259 
IX. 
PROP ESDINGS OF THE CONSULTANT 1 S 
COMMITTEE ON PATHOLOGY 
Translation prepared by: 
0. S. Naval Technical Unit, Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government (U. S.) 260 
Death caused by heat and burning* 
(See Section V, Article 5) 
Death caused by dust. 
(See Section V, Article 6) 
Carbon monoxide poisoning and CO test. 
(See Section V, Article 8) 
Review of the non-organic heart-diseases; vegetative 
disturbances of regulation (postinfec'tious and 
others). 
_(See Section VIII, Article 7) 
Acute tuberculosis of juveniles• 
(See Section XIII, Article £TT 
1. Fatal early coronary sclerosis. 
Stabsarzt (Captain. MC.) Prof. ERICH MUELLER 
The present report concerning early coronary sclerosis 
of juveniles is based upon 127 cases of coronary scleroris 
with fatal termination in soldiers between 20 and 40 years 
of age and corresponding control examinations of persons of 
the same and higher age. 
The number of fatal coronary changes in youths appears 
to be raising in comparison to the period before the war. 
The main object of the study was to solve the follow- 
ing problem; 
1. Why is sudden death in cases of juvenile coronary 
sclerosis occurring so frequently without any noteworthy 
previous clinical phenomena? 
2. Does fatal early coronary sclerosis differ mor- 
phologically in any demonstrable aspects from the alterat- 
ions observed in advanced age? 
3. To what extent may the fatal termination of early 
sclerosis be ascribed to influences of the war? 
Clinical statements as to the causes of death were as 
follows; Coronary death after physical strain (drill, 
sport, marching) 24 cases; after excessive drinking, usually 
during the preceding night 9 cases; caused by an extra- 
ordinary rapid drop of temperature 7 cases; caused by 
overloaded stomach 5 cases; while bathing 4 cases; during 
or after a truck ride 3 cases; after acute abuse of nicotine 
(anamnesis: heavy smokers) 2 cases; fright, or psychic ex- 
citement 2 cases; after testing gas masks with bromacetone 
gas 1 case. 
29 of 65 reliable reported cases were, as was express- 
ly emphasized, heavy cigarette smokers with a daily ration 
Of 15 - 50 cigarettes (according to LOESER it was found 
that 7-10 per cetit of the examined soldiers smoked more 
than 12 cigarettes daily). Previous attacks of heart troubles are mentioned only 
19 times; with a surprisingly high percentage death occurred 
in the first attack and was due in 50 per cent of all cases' 
to a particular cause. 
The non-fatal early changes appear under the microscope 
as simple thickenings of the connective tissue, mostly with 
lipoids deposited in a strikingly regular way. If there are 
larger centers we find hyaline structures in addition, and 
the lipoid deposits are shifted into the deeper structures 
of the intima. with an increased spread of the disease the 
nourishment of these zones near the media becomes worse* 
Consequently In 13 of 40 control cases (in which death was 
not due to circulatory disorders) the fibres of the connect- 
ive tissue showed slight evidence of swelling. 
The fatal, early sclerosis of .juveniles, however, shows 
a marked tendency to considerable swelling and necroses of 
swollen tissues appearing in the connective tissues of scler- 
otic focuses. The histological examination of 45 fatal 
coronary cases in juveniles revealed a fatal focus without 
marked swelling in only 5 cases. The lipoids located in such 
focal areas will be cast off by the progressive swelling to- 
wards the edge of these areas and will frequently be subject 
to the formation of crystals following the direction of the 
swelling pressure. 
Fatal coronary cases over the age of 40 show in almost 
every case symptoms of necrosis in the center of the foci in 
the intima. Half of these cases show simple necrosis of the 
fibrous vascular tissues without swelling of the fiber sub- 
stance. The swelling power and tendency to swelling of cor- 
onary foci distinctly decrease as the hyaline fibres are 
hardening and the protein colloids decaying. 
The swelling process itself can only develop in the 
presence of protein substances. The fact that the swelling 
process most frequently occurs in juveniles is due to the 
greater tendency to swelling of freshly hyalinized connect- 
ive tissue fibres and to the particular tendency of young 
tissues to swelling. 
The swelling is of pathogenetic significance for coron- 
ary fatality, as it brings abouFan acute narrowing of the 
diameter of the vessel, which leads to fatal insufficiency 
.of, the blood circulation or coronary thrombosis. 
The senile sclerosis of the coronary system is not 
equally prone to acute swellings of the intima. It is part- 
icularly dangerous,and fatal termination is frequent. 
How extensive and how often a coronary spasm may bring 
about anginal troubles without simultaneously causing ana- 
tomical parietal changes is difficult to determine at au- 
topsy. By our postmortem examinations, however, it was as- 
certained that fatal coronary disease of juveniles is almost 
always combined rith serious parietal changes. We should 
keep that in mind when evaluating vasoneurotic complaints. The main factors aggravated by war-conditions which may 
cause the above mentioned intima swellings chiefly affected 
already existing coronary foci. Such factors are-above all 
conditions caused by lack of oxygen (loss of blood, carbon 
monoxide). According to our investigations heavy smoking 
too may be counted among the factors that bring about necrot- 
ic swellings of coronary centers. It is also possible that 
climatic influences may produce swelling *n connective tissues 
by modifying the turgor of the tissues. Sporadic cases of 
death caused by most serious acute swelling of the focus may 
be interpreted in favor of this possibility, as the patients 
died during the passage of very bad atmospheric conditions. 
2. Early coronary sclerosis• 
Stabsarzt (Captain. MC.) MEESSEN 
The collective examination of sudden heart diseases with 
fatal termination in cases of early coronary sclerosis con- 
firms the personal experience of each pathologist that the 
number of these deaths has doubtlessly increased in compar- 
ison to the last war, whereas a corresponding increase of 
coronary sclerosis has as yet not appeared in so far, as one 
may judge from the autopsy reports to date. It is pointed 
out that coronary sclerosis occurs less freouently among 
Japanese. 
As to the origin of early sclerosis local edematous 
formations and swellings in the intima play a part as initial 
injuries. There are, moreover, fibrinoid swellings and hem- 
orrhages to be observed in the intima. The finding of part- 
ial thrombosis is of some significance for the origin of 
(circumscribed) stenoses. In the media hypoxemia adiposis 
of the smooth muscular fibres is brought about. Especially 
characteristic of the early sclerosis are active secondary, 
reparative inflammatory modifications. This inflammatory 
character of early sclerosis is attributed to the fact that 
the capacity of reaction is better in the juvenile organism. 
Transitions between early sclerosis and vascular diseases 
of a more inflammatory character were mentioned. 
Hypoxemia is discussed as one of the pathogenic factors. 
No statistical material is available as to the hypoxemic 
injuries of motor vehicle drivers caused by carbon monoxide. 
The Possibility of infectious-toxic injuries causing the 
early sclerosis is emphasized, and at the same time the 
importance of increased blood pressure and fluctations of 
the blood pressure- should not be overlooked. It is prob- 
able that abuse of nicotine too is of significance. In 
brief it may be said that no single factor may be held 
responsible as an initial cause of this disease, but it nay 
rather be said that the combination of various factors has 
to be considered. An increase of sudden cardiac death has, 
as far as early sclerosis and early thrombosis are concerned, 
not been recorded since 1939/40. About 70 per cent of the sudden cardiac deaths due to 
early sclerosis came to notice by the anatomical findings. 
In 20 per cent more the aiatomical findings in connection 
with the etiological history justify classifying the cases 
as sudden cardiac deaths* In about 6 per cent inflammatory 
modifications are observed, which have to be considered apart 
from sclerosis* In 4 per cent the anatomical examination’ 
was negative. As to the latter groups attention is called 
to the discrepancy between the insignificance of anatomical 
acute cardiac failure. The possibility of pure- 
ly functional trouble causing cardiac failure must be admitted. 
3_. Coronary diseases in young people• 
Oberstarzt (Colonel* MC.) Prof* UHLENBRUCK 
The freouency of coronary diseases in juveniles will be 
confirmed by any clinician. Whether the increase of the 
number is absolute or relative remains unsettled. Constitut- 
ional, physical, psychic strain, nicotine, cold, carbon mono- 
xide and changes of climate may be of influence. In addition 
to the phenomena pathologically and anatomically demonstrated, 
of hypoxidotic-acidotic swelling the problem of snasm and 
atony as a functional regulatory disturbance of the coronary 
blood circulation must be considered. r hat makes the '-’hole 
problem of juvenile coronary disease so difficult is that 
there are comparatively so few patients organically serious- 
ly endangered, and these often have their fatal cardiac 
attacv without any preceding symptoms, and furthermore, that 
these comparatively few cases have to be picked out of a host 
of cases showing nervous regulatory disturbances of the cor- 
onary circulation or anginal complaints. The surgeons and 
clinicians follow entirely different methods in picking out 
these cases. In any cases the experienced army surgeon will 
soon learn to classify correctly the vaso-labile sympathico- 
tonic, the vagotonic with vagus heart, the man with over- 
trained athletic heart, the patient with Basedow’s disease, 
the man with a propensity to circulatory collapse (collapse 
type), the emphysematous, the allergic, the case with a focal 
toxicosis, the case with a Roemheld complex, all of which 
have more or less pronounced anginoid cardiac complaints. 
Generally speaking the army surgeon is able to avoid blunders 
by taking into consideration the soldiers psychic structure, 
constitution, history, the statistics of age, the blood press- 
ure readings, the test of circulatory function, the erythro- 
cyte sedimentation rate and the control of temperature. 
He must know the differential diagnosis of ulcus ventri- 
culi, bilious colic, appendicitis. If organic coronary 
disease is suspected the case should be brought before the 
clinician in the hospital for differential diagnosis, which, 
as regards cardiac infarct, can attain almost oanatomical 
exactness by means of the electrocardiogram. Infacts of 
anterior and posterior areas give typical EKG if, on the 
other hand, the conduction mechanism is affected, the infarct 
is likel3' to be concealed by different kinds of blocks. The 
infarct is traceable after eight at the earliest, in 
three to four days at the latest.’’Silent” infarcts not mani- 
festing themselves by EKG changes are very unusual. ST and T deflections of the EKG together with the anamnesis and 
clinical findings often permit in addition a specific dif- 
ferentiation betvreen myocarditic processes, organic coronary 
modifications, and reversible fluctuations of the coronary 
blood circulation of vasomotor origin. In brief summary: 
!• An organic coronary insufficiency may be token 
for granted: 
a. in cases of attacks of angina pectoris in 
men who show typical ST depression in the attack (Which 
is generally reproduceable in the functional EKG); 
b. in cases of typical attacks of angina pectoris 
with femur block, arborization block, Wilson block etc. 
after the attack - unless myocarditis is suspected? 
c. in cases of angina pectoris complaints with 
frequent in various places of origin 
after the attack and especially after the functional- 
strain of the attacks; 
d. in cases of transition from the EKG of cor- 
onary insufficiency to the EKG of cardiac infarct in 
the course of several attacks ; 
e. in those cases showing a typical EKG after a 
severe infection combined with stenocardiac complaints, 
and also in cases of intense exposure to excessive cold, 
of carbon monoxide toxication and in cases of a trauma 
of the chest wall. 
2. 2* i’An Organic injury is possible; 
a. in cases of hypertonias, even of juveniles, 
which show the typical hypotrophic form of EKG, although 
it is still debated whether this form of ST depression 
is not merely due to the changes of the myocardial sub- 
stance $ 
b. in asthmatics with a dextrohypertropic form 
of EKG and typical ST depression in the attack and after 
working. 
3. An organic coronary disease is not likely in the 
following cases: 
a. ST depression and T modifications after in- 
fections without anginal complaints. In this case we 
usually have to deal with myocarditis? 
b. in coronary EKG’s of pericarditis, where we 
have an anemia of the external parts of the myocardium 
caused by pressure. The coronary EKG’s of pulmonary 
infarct are reflexions of vascular spasms; 
c. the coronary EKG1s of thyreotoxicosis, myxo- 
edema, tetany and of diatebes simulate metabolic dis- 
turbances of the myocardium and ordinarily they arc not 
reproductions of coronary changes; d, the ST depression of nervous tachycardias, 
of juvenile hypertonias, of vegetatively labile persons, 
of allergies, of cases with manifest focal toxications 
are not caused by organic coronary diseases. 
Besides the EKG roentgenography may give an indication 
(enlargement of the heart, chronic pulmonary congestion, 
kymographic zones of calcification of the coronary vessels, 
aneurysma of the heart)* The basal metabolism test can be 
of importance, but must be regarded critically. 
Discussion of the reports on early coronary sclerosis; 
LAUCHE: We have to be particular about the matter as 
to whether coronary sclerosis has increased only during the 
war, or whether there has been general increase in recent 
decades. On the strength of the material published by 
MEESSEN, I am inclined to deny the first of these 
ities. The latter possibility, however, must be answered *«?. bu 
in the affirmative according to the material of NUERNBERG. 
OSTERTAG: The cases of coronary sclerosis among par -' 
tients younger than forty or fifty years of age have not 
increased during the war but according to my own findings 
since 1936. Among the causative factors recurrent infect- 
ions are of utmost importance. Reactions in the lymph 
channels and the lymphatic vessels are frequently observed, 
especially in the patients suffering from recurring pharyn- 
gitis. Chronic relapsing pharyngitis is very important 
especially ih:those capes in which generaInvahcuMr symptoms 
snpe'tGbsfervedipwifch juveniles*edit must be pointed out, how- 
ever, that in these cases the cause of death, the so-called 
"coronary death”, may not be ascribed positively to corbn- 
ary disease in consideration of the co-existing sequels to 
the vessel disease in the cerebrum or in the pancreas. 
It is against my experience to consider the vascular 
involvement of the coronary system separately without a 
thorough examination of the other vessels bff the body* If 
the general involvement of the vessels has a special effect 
upon the coronary system the reason for this is due to local 
and often to constitutional factors. 
SIEGMUND: It is my own opinion that specific proof 
of an increase of coronary sclerosis in juveniles caused 
by the war, cannot be established. Coronary sclerosis 
resulting in sudden death of juveniles has always been 
found frequently as long as the material which is taken 
a basis for our statistics is not taken only from the 
pathological institutes of the hospitals but also from 
the so-called police autopsies. The question of utmost 
importance is found in the relations between the function- 
al disturbances of the blood circulation and the develop- 
ment of changes of the wall of the coronary vessels which 
proved morphologically. It is my opinion that the 
changes which take place in the walls of the coronary 
vessels are generally the consequence of local disturbances 
in the walls of the vessels after alteration of the tonus 
and the blood circulation caused by the nerves. must 
take into consideration not only spasms but also atonies. 
All varieties of morphological changes, from the hypoendo- 
thelial formation of fibrinoid with and without thrombosis 
to the centers of swelling and necrosis; all of them must 
be considered under the point of view of an altered per- meBbiUty of the endothelium with a change in the relations 
of the blood circulation of the blood tissue. In the eval- 
uation of the functional disturbances of the blood circulati- 
on we must take into consideration the particular anatomic- 
al condition at certain points along the coronary vessels 
as observed by ZINCK from my institute. Besides this we 
have to consider the extent of the changing anastomosis bet- 
the left coronary artery in connection 
with the functional^circulatory disturbances. The point 
of attack of the initial stimulus is the vegetative nervous 
system. The tonicity and the sensitiveness which may change 
even in the same person 3s decisive for the effect of the 
stimulus. In the case of an extra sensitivity of the vege- 
tative nervous system nicotine may be important for initiat- 
ing1 changes of tonus and may even be held responsible for 
fatal changes of the blood circulation. Besides this other 
factors, such as infectious-toxic and psychic factors, are 
important also. 
GRAEFE: I would like to ask the speakers what signi- 
ficance they attribute to lipoid metabolism in connection 
with the origin of coronary sclerosis in juveniles. This 
Question has arisen from the observation that we find cor- 
onary sclerosis of the same kind and in the same incidence 
in Russian prisoners of war, as long as they are well fed, 
as r,e find in German soldiers. 
In case of a longer lasting inanition the frequency 
of atherosclerotic centers in the vessel system diminishes 
rapidly and is not observed anymore in case of malnutrition 
r’hich has existed over years. This observation confirms 
that the fat metabolism is of utmost importance in the de- 
veloping of atherosclerotic centers. The importance of 
nicotine in the case of vessel damage is demonstrated in 
the following observation: A soldier employed as a cigar- 
ette taster and who had tested about 2 - 300 cigarettes 
daily and who had contracted a nicotine intoxication was 
found to have a completely normal vessel system when he 
died years later. 
ZINCK: I thank Prof. SIEGMUND for the hint in con- 
nection with the throttle mechanism of the heart muscle 
which I have referred to several times. I would like to 
ask the two speakers if they have observed an accumulation 
of these centers in the area of these throttle spots, 
especially in the small vessels. Here, we may find a 
link from the functional to the pathological anatomical 
spheres. 
RANDERATH; He asks which anatomical changes are 
suitable for judging the age of swelling of the intima. 
It is remarkable that neither of two anatomical-patho- 
logical specialists refer to findings in the heart muscles 
in the case of acute swellings although this would furnish 
a clue to the age of the changes of the intima. 
HUECK: The swelling may develoo very quickly. This 
does not account for the origin of the stenosis because 
it is a symptom of the disturbed vasomotoric tonus. It 
may be found also in other arteries. From the etiological 
point of view first of all fresh catarrhal inflammations 
of the respiratory passages are important if persistent 
foci of previous inflammations still exist. NDNNENSRUGK: The difficulty In detecting the suscept- 
iDllity to coronary thrombosis is lllustrrated by the fol- 
lOFing example: In the morning careful examination include 
findings. In the evening myocardial infarct, 
if Infectious foci are thoroughly eliminated the prognosis of 
coronary thrombosis in juveniles is favorable according to 
my personal experience. 
BUECHNEH: 1, Contribution to the problem "functional- 
organic”. Recently it was reported to me that in a case 
arteriosclerotic coronary infarct a sound coronary system 
a sound heart were diagnosed eight days before fatal 
termination occurred during a thorough examination of the 
functions of the heart. 
2. In connection with the question of side effects of 
smoking, especially cigarettes; I would like to point out 
that contrary to the negative findings of GIESE we have 
numerous cases of juveniles afflicted with severe coronary 
sclerosis even with fatal termination directly due to smok- 
ing to an excess. 
MUELLER* Erich; Final remark: I wish to say that in 
the case of subsidence of the swelling of centers in the 
intima the pressure of the circulating blood is not of 
great importance. The tension in the completely closed 
swelling center is too great and the liquid causing the 
swellings has no channels of exit. 
In connection with the question how quickly swellings 
may develop I would like to point out that the movement 
of lipoids and chromatic substances out of the center of 
swelling and their deposit in the coronary zones and at the 
same time symptoms of an unequalized swelling pressure may 
be the evidence of the suddenness of the swelling. Besides 
this we rather seldom found distinctly developed and macro- 
scopically perceptible muscle necrosis or advanced heart 
muscle changes in juveniles which fact also indicates an 
acute swelling with sudden fatal termination. 
As to the vessel-wall-lipoidosis in the case of ar- 
teriosclerosis this problem is of minor importance compared 
to the swelling symptoms which are dependent on protein 
factors. It seems to be advisable to contrast a late 
lipoidosis to a premature lipoidosis caused by the infilt- 
ration of blood plasma into the vessel wall, spread rather 
regularly over the intima center. The late lipoidosis de- 
velops in the insufficiently nourished medial zones of 
larger intima centers probably in the way of a fat phaner- 
osis with an anoxia of the tissue and a decay of hyaline 
fibre structures in these zones. 
MEESSEN: A higher incidence of sudden fatal coronary 
cases in drivers of motor vehicles was not observed. Gen- 
erally speaking it may be said no particular branch of the 
service has a marked incidence of this disease. The ex- 
amination of the heart muscle revealed that fifty per cent 
of the cases were due to previous injuries. 268 
Statements concerning early coronary sclerosis. 
1. The systematic examination of, numerous fatal cor- 
onary cases in soldiers between the age of twenty and 
forty five reveals, with an amazing regularity in the 
arteriosclerotic centers, marked acute swellings in 
contrast to similar cases among aged persons. The 
centers of swelling usually associated with marked, de- 
crease of efficiency may lead either to an acute ir- 
regularity of the blood circulation in the heart muscle 
or to fatal coronary thrombosis# These findings were 
made at the same time by the Army and the Airforce. 
They confirm that in early coronary sclerosis in juven- 
iles sudden death very often occurs during the first 
attack. Reparative inflammatory changes are more fre- 
auent than in older persons. 
2. The changes and the resulting acute coronary death 
of young soldiers may be ascribed certain extent 
to the abuse of tobacco as observed in thorough ex- 
aminations by the troon surgeons. Infoctoue toxic 
influences must also be considered. It cannot be proved, 
however, that CO is often involved. 
3* During this war an increase of the fatal coronary 
sclerosis cannot be proved statistically. 
4. Clinical experience confirms the existence of a 
large number of fatal cases of juvenile coronary_scler- 
osis which very often appears without any preceding 
symptoms. 
5. The clinician is in a position to control the 
course to a certain and important extent pathologica ly 
as well as anatomically. 
6. The diagnosis "Coronary insufficiency11 should 
take the etiological aspect into account. 
7, The troop surgeon is in aposition to differentiate 
which patient is seriously endangered and which one 
probably not according to the anamnesis and the con- 
stitutional conditions of the patient. If a senouvs 
prognosis is foreseen the patient should be brought 
to the hospital as soon as possible for clinical ob- 
servation. 4, Cases of sudden death in troops. 
Stabsarzt (Captain. MC.) BOEMKE 
By sudden death is understood a transition from apparent 
health to death taking place in a few seconds without ex- 
ternal injury. Furthermore it will be considered a case of 
sudden death if the patient dies unexpectedly after a relat- 
ively insignificant illness or after a short indisposition. 
