observed last 
autumn and winter, the ratio of late manifestations of 
diphtheritic paralysis also was on the increase# 
As a result of the pathogenetic study of encephalo- 
myelitic and neuritic processes it must be concluded that 
there are great natural variations in the virulence of 
the diseases and also variations in the susceptibility 
of the organism, due to congenital or acquired disposition. 
In conclusion it may be said that the problem of reduced 
individual resistance and susceptibility in its complexity 
should be given careful consideration. 
Comments upon the above report by Oberstabsarzt 
(MajorMC.) Prof* EWALD 
It will be necessary to consider both, the histo- 
pathological and the clinical aspect. We clinicians often 
observe a multiple sclerosis developing out of encephalomye- 
litis. A differential diagnosis between encephalomyelitis 
and acute multiple sclerosis cannot be established* PETTE 
has the merit of having rediscovered the role of neuro- 
allergies for the evaluation of these problems* 
however, that I cannot share his doubt about the virulent 
character of the medullary wasting type of encephalomye- 
litis. The sudden onset of acute illness is also observed 
in poliomyelitis. The early Infectious symptoms are much 
the same in encephalomyelitis and poliomyelitis* The fact 
that cases of communicable encephalomyelitis have not yet 
become .known cannot be considered as a sufficient support 
of PETTE1s hypothesis. Some antigen of presumably an in- 
fectious character must have been effective and caused the 
allergic reaction* I see a direct relation between the 
acute articular rheumatism of infectious origin and the 
later developed arthritis* We are accustomed today to 
view diseases from the point of view of the resisting body 
but this should not lead one to disregard the exciting 
causes. The problem of focal infection is of special im- 
portance with regard to pension claims. If encephalomye- 
litis develops as a sequel to acute catarrh and develops 
later into multiple sclerosis, this cannot be ascribed to a 
bad tooth but it must be admitted that an infection contracted 
in the service was the cause of the reaction* A pension 
claim would then be considered justified. Directions, 
Poliomyeliti s : 
Diagnosis.; Cerebro-spinal fluid shows lymphocytosis 
with little increase of protein in the meningeal stage and in 
the early paralytic stage. The lymphocytosis drops rapid- 
ly and the protein content increases in the advanced 
paralytic stage. Besides the paretic form (flaccid 
paralysis, indicentally affecting the cranial nerves) 
there exists a non-paretic (meningeal) form manifested 
by fever, meningismus, lymphocytoses in the cerebro- 
spinal fluid, catarrhal and gastro-enteric infections, 
dysentery, typhoid fever, typhus, vaccinations and some- 
times even after strenuous work or marching etc# 
Therapy: Convalescent serum should be administered 
(20 - 40 cubic centimeters intramuscularly) if available. 
Sulfonamides are without effect. Evacuation only when 
paralysis is not ascending, (Danger of asphyxia in acute 
Landry's paralysis,) 
Virus Meningitis; 
a* Primary form; Known as idiopathic aseptic 
meningitis, marked by an increase of temperature, meningis- 
mus, lymphocytosis of the cerebro-spinal fluid without 
local cerebro-spinal symptoms* A differential diagnosis 
of virus meningitis and the non-paretic form of polio- 
myelitis is impossible* The is unknown and 
probably not uniform. The so-called ’'Russian headaches" 
spreading in certain sections of the Eastern Front with 
associated fever are probably of a very similar origin, 
b. Secondary form: The secondary form appears as 
a side- or after-effect of other virulent diseases such as 
influenza, mumps, varicella, etc* 
Prognosis: Favorable. 
Therapy: Repeated lumbar punctures. Sulfonamides 
are without effect. 
Epidemic encephalitis: 
Epidemic encephalitis was observed only sporadically 
in this war. Ihere is no treatment of choice. After- 
effects of encephalitis (Parkinsonism with or without 
tremor) render the patient unfit for active duty in the 
field. 
Panencephalitis : 
This category of diseases covers typhus encephalitis 
and domestic panencephalitis marked by pyramidal and extra- 
pyramidal symptoms, regulative disturbances of vegetative 
functions (restlessness, disturbances of the bladder and 
bowel*y vaso-lability, fluctuating blood-pressure) and 
psychic disturbances. (The Weil-Felix1 reaction is positive 
only in case cf typhus.) Medullary wasting encephalo-rnyelltidess 
This gjroup comprises the disseminated and diffuse 
encephalo-mjyelitides occurring as an after-effect of 
acute infections (catarrhal and gastro-enteric infections, 
influenza, measles, typhoid,varicella, etc*)^and^sporadic- 
ally as an after-effect of prophylactic vaccinations. In 
accordance with the disseminated and diffuse processes the 
pat1ents exhibit very different symptoms varying between 
light forms (paraesthesia in certain parts of the body, dis- 
turbances of the bowel and bladder function, paralysis of 
the ocular muscles, impaired vision as an aftermath ofc 
optic neuritis at the worst resulting in an choked disc, 
anomaly of reflexes) and severe cases (spastic ataxic 
complex of symptoms, transverse paralysis, hemiplegia, 
paraplegia, tetraplegia, Landry*s type of paralysis) in- 
cluding all intermediate stages* Acute multiple sclerosis 
can hardly ever be differentiated in this general symptom 
complex. Similar to multiple sclerosis, these cases show 
a marked tendency to deterioration. The examination of 
the cerebro-spinal fluid reveals an increased content of 
cells and protein. Normal conditions of the spinal fluid 
were, however, not infrequently observed. The etiology 
is unknown. The therapy is non-specific. Patients need 
rest. Evacuation to hospitals at home is required. 
Patients afflicted with multiple sclerosis will as a rule 
be classified as unfit for military service. Pension 
claims must be approved if the acute onset of the dis- 
ease occurs during the period of service rath the Armed 
Forces. If multiple sclerosis existed when joining the 
Armed Forces the pension claim will then be considered 
only to the extent of the aggravation. 
Mononeuritis* pleKUsneuritis and polyneuritis: 
Anatomically speaking this category of diseases pre- 
dominantly involves the nerve toots* The examination of 
the cerebro-spinal fluid reveals: Increase of protein, 
few or no lymphocytosis. Neuritic sciatica also falls 
under this category. Slight forms of polyneuritis mani- 
fested subjectively by weakness of certain muscles, 
fatigue and objectively by diminished reflexes and slight 
ataxia are very liable to erroneous diagnosis* In severe 
cases culminating in the Landry type of paralysis there is 
imminent danger of respiratory paralysis* Special care 
in case of an evaluation of the patients is therefore 
necessary. The etiology is often associated with focal 
infections, suppuration processes acute infections and 
especially with catarrhal infections, gastro-enteritides 
including dysentery. In rare cases plexusneuritis was 
observed as an after-effect of prophylactic vaccinations. 
Diphtheritic polyneufitis closely resembles all other forms 
of polyneuritis. 
Therapy: Treatment of all important pathogenic factors 
(suppuration, focal infections, catarrhs). In the acute 
stage administration of pyramiaon, and salicylate pre- 
parations, physical-medical treatment (heatj diathermy, 
short weaves). Vitamin B and C preparations, 5» The inflammatory diseases of the nervous system# 
Kriegsarzt (War Surgeon) Prof, HALLERVOHDEN 
During the course of the war the cases of encephalitis 
and polyneuritis have increased considerably. In most of 
the cases the well-known types of encephalitis were dia- 
gnosed, Encephalitis is characterized by independent in- 
flammations usually caused by infectious agents (SPATZ); 
according to RISSL and SPIELMEYER, however, due to cellular 
infiltration. The serous inflammation should also be con- 
sidered as a manifestation allergic processes. Besides 
the histological complex, the distribution of the changes 
is of importance* These changes have been subdivided by 
SPAT2 into 6 types? which are of no etiological importance. 
On the other hand it must be noted that other types of 
encephalitidos have been discovered which are not included 
in this classification, namely: a type of polioencephalitis 
characterized by the formation of glial nodes (typhus) 
and a diffuse type of encephalitis (encephalitis lethargica). 
The following problems are now placed in the foreground 
of interest: 1, Precise definition of the special type 
of encephalitides characterized by wasting of the medulla, 
2, Definition of parainfectious encephalitidos and their 
relation to allergic processes. 3* Definition of poly- 
neuritis of the type of ascending paralysis, PETTE in 
his new book refers to the medullary wasting type of en- 
cephalitides as including the groups of multiple scleroses 
and parainfectious encephalitides, whereas SPATZ distinguishes 
between focal medullary encephalitis and peri-venous focal 
encephalitis. According to PETTE*s theory both types are 
of an allergic origin. 
In spite of some similar symptoms a conspicuous dif- 
ference is observed in the distribution of the medullary 
wasting foci in the two groups. In multiple sleroses the 
wasting of the medulla is a seleclrTve process sparing the 
axis-cylinder. This may be due to the diffusion of a sub- 
stance which dissolves the medullary sheath from one definite 
spot of the vessel all through the tissue regardless of 
structures and vascular supply. The process is characterized 
by large proliferation of glial elements affecting with 
preference the astrocytes and causing extensive 
glia scar, that is to say a sclerosis, spread by dif- 
fusion is particularly demonstrated by the concentric 
sclerosis in that striae with pronounced destruction of 
medullary substance alternate concentrically with zones 
containing medullary substance. This phenomenon can only 
be explained as a rhythmic diffusion analogous to LIESE& 
GANG1s rings. 