It is still necessary to speak of sudden death in such cases 
where the autopsy reveals a severe chronic disease as ac- 
counting the fatal termination if the particular disease 
did not appear clinically. Fatalities due to external in- 
fluence in consequence of a poisoning will not be considered 
as cases of sudden death as they were caused either intent- 
ionally or unintentionally. 
In consideration of these points of view about 3000 
cases of sudden death were thoroughly reviewed. Of these 
I8l6 cases are described as sudden death cases in the sense 
of the above definition. The classification of the basic 
diseases causing sudden death reveals, in accordance with 
all other known statistical material, that the failure of the 
heart or of the vessel system accounts for by far the great- 
est number of these cases (1496). 70 cases of sudden death 
were caused by some failure of the central nervous system. 
In 35 cases death was due to an illness of the respiratory 
passages, in 32 cases - according to the findings of the 
autopsy surgeon - as a result to a status thymico-lymphaticus, 
14 cases of sudden death were due to illness of the other 
organs of internal secretion, in 8 cases we found an illness 
of the digestive system. In 6 cases by an allergic reaction 
and in 8 cases by a cerebral or lung embolism. 46 cases 
of sudden death are especially remarkable because of the un- 
usual pathologic-anatomic In 95 cases a genuine 
pathologic-anatomical cause responsible for the sudden death 
was not observed. 
when considering the incidence of sudden death of 
soldiers with regard to we find that the peak of mort- 
ality lies between the age of forty and fifty. This fact 
finds its explanation in that soldiers older than fifty 
years are rarely drafted. 
rhen considering the incidence of sudden death with 
regard to different countries, respectively the different 
frontieiE we see that the homeland ranges first with 1199 
sudden death cases. Then comes France with 229 and Russia 
with 160 sudden death cases and then Poland with 10? cases, 
and with far less cases the rest of the countries. It 
may be concluded therefrom that the conditions at the dif- 
ferent frontiers do not influence the incidence of these 
sudden death cases. 
In 294 cases sudden death occurred while dressing, 
washing, undressing, after meals, while painting, playing 
at cards, in conversation and while asleep. In 166 cases 
it appears from the anamnesis that death occurred after 
excessive strain either during the service or otherwise. Thcrr is hardly any case of sudden death during or after a 
combrt or after strenuous marching. The greater part of the 
above mentioned 166 death cases rather occurred while in- 
dulging in sport either in the service or voluntarily or 
after strenuous missions. Several cases of sudden death 
occurred also during or shortly after guard duty. In 125 
cases death occurred during service in the orderly room or 
in the barracks without previous strain. 109 cases of sudden 
death occurred in the street or in public restaurants, 79 
when traveling. 
Among the many external factors causing sudden death we 
must mention psychological excitement with symptoms similar 
to angina pectoris. Furthermore it is worth while mention- 
ing that death occurred in a few instances after Participat- 
ion in merry parties the previous night. In 35 3 cases of 
sudden death the circumstances which led to the sudden death 
were not known. As far as information about profession and 
military rank was available it was found that 1409 soldiers 
and 324 officers and officials were concerned. os; .-e: 
high incidence to -a 'particular group or profession nnt 
observed. With regard to the relatively high incidence of 
sudden death cases in officers and officials it must be born 
in mind that their average age is much higher than the aver- 
age age of the enlisted men and that, as was pointed out in 
another place, coronary insufficiency ’~ith fatal termination 
was relatively high in officers* In several cases the dis- 
eases of the organic system were subclassified for the pur- 
pose of this lecture, according to the exact seat of the 
fatal disease and especially important rare findings were 
given special attention; (In cases of sudden death, caused 
by diseases of the heart; coronary aneurysm, ruptures of 
the aorta in consequence of an idiopathic necrosis of the 
media, rupture of the heart after an old trauma. In sudden 
diseases of the central nervous system: Several cases of 
swelling of the cerebrum, one case of multiple sclerosis. 
In cases of sudden death due to special caused; Tnrne cases 
of tuberculoma of the heart, one case of cysticercos In 
diseases of the endocrine organs: one case of basophilic 
hypophysis etc.) 
In conclusion it must be emphasized that a full report 
on the cases of sudden death in troops cannot be given be- 
cause there is almost no disease which after a latent course 
may not terminate sudden death. Tn order to determine the 
degree of disability contracted in the service it is essent- 
ial to ascertain the anamnesis as correctlv as^ 
by the line surgeon as well as by the pathologist. It is 
required as a matter of course that the line surgeon be 
present at the autopsy. At the same time the interest of 
the soldier and next of kin requires an autopsy in each 
case of sudden death, which should be performed only by 
a pathological specialist. A very detailed histologica 
examination of all vital organs rill br necessary if the 
case is uncertain. At the same tine a blood test should 
be made with a vievr to determine -blood alcohol even in 
those cases when an alcohol abuse is not suspected. A 
the sane time it will be necessary to make a chemical an- 
alysis of the contents of the stomach and of the bowels and 
of the urine if the macroscopic findings and the histology 
cannot explain the cause of death. Even bacteriological ex- 
aminations should not be forgotten if the cause of death 
cannot be verified. Statements In connection with sudden death cases in 
troops. 
1* majority of all sudden death cases in troops 
caused by natural factors are heart and circulatory 
insufficiencies. In this group the fatal coronary cases 
are most numerous. Fatal termination of myocarditis, 
valvular deficiency and hypertonia range next. Small 
groups of fatal cases caused by diseases of the central 
nervous system, or, of the respiratory organs, of the 
endocrine organs,of the kidneys, and of the digestive 
tracts. 
2. In every sudden death case an autopsy should be 
performed by a pathological specialist as quickly as 
possible after death. 
5.» Macroscopic-anatomical findings in hepatitis epidemiea. 
Oberstarzt (Colonel, MC.) Prof* KALK 
255 liver punctures were performed in case of hepatitis 
epidemiea. The puncturing needle was directed with the eye 
by means of a laparoscope (KALK). During this process the 
liver could be visualized* 
In the first phase of the disease the liver was swollen 
and of red-brown color in contrast to the green color of the 
liver in mechanical icterus* The liver was of soft con- 
sistency and the serosal surface was diffusely spotted and 
red colored. During the first phase and when the illness 
was at, its height ciuite often the gall-bladder was only 
slightly filled or empty, its tonus was weak. The spleen 
was often found to be enlarged. In the following phases 
the liver usually becomes smaller and harder, Sometimes, 
however, it stays larger than normal and shows a little 
flat hump on its surface. The diffuse reddish spots of 
the serosa-cover become scarred and somewhat white. In 
this phase the gall-bladder is amazingly engorged like a 
case of congested bladder with vascular dilatation visible 
on its surface. In most of the cases the liver and gall- 
bladder showed a normal macroscopic picture after healing. 
Two cases, however, were different. In one case we found 
a larger brown and hard liver, eleven months after the on- 
set of a serious icterus which had not come to clinical 
cure. Its surface showed deep septic connective tissue 
and radiating scars similar to a hepar lobatum. In the •• 
other case we found a surprisingly light, almost reddish 
white liver three months after the beginning of a serious 
hepatitis epidemic which could not be healed clinically. 
On its surface we found numerous dark red-brown islets 
differing in size from a cherry to a walnut with a rasp- 
berry-like surface. They probably were fresh liver tissues.  The histological picture of the liver in hepatitis 
epidemica. obtained from biopsy material« 
Stabsarzt (Captain, MC.) KOEHN 
By means of the directed liver puncture of KALK we have 
made 179 liver punctures in the cases of 149 patients with 
jaundice. Most of the cases have to be considered as hepa- 
titis epidemica according to the anamnesis and the course 
of the disease. The smaller group of the cases showed symp- 
toms which formerly would have been considered as icterus 
catarrhalis. The biopsy specimen were obtained in all phases 
of the disease, from the second day of the jaundice to the 
convalescence. One group of the patents was punctured sev- 
eral times (up to three times) in order to follow up the 
histological changes in the liver. Even some cases in which 
the disease was \ or 1 year old were examined. 
In conclusion the results of these histological exam- 
inations are as follows: 
The very first phases of the disease predominantly show 
changes in the periportal areas. Besides a loosening of the 
connective tissue and a dilatation of the vessels and of the 
lymphatic spaces we see here an infiltration with cells of 
connective tissue origin. On the other hand we find smaller 
quantities of lymphocytes and plasma cells and isolated 
eosinophilic leucocytes. 
In the lobe itself we observe only trivial changes in 
this early phase of the disease, first of all isolated dis- 
seminated liver cell necrosis which leads to the change of 
the liver cell into hyaline lumps with a pyknotic nucleus 
or, which may also lead to a complete loss of the nucleus. 
In the early phases of the disease liver cell necrosis is 
found mainly in the periphery of the lobe and only very 
occasionally in the rest of the lobe. 
The reticulo-endothelium shows swelling and mobilization 
of varying extent but we do not yet see any proliferation. 
Very soon we see extensive changes inside the lobe. The 
above described areas of liver cell necrosis are found in 
greater numbers. They are spread all ober the lobe but 
generally keep their disseminated structure. The hyaline 
lumps are cast off the trabecula-unit and absorbed by 
KUPFFEH* s stellate cells. These cells proliferate dif- 
fusely in the lobe and are very active. In general they 
are lying free in the lumen of the capillaries as round 
cells. A part of the KUPFFEH!s stellate cells show an 
Intense accumulation of fine-grain pigment, which, accord- 
ing to its staining characteristics must be looked upon 
asecell decomposition pigment after phagaytosis of necrotic 
liver epithelium (erythrocyte decomposition pigment;. 
In this stage the bile capillaries effuse homogeneous 
protein which, in the further course of the disease, imbibe 
blleplgment give rise to the well-kn 
bosis. These findings are considered to be the expression 
of a primary "albuminocholia" in the case of hepatit s. A a symptom of a beginning regeneration of the liver 
Tn th?«°SS 0bse7?s very earlv a mitotic liver cell division. 
Tn *!LS P?afS °{.tho disease amitosis is seldom observed. 
alJ?8 liver vessels contain an abundant amount of 
glycogen while an adiposis was never observed. 
in the periportal areas still increased in 
t is phase of the illness. The small biliary ducts may show 
observed pro^^^erab^on* Inflammatory symptoms are not 
Some of the cases reach their peak degree nth the above 
described changes. The changes inside the lobe subside quick- 
ly-. Amitosis is an important feature of the regeneration 
during the healing process* The reticulo-endothelial react- 
ion may persist for some time longer than the clinical as- 
pect of the disease# This fact is rather regularly observe 
nth regard to periportal infiltration. Finally such cases 
heal rithout any residual symptoms* 
In a second group of cases which show a more severe and 
especially protracted course the center of the lobe shows 
more loss of parenchyma which is compensated by a typical 
and amitotic regeneration. The latticelike tissue frame 
work always remains intact even in case of the most serious 
destruction of the center of the lobe. During the healing 
nrocess of such cases there is always an increase of the 
collagenic fibres about the central vein, sometimes even a 
connective tissue extension of the periportal areas and the 
proliferation of collagenic fibres inside the entire lobe. 
A third group clinically characterized by its chronic 
course shows a specific formation of connective tissue dur- 
ing the healing process principally a formation of connect- 
ive tissue “streaks’' between t1~e very broad areas which, 
for a long time, are infiltrated by fibres and strong scler- 
otic lobe centers. These pictures resemble a beginning liver 
cirrhosis, but the development of a true cirrhosis could not 
be detected. 
In their entirety the changes are considered to be the 
expression of a diffuse inflammatory reaction of the organ 
due to an injurious agent infiltration from the portal vein 
or from the greater circulation in which the typically dis- 
seminated arrangements of the necrosis sneaks for a direct 
attack of the hypothetical excitant on the cells of the 
liver and against the effect of additional related disorder 
of the blood circulation. A “serous inflammation” was found 
onlv in seriously destroyed lobe centers, never, however, 
in early cases. It is refuted that a serous inflammation 
plays a part in the pathogenicity of hepatitis. No dif- 
ference in the histological pictures of hepatitis epideraica 
and of icterus catarrhalis could be ascertained. 
Discussion concern?ng the lectures on the biopsy 
picture of hepatitis epidemic?» 
NONNENBHUCH: Hepatitis epidemica and icterus catarrh- 
alis cannot be separated, either clinically or pathologic- 
anatomically. There is always in question a preponderant 
reticulo-endothelial reaction. In clinical cases of a 274 
pseudo-hepatitis epidemics a true, hepatosis was found anatom- 
ically* It was a Morbus Weil. The supporting tissue remains 
intact* According to our own findings no case of final de- 
velopment into liver cirrhosis occurred* There are protract- 
ed courses of the disease, without any progression in the anat- 
omic findings. Functional disturbances may be completely 
dissociated. Occurrence of bilirubin, Felix-reaction (para- 
oxyphenyl-pyro-racemic acid) galactose and santonin test, 
must often be made at the same time. 
LAUCHE: In judging the histological findings in liver 
puncture biopsies greatest caution must be taken when com- 
paring them with post-mortem findings. Seemingly broadened 
Disse’s spaces may be also caused by physiological contents 
of glycogen. An observation by BRASS of the clinic of NON- 
NENBRUCH proves that there are also cases of hepatitis epi- 
demics without icterus* In that case the patient was punct- 
ured three times. The last puncture was done during a clin- 
ical relapse without icterus with the typical histological 
findings of a typical hepatitis epidemica. 
SIEGMUND: A special discrepancy between the findings 
in the liver at autopsy and puncture biopsy do not exist if 
the peculiarity of the liver is taken into consideration. 
Each evaluation of puncture biopsy of diseased cases must 
start with the normal picture of the biopsy and not with 
the usual liver findings at autopsy. The normal picture 
of the biopsy is characterized by an abundant glycogen con- 
tent of the liver cells and the vegetable like character 
of the protoplasma. Artefacts due to fixation methods must 
be taken into consideration* The condition of the circulat- 
ory vessels must not be judged by the puncture biopsy. The 
significance of the periportal infiltrates as an incipient 
change reauires further examination. In those early cases 
that I observed the periportal changes did not occur re- 
gularly and extensively enough so that special significance 
could be attached to them. They are also found in livers 
without icterus epidemica. All the other changes are found 
in livers at autopsy as well as in my puncture biopsies. 
(See; "Friegstagung der Gesellschaft fuer Innere Medizin”, 
rlen, 1943.1 
WURM: The appearance of liver cell necrosis seems not 
to be an indication of the seriousness of the disease. I 
remember very well one case of a sporadic icterus which led 
to the death of the patient after a lapse of^three days 
and which did not show any liver cell necrosis* 
MUELLER, Erich; Survey on preliminary examinations 
of 125 liver puncture biopsies in cases of hepatitis epi- 
demica in the Mediterranean Area in collaboration with 
Oberarzt (1st Lt., MC.) Prof. Dr. B0CK_(clinical picture). 
In judging histological changes it is important to be ac- 
quainted with the characteristics of nfin-diseased liver 
puncture biopsy. At the same time we ®ust Jak®. lnto-°W" h 
slderatlon changes occurring in the quick fixation of fresh 
tissue. Here the evaluation of a cloudy swelling of liver 
cells may lead to a faulty diagnosis. To its greater 
the findings of the histological Picture of hepatitis epi 
demica of the Mediterranean Area is similar to the ab ve described findings. In the earlier phases of the clinical 
picture we find periportal cell infiltrates, street-like 
proliferation of the capillary endothelium, symptoms of 
swelling and decay of liver cells, usually without any re- 
cognizable preference of certain areas of the lobe# Very 
often it is restricted to a few liver cells only* We did 
not see any symptoms of a previous or still existing serous 
inflammation* At the same time it is amazing to note that 
adiposis of the vessels in the liver parenchyma does not 
exist which, however, was sometimes present in KUPFFERfs 
stellate cells. The iron-test,with the Berlin blue reaction, 
is usually negative* Bile deposits were found intra-cellular- 
ly and in the biliary capillaries in varying quantities* 
Early, or sometimes in a later phase, there comes into ex- 
istence a localized little knot-like accumulation of KUPFFFR 
stellate cells. Mostly they are found in the vicinity of 
decayed liver cells. It is not yet certain whether this 
is the symptom of a true or a pseudo proliferation the 
latter being caused by shrinking of the capillaries in the 
way of a circumscribed parenchymal atrophy. No increase of 
fibres in an advanced stage of the disease, i.e. no symptoms 
of sclerosis became apparent in the preliminary results of 
fibre observation by silver staining which, regarding the 
previous conditions of a serous inflammation would be ex- 
pected in at least some cases. Patients who were punctured . 
repeatedly because of relapses occurring during the period 
of their hospitalization showed a return of the acute early 
picture of periportal infiltrates, capillary endothelium 
proliferations and injury of the liver cells. Examinations 
of these cases made up to 220 days later did not show any 
symptoms characteristic of cirrhotic processes. 
MEESSEN; Only in a single of a serum disease 
did the liver puncture biopsy reveal pathological findings. 
Statements concerning: "The biopsy picture of hepa- 
titis epidemics* 
1. In early cases the laparoscopic picture of the 
liver in the case of hepatitis epidemica reveals an 
enlargement and a redness spread either diffusely or 
in spots with a thick edge and a soft consistency, in 
contrast to the green color of the liver in the case 
of mechanical icterus* The gall-bladder is often 
empty and loose* Some time later the liver is smaller 
and harder and freouently has small flat humps on its 
surface, the gall-bladder being filled. After the 
healing most of the cases show a normal liver and gall- 
bladder. In very few cases r,e found pictures resemb- 
ling cirrhosis after the clinical healing of partic- 
ularly serious and long lasting hepatitis epidemica. 
2. The macroscopic picture of hepatitis epidemica 
shows in its early phase strong mesenchymal lympho- 
cytic plasma cell infiltrates in the periportal areas 
and in the liver parenchyma, disseminated single cell 
necrosis. In the further course of the disease we 
see proliferation of the lobe endothelium, in serious 
cases central parenchymal decay. The decayed liver 
epithelium is completely regenerated, in general 276 
by mitosis and anitosis. Periportal infiltrates and 
small endothelium knots frequently outlast tfce clinical 
disease. In very serious and chronic cases re some- 
times observe streaked developments of collagenous 
connective tissue. According to the material at hand 
it ras not possible to prove that these cases resulted 
fop certain in liver cirrhosis. 
3. The clinical diagnosis of icterus catarrhalis 
shows the same histological picture so that an identity 
of these diseases must be considered probable. 
4. The alterations are considered to be the result 
of a hypothetical excitant ia the parenchyma and nesen- 
chyma of the liver. The serous inflammation is of no 
importance as to its pathogenesis. 
2j Pathological anatomy of closed and open rounds, of 
bra in • 
Oberfeldarzt (Lt. Col., MC.) Prof. SPAT2 
We must distinguish between blunt and sharp cerebral 
injuries, according to the method by which the injury is 
inflicted, according to the reaction of the dura and the 
brain we speak of closed and open wounds of the brain 
(cerebral contusions - cerebral wounds). 
In the case of an injury inflicted by a blunt instrument 
upon the skull (moderate speed, broad area of impact) the 
impu3se is transmitted from the unperforated skull to parts 
of^the brain which are distant from the side of the impact. 
..uch remote effects are manifested on the one hand^by the 
symptom complex of commotio without leaving any evidence# 
On the other hand we observe contusions (primarily contusion 
center of the cortex) usually at the spots of contre-coup 
at the brain base and at the transition from the base to 
the convexity. The topographical distribution depends large 
ly on the direction of the force and accordingly we have to 
adopt the following classification: 
from the right side, tyfe 
TV 
from above, type V 
from below, type VI. 
from the rear, type I 
from the front, type II 
from the left side, type III 
In peace-time head-injuries of type I prevail. Type II 
is predominant in air accidents (75 per cent), 
types show center of contre-coup in the area of the olfact- 
ory center. A smelling test is indispensable in the exam- 
ination of all head injuries# The preference of the basa 
cortex explains the occurrence of changes of Personality. 
In type IV aphasic symptoms may appear• The petechiae in 
contused areas of the cortex come into existence the very 
moment, of the impact and will be- c&PatMefibed throe days 
later by a wedge— shaped necrosis, .at the edges of tne 
wedge-shaped necrosis-center, which is due to the direct lmpact> ve see an area of proliferation in the 
sound tissue, caused by an active proliferation of the small 
granular cell^h^ln0"' rlc?har|? t?e res°rptlon by mesodermal 
cells begins. In the final stage the center is tra- 
versed by a net of connective tissue which is often rather 
loose. Usually replacement by a solid scar of connective 
j0es occur. There was no evidence of a progression 
. t!?® damage (ESSER). The contused areas have no importance 
* pr?Vessive clinical symptoms. At the same time they 
cannot explain essential symptoms of the "contusio-cerebri” 
in the clinical sense# The peripheral cortical contusion 
centers are not pathognomonic for the trauma and even in the 
iInal analysis they only prove that an injury must have taken 
place. An infection of the meninges and the contusion centers 
is extremely rare. The rather freouent occurrence of subdural- 
hemorrhage does not develop progressively and must be dif- 
ferentiated from pachymeningitis hemorrhagica and dura hema- 
toma. Other changes of the brain occurring in the course of 
the injuries are areas of softening caused by vasomotor dis- 
turbances (RICKER), and large hemorrhage in the first place, 
the fat embolism (especially in the case of an airplane 
accident). A comparative study of commotio and contusion 
is of historical significance only. Commotio is a clinical 
complex of symptoms, contusio is very often exaggerated 
whereas the processes which leave no trace are underestimated* 
In case of an injury inflicted by a sharp Instrument, 
especially in the case of gunshot injuries, (high speed 
small areas of impact with a very strong cross section load), 
part of the energy may be absorbed by the perforating of the 
cranium and the penetration of the tissue so that remote 
effects and the process causing commotio, may be prevented. 
Besides the alterations at the point of impact we often find 
isolated rebound fractures in the thin bones of the front 
brain cavity (hydrodynamic effect)/ We do not find, however, 
the well-known compound fractures of the basal skull fract- 
ure as in the case of a blunt impact. The essential dif- 
ference between an open and a closed bfain injury lies in 
the fact that the first one is always infected,. ' Next to the 
site of the open wound and the paths of the projectile nro- 
duced by the penetration of the tissue a bruised zone de- 
velops possibly followed by a zone of necrosis often tending 
in the direction of the ventricle. The proliferation zone 
that is also developing here in the stage of resorption 
at the edges of the sound tissue is permeated by free in- 
filtration of vessels and has the character of a true in- 
flammatory granulation tissue which is covered by suuourat- 
ion remnants of necrosis. At the bottom of the granulated 
wall solid scars of connective tissue are observed. If the 
infection does not come to a stand still, a series of pro- 
gressive inflammatory complications are added which are not 
found in closed brain injuries. This is, first of all, the 
meningitis that can be proved in 75 per cent of all autop- 
sied On the one hand it may start directly from the 
wound subdural empyemata may originate which were 
not recognized during the first world War. On the^other 
hand the meningitis may be caused indirectly by 
or secondary ventricle infection. Frequently the ventricle 
infection is associated with a depression of the functions 
of the vegetative center which lies near the ventricle of 
the brain stem and results in symptoms which till then were 278 
erroneously associated with the meningitis. Further in- 
flammatory complications are: the abscess, the phlegmonous 
marrow encephalitis, the inflammatory prolapse and finally 
hydrocephalus occlusus caused bv inflammation. One of the 
most important nroblems in the treatment of gunshot wounds 
of the brain is to combat the spreading of infection in the 
brain wounds and meninges because & primary wound closing 
and a closed treatment are usually necessary. Mydriasis 
which freouentlv occurs in the phase of the edema of the 
center (TOENNIS) must be explained by the pressure of the 
swelling uncus upon the root of the oculomotor nerve. 
Discussion: 
OSTERTAG: The significance of the fluid cushion was 
correctly evaluated by SPATE, His theory as to the route 
of the escape of cerebro spinal fluid in cases of cerebral 
contusion, in the direction of the subarachnoid area of the 
spinal cord, were confirmed by own observations in cases of 
high vertebral gunshot wounds, A characteristic contre-coup 
originates in the oval cerebral parts in the case of a non- 
penetrating gunshot wound of the cervical spine. 
Apart from the meningitis caused by ventricle infect- 
ion, there is an early meningitis which infects the plexus 
plate via the cisterna ambiens. This is the cause for hydro- 
cephalus of the third ventricle which until now could not be 
accounted for. 
In brain injuries the collateral subcortical centers 
depending on the vessels in which the infection spreads are 
of special clinical significance. The dura is not opened 
unnecessarily and so these centers cannot be taken care of 
durinr the wound revision. On the other hand they do not 
show any particular symptoms in the beginning but they 
present a danger in the later course of the case which may 
even frustrate the success at an unexpected moment. 
Statements concerning pathological anatomy of closed 
and open wounds of the brain• 
1, Tre must differentiate between closed brain in- 
juries, contusions especially in case of a blunt im- 
pact and open brain rounds especially in case of a 
sharp impact. The blunt impact may lead, besides other 
effects, to remote effects in the brain stem and this 
generally implies commotio, which does not necessarily 
ensue in the case of a sharp impact. 
2, The most important contusions, namely the contusion 
of the cortex, prove to be of pathological importance 
for the trauma as revealed by certain characteristic 
symptoms even in the final stage. There are no actual 
evidences for a progressive damage. Contrary to the 
pachymengitis hemorrhagica, subdural bleeding does not 
develop progressively. 
3. The cortical contusion centers, owing to the con- 
centration of contre-coup effects, are more frequently 
located in areas near the bone in those areas hav- 
ing a low content of cerebro-spinal fluid, the so- 
called silent areas of the cerebral cortex, the base and the transition area from the base to the convexity. 
The convexity itself, however, is rather seldom in- 
The frontal impact predominates in cases of 
air-accidents (to 75 per cent), the impact from behind 
predominantly in injuries occurring in peace-time. 
4. The frequent implication of the silent areas of the 
basal cortex, especially of the frontal brain in case of 
an impact from in front, behind and above, explains the 
scarcity of neurological signs in those types. The most 
important symptom of the center is an olfactory disorder. 
Extended bilateral centers of the basal cortex may re- 
sult in late changes of personality. In the case of an 
impact from the right side aphasic symptoms may occur. 
5• The significance of contusion with regard to a 
serious general disorder of the body which may lead to 
a decrease of the earning capacity is clinically over- 
estimated. The contusion centers are not responsible 
for the main symptoms of the clinical picture of con- 
tusio cerebri. They must, however, be explained by 
processes which leave no anatomic trace in the brain 
stem, which arc also a basis of the clinical syndrome 
of the commotio cerebri. 
6. In contrast to the closed brain injury, the open 
injury must always be considered as infected, trhich 
fact appears anatomically in the occurrence of Pact- 
eriologically stimulated inflammatory processes which 
may develop progressively (abscess, phlegmonous en- 
cephalitis, inflammatory edema, infection of the vent- 
ricle, hydrocephalus occlusus). During the healing 
process we freauently see solid scars of connective 
tissue in the final phase. 
7. Meningitis was found in 75 per cent of all fatal 
gunshot injuries of the brain. If the Infection starts 
directly from the wound a subdural empyema will be the 
result in 50 per cent of the cases. If a basal menin- 
gitis occurs via an infection of the ventricle, veget- 
ative symptoms arise by the depressant effect on the 
vegetative centers of the brain stem adjacent to the 
ventricle. 
8. The combating of persistent infectious agents in 
brain rounds and in meningitis is an important problem 
in the treatment of brain gunshot wounds. X. 
0_F T_H_J C _Q If S.II LnT A N.TS* 
£JLM_J1JL3L£-1L1 0_N P H A _R M A. C m0 L 0 G J 
A_JO T_OJ£_I_C_0_L_0_G_Y 
Translation prepared bys 
U# S, Naval Technical Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government ( U, S# ) (See Section V, Article 7 - 9 ) 
Specif ic_and_gen era l_forensix-toxi co lpgic_eucs tip ns 
(See Section V, Article 14-7 
ToxicologyiofiinsecticidesA 
XSee Section VII, Article 11) 
1A Problems . docontamination, 
0^£stsr2i-X-Col£nei.M-tCJLl-ProfJ._WIHTH 
The use of poison gas of the "Lost”-group (mustard) 
will probably be of great importance in case the enemy 
has recourse to chemical warfare. Protection by the use 
of anti-gas clothing and impregnated clothing etc,,seems 
to be possible but it will not afford sufficient protection 
in most of the cases. Therefore preparations have b en made 
to decontaminate the skin, the clothing and The 
mobile installations of thn troops and medical services of 
the field army and fixed installations behind th'' lines 
were reviewed* 
The organization must bo decentralized to a ex- 
tent. It is very important that the activity in the first 
place be deployed the front bo that the poisoned 
soldier can bo given help as ouickly as possible. 
In the replacement units we have a similar organization. 
In the field army the physical decontamination is taken care 
of by the medical services. They howeyer, not concerned 
with the decontamination of The pharmacologists 
of the army who In the territory are consul- 
tants of the responsible surgeon of th military district 
with regard to all pertaining to the medical anti- 
gas defense measures. 
Discussions 
LOESER, HEIDENREICH, HEITE, KONZETT, PENDL; These 
gentlemen reported about the peculiarities of anti-gas de- 
fense in the West, East, North, South-East, and South, 
(Editors Mote: The report does not include their remarks.) 
gx Acute arsenic hydride poisoning^ 
(According to findings of the Institute for Pharmacology 
and Military Toxicology of the Military Medical Academy) 
The captured documents of the French Central Office of Chemical Warfare Research at Le Bouchot established the 
special interest our enemies had attached to The 
persual of the captured documents did not bring about 
any now facts for the ©valuation of this poison or for 
its treatment. 
The French reports confirm general opinion ex- 
pressed in previous experimental research work and in new 
experiences in cases of an acute poisoning, that in 
moderate concentration will lead aft'r a latent oeriod of 
a few hours to hemolysis with a secondary anoxemia and ob- 
struction of the urinifprous tubules. The human body may 
resist the above mentioned poison as long as kidneys 
do not fail, ( Death caused by uremia occurs in U - 8 
days,) A stronger concentration, however, may load to a 
serious poisoning and death may occur during the first 
hour. The reason for this is a cardio-vascular collapse 
and the central nervous intoxicating effect of the gas in 
addition to the previous onset of hemolysis with a oossible 
anoxemia, A damaging effect noon liver v;as not found 
orimarily but only in consequence of the decomposition of 
the blood corpuscles. Icterus symptoms rrp found only 
after two or three days. The bronze-rod color of the skin, 
which is observed early in cases of a serious poisoning is 
due to the imbibition of hemoglobin by the skin. 
We have included in our discussion some theoretical 
considerations in acute poisonings for which a definite ex- 
planation cannot yet be given but which will bo presented 
here in their practical results. 
On inhalation of moderate - concentrations (0t5 - 
1,0 milligram/liter/ 30 - 60 sec,) hemolysis with subsequent 
anoxemia, anemia and anuria will occur after a few hours 
time. The chemical processes leading to hemolysis, which 
take place only in the presence of oxygen, are known by the 
publications of LABES, HEUBKiER and thfir collaborators. 
The course of such poisoning in cats is characterized 
by the following peculiarities. During the inhalation of 
the gas an irritant effect is not observed. As a first sure 
symptom of. poisoning■vomiting will occur after 15 - 60 minu- 
tes which some time later is accompanied by a violent chok- 
ing or even vomiting of bile or blood, 1-2 hours later 
tenesmus and diarrhea with an excretion of mucus begins. 
Still later we observe a serous, even bloody-mucous liquid. 
These experimental findings correspond to clinical experien- 
ce as to the early symptoms in occupational ooisoning (pains 
in the upper abdomen, vomiting and frequently colic and 
diarrhea,) 
In about the second or third hour the inhalation, 
when a hematuria cannot yet be observed, animals become 
restless and they show an increased fronuency of breathing* 
The color of their mucous membranes varies between faint li- 
vid and cyanotic. After that we see a grov/ing weakness and 
a distinct dyspnoea. The animals lie down on their side, 
often we see cramp-like twitchings and some hours later the 
animals die of a paralysis of the respiratory organs. The 
heart activity ceases later. Obviously there is in ruostion a suffocation without any recognisable direct paralysis of 
the respiratory center under still favorable conditions of 
metabolism. This means that there is in question an anoxemia 
with increased respiration while the metabolism is still in 
relatively good condition. It must be concluded therefrom 
the exchange of oxygen in the lungs is not sufficient or that 
the oxygenation of the blood is insufficient. The pathologic- 
al and histological examinations showed no evidence of capil- 
lary damages or the development of pneumonia in the lungs 
where ste strongest concentration takes olace. ( Oborfeld- 
arzt ( Lieut* Col, M.C,) Prof, LAUCHE ), Therefore wo must 
take into consideration an insufficient oxygenation of the 
hemolysed blood because no considerable loss of blood p-ig- 
ment, i*e, an anemia, is observed during the first hours. 
Preponderantly we attributed special care to this 
question, which was given little attention in thr> past, by 
determining the amount of oxygen and cd*>onic acid in the 
blood of poisoned animals and measured its oxygen carrying 
capacity ( van SLYKE ), In all it was possible to 
prove a lack of oxygon proportional to the suffocation. The 
oxygen carrying capacity, however, was not so much influenc- 
ed, At the same time we were in a position to demonstrate 
a content of methemoglobin of about 20 - 40 per cent which, 
however, must not be considered to be responsible alone 
for the inusfficient saturation with oxygen. In order to 
produce a suffocation methemoglobin values of 50 - 60 % 
would been necessary. So the ruestion has arisen 
whether the insufficient saturation with oxygon can be ex- 
plained by other products of an advanced decomposition of 
the hemoglobin ( verdo-hemochromogen ( HEUBNER ) or perhaps 
heraatin). This Question is under study. First exoerimonts 
by Dr, KIESE show positive findings of verdoglobin. The 
oxygen-carrying-capacity-tests make it clear, however, that 
its share cannot be very great because the combining power 
of oxygen is still sufficiently high in vitro. 
So we must come to the conclusion that hemoglobin ox- 
travasating from the erythrocytes cannot be sufficiently 
oxygenated in the blood, stream even if it is still in per- 
fect condition as to its chemical composition. This sup- 
position is underlined by BARCR®FT*u physiological experiences 
concerning the properties of hemoglobin solutions in compare 
ison with the blood itself. Control tests with hemolysed 
blood in vitro showed a decrease of saturation of 12 - 30%, 
Some disturbance of the circulation is a possible addition- 
al contributing factor to this anoxemia in vivo. 
The findings as to the formation of mcthemoglobin by 
inhalation of arseniuretted sulfate have so far been given 
very little consideration because of special significance 
in connection with the explanation of most acute poisoning 
after the inhalation of strongest possible concentrations 
(4-8 milligram/liter ). In this case death occurred with- 
in 20 - 50 minutes. Preliminary symptoms wore: unrest, 
ataxia, symptoms of paralysis and wild excitement, cramps 
predominantly of the tonic kind, finally labored respirat- 
ion was observed, 10 - 20 minutes later the animals show- 
ed a distinct dyspnea and a dark-blue coloring of tongue 
and lips. Blood jfcests showed high ouantities of methemoglo- bin, from 4-0 up to 60 per cent, A hemolysis was hardly 
present at that time. These findings explain the oicture 
of this kind of poisoning as an acute suffocation character- 
ized by the formation of methemoglobin and additional dis- 
turbances of the oxygenation ( also deficient circulation). 
Therefore a direct nerve paralysis or stimulation by arsen- 
iuretted hydrogen must not be assumed any longer. 
During those tests some histological examinations of the 
organs w re also made by Prof, LAUCHE which only confirmed 
the well-known kidney-findings. Pathological findings could 
not bo demonstrated in the lungs and brain. The findings 
in the intestinal canal were of special interest. During 
the acute hemolysis a surprising red coloring of the mucous 
membranes and musculature was observed and frequently bloody 
serous or mucous substances were found in the duodenum, 
especially in the area at the end of the intestine. Here, 
a hyperemia or hemorrhage could not be observed. Presumably 
there is in question a coloring by imbibition with hemoglo- 
bin as was previously assumed by TRADER, The passage of the 
blood pigment into the intestinal contents must occur through 
the intact capillary vessels ( normally intestinal capillary 
vessels are somewhat pervious to albuminoid) but also the 
epithelium must be penetrated. There are many reasons why 
a damage of the capillary vessels by arseniuretted hydrogen 
occurs very early ( perhaps by the quick supply of arsenic 
oxide) so that we see hero an explainable acceleration of 
the poisoning, which might also explain the above mentioned 
symptoms of vomiting and diarrhea. 
I am not in a position to go into further details as 
to the problem of the poisoning by arseniurotted hydrogen, 
I only want to point to some negative experiences we made. 
We have tried for various reasons to influence the reasoning 
indirectly by administering oxidizing or reducing 
( catalysin, glutathione ) and by active sulphur compounds 
( detoxine, calcium thiosulfate, tetrathionate), We did not 
succeed in confirming in practice these somewhat theoretical 
possibilities,. 
The results of our findings with regard to symptomatolo- 
gy and therapy were published in their essential parts in 
Army Manual 396 of January 1, 1943* 
2* The Toxicology of poisoning^ 
Ob^sta^arzi^X-MaJsr-iUC^i.SEXTL 
In connection with the examinations of the correlation 
of ct-products ( product of concentration in milligram per 
cubicmeter multiplied by the time in minutes) to the con- 
centration of the inhaled gases we have also examined arsen- 
iuretted hydrogen. 
First of all we have used in dogs ct-values of 3000, 
5500 and 30 000 in such a way that during one series of test 
low concentrations and in the other high concentrations of arseniuretted hydrogen came into effect. The extent of the 
damage was determined besides the general clinical examina- 
tion - by the result of the urine findings, the red and 
white blood-cell count, the resistance of the erythrocytes, 
frequency of the pulse and respiration and a graph of the 
weight. In all three ct-values it was clearly proved that 
in each case the influence of the stronger concentrations 
during a shorter time of action caused greater damage than 
the lower concentration during a correspondingly longer 
period of action. 
In order to be able to study thoroughly and nuantita- 
tively the findings in dogs we made a greater number of 
tests with white mice. In the analytically determined con- 
centrations of inhaled air and arseniuretted hydrogen of 
9>500, 4.*500, 2,500, 1,200, 650 and 100 milligram per 
cubic meter we exposed each time seven groups of animals 
( each having 20 nice ) for different periods of tine. In 
each case we ascertained the concentration and period of 
time in question and with it the corresponding ct whioh had 
caused the death of all animals. At the same time we de- 
termined the exact length of time which all animals could 
barely survive. It was observed that the upper and the low- 
er level of the time of exposure, independent of the concen- 
tration, is in a proportion from about 3 - 4- : 1 so that 
the upper limit is 3 - 4 tines higher than the lower. 
The product of ct under the influence of which half of 
the test-animals died is the average fatal dose for the 
corresponding concentration, The period of observation 
after the exposure to the gas was extended over a maximum 
of 10 days. 
It was observed that the average fatal dose of the 
examined concentrations has a direct proportion to the con- 
centrations, In the case of a lower concentration we find 
much more ct than in the case of a stronger concentration. 
As for example: 
concentrations 
average lethal ct 
100 mg/cbn 
about 6000 
650 " 
« 4000 
1200 " 
»» 3000 
2500 " 
" 1800 
4500 » 
" 1300 
9500 11 
" 1000 
Discos sios_o£_iiie_££po£ts_£OBC£rr2i£2«A£iI3_£o4sonii32* 
FLUEY: According to the personal statements of Prof, 
Renh FABRE in Paris who was himself seriously poisoned by 
arseniuretted hydrogen ” the whole Faculty of Medicine” in 
Paris was not in a position to find a specific remedy. There- 
fore, the therapy mentioned in Army Manual 396 ( publ. Jan- 
uary 1, 194-3) seems to be absolutely suitable. HEUBNER: In a man who had died during the first day 
and was thus a subject of a severe poisoning, I did not ob- 
serve coloring which would Indicate the presence of methemo- 
glbbiB, In another case I observed the return of the hemo- 
globinuria after an interval of a couple of days during 
which it had completely disappeared* 
(To SEXTL): It was observed by KIESE in the case 
of a lower concentration a considerable part of the arson- 
iuretted hydrogen was eliminated by exhalation. Therefore, 
the inconsistency of the ct-product is understandable. 
EICHLER: Hemoglobin precipitates and obstructs the 
uriniferous tubules. All this may be prevented by increas- 
ing the diuresis. It is suggested to alkalise the urine be- 
cause the iso-electric point of Hb is near 6,8, 
£a ThG_eff oct of hydrocyanic acid, 
rsi_,LtJl_MJ>CJt j_.SC HO LZ 
(According to findings of the Institute for Pharmaco- 
logy and Military Toxicology of the Military Medical 
Academy,) 
Volume and freeuency of the respiration in rabbits and 
cats were recorded. The apparatus used made it possible to 
expose the animals either to air or to a mixture of 
air and gas. The volume of respiration did not change under 
the influence of different concentrations of hydrocyanic 
acid. The freeuency did not change, as is observed when 
hydrocyanic acid is administered intravenously thereby sti- 
mulating the carotic sinus ref lx and causing an abrupt in- 
crease of the ventilation, Blood-gas-analysis in animals 
poisoned with hydrocyanic aied reveals a marked difference 
as to the anoxemia which depends on the mode of administra- 
tion. In case of inhalation of hydrocyanic acid, especially 
in the case of a stronger concentration, only low-grade an- 
oxemia is observed, i.e, not the blocking of respiratory 
exchange b*t the paralysis of the centers in the medulla ob- 
longata prevails. This differs from what is observed if the 
poison is administered in a different way involving a stop- 
page of the vascular respiration owing to the slower loading 
of the blood with hydrocyanic acid. 
The practical consequences are as follows: An increas- 
ed intake of hydrocyanic acid by inhalation owing to acce- 
lerated respiration must not be expected. The finding that 
the central effect prevails and that anoxemia is not so im- 
portant v/hen hydrocyanic acid is administered by inhalation 
in contrast to other ways of administration, justifies the 
opinion that a general damage of the cells due to anoxia 
need not be feared. The tests proved that the treatment with 
oxygen which was recommended in Army Manual 396 is suitable 
especially when stronger concentrations of hydrocyanic acid 
have been inhaled. Discussiopj 
HEUBNER: Contrary to the findings of the last speaker 
I was in a position to prove - in collaboration with FLURY - 
a lasting arterial coloring of thr venous blood con- 
tinous inhalation of sublethal but toxic concentrations of 
hydrocyanic acid. The animals died of the after-effects in 
spite of a temporary recovery of the respiration. 
WIRTH: In previous personal experience with rabbits 
we observed a stronger shifting of the hydrogen -ionconcen- 
tration of the blood to the acid side after a preliminary 
shifting to the alkaline side after inhaling toxic concen- 
trations of hydrocyanic acid. This leads to the conclusion 
that even in case of a non-fatal outcome a gen ral impair- 
ment of the oxygenation occurs. According to those tests 
the impaired oxygenation may considerably outlast the time 
of actual influence of hydrocyanic acid. 
Fh2^£®5G_oxideJl 
z t_X_£ant BER 
The author reports about the results of the examinations 
and decontamination obtained by the Institute for Pharmaco- 
logy and Military Toxicology of the Military Medical Acade- 
my. 