The so-called multiple sclerosis may not infrequently 
be diagnosed before the onset of medullary destruction if 
a typical focal distribution is recognizable* The process 
of medullary destruction is a common attribute of myelitis, 
neuromyelitis optica, encephalitis disseminata and diffuse 
sclerosis if the latter has an encephalitic character. 
Practical reasons speak in favor of a separate classification 
for these diseases, which have their clinical peculiarities 
from multiple sclerosis. In cns6 of para-infoctious encephalitis the medullary 
destruction is not selective but only symptomatic and is 
caused by plasma extravasation from the vessels. The me- 
duiiary destruction is limited to the outer fringes of the 
cells* The medullary sheaths and axis-cylinders decay. 
The glia proliferation consists of oligddendrocytes and 
Hortega cells, the astrocytes having hardly any part in 
it. The process leaves small scars. The decay of the 
medullary substance is slow and striated or spotty and 
must not be confused with the picture of multiple sclerosis. 
There are also marked clinical differences: The para- 
infectious encephalitides may heal with or without sequelae 
but will never turn into a progressive process such as 
multiple sclerosis. 
The same picture of para-infectious encephalitides 
is observed as an after-effect of small-pox vaccination, 
measles, varicella, rubella, and influenza, that is to 
say of etiologically quite different diseases. The opinion 
of GLANZMANN (1927) that allergic conditions are associated 
with this disease has most generally been accepted. This 
concept is clinically supported by a distinfet interval 
between the onset of the disease and the appearance of 
encephalitic symptoms. Anatomically speaking,•there does 
not exist a typical picture of allergic tissue, but a series 
of morphologic peculiarities are demonstrable from which 
the presence of allergic conditions must be concluded 
(KLINGE). The findings in parainfectious encephalitides 
rather support than oppose this concept. They show the 
picture of a serous inflammation. The fact that similar 
pictures and the same anatomical findings have been ob- 
particularly with rabies for instance, seems to 
point in the same direction. Experiments on animals re- 
vealed similar results in many points but the concordance 
was not entirely convincing. 
In para-infectious encephalitis, allergy is highly 
probable* Mulbipl"sclerosis, however V cannot^"be evaluated, 
neither clinically hor anatomically, with this type of dis- 
ease* Clinically the latter is a chronic progressive pro- 
cess characterized anatomically by a selective discontinuous 
medullary destruction which is not due to a serous in- 
flammation as is the case in para-infectious encephalitis. 
Both these facts seem to confirm the presence of allergic 
reactions in multiple sclerosis, as far as we can say. 
The term "medullary" wasting encephalitisn therefore correct- 
ly applies to multiple sclerosis but not to para-infectious 
encephalitis. 
If the assumption is correct that the pata-infectious 
encephalitis originates in allergic processes, similar# 
foci may be expected to occur also in other encephalitides 
as allergic reactions may be a part of any kind of in- 
fection. In this case we would have to deal with allergic 
complications. Foci of this kind have been discovered 
and described in poliomyelitis by PETERS and HECHST. Not 
Infrequently we observe such combinations with foci of 
acute multiple sclerosis in a variety termed "encephalitis 
disseminatan• The typical selective medullary destruction 275 
peculiar to multiple sclerosis is, however, not observed 
types of encephalitldes. Where reports to that 
errect nave been made, the significance of the process is 
not clearly established. 
The situation is much clearer in the case of in- 
flammatory polyneuritides which played an important 
role even in World War I and which have been on the in- 
crease ever since. Their etiology is not uniform. All 
attempts to find a virus have been in vain. In almost 
any case the disease is preceded by pathologic conditions 
of various kinds! gastro-enteric catarrhs, dysentery, 
angina, common cold etc. After an incubation period of 
3 to 3A days we observe the sudden onset of the disease. 
Polyneuritides may also be due to the inoculation of serums 
and vaccines of different kinds and most generally affect 
the upper extremities, whereas the inflammatory poly- 
neuritidcs primarily Invade the lower extremities. Ex- 
ceptions to both rules have been reported. Based on these 
observations, GRDNEWALD as early as in 1922 and nowadays 
PETTE and BANNWARTH assumed the presence of an allergy. 
My collaborator KRUCKE has (on the basis of his examin- 
ations concerning hypertrophic neuritis and neutral atrophy 
of the muscles) assumed a serous inflammation of the nerves 
in inflammatory neuritides and was able to prove it later 
on in one case described by BANNWARTH. I myself can con- 
firm these findings from my own experience. Thus the 
GUILLAIN-BARRE1s syndrome (great increase in the protein 
in the cerebro-spinal fluid without corresponding increase 
in cells) has found its explanations. BANNWARTH thought 
this Increase to be due to a serous inflammation of the 
roots of the nerves. Thus inflammatory neuritides are 
thought of as probably originating in allergic conditions. 
Not Infrequently inflammatory alterations of the 
meningitis type (BANNWARTH) and encephalitis of the spinal 
cord and brain, that is to say a disease tt the entire 
nervous system, are observed in many cases cf polyneuritis. 
On the other hand we know from many encephalitides that 
the disease may spread to roots and nerves. In typhus 
this fact is well known (even the nervus sympatfleus being 
affected) but also in poliomyelitis, encephalitis epidemica, 
rabies, encephalitis disseminata and multiple sclerosis, 
diseases of the nerves have often been described. PETTE 
mentions an ascending paralysis with revaccination, BANN- 
WARTH in encephalitis Japonica. The prosess of the dis- 
ease has no limits in-the nervous system, and for the im- 
provement cf our knowledge, it is therefore necessary to 
thoroughly examine ganglia and peripheral nerves not only 
in cases of encephalitis but also in polyneuritides* of the 
spine and brain. An examination of the inner organs should 
never be forgotten. Only if a great many examination 
results are available for comparative studies, will we 
be able to gain more knowledge concerning these diseases* 6• Malarial therapy in the treatment of postdiphtheritic 
paralysis. 
Oberfeldarzt (Lt. Col.. MC.) FUCHS 
Malarial therapy has been applied in the treatment 
of postdiphtheritic paralysis by MAYRHOFER in pursuance 
of the trials ofPCETZE in the Reserve Hospital XXain 
Vienna (Muenchener Medizinische Wochenschrift 194-2, page 
974)4 
Patients suffering from very extensive and severe 
paralysis after having been for weeks and months in the 
hospital, were brought to full recovery by malarial 
therapy after two or three weeks with the exception of 
two cases out of 26. In most of the cases a marked im- 
provement was observed from the very beginning of the 
treatment. In seven cases it was even possible to bring 
a still progressing paralysis to complete recovery# 
Damages due to the therapy have not been observed. 
Observations of the heart functions (including electro- 
cardiogram) made at the clinic of Prof. EPPINGER. Vienna, 
did not reveal any clear pathological effects although 
in the worst cases there was a suspicion of a myocarditis 
damage. 
The therapy consists of a maximum of 4 or at most 5 
malaria inoculations. A culture which is free of lues is 
to be used. For prophylactic purposes Digitalis is given 
Simultaneously and during the fever strychnine, cardiazol, 
if necessary epethonine and in emergency cases adrenaline 
will be used. 
. It must be made a condition that the malarial 
therapy be exclusively applied by qualified medical 
officers with the necessary experience and. knowledge 
of possible complications and hazards. 
If applied under such circumstances the malarial 
therapy may properly be said to save the patient weeks 
and months of great inconvenience in case of postdiph- 
theritic polyneuritic paralysis. 
Successful application of the malarial therapy in 
three cases seems to confirm the hope that it will hence- 
forth be possible to cut down the rate of fatal terminations 
in polyneuritic paralysis. 
Discussion; 
GUTZEIT: The ban on malarial therapy in postdiph- 
theritic paralysis which was originally advocated by 
RODENWALDT seemed to me to be well founded at first. 
After the examinations of FUCHS, however, I am convinced 
that this therapy may prove life-saving in emergency 
cases as for instance in glossopharyngeal paralysis# In consideration of the extremely long treatment of some 
cases of postdiphtheritic paralysis which last J to 1 
year and longer, a short cut in the therapy will be wel- 
comed* As a matter of fact the number of cases treated 
by FUCHS is not .yet high enough to allow for a definite 
evaluation# If the average period of treatment could not 
be shortened in comparison to other kinds of therapy it 
may also be due to the small amount of practical ex- 
perience with the malaria treatment. The apprehension 
of a^damage to the circulation by malarial therapy is not 
justified in view of the perfect compatibility of this 
therapy in taboparalytic patients with serious heart 
and circulatory defects. Electrocardiographic examin- 
ations are indicated in every case. In the postdiph- 
theritic state of the paralysis a weakness of the cir- 
culatory system was rarely observed. A support of the 
circulation by medication of cardiazol. or sympathol is 
common practice not offering any difficulty to^the ex- 
perienced physician. In case of life endangering pheno- 
mena the internist must assume the responsibility for a 
radical and dangerous therapy, even if the chance of 
success is not great. A certain risk must be taken in 
the interest of the patient. As a matter of course a 
dangerous therapy should only be used by qualified and 
experienced physicians. I wish to conclude, saying that 
I believe that the ban on malarial treatment of post- 
diphtheritic paralysis is no longer justified and I 
propose that the therapy be introduced under observation 
of the precautionary measures as outlined by FUCHS. 
RODENWALDTs I fully realize that only questionable 
value is attached to the opinion of an hygienist in clinic- 
al matters. I was always of the opinion that malaria 
tertiana is a disease that should not be overestimated. 