The examinations of W. WIRTH, KOETZING, POSTEL, NIE- 
MANN and the captured findings of the Russians were re- 
ferred to. The most important subject of his report con- 
cerns the extraordinarily quick reaction of phosrenc oxime 
on the skin and furthermore the effect upon the respiratory 
organs, A skin-damaging effect occurs within a few seconds 
to one minute. This fact illustrates how ouickly deconta- 
mination of the skin must be carried through. Numerous al- 
akline and acid chemicals ( salts, protein compounds and 
mixtures with skin decontamination-paste) were examined 
with regard to their decontaminating effect. In part, the- 
se examinations turned out highly satisfactory. Their ap- 
plication, however, is rather limited owing to th ru.i ck 
reaction of phosgene oxime upon the skin, ,fLosantin'1, de- 
contamination-paste for skin and weapons is not suitable 
‘for decontamination of the skin in case of contamination 
by phosgene oxime. The MS-soap, however, is suitable to 
e certain degree if it is applied quickly enough. As an 
improvised means of decontamination of the skin a solution 
of 5 % ammonia may used. Even an immediate washing 
with plenty of water affor-'s a certain decontamination - 
effect. The so-called inhalant-tubules of ammonia are not 
suitable for decontamination of the skin because the contents 
are too small. If a 5$ solution of ammonia is at hand the 
decontamination mst be done immediatelyx Uniforms may be 
decontaminated by boiling them in wat'r for an hour. The 
terrain must be decontaminated by spraying it with the 
decontamination-material which we have introduced. Ve- 
hicles, weapons and eouipment may be docontarained by wash- 288 
ihg then with plenty of water. 
Furthermore a number of homologues of phosgene oxime 
were examined but in their toxicologic effect they were less 
effective than phosgene oxime. 
sionj. 
GILLERT: According to own capillary-miscroscopic 
observations we may presume there are changes in the capil- 
lary as a result of phosgene oxime, perstoff and phosgene 
which may be important for the evaluation of after-effects 
of these substances. 
KROEBER: According to the Russian findings, the ouest- 
ion ( LENDLE ) whether or not the resorptive effects of ex- 
posure to phosgene oxime can be diminished by urotropin must 
be answered in the negative. 
]■>.* tut es_i n_£pxic_pulmpnary_ edem^j. 
z t_X_Caotai n^Mj.C^i^PENDL 
The ouestion of the comoatibility of blood-substitutes 
in the field of crystalloid solutions. In case an inflam- 
matory edema of the lungs was thoroughly studied jby LAQUEUR 
and MAGNUS during the first World War, The finding was that 
isotonic solutions of common salt produced a temporary di- 
lution of the blood whereas hypertonic solutions of common 
salt after a slight dilution increased the edema in the 
lungs in most cases. 
The question was whether the now colloidal blood-sub- 
stitutes ( dried human serum and oeriston) would maintain 
a longer lasting dilution of the blood, even in case of a 
toxic edema of the luhgs, and eventually have an effect of 
diminishing the edema. In a number of tests cats were poison- 
ed by nitrose gas or "perstoff " . 0ontinttoim examinations of 
the haomoglobin and erythrocyte-values and the weight of the 
lungs 24 hours after the poisoning permitted one to examine 
the course of the poisoning. Venesection proved host for 
the treatment of the progressive toxic lung edema. In 
order to increase the effect of venesection dried human sc- 
rum or "Periston” was administered. This, however, leads 
only to a shorter period of dilution of the blood and causes 
higher lung weights, A decrease of the lung edema could not 
be obtained even by administering the concentrated solutions 
of Periston K or the four-fold concentration of dried human 
3<"rum, The same result was obtained when the colloidal 
blood-eubstitutes wore administered as a substitute for the 
loss of blood ■pLa sma caused by thickening of the blood. In 
case of a subsiding toxic lung edema v i,e» 15 or more hours 
after the poisoning) a blood dilution, which lasted longer 
than 24- hourB, ¥/as obtained by administering the above men- 
tioned colloidal blood-substitutes. In a growing toxic lung edema the administration of 
colloidal blood substitutes ( dried human snrum, solutions 
of “Periston1’) is injurious and therefore not indicated. 
( Detailed publications in preparation). 
Discussion: 
HEUBNER: The published tests underline the experiences 
of the gas-hospitals in the last World War: Each infusion 
of a liquid is disadvantageous for a spreading lung edema. 
It is highly regrettable that again and amain in the lite- 
rature and even in manuals the injection of isotonic and 
hypertonic solutions is recommended. By doing so the life 
of many humans may be endangered. 
1* lla,. ard_gas_i_ njuri esA 
S t jabsa,I2i-l_C n_MJt_Cul_J._SOEHRI NG 
1# The local treatment of persons injured by mustard 
gas requires - according to general experience - large quanti- 
ties of dressings and ointments. In order to make the mus- 
tard gas therapy independent from supplies, tests were made 
in the cases of eleven workmen who were seriously injured 
by mustard gas. Human plasma and horse plasma wore applied 
locally. After a wet treatment for the removal of the nec- 
rotic tissue - a physiological solution of common salt is 
sufficient - plasma crusts were put on thQ cleaned wound sur- 
faces under which a good and painless healing was achieved. 
2, The right moment of application must bo deter- 
mined correctly. If the application is done too early the 
crust will not adhere and may even lead to an undesirable 
accumulation of the secretion. The therapy has to start at 
the same moment when granulationshave replaced the loss of 
substance and the suppuration has come to an end. Till then 
the wet dressings with common salt solutions are sufficient. 
3, Comparison with the treatment using a 5% anaesthe- 
sin-paste showed that the application of plasma is advantage- 
ous, It iii difficult, however, to coordinate this procedure 
with the usual therapeutic methods. 
Um Plasma therapy should be reserved for all cases 
in which supplies are either difficult or impossible to ob- 
tain, As soon as its application is sufficiently tested 
under field-conditions the final decision may be made. 
5, The application of horse plasma is eouivalent to 
the therapy of pooled human plasma and thus a mass-treatment 
will easily bo possible. lu—Zlasnfl.ihjsiasx-lfl-fflaaiflsa-sas-iuiuEifi.a.* 
o^rnzzi.i^Firsi.Li^M^c^i^pgsTEL 
SOEHRING*s successes ih treatments with plasma gave 
rise to systematic examinations of the described method 
under most strict observation. 
In animal tests a closing of the wounds of all animals 
treated by an artifieal formation of a crust was obtained. 
In 50% of the cases, however, the crust formations was cast 
off by pus after a couple of days, in the other cases the 
healing process was sometimes favored but in general was 
not influenced, A difference in the effect of horse plasma 
and other preparations such as gelatinous mucus collodium 
elasticum and glycerin paste could not be observed. None 
of the methods tested has shown an exclusively favorable 
re-sult in animal-tests. Owing to the particular suscept- 
ibility to secondary infections the danger of a delayed 
healing is by far greater than the chance of a prompt heal- 
ing. 
Even on human skin the closing of the wounds was 
successful by the formation of crust in all cases, but two 
in which after a lapse of a longer or shorter time, violent, 
pulsating pains reappeared until finally after the lapse of 
two to nine days the crust was cast off by pus with con- 
siderable destruction of the granulations. 
In 20 attempts to close a mustard gas ulcer by artific- 
al formation of a crust in order to protect it against in- 
fection and to accelerate the healing process, 18 failures 
occurred and led to secondary infections and delayed heal- 
ing, Even in an eventless course a favorable effect upon 
the h ealing could not be observed. In none of the cases 
has plasma proved to be an "especially suitable medium for 
germinating epithelium" and therefore did not come up to 
the expectations. 
Dj.scu.ssions. about the reports concerning nlasma- 
t]} p mustard-gas injuries , 
EICHLER: The differences in the results of the treat- 
ment tests by SOEHRING and respectively POSTEL may possibly 
be due to the fact that SOEHRING compares his plasma-treat- 
ment with anesthesin-paste. Thus the plasma treatment might 
have appeared in a more favorable light. 
SOEHRING: The fundamental difference in the findings 
of POSTEL in comparison to our own experiences lies in the 
fact that the secondary suppuration prevails in the cases 
described by POSTEL, which cannot be explained yet. Poss- 
ibly the different reactions may be due to different mixtures 
of mustard gas. 3.1 TilS-£oi£or3ii}^_2f^Isrge_.saDpliI£S_of_driijkin2-Wat-r_b3r 
£h£mi£sI_war£^re_s£sut^_^r}^_t^_nossibilitj_of 
il2eir_xilS0vaIA 
t he]cer_X_C o lo nelj._P]iar n;acx„C o J. 
GEMEINHARDT 
We must distinguish between subsoil surface water 
supply. In case of genuine subsoil supply possibilities of 
contamination may be excluded. In case of an artifical sub- 
soil watpr collection, however, contamination sterns to be 
possible. In processing the wat'-r at the wat«r works con- 
tamination can easily be eliminated. Large accumulations 
of water ( lakes, water reservoirs ) can be efficiently 
contaminated temporarily. The methods of decontamination 
depend largely on the kind of chemical weapons used. All 
chemical weapons inclusive mustard gas which can be neutral- 
ized by hydrolysis, do not present an important danger. In 
order to facilitate and shorten th° time reouired for decon- 
tamination w® must use a chlorine-carbon suspension or car- 
bon filtration in case of mustard gas. Chemicals which can- 
not be decomposed easily ( chlorpicrin, N-mustard gas) are 
also easily absorbed by carbon. Greatest difficulties, 
however, are encountered with arsines which, so far, can be 
removed below the toxic limit only by a very slow filtra- 
tion through active carbon. In case of large accumulations 
of water, ( water reservoirs) chemical weapons which were 
used in large quantities will dissolve only to a very small 
part whereas the main quantity will settle down at the deep- 
est spot ( base of the reservoir wall) and slowly become in- 
effective there. The water usually not being drawn from the 
deepest place , only little quantities of the chemical will 
be contained therein. It is considered unnecessary to de- 
contaminate the entire body of water but only as much as is 
necessary for consumption. For this portable de- 
contamination equipment is recommended. Question of 
an improvised decontamination by carbon suspension and other 
means is under study. 
In the decontamination of drinkine it sterns to 
be more practical to separate the poison rather than to e- 
liminate it by chemical combinations. 
JL£U fifiCfiBtsmiaaiiSB-Of^rirjking-Waier^frpm^supplies^cox- 
t]i_c]i emi cal_war f &r e_agen t s^. 
n-MJCa-J-_KR0E3ER 
In tests made to neutralize chemical weapons by way of 
oxidation (HCIO) we found that only S-mustard gas and sul- 
fone can be neutralized efficiently. Arsenic containing 
materials can only be oxidized into arsenic acids, N-mustard 
gas and chlopicrin, however, defy this treatment, (chemical 
part in collaboration with Dr. NIEMANN), The products of oxidation in the arsenic containing 
material were examined toxicologically in the Institute for 
Pharmacology and Military Toxicology of the Military Me- 
dical Academy, The examinations revealed that in aromatic 
as well as in arsenic acids the examined Quantities of 20- 
200 gamma for two cubic centimeters, were used in 
animal tests, did not show any important irritation of the 
mucous membrane of the stomach and the intestines. 
Furthermore tests w«re ma'e to establish the irri- 
tation level of diphenyl-arsenic-acid and chlorine-vinyl- 
arine-acid ( compounds containing 5% arsenic) in the mouth. 
The now available but not yet definitive results show that 
the irritation level of these chemicals in humans is much 
higher than $0 gamma of water. 
Discussion,concerning contamination of drinking 
w^tnr_systernsA 
FLURY: The speaker reminds of the experiences gather- 
ed during the examinations of sweet cider and ?;ine with 
regard to arsenic content, A damaging effect caused by 
short periods, but not chronic use of cider containing some 
milligrams of inorganic lead-arsenate (3-4 milligram per 
liter As) was not observed. 
£ossibility_of_substitut es_ln_thi_use_of_dru£SA 
U££alar zt_X_5£igJt_G£C£ial_MJ>C f 
The possibilities of substitutes for important drugs 
which for the time are scarce are reviewed the 
pharmacologic point of view. It is a well-known fact that 
as is the case with all substitutes, the "ersatz" drug 
has often proved unsatisfactory. Under the conditions of 
war, however, evcn the medical doctor has to make allowances. 
In the following we ar° going to give you some hints in 
catch-words, 
With regard to means_of_narcpsis the tm°stion arises 
again: Ether or chloroform? Instead of ether which is 
scarce now we recommend "Evioanatriurn" and "Eunarkon" for 
longer narcosis. 
With regard to hyjonotics "Adalin" and"Luminal" may 
be replaced by "Bromural" and "Phanodorm", "Bromural" seems 
to be suitable as a substitute for "Adalin". "Luminal" 
however, can hardly be replaced bv any other drug with re- 
gard to its exceptional importance and its great efficiency. 
Unjustified use of hypnotics should be avoided. 
Among the opiates "Morphine" may be replaced more or 
less satisfactorily by the stronger and more effective 
*DilAudid", also by "Eukodal" as in the S.E,E,-combi nation 
(Scopalamine HCL - Eukodal - Ephetonin), "Dolantin" com- 
bines the effects of "Morphine" and "Atropin". All these 
drugs may lead to mania. "Paracodin" has proved to be a 
good substitute for Instead of "Paoaverin" we 
pay use "Octin D" and "Dolantin", In case of a shortage of ”Atropirj" it may be re- 
placed by similar natural alkaloids and synthetic trope- 
ines, The different indications must be separated and 
studied separately as is the case will all drugs which 
have multiple effects. Antispasmodics havr to meet various 
requirements such as the absence of secondary effects and 
suitability for injection. First of all "Octin" and "Do- 
lantin11 are to be considered. Against asthma "Fphedrin" 
and related products are available, A substitute for 
"Atropin" for ophthalmological use is not necessary. 
£££diac_d;rugs: "Strophanthin" may be replaced by 
injectable ’'Digitalis” preparations, Fv-n the time honorrd 
”Blaetterpulver" ( leaf-powder) has not yet lost its import- 
ance, It is supposed, however, that the surgeons are 
familiar with the proper determination and regulation of 
doses of "Digitalis", "Digitalis" must not be considered 
a universal drug against any kind of heart disease hut only 
against insufficiency of the heart. 
are available in sufficient ouantities. 
Instead of "Cormed" (coramin) "Cardiazol" may be used. 
Furthermore we have camohor-oil and "Hexeton" at our dispos- 
al as well as "Lobelin", 
"2MiDIDe" • For the greater part of the indications we 
have satisfactory substitutes available. Against malaria 
we have "Atebrin". In cases of pneumonia we use sulfona- 
mides; against febrile diseases, neuralgias, headaches the 
"Antipyretika" and "Analgetica" of the "Pyrazolon"-series 
andat the same time salicylate preparations, Quinine as 
well as "Quinidin" considered non-replaceable in certain 
of arrhythmias. 
He§vz_]?etals must be conserved, for instance mercury, 
silver, gold, and rare metals. A very serious bottleneck, 
however, is encountered in case of bismuth. Sulphate 
of barium is a good substitute for X-ray diagnostic pur- 
poses. The situation is rather difficult with r gard to 
chemo-therapeutic purposes. For the treatment of lues we 
have only mercury besides "Salvarsan" which has the Quickest 
and strongest effect. If bismuth is not at hand we have 
to put up with the well-known disadvantageous effects of 
mercury in case of a combined treatment. The possibilities 
to replace bismuth for internal medical purposes, for the 
treatment of wounds especially burns are much more satis- 
factory, Here we have at hand ouite a number of absorbing 
or astringent materials and disinfecting agents. 
In the series of antiseptics some difficulties must 
be overcome. The replacement of boric_aeid should be re- 
alized as auickly as possible. The rurstion arises, whether 
or not boric acid may be spared completely or partly. Its 
advantages are the absence of some undesirable character- 
istics. Substitutes are the so-called "tissue-friendly" 
antiseptics, indifferent salts and anti-inflammatory veget- 
able agents. Borate ointment can well be replaced by other 
wound-and healing ointments, even oerhaps by a durable 
sterile ointment base. All animal_£roducts are scarce. A substitution may 
take place only when synthetic material is at hand. We 
know very well the difficulties in supplying "Insulin", 
liver preparations and others. 
So we can see that only a limited number of remedies 
of vital importance cannot be substituted at all. For most 
of the important drugs we substitutions. In order to 
eliminate the difficulties we to find out th° real rea- 
sons for the shortage, largely caused not only by the Gene- 
ral lack of raw material but also by inao^rooriat® distri- 
bution, storage, prescription and usage. Sharp measures 
must be taken against any waste and hoarding of medicines 
and wound dressings. 
12A Po ssibi li ty_of_subs ti tut es_i n_t he_use_pf _drugSj. 
clone l_>_pj2armJ-_Cpr ns WORT MANN 
In the supply of sanitary material w° observed 
a perceptible shortage of many important during this 
war, 
There are many reasons for the shortage of the differ- 
ent drugs. The general situation_with_regard_to_raw_ma,teri.- 
als is in the foreground. Barium for instance, which is the 
main product for the manufacturing of contrast mediums on 
the basis of barium sulfate was delivered by England, That 
is the reason why have now a shortage of X-ray material 
such as "Roentium", "Roebaryt" etc. Iodine was made out of 
Chilean saltpeter which fact may explain the lack of all pre- 
parations containing iodine. Bismuth and bismuth salts in 
their greater part had come from America. Therefore we 
must economize all bismuth preparations for the lues-treat- 
ment, Furthermore we must economize all products contain- 
ing bismuth subnitrate and bismuth subgallate. The nearly 
indispensable "Atropin sulfate" is made of the root of 
Belladonna" and the Seed of stramonium. Both drugs are found 
in Southern Europe, in Asia and South America and im- 
ported from there. Furthermore all drugs containing alka- 
loids made out of opium, especially "Codein phosphate" are 
scarce now for similar reasons. 
yielding the necessary product 
for many very important medicines arr> now being used as 
food stuffs and they must in thr first place be reserved 
for this purpose. Among those are all preparations made of 
liver, pancreas, hypophysis and bile. This explains the 
evident shortage of liver preparations such as "Insulin" 
and the different preparations of bile and posterior lobe 
preparations. 
Other medicines which were produced in this country 
too, cannot be produced because of lack of manpower. This 
is particularly true for camomile, linden tree-blossoms and 
the different ingredients of pectoral tea etc. 295 
A further reason for the critical situation in the 
supply of drugs, the same as for other goods, is the da» 
caused by the enemy airforces. Thus 
a delay was caused with regard to the supply of disinfect- 
ants especially "Liquor Cresoli" because the firm which 
produces the "Emulgant", necessary for the manufacture of 
disinfectants was completely destroyed by air-attack. This 
even caused other firms using the same "Emulgant" to stop 
their production. By the fact that very valuable fats are 
necessary for the production of th°se agents, many of them 
being supplied from foreign countries all these articles 
must be considered as critical items. Conclusion: All 
disinfectants are critical items. 
are sometimes responsible for the 
shortage of such items which can be oroduced in sufficient 
ouantity such as the lack of ampules and binding material 
for certain tablets which cannot be secured the firms 
producing medicines which require these binding materials. 
Reasons for the shortage of "Sulfonamid"-amoules are: Lack 
of machines, supoly of spare parts, lack of skilled per- 
sonnel, etc. For this reason we cannot push forward the 
manufacture of synthetic caffein the formula of which is 
knwon. All caffein-preparations are critical items. Lack 
of tools, eouipment apparatus etc,, explain the lack of 
supply of "Detoxin", "Pandigal", "Trypaflavin", "Tumenol", 
etc, 
The requirement of the whole German Army regarding 
"Prontosil", "Eleudron", and "Istizin"-tablets, "Yatren 
Dragees" and about 70% of "Atabrin"-tablets were manufactur- 
ed in factories owned by the Army, The production there is 
on a considerable scale. For example about 500,000,000 
"Atabrin"-tablets produced in one year. 
The first condition to avoid friction and to secure 
a well organized supply of sanitary material - as long as 
it is available - is that the reouests be in accord with 
the actual reruirements. The requests submitted to the 
supply uhits must be made up by competent personnel and with 
observation of the utmost care. 
Only in this way will it be possible to prevent a 
stock-piling of medicines in one place while the same mater- 
ial is keenly wanted in another place. 
possibilities of substitutes in 
i5e_iise_of_drug.§.* 
DRUCKREY, EICHHOLTZ, FISCHER, HEITE, HEUBNER, XONZETT, 
KROEBER, SCHLUETER, SCHHOEDER, SOEHRING, WIRTH: The 
hints given by the mentioned gentlemen during the 
discussion wer*e taken into consideration in compiling the 
direction. 12.. iiV£r_damagir!g_p2i s os£. 
P£o£HEUBNER 
The toxicological aspects of pathology offers 
special difficulties which do not exist in other organs to 
the same extent. In comparing a disease ih humans as well 
as in animal tests a considerable discrepancy was fre- 
quently found between the findings in the living organism 
and at autopsy in the liver tissue. The examinations of 
the functions of the liver do not clarify these discrepanc- 
ies although the advantage derived from the tests for cli- 
nical diagnosis is evident. These examinations proved un- 
suitable with respect to the most important problem of re- 
cognizing an imminent danger of the liver in time. This is 
true at least with regard to our examinations in rats and 
dogs in which, according to FELIX, the excretion of p-oxy- 
pyro racemic acid, which was fed to the animals, served" as 
an indicator. We must take into consideration that other 
well proved liver function examinations in humans have fail- 
ed in animals. On the other hand other investigators who 
have used the FELIX-tests obtained the expected results in 
animals but we succeeded, even in the case of phosphorus 
poisoning with most obvious histological changes, only in 
extremis, 
A further great difficulty for the evaluation of pois- 
onings of the liver is the particular discrepancy between 
the amazing regeneration ability of the liver in case of 
relatively small injuries - and it may be said that the 
liver may be reduced to 1/5 of the normal size ( MANN and 
MAGATH) - and the long and chronic course of recovery, 
characterized by a very slow restoration of integrity and 
by specific sensitivity against greasy meals or alcohol for 
a very long time. In case of a ooisoning this becomes ob- 
vious in that acute moderate poisoning may lead in one day 
to a central lobule necrosis of considerable extent, and 
a couple of days later, a complete restitution and regene- 
ration of the liver tissue will be observed. Chronic 
poisonings of the same kind result, however, not only in a 
cirrhosis-like increase of connective tissue but also in an 
intense loss of the regenerative ability of the parenchymal 
vessels which distinctly manifest a changed allobiosis. This 
reaction was proved by numerous animal tests with tetra- 
chlormethane, in dogs by BOLLMANN and MANN, in rats by 
CAMERON and KARUNARATNE. Also during these animal tests 
a complete regeneration of the liver parenchyma was possible 
after a chronic damage, but only after the lapse of an un- 
usually long period of time. The difference in the nature 
of an acute and a chronic poisoning was especially clearly 
demonstrated by these tests. The special reaction of the 
liver can only be explained in cases of a serious involve- 
ment as a damage of these parts of the cells participating 
in hereditary transmission. For a series of generations of 
liver vessels we cannot but presume a "hereditary transmis- 
sion of lost capacities"* Tetrachlormethane is the prototype of mite a number 
of liver poisons acting in the same way as its chemically 
related compounds chloroform, tetrachlorethane; further- 
more, some etheric oils, the most important mushroom pois- 
ons, atophane, arsenic, phosphorus, as well as others. 