This disease interfers less with the constitution and 
habits of life than an angina. The situation is entirely 
different if malaria tertiana and other diseases occur 
concomitantly. Complications and even fatal terminations 
were not infrequently observed in the latter case. It 
is a well known and common practice in tropical climates 
to follow up each puerperium or even injuries associated 
with considerable loss of blood to use a malarial treat- 
ment just to avoid these complications# - Every malarial 
infection, including tertiana, especially in case of several 
attacks, causes a considerable loss of erythrocytes. I 
therefore think that it is dangerous to provoke an addition- 
al infection in case of these diseases, which as is known 
by experience affect the heart and the circulation# It 
may sound exaggerated if I maintain, in view of the great 
quantity of remedies administered to support the_circulation, 
that in the cases described by MAYRHOFER the patients sur- 
vived not due to the malarial therapy but in spite of it. 
Finally I would like to ask how the clinician is able to 
determine whether a paralysis is definitely progressive or 
definitely stationary. Directions for the treatment of postdiphtheritlc 
paralysis by malarial therapy* 
The institution of the malarial therapy may be taken 
into consideration in the following cases: 
1* In malignant rapidly ascending paralysis and 
threatened spinal involvement; 
2. Severe cases of paralysis lasting over several 
months. 
i The therapy will be instituted only in such hospitals 
xvhich have the required facilities and personnel fully 
acquainted with malarial therapy and all possible com- 
plications, who are qualified to assume the responsibility 
for this treatment. These special requirements will prac- 
tically only be met in medical schools, neurological 
clinics, special hospitals and special asylums. 
The Institute for Tropical Medicine of the Robert 
Koch Institute is prepared to supply from their anopheles 
colony infected mosquitoes for military hospitals* Trans- 
port by courier is recommended. 
]• Late sequelae of commotio and contusio cerebri* 
Qberfeldarzt (Lt* Col., MC.) Prof* BOSTROEM 
The conservative classification of brain injuries 
in commotio, contusio and compressio is maintained, al- 
though it is sometimes difficult to differentiate these 
types which may occur concomitantly. 
Commotio: No pathologic-anatomic findings; clinically 
no neurological findings in simple cases a 
Characteristic manifestations: Fainting spells and 
vomiting, gap in memory, headaches, nausea, giddiness, 
progressive subsidence out often vestibular - vertigo, 
prognosis favorable. 
Contusio: Bruise of the peripheral ends of the 
cortices (contrecoup). Fainting spells are not necessarily 
associated with it but are frequently observed because of 
a combination with commotio, recovery is slow in these 
cases* 
Clinically: In severe cases delirious symptoms, 
frequently retrograde anamnesis. 
Neurologlcally: No symptoms beside an occasional 
impairment of the sense of smell, in case of bruised foci 
local symptoms in important cortical regions are rare* 
Psychic disposition to euphoria or lack of will-power* 
Hypersensitivity and occasionally incontinentia is observed. Prognosis may said to be favorable in most cases* 
Cortical bruise foci sometimes do not cause any trouble 
whatsoever. 
Complications generally aggravating the prognosis: 
1* Viewed from the aspect of the constitution; 
a. Anomaly of the skull, tower-shaped deform- 
ations, digital impressions* 
bf Vasomotoric* 
2* Age of the patient. Aged patients recover slowly 
from relatively simple commotio* Sequelae occur 
frequently, 
3* Alcoholism. 
4-, Hypertonia and arterio-sclerosis* 
Special importance must be attached to differential 
diagnosis. Special care is necessary to exclude the 
possibility of brain hemorrhage with compression* Con- 
sult the neurologist early with the view of; 
a. determining possible compressio; lateral 
localization of hemorrhage; 
b. establishing neurologic diagnosis for later 
reference; 
c. facilitating early recognition of hysterical 
symptoms. Otologic examination is indicated 
(vertigo). Late after-effects in case of 
commotio without complication are not to be ex- 
pected. Especially in case of vasoraotorics, 
attention must be paid to possible: vestibularis, 
impairment of vision, vegetative disturbances 
such as excessive perspiration, insomnia, emacia- 
tion, impotentia, alcoholic intolerance etc. 
The same disturbances may occur in brain contusions. 
In addition to the above symptoms special attention must 
be paid to possible impairment of the sense of smell and 
discrete focal symptoms. 
Physically: Sometimes organic inefficiency, lack of 
initiative (examination with physiologic testing instruments 
does not exclude a possibility of a confusion with pseudo- 
dementia, the unobtrusive forms of which are often diffi- 
cult to recognize). 
Notice: Cortical bruise foci according to ESSER gener- 
ally do not exhibit progressive processes of decomposition. 
They may even be completely exempt from pathological 
symptoms# Late hysterical manifestations: 
As a sequel to commotio: Generally no massive symptoms. 
Demonstrative attitude of the patient is the most 
apparent feature. 
A hysterical superposition to organic defects is some- 
times observed in contusio which can only be clarified by 
careful clinical observation. 
It is improbable that hysteroid symptoms are simple 
sequelae to brain injuries. It must be admitted, however, 
that the failure to discover slight organic impairments 
explains the obtrusive and demonstratory attitude of cer- 
tain patients ■who are considered as hysterics. 
Comments on the above report by Stabsarzt (Captain, 
IffC.rBoaent mi^G 
Psycho-pathological findings in brain injured patients 
may be of importance if tv&umatifc. damagec of aho brain ' 'u 
exist in those cases where contusion cannot be positively 
diagnosed somatically (neurological evaluation, X-ray ex- 
amination, encephalogram, electro-encephalogram). 
psycho-pathological findings will in any case be used in 
the evaluation of the suitabD-itjr for military service. 
Apart from psychic symptoms emanating from the centers of 
the brain, all degrees of psychic disturbances may occur 
in brain injured patients according to the manifestations 
observed in a progressive disintegrative process of the 
brain. In accordance with the severity of the disturbances 
and the occurrence of psychogenic reactions as a sequel to 
the psychic inefficiency realized by the patient, there are 
complex symptoms and intricate pathological pictures. Among 
the psychic symptoms, disturbances in the sphere of the 
intellectual capacity may be evaluated in psycho-pathological 
examinations. Disturbances of the individual character and 
mental cast of the patient may be approached by continuous 
observations in the hospital or in the performance of work. 
The extent of the impairment of the intellectual capacity 
varies from severe mental deterioration (alogia and para- 
logia. KLEIST) to slight disturbances frequently exhibited 
only in subjective peculiarities of sensation. Besides 
an accurate analysis of the irregularities observed by the 
patient himself, it was found that tests concerning the 
systematic order of things and colors, in addition to the 
common intelligence tests, are especially suitable for the 
purpose. In almost all brain-injured patients a condition 
prevails of elevated vegetative and psychic lability and re- 
duced resistance to strain. Abnormal psychogenic conditions 
in brain-injured patients may be due to a true incapability 
and must not be rated as hysterical reactions. Only a very 
elaborate diagnosis, established with all available methods 
will furnish the necessary elements for an adequate employ- 
ment with the Armed Forces or ether assignments and allow for 
an appropriate prophylaxis in order to avoid undesirable re- 
actions in case of psycho-labile brain injuries. Directions concerning the treatment of late sequelae 
following commotio arid cbntusic cerebri» 
1* Fresh cases of commotio and contusio with the 
exception of very mild cases, will as a rule be admitted 
to the hospital, A full report concerning the details 
of the accident will be furnished (stating in detail 
the duration of any possible unconsciousness, cloudy 
consciousness, vomiting, spells of cramps, bleeding 
from ear and mouth, pulse rate, pupillary reflexes). 
Supine position in evacuation. The hospital must 
have the facilities for a psycho-neurological examin- 
ation by specialists and examinations by an aurist 
and oculist should be included* 
2* The classification report in case the patient is 
discharged from the hospital as "fit for combat 
assignment", "fit for garrison duties in the field" 
will include a notice as to the duties which in the 
beginning could be hazardous to the soldier (for in- 
stance wearing of steel-helmets, no assignment as 
driver, etc*) 
3* Complaints of soldiers who have had an accident 
affecting the skull concerning head-aches and vertigo 
should be given serious consideration especially in 
case of aged or vegetatively labile soldiers. It is 
a fact that the greater part of brat.’, concussions do 
not leave serious aftermaths® In case of brain con- 
tusions, howeverr a careful evaluation is necessary. 
In dubious cases it will jo necessary to institute 
a psychiatric and otologics 11 examination* A report 
of the general conduct of the salc’iet? in combat is 
required. 
4. In case of a discharge from the hospital as 
"fit for garrison duties an home" cr "suitable for 
labor duties" it is necessary to specify the type 
of assignments which should he given preference in 
the opinion of the examining specialist. The date 
of the re-examination has to be fixed- XII. 
PROCEEDINGS of the consultants1 
COMMITTE EON TUBERCULOSI S 
Translation prepazod by? 
Office of Military Government for Ge.Tiany S* ) 
Office of Naval Advisor 
Medical Section Sulfonamide treatment of gunshot wounds# 
(See Section IT, Article o) 
1« Treatment of pulmonary tuberculosis by occupational 
therapy# 
Oberfeldarzt (Lt# Col#, MC.) STEINMEY2R 
The medical treatment of tuberculosis is incomplete 
as regards its efficiency if it is not supplemented by 
occupational therapy# Therefore this treatment is to be 
added to every medical treatment of tuberculosis as a 
regular part of the plan# It has the purpose of making 
the patients able to again perform their duty or their 
Fork by a slowly increasing activity whether it be at 
their former trade or another work# This therapy is not 
voluntary employment but an activity prescribed by the 
physician which is a duty and service for the convalescent 
soldier as well as for the soldiers needing regular medical 
care# The work has to be limited as to nature and time 
and has to be adapted to the ability of the patient# The 
therapy has to accomplish the following tasks: To com- 
pensate the disadvantageous sequelae of the rest cure, to 
restore discipline in the service, to accustom the patient 
to work, to give him back the belief in his own capacity 
to work, to make his resources gradually fit for the normal 
work .of a trade, to ascertain how far the work is compatible 
with the tuberculous process, and to judge the degree of 
fitness for military service and the fitness for work upon 
release from the hospital. Inferiority complexes are to 
be dissipated with those patients who cannot be considered 
able to regain their fitness for service or work because 
of the kind and intensity of Lhe process of tuberculosis. 
The patients are to be instructed about the purpose of 
the occupational therapy. 
The therapy should begin at the point when the clinical 
treatment has reached its optimal result# The patients 
are to be classified into the following groups: 
Group I 2 Closed tuberculosis 
Group II 2 Potentially open tuberculosis 
Group III2 Open tuberculosis 
The classification into the groups is performed by 
the chief physician# Skilled workers are to be used in 
their own or a related trade. The working patients are 
moved to the Section for Occupational Therapy* that means 
they are separated from the patients of the medical sections. 
The supply department of the Army is charged with the 
supply of work clothes (in summer, strong ticking)# A 
permanent control by medical specialists is necessary as 
"the dose” of work is determined by the physician# Under 
these considerations there are no doubts that the patients 
with collapse therapy may be employed# The occupational 
therapy is a treatment by stimulation# If unfavorable 
reactions occur the patients are sent back to the medical section. The products manufactured by the patients have 
to be marketable and they have to be paid accordingly. 
Since the therapy belongs to the treatment in the hospital 
no trade liceiise is to be paid but only an exchange tax. 
The variety of possibilities to Fork is restricted only 
by the decision of a physician as to whether the work is 
suitable to the patients or not. Piece work is forbidden 
on principle. 
The personality of the chief physician and his medical 
collaborators, and the proper selection of the military 
leader of the business (Sergeant Major of the unit) and 
of the foreman are decisive for a general success. The 
greater number of those who have attained their position 
from the group of patients under labor therapy, the 
greater will be the understanding for the healing influence 
of work and they will treat the patients in the right 
way. A success will be possible only if the 
is not approached with inadequate arrangements. Military 
discipline and order are guaranteed by house and work re- 
gulations appropriate to the work hospital which are to 
be signed by everybody on his reception at the Hospital. 
Unsociable persons are to be separated, if necessary by 
compulsion. 
Discussion: 
LINDIB: Occupational therapy was always inadequate 
until now in two points: The procurement of work and the 
market outlet of the products. Both of these difficulties 
have been removed in Corps Area IV by the work ordered for 
the wounded and sick men of all hospitals including the 
hospitals for patients suffering from tuberculosis. The 
technical performance of the work is regulated by the 
different ordnance detachments. Various operations are 
moved from the ammunition factories to the reserve hospitals. 
The payment is determined according to the piece wages in 
use at the location concerned. The firms are expected to 
pay moreover an additional amount of 25 per cent to com- 
pensate for the lack of overhead expenses* This amount 
is at free disposal of the chief physician and is to be 
used in favor of the working patients. A technical and 
a commercial foreman who are taken from the patients of 
the hospital and who are trained in the factories, see to 
the supervision and control of the working patients, to 
the accounts with the different firms and to the payment 
of the earned wages. As piece work is usually concerned, 
which is examined thoroughly upon its delivery as to its 
value and usefulness, every patient is responsible for the 
work performed by him. The extraordinary high advantage 
of this solution consists in the firm organization which is 
free from the influence of the hospital and which makes 
the occupational therapy independent to a great extent 
from the changing point of view and temperament of the 
factory management. As under the present conditions we 
will not succeed everywhere in the immediate establishment 
of special hospitals for occupational therapy as demanded 
by the consultant, the various institutions of reserve 
hospitals for patients suffering from tuberculosis must be 
continued for the present and must be utilized as much as 
possible* F. MEYER: Occupational therapy can be carried out in 
Smaller hospitals only if simple work is chosen which will 
require no machinery. It is necessary to regulate the 
Period of work according to the capacity of each patient. 
Change of trades and training for trades can be promoted 
only if greater units of occupational therapy are established. 
GRASS; 'As far as I understand occupational therapy 
is chiefly applied to patients whose treatment is considered 
as nearly finished and who are to be prepared again for the 
demands of life as Regards their ability to work* On the 
other hand it seems that occupational therapy is regarded as 
less important for those persons who live in asylums. For 
those persons, however, work is particularly necessary 
because they are forced to spend a very long time in hospitals 
often only as a protection for healthy persons. Work can 
give them a new concept of life and sometimes also the 
necessary income for the maintenance of their families. 
ROLOFF; A difficult problem of occupational therapy 
is the question of wages. If we pay piece wages proceeding 
from the secret order of headquarters dated lo February 1943 
and the direction of the physician of the Corps III dated 
10 April 1943 the following situation will be created for 
our hospital; With an average price of 0.50 mark which is 
paid by the firm of Daimler-Benz for the single armatures, 
the patient makes 400 marks per month if he should^produce 
only 10 pieces per hour and should work 4 hours daily and 
5 days per week. Since the patients stay there from 3 to 6 
months at least the profit for the individual man would 
mount up to thousands of marks. Pretty soon* however, this 
would disturb considerably the traditional principles of 
free service in the Army. Patients whose physical con- 
dition does not allow such activities and possibilities 
of profit would envy their happy comrades as well as those 
who work in the kitchen or in the garden without any pay- 
ment. As no regulation has been passed until now as re- 
gards these questions the following procedure was carried 
through in the Treuenbrietzen reserve hospital which has 
proved satisfactory and the subsequent approval of which 
is asked for: 
1. The firm keeps the wage tax of the piece wages 
to be paid for the manufactured goods and pays it 
to the agency concerned. 
2. The working patients do not get piece wages but 
are paid per hour in order to avoid every aspect of 
piece work and the injuries to health connected with 
it# 
3. The pitient receives 0.40 mark per working hour 
which are recorded exactly. This amount is paid 
to him at the end of each month by the sergemt-ma jor 
or a parson charged with that task. 4# The rest of the money gained by this work is 
shared among all patients of the hospital (in Treuen- 
brietzdn reserve hospital) e.g# there could be dis- 
tributed special gifts such as books, beer, wine, fruit 
to all ipatients on Christmas and some other occasions. 
Nevertheless even with this system of payment which has 
met with no difficulties up to now and which is the most 
favorable one according to our experiences, the problem 
Cannot be solved completely because the collected money 
cannot be fully utilized under the present circumstances# 
Thus we have hoarded up in our special account already an 
amount of more than 18 000 marks# The further use of this 
amount is still to be determined. It is necessary that 
the question of payment for the occupational therapy is 
regulated for all reserve hospitals in a uniform way. 
Directions on occupational therapy with pulmonary 
tuberculosis. 
1. Occupational therapy forms a regular part of each 
medical treatment of tuberculosis# 
2. It is the aim of occupational therapy to make the 
patients able to again perform their duty or their work 
by a slowly increasing activity, be it their former 
trade or another employment. This therapy is no 
voluntary employment but productive work prescribed 
by the physician which is duty for the convalescent 
soldier as well as for the soldiers needing regular 
medical attention# 
3* Occupational therapy has to accomplish the follow- 
ing tasks: 
a. to eliminate the disadvantageous consequences 
of rest treatment; 
b. to restore the patients1 discipline in ser- 
vice and to accustom them to work and to give them 
beck their belief in their own capacity to work; 
c. to make the forces of the patient gradually 
fit for the normal work of their trade and to 
asceitain how far the work is compatible with 
the process of tuberculosis; 
d. to judge the degree of fitness for military 
service or work attained when released from the 
hospital; 
e. those patients who cannot be considered 
capable of regaining their fitness for service 
or work on account of the kind and intensity of 
their process oT tuberculosis are to be influenced 
psychically In a favorable way# 4# It is to be aimed at that the patients destined for 
the occupational therapy are housed in a special section 
separated from the medical section. 
5* The kind and duration of the work is determined 
by the chief physician who is also responsible for 
the medical control. If the patients react unfavor- 
ably to the occupational therapy they are to be sent 
back to the medical section. 
6. The products manufactured by occupational therapy 
have to be marketable and have to be paid for according- 
ly. Each patient who has to work under the occupational 
therapy program is to be paid accordingly. 
7.i' ilt is to be aimed at that in each military dis- 
trict a large unit for occupational therapy is to be 
established in a reserve hospital for tuberculosis 
where different kinds of work may be carried through 
■with payment. Moreover, occupational therapy is to 
be carried out in every reserve hospital for tuber- 
culosis for the hospital itself even without payment 
according to the possibilities available* 
8, On account of the present situation of the total 
mobilization of every working power the occupational 
therapy in the hospitals f°r tuberculosis is of extra- 
ordinary importance because a great number of patients 
who are still fit to perform productive work have to 
stay there for a long time, Fe cannot account for 
leaving unused the working power which these patients 
still possess. In order to obtain work the hospitals 
contract their own armament units or proper firms• 
2, Investigations of pulmonary tuberculosis and. other 
* pulmonary diseases by tonograpTucTray* pictures• 
Geschwaderarzt (Lt. Col., MC,. Airforce) 
'Pr of es s~MCMETSTEEr “ ’ 
The following directions result from film findings 
and interpretations# 
1# By dividing the usual X-ray pictures into planes 
or sections an insight into the conditions of organs 
and an exact localization of the changes caused by 
diseases and foreign bodies (bullets) in the lungs is 
possible. 