Apparently the absorption of ohosphorus through th<= skin 
is negligible. 
The poisoning manifested in the form of a primary 
central lobule necrosis is not the only one in existance. 
Primary points of attack were also observed in KUPFFR»s 
stellate cells ( for colloidal copper by JANCSO) in blood 
capillary vessels ( for allylformial, haemogyrrol derivative 
and others, in the cystic ducts ( for manganese 
FINDLAY and others). Furthermore for toluylendiamin there 
is a disturbance which differs from all other noisonings 
( MELCHIOR, ROSENTHAL and LIGHT; WOJ.FF, Me BOLLMANN and MANN). 
No apparent difference between the clinical course and the 
final outcome has been observed in practical cases of 
poisoning. It is remarkable, however, that it has been ob- 
served in tests on do«?s made in connection with Salvarsan 
poisoning that is, in contrast to the above mentioned more 
freouent variations of poisoning, unfavorably influenced 
by a carbo-hydrate diet whereas a protein diet reacts favor- 
ably ( CRAVEN, SCHIFRIN), 
In war time poisoning by explosives must be considered. 
Trinitrotoluene is especially hazardous to munition workers 
having a long exposure because it may unexpectedly cause 
acute liver atrophy,' During thel&st years extensive experi- 
ments with rats and dogs were made in our own institute 
and changes in the liver were intentionally produced by 
long lasting treatments with trinitrotoluene with the view 
of facilitating early diagnosis. In fact we observed dis- 
tinct histological changes which, however, did not reach a 
life endagering extent, A recognition by the FELIX test 
in living animals was possible only exceptionally. After 
the administration of dinitroanisol, HINDEMITH (Breslau) 
observed histological liver changes occasionally. 
The effect of alcohol is of soecial significance in 
munition workers. It was presumed from the very beginning 
that abnormalities in this respect might be caused by dis- 
turbances of the liver functions, A number of findings al- 
ready published were reviewed according to which the func- 
tions of the liver could be stimulated by simultaneous 
or previous ingestion of alcohol. On the other hand the 
effect of alcohol and oth'r narcotics was decidedly in- 
fluenced by the condition of the liver. In tests made 
by HINDEMITH rats proved to be much more sensitive to di- 
nitroanisole after a long administration of alcohol. On 
the other hand, cats were much more sensitive to alcohol 
after a previous long with dinitroanisole, even 
after a long interval between the last treatment with di- 
nitroanisole and the administration of alcohol. In the tests 
made in our institute we observed, in one case of a dog 
and almost regularly in rats, an intensified effect of al- 
cohol accompanied by cramps and paralysis aft~r administra- 
tion of dinitrobenzol. For theoretical reasons we also 
tried acetaldehyde after a corresponding previous treatment and it proved to be much more danngerous. 
These and other finclins ar<=> further examples to 
demonstrate the great significance of a combination of 
two or more injuries caused by intoxication which neces- 
sarily will have a multiple effect on the complex function 
of the liver. In case of disease, a toxic etiology will 
always have its special although not exclusive medical sig- 
nificance - which has been we11 known for a very long time 
with regard to alcohol. 
Slscussioja 
KROEBER; Regeneration of a liver which is degenerated 
in the connective tissue, seems to be impossible, for 
serial sections of such a liver show all phases of the dis- 
ease beginning with completely normal liv®r tissue and ter- 
minating with the most extreme of cirrhotic degene- 
ration. 
DRUCKREY: According to statements made by Japanese 
authors it is possible to prevent or to heal existing 
liver damages by feeding liver substances after the effect 
of liver poisons. 
SCHOLZj Examinations made by HECHT Elberfeld showed 
that in rats liver damage in the sense of a distinct fatty 
degeneration of liver cells occurs even after a single 
short period of influence of chloroform. 
EICHLER; After a poisoning by chloroform the adminis- 
tration of "Eunarkon" showed a disturbance even after a 
couple of weeks which was not observed with "Avertin'1, 
"Lost" (mustard gas) causes liver-damages which can be de- 
monstrated months later. 
HEUBNER: The clinical picture of chronic dinitroben- 
zol poisoning could not be changed by feeding liver. His- 
tological examinations of livers in the case of liver damage 
from the influence of explosives is under study. Chronic 
dinitrobenzol administration clearly increased the sensi- 
tivity for a large single dose, which may be considered as 
analogous to the mustard gas examinations, mentioned above, 
by EICHLER, 
c effects of 11Periston% 
Si£bsai£:k_I_Ca£t£i£_MACAl_Profx_EICHLER 
"Periston"-tests made with rats, guinea-pigs, rabbits 
and cats did not show any disturbances of the liver funct- 
ions, "Periston’1 was in some cases given chronically up to 
three months, in single cases daily. In function tests 
FELIX* and TESKEfs methods were adopted (Phenyl-pyro-race- 
mic acid). In tests of the plasma content of bilirubin the 
methods of JENDRASSIK and GROF were used. The bilirubin - 
content was rather diminished which may be explained by in- 299 
hibition of the reticuloendothelial system. This effect 
is proved by the disappearance of congo-red from the plas- 
ma, and by the histological examination of the accumulation 
of trypan-blue and the Turnbull-blue reaction upon iron 
after a saponin hemolysis. The inhibition is short in the 
case of a single dose (l gram per kilogram of body weight), 
after repeated dose, however, it is relatively long lasting. 
The inhibition does not occur as regards phagocytosis. 
There is no reason to presume a diminished resistance 
against infections. 
If administered over a long period of time we observe 
changes in the supra-renal cort°x which point to an in- 
creased activity. This change must be attributed to the 
function of the supra-renal cortex in regulating the blood- 
volume, which, therefore must be expected in the case of a 
regular clinical application, i,e. not directly toxic. 
The kidney did not show histological changes even in 
the case of prolonged administration. 
11* 
QJ2®rstjj,bsarz t_X_Major__MJtCJ>J.__Prof 
In continuation of previous tests regarding blood sub- 
stitutes we examined; 
1, the general effect of "Kollidon" in different 
animals, 
2, the time during which "Kollidon” may bo traced 
in the blood, 
3, the secretion of "Kollidon” with the urine, 
4, the histological changes after "Kollidon” ad- 
ministration, 
5, the effect of "Kollidon” upon the regeneration 
of the blood protein bodies, 
6, the influence of "Kollidon" upon the resorptive 
effect of "Novocain”, 
In the acute test, mice, rats, and guinea-pigs can 
tolerate 10 grains of "Kollidon" per kilogram body-wei ght 
if "Kollidon" is administered subcutaneously and intra- 
peritoneally, Dogs did not show any abnormal attitude after 
subcutaneous and intraperitoneal doses of 8 grams of 
"Kollidon” (as a 10$ solution). In mice , rats and dogs 
a slow intravenous injection of 7,5 grams per kilogram 
"Kollidon" did not lead to any toxic symptoms. The re- 
sults prove that "Kollidon" does not cause any immediate 
reaction if it is administered more concentrated than con- 
sidered possible therapeutically. In case of an injection of a 7% solution of "Kollidon" 
which was given three times weekly, more than 10 grams of 
"Kollidon" were given to white rats in a five w»eks time 
without any toxic symptoms. Growing animals increased 
their body-weight normally. Full-grown rats kept their 
body-weight. Three intraperitoneal injections of 2,8 
grams each of "Kollidon" administered at intervals of two 
days did not harm guinea-pigs in any way that could be 
proved, 
In cats and dogs which had a hemorrhagic collapse the 
,,Kollidon,f-content of the serum falls 20-30% within 5-6 
hours after an infusion of Periston and amounts to 40-50% 
24 hours later. "Kollidon"-determinations were made by 
means of the Methanole-raethod of HECHT, 
The secretion of "Kollidon” in the nrine of normal 
dogs was determined after an intravenous and intraperitoneal 
infusion of a 3,5$ solution of Periston. The method develop- 
ed for this purpose is based oh the precipitation of 
"Kollidon" in the urine, which is sulphuric acid and protein 
free by a concentrated trichlotic-acetic acid with a follow- 
ing determination. This method which will be published in 
detail in another place allows the exact determination of 
1-2 milligrams of "Kollidon". In a modified form this 
method allows the quantitative determination of the "Kolli- 
don" in the blood and tissue. In case of an injection of 
Periston which corresponds to 1/3 of the normal euantity 
of blood there are secreted in the urine first day 26.3 - 
37%; second day 4.6 -16.7%; and third day 1,7 - 6%, During 
the following days the secretion of "Kollidon” diminishes 
so that it amounts to 0,6 -1,4% on the sixth day. Within 
5-6 days 4-7,2 - 59.1% of the injected ’’Kollidon" is eli- 
minated by the kidneys. 
In collaboration with Prof, BERGMANN,first assistant 
professor of anatomy of the Anatomy Institute at Koenigsberg 
in Preussen, we studied pathological changes. White rats 
which were given intravenous injection of 700 milligrams per 
kilogram body-weight as a 7% solution for a period of five 
dsys did not show any organic changes in the liver, kidneys, 
lungs and thyroid gland. The spleen showed only, varying 
in the different animals, stronger vacuolization of histio- 
cyte el ements. Guinea-pigs which were given 700 milligrams 
per kilogram of "Kollidon*1 subcutaneously daily for five 
days did not show any changes in the structural appearance 
of the organs. Even after three intraperitoneal injections 
of 2S00 milligrams per kilogram "Kollidonn, each at inter- 
vals of two days, guinea-pigs did not show any histological 
changes of the organs. In the chronic tests white rats 
were injected with 350 milligrams and 700 milligrams per 
kilogram bodyweight intravenously three times weekly for 
the period of five weeks. The liver of such animals occasion- 
ally shows swollen stellate cells. A distinct increase 
in comparison to those treated with "Normosal" could not be 
observed. The kidneys and lungs of the animals treated 
with "Kollidon" and those of the control animals showed the 
same finding. The R.E.S, (reticulo-endothelial-systern) of 
the thyroid gland does not show any peculiarities. The spleen of all test animals treated with "Kollidon" shows 
a vacuolization of the entire area of the red pulp clearly 
visible under low power magnification. The little knots of 
the spleen are free from vacuoles* The vacuolization is 
especially clear in the peripheral areas of the organs. 
It is more distinct in animals treated with 700 milligrams 
per kilogram than in those treated with 350 milligrams per 
kilogram. If studied in immersion (under oil immersion) 
the vacuoles appear as enlarged nustular elevated histio- 
cytic elements which according to BARGMANN must be con- 
sidered as cast-off reticulum cells. The cyto-plasma of 
the cell is limited to a narrow area enclosing the cavity. 
All varieties between small vacuolated and larger vacuolated 
cells are seen. A sudanoohilic content which might have 
been considered as a fatty deoosit was not observed. The 
iron reaction in prepared sections revealed a fine and coar- 
se granulated blue-tint in the cyto-pLasraa of the cells. 
It corresponds to the visible deposit bf brown pigment seen 
in some preparations with preference for the fringe of the 
cells. The cell-inclusions with a positive iron reaction 
in the vacuolized cells could possibly consist of hemosider- 
in. In comparison to the normal condition the sub,stance 
containing iron seems to be increased. Besides this the 
spleen in animals treated wjth "Kollidon" did not show any 
changes. 
We studied the influence of the ’’Kollidon" upon the 
regeneration of the blood protein bodies in cats and dogs* 
Besides the total protein, fibrinogen, albumin and. globu- 
lin, we determined the "Kollidon"-N with the methanol method 
of HECHT took it into consideration in our calculations. 
The decrease of the blood protein bodies after the infusion 
of Periston corresponds on whole to the degree of di- 
lution of the plasma. The regeneration of the blood protein 
bodies after the administration of "Periston" is not delayed, 
at least not during the first hours, A change of the albu- 
min-globulin-*relation was not observed during the short 
tests. Longer tests with a mor 1 exact determination of 
"Kollidon" in the blood (after the trichloride-acetic acid - 
method) are under way. 
The resorptive effect of "Novocain" is not influenced 
by "Periston". In white mice and guinea-pigs the effects 
of fatal dose, the average fatal dose and the average con- 
vulsion dose of "Novocain" is not traceably diminished by 
an admixture with "Periston", 
Discussion concerning the action_of_Perlston 
SOEHRING: Besides occasionally occurring chills no 
disadvantageous effects were observed when "Periston" was 
administed on a large scale in an army in 18 months,. About 
8% of these reactions ar - attributable to the use of pre- 
served serum ( SCHWIEGK), I suggest the use of preserved 
serum chiefly in those patients who are already deficient 
in albumin, i,e, 'in the war hospitals, "Periston",however, 
should be used by the front medical units. LOESER: It is suggested that the examinations made 
on normal animals should be repeated on animals deficient 
in blood. The morpholgic changes of the spleen observed 
in rats which were treated with "Periston" (ZIPF) should 
be studied more thoroughly. 
ASCHENBRENNER; The problem of the kidney injuries 
due to "Periston" is, in practice, of importance only in 
connection with the treatment of field nephritis where 
occasionally " Periston" was used in a concentrated so- 
lution for the stimulation of diuresis. 
LANGE; Summary of the experiences made with "Periston", 
It hafl no disadvantageous effect at all when used as an 
infusion for deficiency of liouid, as with bleeding ulcer 
etc , 303 
xi. 
ILfLfiJLSJLlLIJL2-.§ 0_F T_H_E C_0_ N_S_U_L_T_A_ N_T_S^ 
C 0 M M I T T E E 0_N P__H_A_R_M_A_C_Y A_N_D 
F_0_0_p C__H_E_M_I_S_T_R_Y 
Translation prepared by : 
U. S, Naval Technical Unit, Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government ( U, S, ) Possibilities_of_substitutes_in t he_ suj2ely_of 
TSee Section X, Article ’ll) 
C0NTR0L_0F_PREPAREp_F00D_F0R_TR00PS 
lx G eneral_introduc t i o eas ons__f or_co ntrol^ 
2i?ersiabsapothekeri_M^jor^_PharmACor2sJ LEHMANN 
It Is believed that the nutritive value of food served 
to troops in this war is no longer in accord with the desir- 
able Quantities of protein, fat, carbo-hydrates etc., due 
to a general decrease of the Quality of food. The Medical 
Department of the Army, by agreement with the Army Adminis- 
trative Branch, therefore decided to introduce routine exam- 
inations of the nutritive value of the rations served to 
troops especially at home and in occupied countries. 
By this measure reliable information suitable for 
correction and amendment of the appendix of Service Manual 
4-3 a, will be gathered. The tables contained therein proved 
to be incomplete and often erroneous, the percentage of 
wastage provided for potatoes for instance amounts to 25 
to 13 %; the 194-3 crop, however, makes a modification of this 
percentage to 4-0 to 50$ necessary. In the 
ment ( German Administration of Polish Territory) the dua- 
lity of beef of category B and C cattle reached only 79 - 
87 % of the standard, A part of the ready made dishes, as 
for instance meat balls, hamburgers, stew of minced meat, 
fried meat balls etc., are not listed in the appendix. 
As a matter of fact the supervision of the Quality of 
the food will give to recommendations relative to the 
quantity and variety of the food prepared, the operation of 
kitchen and messes and the methods of cooking which are of 
special interest to the higher command. 
The Chemical Examination Centers are charged with the 
responsibility of investigating the food. Their reports will 
be checked by the Institute for Army Pharmacy and Applied 
Chemistry who will make recommendations for the correction 
of all deficiencies. 
In order to obtain a good average result it will be 
necessary to include as many army mess installations as 
possible. The Chemical Examination Centers were therefore 
directed to carry through regular examinations at least 
every second month in all kitchens and messes under their 
jurisdiction. It must, however, be born in mind that the 
number of kitchens and nesses differs widely from one dis- 
trict to another and is subject to continuous fluctation. 
The number of obligatory examinations to be carried through 
by each Examination Center was later reduced to 30 per month. 
The food examinations being relatively tedious, this still 
presents an extraordinary amount of additional work for the 
Examination Centers. The chief object of the examination is 
to ascertain the following Questions: 1. Is the soldierfs food in perfect condition or not? 
2, Does the nutritive value of the served food (especially 
hot meals) come up the desired standard? 
3, Was the nutritive value diminshed by poor preparation 
of the food? 
4. What is the proportion between the nutritive value of 
the prepared food in comparison to the raw material 
used? 
In the following we will hear s ome reports about the 
experiences made up to now in the chemical examination of 
the food served to troops. We are in a position to state 
that with regard to the fact that we are in the fifth year 
of war these chemical tests are mad© in the interest of the 
German soldier. Therefore, even in the future it will be 
worth the effort to continue these examinations. Besides 
the sanitary control the chemical examinations will give rise 
to valuable recommendations in the general management of 
kitchens and messes. 
2-t result s-o^ili^control-oi:_pr^Bared_food# 
0l2.§r.§tapotheker_i_Colonely Pharm^Corusj. 
GEMEINHAHDT 
More than 2000 analyses from the testing stations have 
come in up to 10 May 1944# About 1750, which had come in 
prior to the end of March 1944 could be checked. They were 
partially reported upon or submitted to further investiga- 
tions. All examinations revealed that the difference bet* 
ween the actual nutritive values contained in the food ser- 
ved to the soldier did not differ as widely from the calcu- 
lated table values (protein, fat, carbo-hydrates) as we 
were originally inclined to believe. There is no excess in 
the nutritive value of the food, but the quantities were 
found adequate within tolerable limits. The differences bet- 
ween theory and practice arc, for the most part, within the 
10% limit. In some cases, notably regarding fat, they some- 
times received more than called for. According to these 
findings the total value of calories varies between 2700 and 
3500 calories in the soldiers daily diet. The results studied 
so far by no means reflect the general situation. But the 
reports at hand and those to be expected in the future are 
very suitable for drawing conclusions on the general food 
situation of the army. The study will be pushed forward as 
much as possible and, first of all, this material will be 
secured. With regard to the direction to be worked out for 
the future control of the ready prepared food we shall give 
some hints. 1* 
Siab5jai?oiii£l£si:-I-Ca£jiaiu-*Plisii:jB4tCj2]:j?sJLFSE2 
The speaker deals with the reouirements with regard to 
Qualified personnel and eouipment for the inspection of 
messes, 
The inspection,storage,and handling of food stuffs, 
the adequacy and suitability of the diets will include an 
analytical examination of the caloric value of the prepared 
food. Only by close study of these single factors will we 
arrive at a final judgement concerning the absolute value 
of the respective kitchen. 
The tables setting forth the results of the food in- 
spections made up to now nrove that inferior caloric values 
rarely occurred and that in most of the cases the prescribed 
calories were actually served or even more. So, the food 
situation of the field army must be considered to be satis- 
factory and well balanced. 
Lm, Beyi£w_s£_tli£_pr£S£iji_m£ti}od_of_conirol_of_£reoared 
£££d_£££-troo££A 
££aksapot]iei££i:_X_CaptainA_Pi}arm^CorDsi_FRANK 
The average results of about 54 controls are compared 
with the calculated nutritive values of the rations distri- 
buted by the FVM kbg, ( Quartermaster Koenigsb-rg). The 
theoretical amount of calories according to the bill of fare 
is almost in accordance with the actual values found in the 
chemical tests. 
In one case it is demonstrated how, by means of the che- 
mical food control, it is possible to orove clearly whether 
or not at a given troop kitchen therpoldiers receive the food 
they are supoosed to get, A comparison of two controls of 
two meals of the same unit proved that despite the same con- 
sumption of raw materials one of the kitchens revealed a de- 
ficiency of 14.8 calories* the other, however, a deficiency 
of 684 calories. One of the daily rations contained 72 grams 
of fat, the other 52 grams. 
A further example demonstrated that it is not enough 
to compare the contents of protein, fat, and carbp-hydrate 
and the total amount of calories of all the meals for one 
day in order to get a true picture of the controls. We 
rather must compart the values of the different meals and 
dishes. Therefore it is recommended to aakfc arrangements 
that these values be set forth in the fragebogen, the complet- 
ion of which was ordered to facilitate the interpretation by 
the respective commanding officers. The difference in the 
percentage of the nutritive values is to modifications 
by the fact that the high amount of 1596 cfldries for the 
bread must be added to both the practical Js well as the theo- 
retical side. On the occasion of instruction given to the commanders 
of the training units regarding food supnly, the officer 
in charge of one of the testing stations reported his ex- 
periences made with these controls and finally pointed to the 
necessity of considering all the details. The man who has 
no chemical background will not be able to understand the 
different findings of the tests. Therefore it is recommend- 
ed that the chiefs of the test stations report to the comman- 
ders about the summary of the findings as at present and in 
addition to comment on them at the same time. In this way 
the interest for these tests was very much increased in 
Military District I, It was seen and’it will always be so 
that the troop, food is especially good where the commanding 
officer as well as the troop surgeon and the manager of 
the troop kitchen are interested in these controls and at 
the same time are interested in their troop kitchens. 