2. Investigations by tomographic X-ray pictures have 
become of great value with pulmonary tuberculosis for: 
a. the recognition and localization of cavities, 
b, the indications for operations* c. The tracing and the observation of the pro- 
cess of the disease and the success of the treat- 
ment (e.g. before giving up pneumothorax and in 
the follow-up of the operative treatment). 
3. The tomographic X-ray investigations can be of 
decisive value to differential diagnosis and local- 
ization in the observation of the course and the healing 
of pulmonary abscesses, tumors, shrinking and deteriora- 
tion processes of diseases of any kind in the chest. 
Especially those cases with congenital acquired 
bronchiectasis and cysts of the lungs in the upper 
lobes without pulmonary symptoms of activity, who 
often undergo in vain long and repeated treatments 
and are considered as suffering from pulmonary tuber- 
culosis. can be isolated more easily by the procedure 
of the tomographic X-ray pictures and can be separated 
from patients suffering from pulmonary tuberculosis 
who need treatment and can be judged in the right way 
as to their fitness for military service# 
4. It is indispensable that every large hospital for 
patients suffering from tuberculosis has the possibility 
to carry through tomographic X-ray investigations 
(perhaps in connection with other hospitals or civilian 
hospitals). Those cases of pulmonary tuberculosis which 
are not clear as to the diagnosis are to be trans- 
ferred if possible to hospitals with the appropriate 
facilities or possibilities. Before carrying out 
collapse therapy, the procurement of tomographic 
pulmonary pictures is always advisable in addition 
to those cases having a special indication# 
Discussion: 
F. MEYER: The essential importance of tomography lies 
in the diagnosis of cavities and the analysis of the pro- 
cesses at the apex. Tomography is necessary: 
1. If differences exist between the clinical judge- 
ment and the XWray diagnosis; 
2. if extensive collapse-surgical procedures are 
applied; 
3* if the judgement of fitness is concerned with a 
special responsibility of the military physician ahfi 
a responsibility as regards social hygiene* 
KREMER: Three sections are not sufficient but we 
must take a section through the lungs every H centimeters 
at least. Probably we will be able to diminish the con- 
sumption of films in the future by the tomographic photo- 
fluoroscopy procedure recommended by JANKER. GRASS: It seems to me that the procedure of sectional 
ohotographs is of special importance particularly if con- 
nected with group X-ray investigations* By my cooperation 
with the chief physician of the reserve hospital in Bee- 
litz, Oberstabsarzt (Major, MC*) KREMER, I became acquainted, 
in addition to the cavities mentioned before, especially with 
caseated bronchi and the smallest cavities and learned to 
eyaluate them. It seems to me that to observe their changes 
with repeated investigations can give valuable information 
about the origin of tuberculosis, principally with group 
investigations when we see again and again tuberculous 
soldiers doing,their duty. The procurement of a tomographic 
instrument for the agency doing group X-ray investigations 
would make it unnecessary to transfer a great number of 
patients to an observation ward* 
3« The organization of investigation by photofluoroscopy 
in the Armed Forces. 
Obersta.bsarzt (Major. MC,) GRASS 
As it is particularly difficult to ascertain the fit- 
ness for military service of tuberculous patients it was 
useful to charge 6ne physician with a greater district as 
far as possible, e.g. a military district (Corps Area) in 
order to reach uniformity of evaluation and to use the 
collected experience. 
For such a task the physician always needs a recent 
X-ray picture which can be produced in such quantities only 
by photofluoroscopy. Processes of tuberculosis unknown till 
now can also be discovered with it at the same time. 
Though the serial X-ray investigation gives valuable 
facts for the diagnosis of all diseases which show up in 
the X-ray picture of the chest, it has by far the greatest 
importance for the diagnosis and evaluation of pulmonary 
tuberculosis. 
Therefore it is useful that the group X-ray investigation 
be performed under the control of a specialist for pulmonary 
tuberculosis because the survey about the general findings 
offers an important base for the evaluation of the individual 
case. He must also have available the means for a prompt 
out-patient and ward investigation cf questionable diagnoses. 
If the leader of the group X-ray investigation is charged 
with determining the findings and the evaluation of the 
patients and if this follows Immediately after the X-ray 
investigation the latter is more than a mere searching 
procedure. Even in earlier times it was a means which fitted 
harmoniously in the general campaign against tuberculosis 
when specialists for pulmonary tuberculosis used it with 
the aid of fluoroscopy. 1 4 ! 4 
Although X-ray specialists have shown that 
of thousands of patients could be Investigated with 
help of fihotofluoroscopy within a relatively short time 
it still is considered only as a searching procedure be- 
cause they have been neither willing nor in the position 
to take over the lesponsibility for the evaluation of 
questionable findings and the care of the patients. Thus 
the value of the original photofluorogpaph was diminished. 
The latter was filed according to a. description, often 
supplemented by an enlargement, together with the ether 
picutres photographed on the same film in a. way which made 
its repeated use nearly impossible. 
If the photofluoroscopy forms a basis of judgement 
f°r the specialist for. pulmonary tuberculosis it is of 
greater documentary value. The leader of the agency for 
group X-ray investigations must be able to verify all 
findings by means of the original photofluorograph and 
it must be at any time at the disposal of other persons 
interested in it, especially for comparison on the oc- 
casion of repeated X-ray investigations. 
Since it is difficult to keep and to look at the in- 
dividual picture when cut off from the film it is placed 
on a holder which shows the name of the patient 
it too may be projected on a screen. If the name is 
registered at the top of the card the card may be kept 
in the health record. If the person examined is designated 
only by a. number this number is entered in the paybook df 
the person. The cards are collected in the Central Archive 
for Military Medicine. 
For the evaluation an anamnesis must be^available 
for all "known" tuberculous patients, which is in the form 
of a questionaire. 
In order to decide questionable findings the possibility 
of fluoroscopy,of manufacturecf enlargements and of blood 
investigations has to be available. Photofluorographs are 
of an average size of 6.4 x 6.4 centimeters which show 
very little grain and arc therefore nearer as valuable 
as an enlargement as to their quality. They might be en- 
larged advantageously much more frequently, e.g. cf all 
those who pretend to be ill. Almost more important would 
be the possibility to produce outpatient tomographic X-ray 
pictures because with the help of them active processes 
can be ascertained earlier. They favor a more certain and 
quicker evaluation and save many assigments to the ob- 
servation ward. 
To perform the evaluation in a uniform way the necessary 
clinical observations are to be carried out in one reserve 
hospital with which the photofluorographic unit works in 
close cooperation. In addition to the usual examination 
methods it must offer the possibility of carrying through 
tomographic X-ray examinations and the culture of the 
content- of the empty stomach. It cannot be ascertained with a first examination 
whether the foci are quiescent. Certainly the recruit 
should be deferred for about half a year, the youth of 
less than 20 years of age for one year* The soldier 
has to be judged as fit for garrison duty and the date of 
the second investigation is to be fixed* This will be 
done according to the kind of foci within the period of 
six months. At the second medical investigation the former 
photofluorograms are to be taken along for comparison with 
the new ones. A change in the X-ray picture indicates 
activity of the process. 
The organization of the group X-ray investigation 
must always be adequate for the tasks in question* The 
number of the investigations, as well as that of the 
personnel and material are to be arranged at each step 
of the working process in such a way that each agency 
is fully engaged if possible and that no interruptions 
occur. A long interruption might disorganize the pro- 
cedure within a short time. This is to be considered 
especially at the medical examination of the films and 
at the evaluation of the findings. Therefore a medical 
substitute must be available at any time lest a lack of 
physicians results in an interruption or a restriction of 
the group X-ray investigation. 
The following requirements have to be mets 
1* The examined persons have to pass as quickly 
as possible in order to spare the working persons. 
About 200 persons are to be ordered to come to the 
investigation per hour, only in the case of a very 
large number up to 300 persons* 
2* Urgent cases have to be judged within a few 
hours, the others within some days* 
3* It must be determined who will perform each 
working process in order to avoid mistakes* 
4. With a repeat examination the former photo- 
fluorograms have to be at hand for comparison* 
5* The findings and the evaluation are to be 
written on the reverse side of the photofluorogram 
card and signed by the physician who made the find- 
ings* Moreover, they are to be put down in lists 
with an indication of all the necessary data* 
6* Persons suffering from active tuberculosis who 
are under the suspicion of being infectious are 
be reported to the physician of their unit if possible 
with an enlargement of their photofluorogram* 
7* The observations are to be gathered in statistics 
and are to be evaluated* The experiences with repeated investigations of the 
same patient, the cooperation with the observation 
and the statistical evaluation of the diagnosis are the 
most important factors of experience for the further im- 
provement of the.achievements. 
The results show the extraordinary importance of 
X-ray group investigations for the evaluation of persons 
suffering from tuberculosis as to their proper use in the 
Army. But they show moreover that great reservation is 
necessary concerning the evaluation and forwarding of 
findings unless numerous people with foci shall be un- 
necessarily made anxious* This would give them not only 
an unnecessary feeling of being ill but at the same time 
it would damage a great deal their capacitjr to work and 
their defensive power. 
The X-ray group investigation is valuable too for 
the findings which are not of a tuberculous type* But 
these are of such minor importance that they can be men- 
tioned by the specialist for tuberculosis* They are to 
be judged by the physician who is responsible for the 
medical examination or the physician of the troop. 
Directions on the organization of investigation by 
photofluoroscopy in the Armed Forces• 
The present directions are to be considered as a 
supplement to those put down on the occasion of the last 
conference of consulting physicians for tuberculosis* 
In this document it was mentioned that the photo- 
fluorographic investigation is suitable, not only as a 
searching procedure but also as a base for the explanation 
of questionable diagnoses as well as for the observation 
of the course. 
Therefore the agency for X-ray group investigations 
has to be headed by a specialist for pulmonary tuberculosis 
who should have available all means for an ambulatory and 
secondary investigation, (fluoroscopy, enlargements, tomo- 
graphic pictures, investigation of blood) usually in con- 
nection with an observation ward. 
It is indispensable that the individual photofluoro- 
gram is kept alone and not together with others on one 
film so that it may be available at any time for a con- 
trol and comparison with new pictures* 
For that purpose it is pasted in or on the file card 
the heading of which is photographed together with the 
photofluorogram for identification. The card is kept either 
in the medical record if identified by the name or in the 
Central Archive for Military Medicine if identified by a 
number which has been entered in the paybook* The procedure of the entire investigation has to 
correspond to the task in question so that a uniform 
drafting is guaranteed with the least use of personnel 
and material and{Without the danger of interruption* 
In case of emergency an extra physician must be avail- 
able who is trained for photofluorographic work but who 
otherwise is assigned at a different place. Moreover 
the personnel, as far as it remains fit for garrison duty 
or fit for labor, should not be moved without consultation 
with the chief of the X-ray agency* 
The following items are also of importance; 
1* In order that the persons to be examined are not 
unnecessarily kept away from their work, the number 
of the people ordered for the examination has to be 
small enough that no long waiting times occur* 
2* Urgent cases are to be judged within hours, the 
others within some days* 
3* It has to be evident who is to carry through 
each process in order to quickly remedy mistakes 
which may occur* 
4* At each repeat investigation the earlier photo- 
fluorogram kept in the medical record has to be avail- 
able for comparison. 
As far as X-ray findings are not the manifestation of 
pulmonary tuberculosis they are to be entered with the 
corresponding number of the defect onto the card so that 
they can be considered by the medical examination physician 
or the physician for the troop. 
4* Functional tests with patients suffering from pul- 
~ monary~diseases in Armed Forces' lib spirals* 
Stabsarzt (Captain, MC.) Professor ANTHONY 
I* The functional tests shall correspond on principle 
to the following requirements; 
1* The method of investigation shall not harm the 
person to be examined and shall not influence and 
change materially the process to be examined* 
2* The physiological relations on which the investi- 
gations are based have to be known* 
3* The standard values have to be assured by a 
large number of investigations* 
4* The procedure must have the possibility of differ- 
entiation as clearly as possible* 5; The findings shall not be ambiguous if possible# 
6. As many tests as possible should be made in one 
examination period. 
t 
Partia‘1 functional tests which relate only to 
one partial function lead very easily to an over- 
evaluation of this partial function according to 
experience. On principle it is more useful to apply 
a more complicated procedure which furnishes uniform 
and clear results than to apply a simpler procedure, 
the results of which are hard to explain.. Highly 
approved investigation instruments are required. 
II* Tests under physical strain ape to be performed ac- 
cording to the following principles; 
1* Very short physical strain is generally less 
suitable because the results are ambiguous* With 
this procedure the reaction during work is not tested 
but rather the reaction to the chhnge to work and the 
change from work to rest. 
2* One cannot conclude directly from the reaction on 
a certain kind of physical strain how the organism will 
react on more or less intensive types of physical 
strain. 
3* The operation of cranks while standing is widely 
used because this work requires only a little practice 
and many parts of the body are used. 
4* Attempts to work for 6-10 minutes are suitable 
for evaluating the respiration and circulation during 
the work. 
However, they do not justify conclusions about the 
capacity to work under physical strain of a longer 
duration. In this case the feeling of fatigue and the 
processes on which it is based take an important part. 
These processes cannot yet be traced down by simple 
quantitative methods of investigation. 
Ill* The results of the different examinations contribute 
to a general evaluation and it is of decisive importance 
to combine the different factors in this sense# The function 
tests are intended to complement the medical diagnosis and 
they require additional chores and a special qualification 
of the surgeon in the evaluation of these factors* These 
methods will therefore be introduced only in such cases in 
which an additional effort is justified* 
IV, With patients suffering from pulmonary tuberculosis 
the exchange of gas at rest may be increased because it is 
the manifestation of the toxic general effect. There ex- 
ists. however, no direct relation between the seriousness 
and the extent of the disease. The kind of breathing can 
show clear deviations in the case of severe lung defects 
in the form of short, more frequent and irregular breathing. 
The shape of the curve of breathing shows to what extent 
emphysematous changes exist in the lungs other than tuber- 
culosis* An increase of the ventilation of the is very 
frequent with patients suffering from pulmonary tuberculosis 
(COBET and his collaborator PETZOLD). 
The vital capacity of patients suffering from pulmonary 
tuberculosis may be diminished in various ways# There is no 
relation to the seriousness of the process of the disease 
but the greater the effort of the scarring in the lungs and 
the pleura on the maximal respiratory movements, the more 
the vital capacity will be diminished# 
The maximal ventilation of the lungs, the so-called 
respiration limit is of special importance# 
In most cases patients suffering from pulmonary tuber- 
culosis consume more oxygen at work than healthy people. 
The consequence is an aggravation of the effect. The ex- 
change of oxygen between the lungs and the blood can be 
disturbed with patients suffering from tuberculosis# This 
hypoxemia can be proved either by investigations of the 
arterial blood of the capillaries or by spirograph in- 
vestigations of the oxygen deficit. 
The investigation of the respiration in rest can be 
supplemented if necessary by splrography of the patient under 
physical strain. In general the ventilation of the lungs 
will be utilized to its limit at work only if the respiratory 
margin is essentially diminished# With healthy and slightly 
sick people the efficiency of the heart is decisive for the 
limitation of work in most cases. 
V# The EKG at rest and after physical strain offers a 
good basis for the evaluation of the heart# GAUBATZ has 
recently carried through investigations of prolonged physical 
strain and performed the investigation method of SCHELLONG 
immediately after ergometer investigations# 
It has already been pointed out that for a large number 
of the heart function tests a short physical strain is Suf- 
ficient# With this the blood pressure and the frequency of 
the pulse are determined. Various investigators who applied 
these methods stressed the fact that with an inefficient 
cardiac function the pulse rate increases relatively more 
than the amplitude of the blood pressure. I have the im- 
pression- that these short tests of functions of the heart 
of the type used until nov; are not yet satisfactory on 
principle# They inform us about the kind of circulatory 
regulation during work but do not give any information 
about the efficiency of the heart. It would be better 
to eliminate completely these short tests and to use in- 
stead a longer period of physical strain# 
A rather good measure for the judgement of the ef- 
ficiency of the heart is the maximal intake of oxygen found 
during a slowly increasing physical strain# VI* The question must now be answered, in which cases those 
methods shall be applied which require a special expense. 
Without doubt it is desirable to use these procedures 
systematically with a great number of patients because 
they always enlarge the diagnostic background and enable 
us to evaluate these methods better. On the other hand 
it is evident that these methods are not absolutely re- 
quired in order to gain a reliable opinion about the dis- 
ease of tuberculosis and its effect on most of the patients. 
The experienced physician has numerous other means at his 
disposal which give him a true picture of the seriousness 
of the effect of the disease. Every specialist knows of 
patidnts where an opinion concerning the capacity to stand 
physical strain is difficult for various reasons (capacity 
to stand surgical approaches and capacity to work). In 
Armed Forces hospitals it is to be considered that with 
one part of the patients subjective complaints are over- 
evaluated and with the other part underevaluated in order 
to attain special objectives. In such cases the use of 
the above mentioned investigation methods should be re- 
quired so that the medical evaluation may be accurate in 
every respect. The use of these procedures is therefore 
necessary with a relatively small number of patients* 
VII. In order to perform these methods, central, separate 
units are more suitable, since the nature of the methods 
and the evaluation of the findings always requires special 
knowledge. Therefore I think it profitable to designate 
some tuberculosis hospitals of the Armed Forces^for such 
investigations and to assure that a really detailed in- 
vestigation of the patients is performed there and that 
the findings are judged by specialists. Further it is re- 
quired that the functional tests of the respiration and 
circulation of patients suffering from pulmonary tuber- 
culosis in hospitals of the Armed Forces are to be per- 
formed in such cases in a uniform manner. 
Directions on functional tests. 
1. With patients suffering from pulmonary tuberculosis 
thorough functional tests of the respiration and cir- 
culation are necessary in order to judge the capacity 
for standing physical strain in borderline cases and 
doubtful cases as well as before major surgery on the 
lungs with serious and relative indications. The use 
of such methods is desirable also with other patients 
suffering from pulmonary tuberculosis in order to be 
able to judge more thoroughly the effect of the dis- 
ease and of the surgical stress on the respiration 
and circulation. 