In this connection it is pointed out that it is not 
practical to always send another man of the test station to 
the units to carry out the control. This seems to be im- 
portant regarding recent objections concerning the variations 
of the nutritive value. In the following a few examples are 
given. 
5a ££j3£Evaiior3S_02_£ood_£outroiA 
fi^Xl^liflPotheker.iLi^.Col^^Pharm^CorBslDILLER 
1, The bills of fare of a Giessen General Hospital 
were used to demonstrate which mistakes are like- 
ly to be made in the calculation of the daily food- 
ration. 
2, The daily contents of the different meals in pro- 
tein, fat and carbo-hydrate and the total amount 
of calories are shown in a chart and the consider- 
able daily fluctuation is nointed out. In other 
charts the contents of the daily supper is demon- 
strated* 
3, Another chart shows the share of meat and vegetables 
in the daily diet. First of all the considerable 
share of bread and potatoes in the total diet is 
indicated, 
4, In the following picture we see the contents of 
vitamin A, Carotin, B and C of the daily food and 
the daily human reruirements, In the calculation 
we see how important it is to find out and to take 
into consideration the exact value of the potato, 
which is the main vitamin-carrier. With the ana- 
lysis made by two hospitals it is shown how great 
the influence of the time of distribution of the 
food can be. 5m Then it is calculated to what extent whole grain- 
bread can absorb raw fiber in comparison to the 
pre-war soldier*s bread, and finally we see varia- 
tions in the bills of fare (soup-days, fresh vege- 
tables and stew-days, desserts, meals made of flour 
etc . ) 
Directions for the chemical inspection of the prepared 
soldiers fopi| 
With regard to the experiences gathered in previous 
controls of the Chemical Test Stations of the army it seems 
to be necessary either to change in part the directions 
given to the chemical service (Anordnung sue chemischen Diene 
Wr. 5 v*. 6.10*194-3) or to complete and enlarge them. For 
this purpose the following suggestions are offered, 
1, The number of tests to be made by each chemical 
test station during a month be reduced to 20. 
Reason: The personnel, the material and the time 
required for each control of the prepared soldier1s 
meal does not permit making more than 20 tests 
monthly with the necessary care. 
2, Distribute this work among the chemical test sta- 
tions of medical depots of the military districts 
and the military districts themselves and at the 
same time the stationary chemical test stations 
according to KStW 13&5 in the occupied countries. 
Special directions will be given to the chief re- 
presentative of Army * edical Services regarding 
the participation of the army groups and armies 
in the chemical tests. Reason: The above men- 
tioned chemical test stations have available the 
qualified personnel and suitable equipment. The 
chemical test stations of the field army may only 
occasionally participate in these tests, 
3, In those cases in which the samples cannot be taken 
by the chief of the chemical test station himself 
or by a member of his staff the garrison pharma- 
ceutical chemists must be charged with the respons- 
ibility of handling this control according to de- 
tailed instructions regarding purpose, technique 
and handling of the examinations. It is intended 
to use a pamphlet of which a draft is already avail- 
able, Reason: The chiefs and scientists of the 
chemical test stations will hare bo devote most of 
their time to their principal assignments. Further- 
more duty travels should be limited to a minimum, 
4, The forms used for these examinations should be 
amended. Reason: It has proved necessary to con- 
sider further facts for the evaluation of the find- 
ings m 5• The meal served at noon should be weighed at the 
spot if possible. It must be mixed carefully by 
passing it through a meat grinder several times 
and only a ouantity sufficient for the test should 
be drawn. The remainder can be used for soups, 
sauces and so on by the troop kitchens. There- 
fore, it is not necessary to take along and to 
test the evening meals if they consist of food 
stuffs, the nutritive values of which can be 
found oerely by weighing them. Their nutritive 
values are well-known bv constant controls, 
(butter, cheese, bread, artifical honey etc,). 
Reason: Saving of food and guarantee of an ef- 
ficient procedure, 
6, It was learned by experience that it is advisable 
to inspect also the kitchens and storage rooms 
during the drawing of the samples. Reason: Re- 
commendation may be given in this connection re- 
garding storage and careful handling of the food 
(Fight waste), 
7, The drawing of sampels in later examinations should 
if possible be done by the same chemist. Reason: 
Knowledge of the local conditions has proved to 
be of practical importance, 
8, Without infringing on the rule that chemical tests 
are to be made unexpectedly it is still advisable 
to inform the troop.medical officer in time so 
that he may take part in the drawing of the food 
samples. Reason: The collaboration with the troop 
medical officers has proved to be a great advant- 
age for the success of these tests. 
The directions in accordance with the above pro- 
posals are in preparations. 
The consultations within th® special groups have proved 
that the success of the food-chemical tests of the prepared 
soldier*s meals must be considered as and efficient. 
The further evaluation of the material gathered by those 
bests, which amounts to more than 2000, lets us expect valu- 
able final results. 
especial ly_ breads 
0£_bfiiird_wai:_shiE£A 
PMEiS^^CorpsI.KLEINKNECHT 
As an introduction the speaker discussed casings made 
of cellulose and at the same time he referred to the require- 
ments regarding permeability of that casing to steam and air, 
fat and arorae density. After that the renuirements of the 
Navy regarding that subject were demonstrated. These 
special renuirrments are caused by the relatively great hu- 
midity aboard ships, on board submarines, and at 
the same time the rough treatment of the crates when taken 
aboard and difficult storage conditions. The reasons why 310 
the humidity of the air is particularly high in submarines 
was illustrated. Further factors affecting the consistency 
of noncanned food aboard submarines are: high temperatures 
when cruising in the tropics and bad effects duo to poor 
ventilation* 
The supply of submarines with fresh fruit and veget- 
able is possible only for the first portion of the cruise. 
After this the food supply depends on canned food. Then 
followed a discussion regarding the use of non-tinned cans. 
Tin plated cans must be reserved for fruit and vegetables 
with strong vegetable acid. After a discussion about the 
influence of the food to be canned upon the can-material 
a report was made about the experiments to supply a butter 
preserve of unlimited keeping quality, by means of the 
,fAlfattbutter procedure; At the same time a report v/as $iade 
about attempts to preserve sausage, ham and bacon by cover- 
ing it with a protective coat of material wMch is based 
Upon polyvenyl alcohol and polyVenyl chloride* This proce* 
dure has already been used in practice. It is intended to 
adopt the same procedure for preserving fresh bread. 
The supply of big ship? with bread is no problem at all 
because they have the necessary installation to bake bread 
on a large scale. Submarines, however, must be supplied 
with canned bread. Then followed a discussion about preserv- 
able fresh bread and canned bread. Finally reference was 
made to the directions regarding the outer wrapping of food, 
the so-called sea-proof casing. 
2a of _££££.* 
M3£i£S2££Est£bsapotii£ke£_i_LtACpmdr^J.Germ3r}_.N£yy, 
WEND LAND 
The speaker dealt exclusively with the preservation of 
eggs by drying them because this procedure is becoming 
more and more important for the food-supply of the Armed 
Forces. Reference was made to the advantages of egg-powder 
in connection with the food supply of the army and methods 
of production were reviewed. The best-known and generally 
applied method is the jet-method. Egg-powder for the army 
is not to be considered as a bakery or a technical product 
anymore but it is supposed to be an eouivalent for fresh 
eggs. This must be taken into consideration by food-chemi- 
cal test methods regarding the appraisal of quality. An 
important test is the sense-test if it is intended to make 
an exact and reproduceable method. The following point sys- 
tem is recommended which agrees with the rules for the con- 
sideration of frozen products. 
5 (very good) completely fresh, without strange flavor 
K (good) tasting somewhat old 
3 (medium) obviously tasting old but not yet dis- 
agreeable, slight smell like ammonia 2 (useable) strongly tasting old but still edible* 
strong taste- of ammonia 
1 (bad) unedibl© 
Consi stency! 
5 (very good) loose, homogenous, not differing from 
fresh egg, no separation of water 
4. (good) more solid than fresh egg but homogen- 
ous* no water 
3 (medium) not entirely homogenous* slight separat- 
ion of water, not conglobated 
2 (useable) strong separation of water, colored, 
strong granular consistency 
1 (bad) strong discoloring, poorly soluble. 
This allows the appraisal of the taste as well as 
the important characteristics such as consistency, color, 
looseness, appearance etc. The solubility can bo found 6ut 
by means of the soluble nitrogen and by whipping. For the 
diminution of ouality by chemical means we must take into 
consideration the water content, the acid and ammonia which 
is bound loosely. Volatile sulphur, oxidation value, change 
of lecithin and absorption of iodine by oil (Lea-number) do 
not give any clue. It is remarkable that tests regarding 
rancidness do not give any clue either, though the "old" 
taste of the food is certainly accompanied by a decomposition 
of fat. 
Finally the importance of egg-powder as a carrier of 
vitamin A was referred to and it was shown that the loss is 
very little during the drying process. 
Jaiii^DSG-Of.rel^tiye^ii^nliity.on^thi^ro^tii^of^micro- 
£££££!smp.in_packpd_fpod, 
fi££i££jajJgS£ai-IfiflSS£flJ3JSlli-Csunso21j2Ei»STILLE 
During the storage of dried food under varying con- 
ditions of humidity "Aspergillus glaucus" proved to be an 
organism which is extremely xerophilic. It is the last of 
a series of hyphomycetes to die in case, .ofr low humidity, 
' T1,' * . ,4 f ; f, * - : ' t \ ■: i' ;; ■ ", •' y 
It was observed that the extreme limit of gemination 
of Aspergillus glaucus is hear, 10% relative humidity and, [the 
upper limit for the formation of spores is near relative 
humidity. These values are,valid only if in,addition the. ... 
hyphomycete grows at an optimal tejnperatum of 31° C , Below 
and abpve the optimum..temperature the development pf the 
hyphomycete is.inhibited by a higher humidity, , , In some practical storage tests for the demonstration 
of the extreme limit of a visible invasion of hyphomycetes 
we observed that in case of dried vegetables the maximum 
value is near 77% relative humidity if the storage tempera- 
ture is 31° Celsius. This represents the maximum density 
at which decay may still be expected. With higher or lower 
storage temperature a higher maximum value was observed in 
all cases. On the other hand all the other dried products 
which were examined generally showed that they were less 
liable to an invasion of hyphomycetes than dried vegetables- 
Analytical_j2robl£ms__pf_c]iemi ca 1_warfare 
1 or dsJ_BRODHANN 
It is demonstrated that the previous regulations re- 
garding the chemical detection of war gas are insufficient. 
The new edition of D 1118 (an army regulation) was then 
commented upon and its advantages and most essential changes 
were reviewed and compared with the previous editions. The 
speaker described the new ouantitative methods of detection 
which are to be used from now on. Finally a ouantitative 
analysis of mustard-gas and nitrogen which wore compi led by 
the Institute for Army Pharmacology and Applied Chemistry of 
the Military Medical Academy was reported. The Be were in 
practical application in connection with food. 
Pi scussion: 
Then followed discussions about all topics which re- 
sulted in a complete agreement on all points. The most im- 
portant results of the discussions are contained in the 
directions concerning the methods for the food-chemical test 
of the prepared soldier’s food. XII. 
PRO CEE DINGS OF T H JE _ CONSULTANT S 1 
COMMITTEE ON SYC H I A T H Y 
AND ME UROLOGY 
Translation prepared by; 
U. S. Naval Technical Unit, Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government (U. S.) Self-mutilation and simulation of sickness 
(See Section V, Articles 10 - I2) 
Psychiatric evaluation in case of self-mutilation and 
negligence while on guard duty~ 
(See Section V, Article' 13) 
Fronto-basal brain-gunshot wounds 
(See Section VI, Articles 7 - 16) 
The pathological anatomy of open and closed brain in- 
juries 
(See Section IX, Article 7) 
Neurosis from the point of view of clinical psychiatry• 
Oberfeldarzt (Lt. Col.. MC.) Prof. Kurt SCHNEIDFR 
It is our task to define the concept of neurosis for 
the purpose of the Army. Personally J never use this term. 
The significance of the new psychopathology"and” psychotherapy 
lies in the fact that they have helped to Prove that a neu- 
roses is of psychic origin and is not a disturbance of the 
nervous system. Paradoxically enough a definition which 
means the' contrary has been retained. Even psycho-therapeut- 
ic considerations' oppose the definition of neurosis; it may 
lead the patient to a lack of responsibility. Therefore the 
patient must realize that he has not been invaded by a neu- 
rosis but that he himself is the cause and the seat of the 
neurosis. 
Functional disturbances of the organs without psychic 
genesis are no longer defined as neuroses by internists. 
(Close correlations must be recognized.) Furthermore the 
opinion held by some neurosis therapists that almost the 
whole field of clinical psychiatry belongs to the study of 
neurosis must be rejected. 
It seems to be acceptable to define a neurosis as con- 
sisting of all those clinical symptoms which incontestably 
are to environmental factors. We have to differentiate 
between psychic factors and physical factors* Among the 
psychic factors I differentiate the abnormal reaction.s_.tg 
environmental occurrences (abnormal reactions to personal 
experience in a narrower sense) and the abnormal inward 
conflict-reactions which are often stimulated by external 
experience. Neurosis of the organs and! afeinal neurosis be- 
long to the body reactions which hro especially observed in 
war-neurotics* I define this entire.group of psychic factors 
as bsydfogenic disturbances of the body. Bverywhere* how- 
ever, observe transitions and intersections. 
The question arises whether or not it is suitable to 
define any of these symptoms as neurosis. - The expression 
’’abnormal reaction to events” cannot lead to any misunder- 
standing. The inward conflict-rections normally occur in 
certain psychopathic patients and are due to a lack of self- 
confidence - contrary to the abnormal reactions to environ- 
mental factors. It is recommended, however, to never use the term "neurosis" for those cases In which the cause of 
ill-health is inherent in the personality of the patient. 
The psychogenic disturbances of the body, however, have an 
exceptional position with regard to their origin; they 
differ from the abnormal reactions to environmental factors 
by physiological factors and from the inward conflict-react- 
ions by the fact that a specific type of psychopathic per- 
sonality is less relevant to their origin. The definition 
"neurosis" may be used for this picture. 
Therefore the following suggestion is made; The best 
thing to do is to drop the expression neurosis completely. 
Presumably it is ineradicable, because not only the physic- 
ians and psycho-therapists it, but also the neurotics 
themselves* (It is much more honorable and much more elegant 
to have a neurosis instead of being called a "psychopath".) 
If one cannot decide to drop the expression completely it 
should be used only for psychological functional disturbances 
which are caused by a psychic disorder. 
2jt— Neurosis from the point of view of psycho-therapy• 
Oberfeldarzt (Lt, Col.. MC.) Prof. J. H. SCHULTZ 
1. The term "neurosis" means faulty reactions and 
faulty attitudes (faulty structures) toward the internal 
and external world due to psychological injuries without 
bionomically conditioned reflexes (grief etc.). These 
faulty reactions and attitudes are understood to be of 
medico-psychological, abionomic or antibionomic, psycho- 
physical Quantitative origin. Congenital and, very rarely, 
acquired sensitivity postulates the existence of neurosis, 
the degree of which may be determinated by the reactions 
to environmental influences ("sensitivity", "depth") which 
have not only a "pathoplastic" but also a "pathogenic" 
valence. 
2. The earlier such an injury becomes effective, the 
more serious the conseouences will be. An injury during 
infancy may change the entire structure of personality 
beyond recognition (characterogenic nuclear neurosis). In- 
jury occurring later, in most cases, leads to a perceptible 
disturbance ("psychogenic stratum-neurosis"). Mnemic de- 
fects are responsible for habitual anomalies (psychogenic 
nuclear neurosis) and an acute feeling of being defenseless- 
ly exposed to "super-powerful antagonists and conditions". 
This hypersensitivity results in faulty reactions and 
faulty1 attitudes (exogenic remote neurosis). 
3. According to the principal psychological source 
of origin, this classification has a clear relation to the 
psychiatric-clinical systematology; Medical-psychological 
Psychiatric 
Therapy 
Diagnosis 
Diagnosis 
0 
Psychopathy 
Serious psychopathy 
Aggravation 
Nuclear neurosis. 
Serious stratum 
neurosis* 
Abnormal "psycho-re- 
active" changes of 
. personality; and 
slight psychopathies. 
Partial aggrav- 
. ation with act- 
ive psycho- 
therapy 
Light stratum 
neurosis. 
Psychogenic reactions. 
Preventive in- 
terference. 
Remote neurosis. 
Reactions of the en- 
vironment (BRAUN), 
"Miliosis" (HAMBURGER) 
Change, 
weaning away 
Peripheral neu- 
rosis or distaste 
4. The characteristic features of neurotic structures, 
attitudes and courses may contribute in an important way to 
other diseases, (structural diseases of the organs (V. v. 
WEIZAECKER, J. H. SCHULTZ, and others), psychoses (KRETSCH- 
MER, SCHULTZ-HENKEL); peripheral neurosis in case of psycho- 
paths and others). 
6. The clinical pictures of neurosis are largely in- 
dependent of the structure: Same symptoms of different 
structure, different symptoms of same structure. 
6. • In comparison to the often intersecting nsychiatric 
classification such as "psychopathy", "abnormal reactive 
(psycho-reactive) change of personalityf’, "psychogenic 
reaction", the genetic-structural classification of neurosis 
in relation to the main psychological sources of origin 
gives a clear survey and Indication for treatment. 
7. In the still prevalent (incorrect) static-des- 
criptive definition of "the psychopathy" as an exclusively 
hereditary, abstract, 'providential, irrevocable fate, the 
nomenclatural classification of light and often not as yet 
psychopathically tainted cases of psychopathy (nuclear and 
serious layer neurotic) as neurotic seems to be advisable 
from a theoretical and practical point of view. In the 
psychiatric classification the peripheral neurotics are 
missing. 8. "Psychogenic reactions" on the one hand and light 
layer neurosis and remote neurosis on the other hand may'be 
equivalent nomenclaturally because even in the case of "psych- 
ogenic reactions" - at least in principle - psychotherapy must 
be taken into consideration; The differentiation between 
stratum neurosis and remote neurosis is based on more posit- 
ive indications regarding structure and indications for 
treatment. 
9. The uniformity of the psycho-physical reactions 
from the clinical of view often causes a complete re- 
semblance of the predominantly hereditary external world re- 
actions and pre-destined false reactions and faulty attitudes 
(structure) in varying shapes and grades. A purely clinical 
descriptive differentiation often may not be achieved. In 
that case it may be obtained only by hereditary-biological 
research and by diagnostic depth-tests. 
10. The neurosis as an abionomic reaction to external 
influence (SPEER) of different types may in principle be a 
sequel to the vicissitudes of life, (sickness etc.). That 
is the reason for its frequency, its practical and social 
significance. According to its nature, it can be healed 
only by psychological - in serious cases by "depth-psycholog- 
ical" - research and treatment. 
11. The dynamic-genetic contemplation of medical psych- 
ology and psycho-therapy is not exhaustively dealt with in 
present German biology. It needs a thorough and active 
penetration, in serious cases with "microscopic" minuteness 
and a permanent aggressive attitude with the keen intent 
of securing critical findings. Otherwise neurosis will in- 
vade precious lives which will be lost for the community. 
3. Neurosis from the point of view of internal medicine• 
Oberfeldarzt (Lt. Col.. MC.) Prof. STEBECK 
The term neurosis is very vague, nevertheless it should 
not be completely dropped in spite of the well justified 
objections. Only those functional disturbances should be 
defined as neurosis, or better, as neurotic reactions which 
occur during a certain period of time or periodically as 
a characteristic trait of personality and which basically 
are caused bv abnormal psychic dynamics, by abnormal psychic 
reactions or faulty attitudes. Vegetative disturbances of 
the functions (metabolism, respiration, stomach, sexual 
etc.) originate, in a similar manner in the physical as 
well as psychic sphere of the dynamics of life, due to 
disposition and are stimulated by particular events or ex- 
perience. All transitions and relations are found in this 
connection. But only when the abnormality in the psychic 
sphere stands in the foreground of medical approach is the 
diagnosis "neurotic reaction" justified. Even in case the 
findings of organic impairments are prevalent the psychic 
influences should never be underestimated. Diagnosis and 
therapy should always consider both spheres, the physical 
and the psychic. 4, The legal responsibility of the neurotics• 
Oberstabsarzt (Major. MC.) Prof. Carl SCHNEIDER 
The neurotic patient may be held legally responsible 
for any offense committed either beyond his neurosis or 
under the influence or contribution of it. In this case 
the general principles of forensic psychiatry are suffic- 
ient. Paragraph 51.1 is applicable only in cases of psycho- 
similar conditions, 51.2 only under special circumstances. 
The responsibility of the neurotic patient for his 
neurosis must be answered in the affirmative in of 
certain contrary considerations. It is based on the ex- 
pericnce that the neurotic patient is in a position to in- 
fluence his neurosis by personal attitude to a very great 
extent. Furthermore neurotics in their varying phases 
adapt to the varying environmental conditions. Therefore 
they must respond to particular situations and they also 
must be subject to influence by legal measures. In con- 
sidering the crimical responsibility of the neurotic it 
is necessary to make a clear diagnostic differentiation 
from 1. other psychic (psychotic; reactions, 2. undetected 
endogenous diseases, 3« acute somatic diseases covered by 
a neurotic superstructure, 4. endocrine disturbances, 
5. allergic disturbances and simple constitutional insuf- 
ficiencies# Only some, of the neurotic diseases are of 
real war significance. First of all we have to 
against the psychogenic reactions, against the psychogenic 
superimposition of organic symptoms and the so-called neu- 
rosis of the organs. In all these cases the frame of mind 
and the will of the individual, i.e., factors which are 
subject to personal influence, have to be fully considered 
in the evaluation of a neurosis even in cases of a prim- 
itive psychic mechanism. In general escape into neurosis 
should not be criminally prosecuted because it is difficult 
to prove it is only an escape and a distinction from mal- 
ingering is extremely difficult and if such cases are to be 
urosecuted even those subjects whose neurosis was primarily 
caused either by a serious shock, exhaustion or disease 
would be liable to punishment. It seems reasonable to sub- 
ject to punishment only those who resist medical therapy 
and show insufficient will to convalescence during the 
therapy. These are the facts well experienced surgeons 
are confronted with. These facts are connected with under- 
mining the moral of the Armed Forces, because they may 
give rise to imitation. Imprisonment and transfer to an 
asylum without' treatment and healing are not sufficient 
in the struggle against neurosis. Means and ways must be 
found to submit a neurotic to a legal procedure if he does 
not want to be healed. After the elimination of hi* symp- 
toms and a’thorough reeducation he should be excluded 
the community for some time. Two practical procedures are. 
immediate transfer by the strength of the verdict of the 
court to a special field unit for hazardous duty. It seems 
to be better, however, to send the neurotic to a concentrat- 
ion camp for an indefinite period of time until the aim of 
reeducation or a healing is achieved. The necessary 
tection of the inoffensive neurotic must be guaranteed in 
that only medical experts and sufficiently qualified sur- 
geons will be authorized to ask disciplinary action. On the other hand a sufficiently great number of surgeons should 
participate in that procedure, and, if necessary the court 
should be composed of physicians besides the juridical chair- 
and one of those at least should be a qualified psychi- 
atrist who must possess sufficient experience* 
Discussion of the lectures concerning neurosis. 
DE CRINIS: I remember two cases which were diagnosed as 
"neurosis" and "psychopathy" one of which later revealed to 
be "cranio-pharyngeoma" and the other a "Wilson1s disease". 
I have observed that those aspects of neurosis are becoming 
popular to which special importance is attached in the ge- 
eral medical research such as the focal toxicosis. In one 
case which I know personally, an officer intended to justi- 
fy his inefficiency by a focal toxicosis and had obtained 
several certificates to this effect. 
With regard to "neurosis" in general and especially 
with regard to the evaluation of the psychic effects, I 
would like to underline that we have not made any proper 
progress regarding the definition of the concept, since 
World War I. This is due to the fact that by emphasizing 
the psychic influence and the contrast of psychic and physic- 
al spheres the strict scientific consequences imposing them- 
selves were not given the necessary consideration. Even the 
"body-anima-problem" which is of fundamental significance in 
the science of neurosis can be considered successfully if the 
body and the anima are considered to be one unity in the sense 
of Goethe’s monism. This important question has begged anx- 
iously for solution in the past. On the one hand nobody 
wanted to adhere to gross materialism, at the sametime the 
general trend is to abandon relations and dualism. With a 
view to avoid fruitless discussion I would like to propose 
that we treat the exterior consequences of an event in the 
outside world, separately from the interior reactions and con- 
sequences, the latter referring to the psychic qualities. 
CHRISTUKAT: re should always keep :*n mind, that the 
pathological conditions known as "psychopathy", "neurosis" 
including "hysteria" must not be interpreted in a moral 
sense. Their confusion with considerations of evaluation 
will make it impossible to eliminate the symptoms in single 
cases and the sociological danger will by no means be dim- 
inished. It seems to be unjustified and even dangerous to 
use the term "neurosis" with too much indiscretion. In. 
dealing ruth suicide-cases I have observed that monosymp- 
tomatic endogenous depressions were covered by some "heart- 
neurosis" or "stomach-neurosis" which were diagnosed re- 
trogradely* This was the reason why we decided in. former 
meetings to refrain from using the term "neurosis". If, 
however, it is not possible to avoid the term "neurosis" 
completely we must give clear definitions in the direct- 
ions intended for the Armed Forces so that even medical 
officers whoaare.not experts in this special field can use 
them advantageously. PETTE; Whilst the definition of the term "neurosis" 
Is very much disputed our knowledge of the conditions of 
"neurotic" or "psychogenic" reactions has nevertheless in- 
creased in comparison to what was known in the first World 
rar• In the same way the definition of the symptoms has 
undergone a change and our medical attitude towards those 
disturbances has changed too and all this seems to be rather 
important when referring to pathogenic questions. Every- 
thing is based on a dynamic mode of consideration which re- 
fers to the vegetative functions and regulations. All this 
makes it clear that it may be rather difficult to distinguish 
a purely psychogenic case from reactions caused, by a patho- 
logical process. Besides the many facts already mentioned 
this is also true for the specific behavior of the attacks 
in the broadest sense and for all phenomena of the hormones 
especially in the hypophyseal system. 
VTLLINGER; Even when adopting the monistic system for 
the appraisal of humans there still remains a certain liber- 
ty allowing for an appropriate evaluation of behavior conti- 
guous to an attempt of malingering. 
I absolutely agree with the concept of Kurt SCHNEIDER. 
We can eliminate the term "neurosis" because it may lead 
to misunderstanding. 
DELIUS: Internists rather often have to deal with 
people complaining about troubles of the heart and other 
organs. In many cases it will not be possible to find any 
objective functional disorder of the subjectively affected 
organs even by means of minute examinations of the functions. 
This may be caused to a large degree by the inaccuracy of the 
diagnosis. On the other hand presumably there are also some 
cases of neurosis or similar symptoms of disease of psycho- 
genic nature which do not show any objective disorder of the 
functions. For these patients the term "psychogenic react- 
ion' of the body" does not properly describe the situation 
at least as far as the terminologv is concerned because re- 
actions or a disorder of the organs is absent. Perhaps it 
will be useful to differentiate between "neurosis" i.e. 
psychogenic symptoms of disease which show only subjective 
disorders, and those showing objective disorders too. 
From the point of view of the internist it seems to 
be undesirable to accentuate too much the word "reactions" 
because of the close relationship between constitutional 
nervousness, light psychopathies and neurosis. In some 
psychogenic symptoms we do not find any transitory reactive 
disease but a lasting condition with certain fluctuations of 
intensity. 
Directions concerning neurosis• 
In practice and literature the term "neurosis" is used 
in varying meanings. This renders discuss?ons^very dif- 
ficult' and gives rise to erroneous interpretations. 
For official use in the Armed Forces it seems to be 
indicated to give the following directions: 1. Abnormal Psychic reactions which are strictly lim- 
ited to the psychic field and which are not accompanied 
by physical disorder of the -functions are termed "ab- 
normal reaction1* psychological factors, for instance 
"depression" caused by plausible reasons such as a react- 
ion to fear and fright. 
These abnormal "reactions to psychological factors" 
are observed in normal persons as well as in those of an 
extraordinary character and in psychopathic nersonalities. 
The surgeon must not forget that even many abnormal 
nersons may be cured by psycho-therapeutic means, espec- 
ially in case of disturbances of the development of per- 
sonality* 
2. The physical symptoms occurring in abnormal psychic 
reactions are termed "psychogenic (caused by environ- 
mental factors) disturbance of the functions". Here 
first of all, we have the well-known so-called "war- 
neurosis", appearing as jittering, stuttering, shocks, 
paralysis, contractures, bladder and gastro-intestinal 
troubles, i.e. in part, symptoms, which formerly were 
termed "hysterical". Terms such as "war-neurotic", "war*- 
jittering", "war-hysteria" etc., must absolutely be 
avoided. 
Therefore the diagnosis must be? "psychogenic 
vomiting", "psychogenic disturbance of the gait", "psycho- 
genic impairment of speech", "psychogenicially fixed 
radial paralysis". 
The necessitiy of giving a description of the per- 
son and of the course of the disturbance is emphasized* 
Even in case of a disease of the organs the same attent- 
ion must be paid In due time to the psychic as well as 
to the physical finding. 
5 # Occupational therapy for brain injury patients. 
Stabsarzt (Captain. MC.) RUESKEN 
The choice of the suitable occupational therapy methods 
for soldiers with brain injury should be guided by the aim 
of that particular treatment. Simple occupations as well as 
true handicraft in workshops cannot meet the reouirement of 
a systematic treatment of the consequences of brain injuries. 
Occupational therapy of brain injury patients must be adapt- 
ed as much as possible to the special conditions of each 
case. It is of utmost importance to know thoroughly all de- 
tails of the injury and its after-effects which must be duly 
considered in the assignment of an appropriate occupation for 
the patient. Besides the local center symptoms such as motor, 
sensation, optic, agnostic and aphasic disturbances etc., the 
so-called general cerebral injuries with the vegetative symp- 
tom complex as well as damage of the psychic-mental functions, 
(meaning a lack of cerebral functional power) must be taken 
into consideration. The cerebral functional nower of persons with brain injury is especially influenced by the vegetative 
syndrome. Often it will not be possible to find the lack 
of cerebral functional power without careful neurological- 
psychiatric examinations and observations. But this point 
requires a thorough treatment and promises, when applied in 
due time, a good result. The work to be earned should be 
adapted to the cerebral functional power of the brain-injured 
patient. Recently injured persons must be given quite a dif- 
ferent kind of assignment from what is given to patients with 
old injuries, whose spontaneous recovery have come to a stand- 
still. It Is exactly the stimulation of the spontaneous re- 
covery which is aimed at by occupational therapy. For the 
treatment of cerebral-injured persons handicraft alone will 
not suffice. They require supplementary mental excersises 
just as in elementary schools including lessons in arithmetic, 
reading, history, geography, natural sciences etc. Their 
purpose'is to condition the power of memory as well as the 
capacity to impress things on memory, the power of concent- 
ration etc. 
Regarding handicraft, only such tasks should be perform- 
ed which do not require any professional skill. Under con- 
sideration of the peculiarity of the brain-injured person 
only such work should be performed as wood carving, day- 
modelling, sheet-metal-work, card-board work etc. The first 
condition is that the spontaneous interest "to be doing 
things" of the brain-injured person must be taken into con- 
sideration. The natural impulse for movement and creation- 
al activity of each person should be taken advantage of use- 
fully. Aimless and inanimated tinkering must not be allowed. 
The physician and the instructor of the workshop must cooper- 
ate fully and in doing so apply true handicraft under consider- 
ation of the psychic capacity of the patient. Pedagogical con- 
siderations should govern him with a view to exercising the 
desired influence. Labor should be performed in a profession- 
al and industrial way only by older brain-injured persons 
whose working power hao been reestablished to such an extent 
that they may be employed again bv their previous firms, but 
who for medical reasons cannot yet be discharged. For this 
purpose hospital owned work-shops are very suitable in which 
war-important articles are produced such as household articles 
and agricultural machines, pig-skin shoes with wooden soles, 
metal buttons and others. Before being discharged as "unfix;" 
from the hospital the soldier should be employed expediently 
for some time on probation in consideration of his previous 
or new occupation. 
Discussion: 
CHRISTUKAT; The complexity of a cerebral injury cannot 
be fully diagnosed with the reflex-chamber alone. There is 
no doubt that in such a case the specialist should proceed to 
a thorough cerebral pathological examination. 
The optimism which was caused by the excellent results 
of occupational therapy were not fully confirmed, especially 
regarding the practical value in future employment. A discrepancy is often oBserved between the cerebral- 
pathological finding and the result of a labor test (in 
continuation of practical occupational therapy methods) on 
the one hand and the result of the final reinstatement into 
the civilian life without the control of the hospital on 
the other hand. It is important to realize that’the brain- 
injured person although fit for labor cannot stand compet- 
ition, This is explained in detail in a publication by 
STADLER which will appear in the near future. 
Carl SCHNEIDER; Occupational therapy in case of brain- 
in.juries must be adapted to the different important phases 
of the healing process. Shortly after the operation and 
during the time required to overcome the edema and the acute 
danger of infection (three weeks) the therapy must be de- 
signed to calm and relieve the patient. In the second phase 
which sometimes lasts several months, the therapy murt be ex- 
tended in three directions; a. Compensation of remaining 
defects, b. Exorcise of quiescent functions which are not 
damaged, c« Restoration of damaged functions. In doing so 
the biological order of the function must be taken into con- 
sideration. During the last phase the therapy should aim 
at achieving the social reinstatement of the brain-injurod 
person. Failures are often caused by not considering tho 
above described principles. 
TOENNISs The reinstatement of the brain-injured pat- 
ients into civilian life under medical supervision represents 
an especially important factor to prevent the Injured pat- 
ient from losing his social level. 
6« Alterations in the cerebral ventricles following gun- 
shot v'ounds of brsiru 
Oberstarzt (Colonel, MC.) Prof. W, TOENNIS 
The changes we found in brain ventricles after gun- 
shot injuries are divided into local dilatations and general 
symmetrical or asymmetrical dilatations. 
The following collection of evidence is the result of 
examining 375 cases of uncomplicated intradural gunshots 
affecting the vault of the cranium. 
1, Local dilatation of the lateral ventricles was ob- 
served in 6l,2 per cent of the cases. The location of 
the injury had no influence in this respect. First 
condition for the formation of a local dilatation of a 
brain ventricle is a defect of the brain substance* The 
buldging of the vault of the cranium is caused by the 
pressure of the fluid. The shape of that buldoing is 
decisively influenced by the shrinkage and the brain 
injury which lafcer undergoes atrophy. 
2, Diffuse dilatation; Regular dilatations of the 
lateral ventricles were observed in 90.6 per cent of the 
caSes, 46.4 per cent slight, 36.8 per cent moderate, 
and 7*4 per cent serious. It was not determined to what extent the duration 
of the unconsciousness is of* importance in $>lte of the 
fact that 80 per cent of the cases showed unconscious- 
ness iifnaeditately after the injury. 
Among the asymmetric dilatations we find also mark- 
ed dilatation of the contra-lateral ventricle. In 0.2 
per cent a progressive dilatation of the ventricle was 
observed. In one case re observed a diffuse ventricle 
dilatation of moderate degree returning to a nearly norm- 
al ventricle picture. 
Even a prolonged increase of the fluid pressure 
does not necessarily lead to a chronic dilatation of 
the ventricle. The chronic and progressing ventricle 
dilatations are caused an atrophy of substance, 
which is due to cerebral edema. It has not been poss- 
ible so far to ascertain whether or not further stim- 
ulating factors exist. 
Pi scussion: 
PETTED Trre must conclude from experience gained in 
peace-time that a ventricle dilatation does not'by itself 
permit one to give a final judgement regarding efficiency 
as long as no. function centers are lost. It seems to be 
important only as regards the ability of the brain to adapt 
to an acute overload-regardless of the cause. This ability 
may be influenced and may show disturbances (epileptic attacks). 
PANSE: If. as observed by Dr# TOENNIS, the fluctuat- 
ions of the ventricle size occur quite frequently at short 
intervals and if they are really caused by fluid-disturb- 
ances, this would be of greatest importance for all of neu- 
rology. The findings gained from single encephalograms 
should in that be considered as being much less static 
and constant. XIII. 
PROCEEDINGS OF THE CONSULTANTS T 
COMMITTEE ON T U BERCULOSIS 
Translation prepared by: 
U. Sm Naval Technical Unit, Europe, (Bfledical Section) 
Office of the Naval Advisor 
Office of the Military Government (TJ. S.) .1* Pleurisy with effusion• 
Stabsarzt (Capt. MC.) Prof. SCHEDTLER 
(principal report) 
The necessity for a precise etiological definition of the 
different forms of exudative pleuritis is emphasized. The 
pleural effusions which appear as independent disease pict- 
ures are often tuberculous in nature. Apart from this, we 
find effusions of the same sort during or after diseases of 
other organs as for instance pneumonia and infectious dis- 
eases. Rheumatic exudative pleuritis occurs rather seldom. 
It is unjustified and unsuitable to consider allergic exudat- 
ive pleuritis as a special form. After that the symptomat- 
ology of the different types of pleuritis were reviewed. 
Cases of doubtful pathogenesis should for practical consider- 
ations be treated as if they were tuberculous in nature. It 
is doubtful whether or not there exists a true increase of 
the number of cases of pleuritis during the war9 
The therapy to be applied should in general be based 
on the well-proved principles according to a uniform plan. 
The particulars, however, may show great differences, part- 
icularly regarding the methods. In the case of a non-tuber- 
culous Pleuritis the treatment of the primary disease should 
be born uppermost in ones mind. Patients with this disease 
are fit for active service after their discharge from the 
hospital. The tuberculous effusions, however, require a 
long-lasting follow-up and a careful treatment. Then the 
question was discussed regarding the deflation of the lung 
by the effusion as well as the use of pneumothorax. This 
ouestion must be examined once more in connection with com- 
parative examinations of test-series which could most pract- 
ically be carried through by special wards for pleuritic 
patients which should be set up everywhere. The skin-emphy- 
sema treatment is rejected. The patients who suffer from a 
tuberculous exudative pleuritis must be followed up after the 
treatment (X-ray control) because in the years to come, new 
tuberculous invasions may occur in case of negligence. Pleu- 
ritis patients should be classified Mfit for civilian labor”, 
(a.v.) or ,ffit for conditional service at home under the most 
favorable conditions possible”, after £ - 1 year at the ear- 
liest. Supposing that those patients are taken care of, they 
may be employed in the homeland or by the supply services 
taking into consideration their general education and know- 
ledge. Only 2-3 years later may a (k.v.) classification 
(fit for active service) be allowed if new symptoms are ab- 
sent. 2. Pleurisy with effusion (exudative pleuritis)• 
Oberstabsarzt (Major. MC.) Prof* HANGARTER 
(co-report of the internist) 
In exudative pleuritis, other than tuberculosis, acute 
rheumatic fever is rather important from the etiological point 
of view. The classical form of rheumatic fever (acute poly- 
arthritis) is often overlooked because of an incomplete symptom 
picture. Observations made under quite different climates at 
the different sectors of the eastern front showed that some 
cases of exudative pleuritis are of rheumatic It is 
typical for the rheumatic origin of exudative pleuritis, that 
it sets in suddenly out of good health with accompanying high 
temperatures, sometimes following angina and infection. Rheu- 
matic reactions may be observed in the joints, in the endo- 
myopericardium, furthermore in the disorder of the cardiac con- 
duction system, musculature, vessels,^skin and nerves. #A11 
these factors must be taken ?nto consideration. Excessive 
variations of temperature and excessive exposure to the sun 
appear to favor the stimulation of allergic-rheumatic exudat- 
ive pleuritis. In case of a pleuritis caused by rheumatism, 
the exudate is cloudy-serous, mixed lymphocytic-leucocytic and 
it has a snecific gravity of 1.018 to 1.022. The speed with 
which the red blood corpuscles settle is much accelerated. 
The presence of infiltratres could not be observed by X-ray. 
The rheumatic effusion is very quickly resorbed, 
pleural thickening and without any impairment of the mobility 
of the diaphragm during the salicylate therapy and "Pyramidon" 
therapy. The speed with which the red corpuscles settle is a 
reliable indication of the healing of rheumatic symptoms aris- 
ing during the pleuritis. 
3• Pleurisy with effusion* 
Stabsarzt (Captain. MC.) Prof. GIESE 
(co-report of the pathologist) 
Exudative pleuritis is always a manifestation of disease 
which is not limited only to the pleura. An exception of this 
rule is the primary endothelial cancer of the pleura, which, 
together with the metastatic pleural-carcinosis in the group 
of the non-infectious exudations in the post-mortem findings 
(besides trauma and lung infarct), are most frequently the 
reason for a serous *scudate. In most cases a sero- 
fibrinous pleuritis on an infectious-toxic basis is caused 
by tuberculosis. The cases of serous exudates accompanied 
by pus-forming germs as the causative agent are very rare. 
Tn the observed cases the possibility of tuberculosis could 
easily be eliminated, even clinically, because of the observed 
formation of foci in the lungs or in the wall of the Ple^al 
cavity. In pleuritis which is sometimes found an accomp- 
anying symptom of the "rheumatismus infectious specifiers 
noaccumulation of a significant exudate is observed. A 
specific-rheuma-pleuritis with significant exudation apparen 
ly does not occur. The sero-fibrinous form is more common than the caseous 
form, as wa'S observed in 137 cases of tuberculosous exudative 
oleuritis which were examined anatomically. After the exudate 
subsides, little knots are observed in the adhesion in the 
v'ase of the sero-fibrinous form and large caseous remnants 
ire still found anatomically many months after clinical heal- 
ing. 
In those 137 cases the tuberculous exudative pleuritis 
lad followed infantile primary infection 14 times and the late 
.nfection of the adult 80 times. It is found 33 times as an 
iccompanying symptom of pulmonary tuberculosis and 12 times as 
in accompanying symptom of a flare up of lymph node tubercul- 
)sis. 
In all cases examined it was proved by the presence of 
tubercles and caseations on the pleural membranes that an 
nfection of the pleura space with tubercle bacilli has taken 
Jace, The existence of very large effusions has not been 
observed on a purely toxic or allergic basis. 
Pleuritis which follows the primary infection of the 
is frequently found between the ages of 18 and 30 years. 
Later on the number of cases decreases rapidly. Pleuritis 
•»rith a flare up of lymph node tuberculosis is exclusively 
found in higher ages most frequently in persons older than 
50 years. Since the beginning of the war, a steady increase 
of tuberculous pleuritis has been observed, first in soldiers 
of the Armed Forces but now also in the civilian population. 
)In a series of cases in which the onset of the primary in- 
fection was approximately determined, it was observed that in 
the course of the first year, pleuritis appeared in a remark- 
able number of cases from three to seven months as the first 
symptom of tuberculosis. Late primary infections as well as 
Infantile primary infections were accompanied by hematogenous 
spreading in about 2/3 of the cases. In 63 per cent of the 
aases of the primary infection followed by an exudative pleu- 
ritis, localized lung effusions without association with a 
general miliary tuberculosis were found. It amounted to 24 
aer cent when an exudative pleuritis was not demonstrated. 