2. I propose the following investigations be made: 
a. The volume of the lungs (if necessary the 
residual air), 
b. the respiratory margin by arbitrary de- 
liberate overventilation, c. ventilation of the lungs and exchange of gas 
at rest and under physical strain (with the cal- 
culation of the oxygen deficit), 
d. the frequency of the pulse and of the blood 
pressure, reclining and standing, 
the blood pressure, the frequency of the 
pulse and the EKG at rest and after physical strain 
• 
The use of these methods presupposes special in- 
vestigation apparatus (a spirograph, an ergometer, an 
EKG, a sphygmomanometer), trained auxiliary personnel 
and physicians who are experienced in the judgement of 
the findings. Therefore I propose to contact those 
hospitals of the Armed Forces which already have avail- 
able such apparatus and to assign them the task of 
performing these investigations* 
5, Gymnastics for patients suffering from tuberculosis. 
Oberstabsarzt (Major, MC») Prof* ULRICI 
Since DBTTWEILER the essential part of the open air 
treatment of tuberculosis takes the form of the rest cure 
while the type originally introduced by BHEHMER consisted 
only in walking and sitting outside. With this measure 
the rest cure entered the hospitals for patients suffering 
from tuberculosis and the principle of rest has been over- 
emphasized. There is no doubt that patients with symptoms 
of very active processes of tuberculosis must take care of 
their bodies. If they have fever they even have to stay 
strictly in bed in some hospitals for many months. Such 
a rest therapy often achieves a calming down of the process 
of tuberculosis which is manifested in the normal#tempera- 
ture of the body, in the values of the sedimentation rate 
and basal metabolism, in the shift of the white cell picture 
of the blood to the right, in the change of the symptoms, 
especially of the cough, of the quantities^of sputum and of * 
the night sweats , It must, however,, be overlooked 
that with complete body rest a debility of the muscles of 
the body is involved and a depression of the automatic 
functions of the inner organs, especially of the circulation 
and the gastro-intestinal functions, and that the patient 
urgently needs the full function of his organs after his 
roconvalescenfce for a hormal life and for his trade, for 
maternity and jo£ of life. Moreover, every healing of a 
tuberculous process is a healing with defects, defects 
which can be measured beyond question in the case of 
pulmonary tuberculosis by using the functional test of the 
lungs with the KNIPPING apparatus. The lungs contribute 
to the exchange gas and thus to an important part of 
the metabolism but the achievepent of the organ is nearly 
an exclusively passive one and the necessary compensatory 
work has to be taken over partly by the respiratory muscles (intercostal muscles, auxiliary muscles and above all the 
diaphragm), partly by the circulation. A permanent healing 
of pulmonary tuberculosis and the capacity of performing 
permanent achievements of the reconvalescent therefore 
depend on the capacity of the circulation. Moreover, the 
stomach and the intestines function much better if the 
organism can work by exercises of the body. Since it is 
not quite wrong to call tuberculosis a disease of domestica- 
tion, it is evident that such a disease can be healed only 
by exercises of the body in the open air. 
Therefore it is necessary to eliminate the principle 
of rest therapy even during the treatment in the hospital 
as soon as the patient's state of health will allow it 
and to restore the achievements of the bod3r through pro- 
gressive exercises. In the hospital, one tries to meet 
this requirement by gradually allowing the patients some 
activity but they are predominantly confined to walks, if 
possible in the so-called "cure-step". If the hospitals 
are situated in the mountains, certain physical strain is 
associated with these walks, that means an exercise of the 
respiration and circulation. The walks on the level, 
however, can hardly claim to be physical strain because 
of the short time permitted. A strengthening of the 
muscles without considering that only the muscles of the 
legs are concerned and those of the heart can hardly be 
expected with such exercises of the body# Therefore we 
receive complaints again and again that especially the 
manual workers leave the hospitals with a proper weight 
but quite insufficiently conditioned for their trade. 
These experiences resulted in the idea of including occu- 
pational therapy in the healing procedure and thus has al- 
ready been discussed for a long time today# The use of 
gymnastics, which only occasionally has been introduced, 
in the convalescent treatment of tuberculosis and as a rule 
only for special purposes, namely after the performance of 
major operations, proceeds from the same experience. Ac- 
cording to my experience of many years I think the problem 
of gymnastics is important and effective enough to make it 
the subject of a separate lecture. 
By gymnastics we mean the daily morning calesthenlcs 
and special exercises. The morning calesthenlcs, however, 
may be compared by no means with the training which students 
or soldiers have to undergo. In all cases easy athletic 
exercises without strenuous runs are carried through. The 
patients are divided into groups. If they are selected for 
the morning calesthenlcs by the ward physician they are 
assigned without exception to group It which begins with 
easy exercises of ton minutes’ duration# They move up 
to group II according to their pulmonary reactions and 
their stfc-tus of disease and they have to perform some more 
difficult exercises during the second ten minutes of the 
morning calesthenlcs in order to move up eventually to 
group HI, if the pulmonary reaction as well as the general 
state of health permits it, in order to do some more dif- 
ficult exercises during the last ten minutes# It happens 
of course very often that patients stay in group I or II. Patients with pneumothorax ©*g. can stay only in group I 
or II since Intensive movements of the trunk and jarring 
have to be avoided. The morning calesthenics are carried 
through in the open air even in winter in light clothing 
as we associate with it a gradual, mild but very effective 
hardening. As to the special exercises we formed again 
three groups: 
for patients after large operations (plastics) 
II for patients with bone and joint tuberculosis 
III for children. 
We selected and put down the light athletic exercises 
for all groups with the help of a snorts officer and a 
physician trained in sport, moreover we have employed a 
teacher of gymnastics for years under whose supervision 
and example all gymnastic exercises are carried through. 
I admit that I met again and again with doubts among 
my collaborators as to the use of gymnastics with the 
patients suffering from tuberculosis. I am sure that one 
or the other would have liked to demonstrate the disad- 
vantages of such gymnastics but I cannot remember of having 
seen in any single case a disadvantage caused by t&e parti- 
cipation in gymnastics. The patients become well ac- 
customed to go out of their ward beds into the cold in 
winter in their shirts and gaiety and good humor always 
prevails with these exercises. Occasionally our teacher 
for gymnastics interrupted the life in the hospitals in a 
nice way by performances of dances and gymnastics. On the 
whole we are extremely satisfied with the gymnastics and 
would not like to eliminate them from our convalescent 
treatment• 
(Demonstration). 
Directions on gymnastics for patients suffering from 
tuberculosis. 
1, Generally the patients suffering from pulmonary 
tuberculosis leave the convalescent hospital or the 
tuberculosis hospital insufficiently prepared for the 
final conquest of tuberculosis as well as for future 
life and trade. In addition to occupational therapy 
(especially with intellectual persons) gymnastics are 
useful to give the patient a better preparation. 
2* After the clinical symptoms of the disease have 
subsided all patients should take part in gymnastics 
which are graduated according to the patients* capacity. 
3* It has proved satisfactory to perform the gym- 
nastics in 3 groups. 
I easy exercises 10 minutes, 
II not too difficult exercises an additional 10 
minutes, 
III more difficult exercises a further 10 minutes. It will often happen of course that patients have 
to stay in group I or II due to their state of health 
and their capacity (e.g. patients with pneumothorax). 
The exercises are to be chosen carefully by physicians 
experienced in sport for the intended purposes and are 
to be conducted by personnel trained in gymnastics. 
4. Special exercises serve to regain a restricted 
use of the limbs. 
I after large operations (plastics). 
II with extrapulmonary tuberculosis (bones and 
joints). 
6. Minor surgery with pulmonary tuberculosis in Armed 
forces hospitals* 
Oberstabsarzt (Major. MCQ RICKMANN 
Directions; 
1. The pneumothorax is a procedure of treatment with 
tuberculosis which is applied with present or threatening de- 
terioration. Its use in time is a presupposition for its 
success. The incomplete pneumothorax is to be supplemented 
in due time by thoracocautery or paralysis of the diaphragm. 
2. If the pneumothorax is ineffective the matter 
should be re-evaluated as soon as possible in consideration 
of another surgical approach. 
3. Each pneumothorax treatment requires constant 
control by X-rays. 
4. In order to make out-patient pneumothorax treat- 
ment more easy and more certain a list is.to be established 
in every military district of the appropriate possibilities 
to have the pneumothorax refilled (military hospitals, hos- 
pital, physicians). These possibilities of obtaining a re- 
fill should be made available to all soldiers and patients 
on their release from the hospital in order to save the 
patient strenuous and injurious trips. 
5. Patients with pneumothorax should change their 
hospital as seldom as possible in order to remain under 
the treatment and supervision of the same physician. 
6* After-controls of the out-patient pneumothorax 
treatments have to be performed in the nearest military 
hospital every six months. ? 
7. As to the artificial paralysis of the diaphragm, 
the temporary elimination of the phrenic nerveby crushing 
is to be preferred in most cases. The paralysis of the 
diaphragm should be performed, in general, only with pro- 
cesses of the lower lobes. 301 
8. The suction drainage of the cavities cannot re- 
place the proved collapse therapy measures but may supple- 
ment them in proper cases. As a' single measure it is gener- 
ally used only with quite isolated large cavities. 
Z» . Major surgery with pulmonary tuberculosis• 
Oberarzt (1st Lieut., MC.) Dozent ADELBERGER 
Together with Directions ; 
!• With the patients of the Armed Forces suffering 
from tuberculosis all necessary methods of treatment in- 
cluding major surgery are to be usedo 
2* The basis of major surgery of the thorax is a 
good general defensive condition of the body which has to 
be assured by preceding and subsequent therapy in spas with 
general and climatic treatment* 
3* Major surgical procedures for collapsing the lungs 
are to be undertaken only after the results of pneumothorax 
treatments indicate that further efforts along that line 
are in vain. 
4. The-following methods are generally approved: 
Thoracoplasty and collapse of the upper lobe* Recently 
extrapleural pneumolysis with subsequent air injection or 
later oil injection has been gaining more and more followers. 
5. By the last mentioned operation the breadth of in- 
dication for surgical approaches has been enlarged a great 
deal because even cavernous processes in earlier states of 
development can be operated successfully. 
6. Thoracoplasty still covers large, rigid tertiary 
cavities in so far as the respiration and circulation, as 
well as the state of the other lung, control the indications. 
Total plastic operations occur relatively seldom with sol- 
diers and only in the case of diseases of one lung or pleural 
empyema. In most cases the upper partial plastic will be 
used with a total resection of the first, second and third 
ribs and if necessary with extensive apicolysis. In order 
to not burden the patient too much the surgical approach 
should be subdivided in two different stages. An apex 
plastic is to be used only in the rare cases of rigid isolated 
apex cavities which are firmly fixed at the top of the 
thorax. 
7. A primary collapse of the upper lobes is main- 
tained in the cases of large tertiary cavities if satis- 
factory conditions for thoracoplasty, on the part of the 
circulation and the functions of the lungs, are not present. 8. The extrapleural pneumolysis includes first of 
all the cavernous processes of earlier stages of develop- 
ment as well as those of loss extent. Nevertheless the 
possibility of revising the collapse shall be preserved. 
A supervision, and if required a revision, of the 
collapse has to be carried through every six month with out- 
patients at a hospital for tuberculous patients. 
10. Major surgery with tuberculosis of the lungs is 
to be confined to certain special hospitals which dispose 
of all the necessary equipment and. personnel. A survey 
about suitable hospitals should be handed to the reserve 
hospitals, the hospitals connected with them, and to the 
military welfare organizations. 
8. Experience with the diagnosis and the treatment of 
extra-pulmonary tuberculosis in hospitals of 
the Armed' Forces. 
Oberstabsarzt (Major, MC.) KREMER 
Directions: 
1. The early diagnosis of tuberculosis of the bones 
and joints is usually a clinical one. The X-ray picture 
is taken too late. The diagnosis is assured, if possible, 
by exploratory punctures and exploratory excisions. Tuber- 
culin tests which produce focus reactions are not to be 
used on account of the reaction of the lungs which usually 
occurs at the same time. Fistula contrast fillings are 
often indispensable. 
2. The basic treatment of tuberculosis of the joints 
and bones is the open air treatment by heliotherapy (caution 
with active pulmonary tuberculosis). Climates which cause 
strong stimulation promise the greatest method* 
3. The climatic treatment has to be combined with 
orthopedic and surgical treatment. The circular plaster 
cast is superior to the traction method. 
4. Surgical approaches are to be applied: 
a. if the period of treatment can be shortened 
essentially without much harm; 
b. because of vital indications. 
5. Tuberculous abscesses are to be aspirated with 
syringes with a large needle (not record syringes) and if 
necessary by stab incision but they are not to be opened 
widely. 6» Patients with tuberculosis of the spinal column 
and tuberculosis of the joints of the lower extremities 
arei unfit for service, while with the upper extremities 
each single case has to be decided individually* 
7* With tuberculosis of the glands, X-ray treatment 
associated with sun and open air treatment is the method 
of choice* Isolated glands can be extirpated* In most 
cases unfitness for service is the result* 
8* In the case of genital tuberculosis a mere con- 
servative treatment is justified only with small nodules 
in the epididymis. Otherwise operation with subsequent 
open air treatment is required. Those patients with the 
unilateral non-fistulating type may be fit for service. 
Patients with the bilateral, non-fistulating type are 
unfit for service. 
9. With unilateral tuberculosis of the kidney early 
extirpation with subsequent heliotherapy is required. 
10. The variety of the methods of treatment re- 
quires the establishment of special hospitals or departments 
with appropriate equipment and properly trained personnel. 
Supplementary remarks 
to the report of the'" Second Conference of the East. 
Concerning the tactical use of small hospital ships. 
Marine-Stabsarzt (Lieut.. MC.. Navy) KUTSCHER 
In World War I the big hospital ships, the structure 
of which had been changed in 1914, were put out of com- 
mission after a short time because of the kind of naval 
warfare and the lack of theaters with oversea bases. The 
number of smaller vessels, however, was augmented. The 
main task of the latter consisted in the transportation 
of patients and wounded near their home shore or from an 
advanced base to the homeland. The medical treatment was 
secondary in this case. Thus the transportation of the 
victims of mine warfare, the transportation of those wounded 
by accidents as well as of the victims of naval warfare 
and torpedo-attacks had to be dealt with. In case of 
landing operations, wounded and sick had to stay on board 
for a long time. That means they had to be treated on 
board until transportation to the far distant hospitals in 
the homeland was justified by the numbers. Inadequacies 
occurred because the possibilities of treatment on board 
were insufficient. Increased demands were made on the 
smaller hospital ships in a short time which surpasses the 
purpose for which they were intended. The demand on small 
hospital ships should not surpass what is expected of the 
fleet train within protected waters. For the treatment and 
for mass transportations, especially across the open sea, 
large hospital ships arc necessary. This war has given new aspects to the tactics of 
using hospital ships for medical purposes because of the 
new conditions of sea strategy and the new numerical pro- 
portions of the naval forces* 
The report deals with the experiences gained during 
a period of more than two years concerning the use of a 
small hospital ship while the ship was used predominantly 
in the area of the Polar coast. 
A modern investigation ship originally destined for 
the Arctic Ocean with a great radius of action and good 
speed had been rebuilt* It had 100 beds (60 regular and 
40 reserve beds) moreover the necessary additional rooms, 
such as operating room, the dental clinic, etc# Besides 
the chief physician, who was responsible for the performance 
of the military tasks, a surgeon, a dental officer, medical 
personnel, naval engineers, signal and radio operators, 
and administrative personnel of the Navy were on board and 
in addition the crew of the merchant marine which was nec- 
essary for operating the ship. 
The ship had to meet the following requirements: 
1. Readiness within a certain coastal sector, 
2# Medical care of coastal defense forces, 
3t Tasks of transportation. 
In case of good communication possibilities the ship 
was lying in continuous readiness in a certain sector 
assigned to it. Medical care was given to the patrol 
flottilla for sea mine-laying detachments, to the convoy 
system as well as to other enterprises of the naval war- 
fare* The low free board of the ship enabled us to seize 
and save directly from the deck these floating in the water, 
moreover the possiblities of rescue were increased by 
numerous rafts, motor boats, ladders, buoys etc# Besides 
the attempts at resuscitation of the drowned, the chief 
task of the physician consisted in the prophylaxis against 
death caused by chilling# Moreover the care for the wounded 
by experts was taken over as quickly as possible# If large 
groups of small naval units were lying in a small naval 
base or in a bay without any base on the shore, the ship 
took over the task of a preliminary base hospital# 
The medical care of iiastal bases could be performed 
without endangering the above mentioned tasks. After 
previous information, only those units and batteries of 
the Armed Forces were visited which could not be reached 
on the overland route or only with difficulty* An en- 
larged laboratory did much work as well as the X-ray 
establishments with X-ray pictures and fluoroscopy. By 
the investigation of fitness, by the clarification of uncer- 
tain diagnoses, by the surgical treatment and by dental 
treatment those soldiers were retained with the unit who 
would have had an extraordinary long trip to the hospital 
because of the peculiarity of the coast and the difficulty 305 
in transportation. T'rhile the ship was absent from the 
batteries a normal sound-movie installation was an im- 
portant contribution to our passing their leisure time. 
By acting as a floating out-patient department we got a 
variable idea of the coastal sector assigned to us. We 
were informed about the landing places of the boats, which 
are dependent on wind, tide and seasonal information which 
proved necessary on account of the snow storms of the 
polar nights.. Thus it was possible to take over the imme- 
diate medical care in case of accidents. Besides the trans- 
portation of single persons from outlying bases, transport- 
ation with full billeting was carried through over great 
distances. During the transportation, medical approaches 
and treatment could be performed. By these measures and 
by the unlimited nursing and care of the soldiers and in 
addition by the occupation of their time with movies during 
the trip a recovery of the wounded could always be observed 
toward the end of the trip. 
Just at the beginning of the Eastern campaign the 
ship was used for the transportation of seriously wounded 
out of the Petsame sector. The ship lay in the same 
position as the advance hospital trains of military hos- 
pitals as far as the tactics of medical service and geo- 
graphy were concerned. After the rounded had been taken 
on board and dressed the- ship corsscd the waterway, which 
was partly dominated by Russian batteries on the Peninsula 
of the Fishermen, accompanied by Naval and Airforces. 
Artificial fogs during the continuous light of the Arctic 
summer as well as later on the Polar nights made the per- 
formance of this task much easier. Thus the tasks of taking 
the patients to the military hospitals in the rear, respect- 
ively to the large hospital Ships in this sector, was 
carried through. If the task of transportation was not 
so urgent the duties of a field hospital could be taken 
over at the sane time. 
The cooperative use of the ship’s berthing space, 
of qualified, personnel, of medical and other equipment 
guaranteed the possibility of making a full use of the 
small hospital ships.