The opinion was expressed, that each infectious exudat- 
ive pleuritis which is accompanied by an excessive long 
.asting serous effusion must be considered a symptom of 
:uberculosis, as long as it is not possible to find another 
ion-tuberculous stimulating focus. It has been impossible 
jO far to prove the occurrence of a rheumatic pleuritis which 
is accompanied by a very large effusion. 
The fact that in a considerable number of cases the 
:uberculous pleuritis develops after a fresh primary infect- 
ion of the adult leads to the conclusion that it is necessary 
:o regocnize the source of infection beyond the finding of a 
Drimary infection. In the case of tuberculous pleuritis, the 
effusion subsides before the tuberculous process in the pleura 
)r the neighboring organs has come to a standstill. Therefore 
Its subsidence cannot be considered as an indication of the 
lealing of the tuberculous process. Discussion concerning exudative pleuritis. 
Comments upon the report of SCHEDTLER b 
Oberstabsarzt (Major, MG.) DEIST 
The view has been expressed by some internists that the 
simultaneous hospitalization of patients afflicted with ex- 
idative pleuritis and those suffering from open "cases" of 
mlmonary tuberculosis may be hazardous to the patients of 
:he first group. It may, howevery be taken for granted that: 
1* the majority of cases of exudative pleuritis are a 
manifestation of tuberculosis, 
2* exudative pleuritis cases of other etiology are 
greatly outnumbered, 
3. each exudative pleuritis must be considered as a 
tuberculous disease in an active sense when'-the non- 
tuberculous etiology has not been proven, 
4. only patients with an txudative tuberculous pleuritis 
eouivalent to active tuberculosis are hospitalized in 
hospitals for pulmonary diseases, or in special convales- 
cence detachments under supervision of tuberculosis ex- 
perts. In addition we may also have patients placed under 
observation for tuberculosis after having been afflicted 
by an exudative pleuritis. 
Two factors are important in connection with the 
'hether or not patients with closed cases of active tuberculosis 
ay be endangered by open tuberculosis cases. It must be dis- 
inguished between endogenous and exogenous reinfection. 
In animals the classical experiment by KOCH stands in 
he foreground of all considerations: A tuberculous guinea- 
>ig cannot be infected again by tubercle bacilli, a local dis- 
ease of the skin, however, is the consequence but general re- 
nfection is not observed. According to the experiments by 
he former leader in this field Bruno LANGE a maximum immunity 
.s observed when tuberculosis is at its peak. The immunity 
ecreas-es, however, with the healing process and subsides as 
toon as the healing is complete. In that connection with 
mmans, Bruno LANGE points to the great difference between 
he attitude of the patient who has been healed a long time 
go and the attitude of the actively sick person with regar 
,o superinfection. He directs the clinicians attention to 
he tuberculin-negative individuals* In his findings in 
nimals, Bruno LANGE does not see the necessity for the sep- 
ration of open and closed cases of tuberculosis. 
For all further considerations it is important to point 
o the fundamental difference of the reaction in juveniles ana 
.dults with regard to superinfection. For Armed Forces pur- 
»oses we may refrain from dealing with the first category* 
Against the clear result of the animal tests of Bruno , „ 
.ANGE stands the superinfcation with its two faced "Janus-head . The reaction of the individuals in relation to superinfect- 
ion may be different in the various phases of the disease 
(NEUFELD). Superinfection may lead to an acceleration on the 
one hand, on the other it may lead to a decrease of the de- 
fense forces of the body against tuberculosis (KAYSER-PETER- 
SEN), The controversies about ’'endogenous'* and "exogenous” 
infection have not yet been settled. So far nobody can deny 
that there is a possibility of an exogenous superinfection* 
The majority of physicians, however, assume a domination of 
the endogenous reinfection especially with regard to our con- 
cept of the hematogenous course of tuberculosis as has become 
generally vnown in the last years. Many speak of a combinato* . > 
of the two possibilities: exogenically stimulated endogenous 
reinfection (GRAEFF), At the same time the question arises 
why a tuberculous person should be more sensitive to his own 
bacilli than to those from others. 
For the clinical evaluation the following facts are re- 
levant: 
1• Occupational diseases of specialists for tuberculosi.s. 
This kind of disease actually occurs. Although 
after one hour of consultation in cervical diseases virulent 
tubercle bacilli could be proved on the cheek and in the 
nasal mucus of the examining physician, cases of infection 
are extremely rare. 
2• Occupational diseases of nurses. 
On the one hand we have the theory of BRAUNING who 
has observed relatively many cases of infection of nurses who 
attend tuberculous patients* On the other hand, however, the 
great majority of sanatorium physicians consider the hazard 
of infection of nurses as relatively rare. It is a matter of 
fact that a superinfection of nurses has been observed rather 
often if regular X-ray control is instituted. But it is quite 
sure, that many of those cases are bent*5iand that they are not 
found at all if X-ray control is not instituted and applied 
regularly and carefully. 
3. Tuberculosis in teachers* 
There is no question that school children have been 
infected by tuberculous teachers. Because of our dealing with 
adults only this question is of no importance here. 
4. Matrimonial tuberculosis. 
——"■■■ «< p nu ■' - ■" 
The hazard of infection is especially high in this 
case, although only 10 per cent of reciprocal infection has 
been reported. In this instance the exogenous superinfact- 
ions moment cannot be the only and decisive reason. It is 
the opinion of KAYSER-PETERSEN that the superinfection may 
even lead to an increase of the defense forces in the case 
of married people. 5• Observations gained in public welfare. 
Patients suffering from active tuberculosis who are 
discharged from hospitals exhibit a more marked relapse rate 
when returning to tuberculous surroundings. Here, however, 
there must be taken into consideration not only infectious 
but also absolute hygienic influences. Healthy dependents 
of tuberculous .persons fall sick 5-7 times more frequently 
than dependents of healthy families. Also in this case in 
spite of most serious exposure there is no 100 per cent hazard* 
Babies which are extremely weak regarding their defense forces 
died in 4.5 per cent of the cases at Halle and in 6 per cent 
of the cases at Stettin, although all of them were heavily ex- 
posed to infection. 
6• Epidemiology of tuberculosis• 
At Davos as well as at Schoemberg the mortality rate 
due to tuberculosis of the population decreases with the de- 
velopment of the health resort and the growing wealth i.e. 
with the increase of the number of patients the greater port- 
ion of which is seriously suffering from tuberculosis. Accord- 
ing to our own experience these facts are especially striking 
at Schoemberg, where many patients suffering from serious open 
tuberculosis are living in private homes. 
7• Earlier special examinations at Ueberruh• 
The final recovery of all patients has been followed 
up who during a period of six years had been discharged be- 
cause of a minor or dubious case of tuberculosis. All those 
patients had shared their rooms with open tuberculous persons 
for four years. Within two years a separation had taken place. 
The result was as follows? 2.6 per cent of the patients had 
died from tuberculosis, 0.9 percent had sufferent from open 
tuberculosis, 0.6 per cent of the cases were still closed but 
their condition of health was aggravated. This makes 4*1 per 
cent changes for the worse. 1724 cases suitable for evaluat- 
ion were taken as a basis for these figures. Under considerat- 
ion of the fact, that extremely severe cases of tuberculosis 
change significantly for the worse in 7 per cent of the cases, 
the above result of only 4.1 per cent of changes to the worse 
is surprising. Without doubt this means that these patients 
suffering from closed tuberculosis had not been infected or 
damaged for the future, by those with an open tuberculosis 
and with whom they had lived together in the sanatorium. The 
low percentage is especially striking, because among those 
1724 patients a rather great number of practically healed 
tuberculous persons was certainly included, who according to 
the theory of Bruno LANGE were especially endangered by a 
new infection because of their loss of immunity. In contrast 
to the theory of Bruno LANGE some of the specialists for 
tuberculosis believe that even inactive tuberculosis cannot 
be endangered by an open tuberculosis under the hygienic con- 
ditions in a sanatorium. 
Without dealing further with the problem of open and 
closed tuberculosis, I would like to point only to the-fset that 
in the same patient the result of examining tne sputum may 
vary from "negative" to enormous quantities of tubercle bacilli. With regard to the clinical animal tests the majority of the 
specialists are of the opinion - the only opponent so far was 
BRAEUNING - that the separation of the certain and uncertain 
cases or cases not to be attended (observation cases) is suf- 
ficient* This separation has been practiced everywhere* 
There is no doubt at all that there actually exists a 
damaging exogenous superinfection. For its coming into effect, 
however, some other damaging components must be present. The 
possibility of a damaging effect concerns only either healthy 
individuals or those whose healing process has come to an end 
a long time ago. 
In the hospitalization of tuberculosis cases only two 
categories of patients will be distinguished; On the one hand 
healed persons i*c, observation cases, and on the other hand 
we have the sick person i,e, even the exudative pleuritis cases 
as active tuberculosis. Furthermore we must differentiate bet- 
ween the clear hygienic conditions prevailing in a special 
hospital for pulmonary diseases and the insufficient hygienic 
conditions outside the sanatorium. 
Therefore we should insist on a separation of cases of 
exudative pleuritis from open tuberculous cases or their hos- 
pitalization in other medical institutions. It must be re- 
peated that only those persons who really require medical 
treatment should be sent to the special hospitals for pulmonary 
cases. As we have always done the observation cases must be 
hospitalized separately. The separation is greatly desirable 
because of psychological reasons when the patient after his 
discharge from the hospital has to return to less hygienic 
surroundings. This education, however, must not lead to a 
fear for bacilli. To speak of a cross Infection of bacilli, 
in sanat~rtu~s for pulmonary diseases, is unfounded from the 
scientific point of view and it is even dangerous, because of 
its effect upon non-professionals and physicians who are not 
specialists. 
The systematic treatment, even of closed tuberculosis 
and of the cases of exudative pleuritis and the treatment of 
the observation cases, by specialists, requires that those 
patients must not be sent to general hospitals or to a sana- 
torium for internal diseases or to general health resort. 
They should be sent only to special hospitals or health re- 
sorts for pulmonary diseases corresponding to the hygienic 
standards where patients are best protected against any new 
infection. 
Further comments; 
BOHNENKAMP*. In cases of pleuritis,the number of which 
is increasing, a strict differentiation must take place bet- 
ween the tuberculous pleuritis* the pleuritis after pneumonia 
and pleuritis after visceral rheumatism, which by the way 
occurs more frequently than is generally estimated. With 
rheumatic pleuritis, myocarditis was more frequently observed 
than endocarditis. After a tuberculous exudative pleuritis 
an early discharge from the hospital may result in a set-back. STEINMEYER: In much the same way that the tonsils present 
a focal exudative pleuritis rheumatica, tubercle bacilli may 
enter the organism through the lymph passage and may give rise 
to tuberculosis or aggravate an existing tuberculosis# 
LYDTIN; In case of pleuritis lasting over a long period of 
time and therefore requiring special thorough judgement and 
care, it is revealed by the onset of a bronchial glandular 
tuberculosis or of an extra-pulmonary tuberculosis that a tuber- 
culous. manifestation of the first infection prevails# The 
sudden onset of tuberculous ?manifestations exhibited as exuda- 
tive pleuritis, requires special precautions more than norm- 
al conditions# 
ULRICIs The prognostic significance of an exudative 
tuberculous pleuritis varies in accordance with its appearance, 
either as an accompanying symptom of a first or second in- 
fection? or as a manifestation of hematogenous tuberculosis, 
or, during the course of tuberculosis, it is always synonym- 
ous with a sudden onset of tuberculosis and therefore it must 
be treated and judged accordingly. The term idiopathic pleu- 
ritis should be avoided* 
Directions concerning exudative pleurltjs. 
1. Each infectious exudative pleuritis accompanied by 
serous effusion must be considered as a symptom of tuber- 
culosis unless another etiology is not provable by the 
hlrstory or clinical examination# 
2. Pleuritis occurlng in connection with non-tuberculous 
diseases must be designated correspondingly after a suffi- 
cient clarification of the diagnosis (f#i#metapneumonic 
pleuritis). fhe supposition of a rheumatic pleuritis must 
be founded on other findings of rheumatic organic diseases# 
3. The results of the jathological-anatomical examinations 
which were sent to us, prove, that the exudative pleuritis 
is often an accompanying symptom of late tuberculous 
primary infection of the adult which is rather often ob* 
served nowadays. In those oases, it must be considered, 
as a first symptom of such a late infection. 
4# Each exudative pleuritis should be brought to clinic- 
al treatment# The tuberculous pleuritis should be ade- 
quately treated in a special section of the hospital after 
the acute symptoms have subsided. 5he arrangement of 
those hospitals must be adapted to the local conditions. 
5. After the diagnostic test-puncture, further aspira- 
tions should be done only if symptoms of displacement are 
observed# Neither frequent aspiration, nor pneumothorax 
prevents pleural thickening, because the pleural tuber- 
culosis determines the degree of the formation of scar 
tissue. 
6. After the subsiding of the acute manifestations of 
disease, the treatment in the special section of the hospital must be continued according to the principles 
of treatment of pulmonary tuberculosis and it should 
be discontinued after the disappearance of all clinical 
symptoms. In general, it will require at least three 
months. 
?• When judging the fitness for active service, we 
must take into consideration, the duration and serious- 
ness of the disease. 
4. Tuberculin treatment of tuberculous pleurisy. 
Professor W. NEUMANN 
The speaker deals with the tuberculin treatment of serous 
pleuritis and demonstrates, that this kind (tuberculin) of 
treatment is the method of choice for this disease* The effi- 
ciency for the cure is clearly seen in the fact, that after 
each injection of tuberculin (either subcutaneously, intra-* 
cutaneously or percutaneously) the existing high temperatures 
decline, and &t the same time the daily quantity of urine in- 
creases proportionally. The effusion is decreased by this 
polyuria. If a ployuria does not appear? we are dealing with 
either a tuberculosis accompanied by serious damage of the heart 
muscle (a bad prognosis) , or a second possibility is that the 
basis of the exudate is not tuberculosis but another disease* 
therefore, the tuberculin treatment is import?nt from the 
differential diagnostic point of view# 
5. Types of tuberculosis. 
Flottenarzt (Fleet Surgeon) Prof. BACMEISTER. 
A suitable scheme of classification for the practical 
work must fulfill the follwoing demands: 
1. It must be suitable for research Fork as well as for the 
clinic, public welfare and statistics. 
2. It must take into consideration the results of the X-ray 
examination which are indispensable, not only for the recogni- 
tion, bat also for the evaluation of tuberculosis. 
3. It must be as simple as possible so as to allow the classi- 
fication of all the variations and pictures of the disease* 
4. It must lenfc itself to modification according to the 
neccessities which may arise* 
5. It must be easily understandable even for those physicians 
who are less experienced in the field of tuberculosis* 
A good preliminary work was already achieved by the "Reichs- 
tuberkuloseausschuss11 (National Tuberculosis Committee) which has prescribed a very simple classlficatioh of the different 
kinds of tuberculosis for the purely practical purposes of 
fighting epedemics by the State Health Departments and the 
public institutions for the care of tuberculous patients* 
This classification was used for the annual report and it in- 
cluded only two main groups of tuberculous diseases, namely 
the cases to be taken care of and those to be observed* It 
has relatively few and easily understandable subdivisions* 
The arrangement and contents of this classification is 
not perfect, but it has proved to be practical and is accept- 
ed everywhere. This is an example of how a uniform working 
scheme can bd laid out if the personal point of view is put 
aside and subordinated to the general interest. 
This simple classification which is very suitable for the 
purposes of public welfare (tuberculosis campaigns) is not 
adequate for scientific work, clinical needs and statistics* 
Therefore, a supplement is required which takes into consider- 
ation the precise diagnosis of the different types of the 
disease including the findings of roentgenology. This supple- 
ment should be included in the system of the public welfare 
organization in order to guarantee a uniform treatment of all 
cases. Most of the classification attempts made up to now 
do not meet these requirements and therefore cannot be taken 
into consideration. Two proposals have however been received 
which seem well suited for the public welfare system and 
therefore should be generally accepted. This refers to the 
proposal of SCHROBDBR, which has been introduced in Berlin 
and the proposal of ULRICI which was given its trial in Corps 
Area VIII. 
By order of the Chief Surgeon of the Navy a meeting of 
medical officers took place at St. Blasien from March 23 to 
April 3 1944. On this occasion the meeting dealt with the 
details of the future systematic combat of tuberculosis in 
the German Navy. Both proposals mentioned above were dis- 
cussed and ULRICI!s proposal was given preference. It 
corresponds more to the clinical requirements and stresses 
more particularly the precise diagnosis and is built up more 
accurately on the results of the X-ray examination. 
Some changes are proposed but they are not of fundamental 
significance. These changes will becfealt with in detail in 
this report. 
ULRICI1s system in its present form seems to meet all 
requirements. It adapts itself to the welfare organizations, 
it has an uniform structure, it 3s very suitable for practi- 
cal and scientific work and can be supplemented and there- 
fore it may be accepted by the military and civilian groups 
equally well. 
The meeting concurred, that the above proposal consti- 
tutes a suitable bases for a classification. Nevertheless 
the question arises whether this classification meets modern 
requirements of statistics because this point was not borne 
in mind when compiling the classification. Modern statistics 
regarding scientific questions have found new means and have 
made great progress. New key numbers were established and all letter symbols avoided. In this way a direct entry into 
the punch-card system is possible. The punch-card system 
(HOLLERIT procedure) is most generally adapted by the govern- 
ment authorities. As to the Navy a new classification of 
diseases is being worked out which will make it possible to 
recognize the history of the disease of the patient seen from 
different angles so as to permit scientific evaluation by 
means of the punch-card system. This method allows a better 
control of certain groups of disease* There is no doubt, that 
this new technic to classify the different diseases will be 
generally approved. Even for the classification of the differ- 
ent types of tuberculosis such a scheme may easily#be laid 
down on the existing basis* During the Tuberculosis Con- 
ference at St0 Blasien, Naval Oberstabsarzt Prof* Dr0 MAYEH 
was delegated to project such a scheme with consideration of 
the previous schemes of the public institutions for the care 
of patients suffering from tuberculosis and at the sane time 
the scheme of ULRICI. 
I am presenting this proposal to you. 
This proposal may be new and surprising to you but it 
is not really new* Without specifying more types of diseases 
it represents a simplification of ULRICI's scheme which con- 
stitutes its basiso A classification is applied by simple 
use of the statistic numbers connoting respective diseases 
in the punch-card system which may be extended according to 
personal requirements. It fulfills the clinical-roentgeno- 
logical demands and requirements and it is very suitable for 
an immediate statistical evaluation. 
Varieties of tuberculosis. 
Xg Infectious tuberculosis of the respiratory organs with 
proof of bacilli. "TreportableT* 
Ac,„ Acute tuberculosisr 
101 Primary tuberculosiss primary complex and its 
immediate subsequent clinical problems. 
102 Acute softening infiltrate with or without 
dissemination., 
103 Hematogenous tuberculosis with disintegration 
(incl.miliary tuberculosis with bacilli)® 
104 Lobar and lobar caseous pneumonia. 
Chronic tuberculosis. 
111 Productive tuberculosis 
112 Productive cirrhotic tuberculosis 
113 Chronic tuberculosis with acute reactivation 
114 Tuberculosis in the final phase. II# Infectious tuberculosis of the respiratory organs with- 
out proof of bacilli (reportable)* 
A# Acute tuberculosis* 
201 Primary tuberculosis > primary complex and its 
immediate subsequent clinical conditions* 
202 Acute and softening infiltrate with or without 
dissemination# 
203 Hematogenous tuberculosis (incl#millary tuber- 
culosis with disintegration and without: bacilli)# 
204 Lobar and lobar caseous pneumonia# 
B# Chronic tuberculosis* 
211 Productive tuberculosis 
212 Productive cirrhotic tuberculosis 
213 Qhronic tuberculosis with acute reactivation 
III# Non-infectlous but active tuberculosis of the respiratory 
' organs (not reportable), 
A# Acute tuberculosis* 
321 Babies with positive tuberculous reactions 
322 Primary infiltration 
323 Acute and sub*acute miliary dissemination 
324 Bronchial glandular tuberculosis with or 
without secondary infiltration 
325 Isolated exudative pleuritis 
326 Acute hematogenous tuberculosis (incl#miliary 
tuberculosis without bacilli)# 
327 Acute infiltration without softening 
B# Chronic tuberculosis# 
311 Productive tuberculosis 
312 Productive cirrhotic tuberculosis 
313 Chronic tuberculosis with acute reactivation 
314 Older infiltrates without softening IV# Active tuberculosis of other organs (reportable)# 
431 Tuberculosis of the glands 
432 Tuberculosis peritonitis and mesentary glandu- 
lar tuberculosis 
433 Genital tuberculosis 
434 Tuberculosis of the kidneys 
435 Tuberculosis of the bones and joints 
436 Tuberculosis of the skin and mucous membrane 
(Lupus) 
437 Tuberculosis of the eyes 
438 Tuberculosis of the ears 
439 Tuberculosis of the central nervous system and 
of the meninges 
440 Tuberculosis of the soft parts (excl# skin and 
mucous menbrand) 
441 More rare localizations. 
✓ 
TT. A, Clinically healed tuberculosis of the respiratory 
organs# ’ 
551 Healed primary complex 
552 Old hematogenous and clacified spreading centers 
553 Old cirrhosis of the apex 
554 Remnants of infiltrates and induration fields 
555 Cirrhotic tuberculosis 
556 Isolated pleural indurations of all kinds 
B# 66l Clinically healed or Inactive tuberculosis 
of all the other organs 
C. 771 Persons exposed or having been exposed# 
Discussion: 
P. MEYER: A classification scheme should be of understand- 
able and simple statistical structure for its purpose is to 
register tuberculosis# It should be arranged in such a way* 
that it is possible to apply it to a punch card system# 
STEINMEYER: The examination of ULRICI’s classification 
scheme has proved its usability in practice so that it is 
desirable to apply it in general# BOHNENKAMP: It must be warned against applying a 
classification scheme of diseases to the HOLLERITH-proce- 
dure because medically qualified personnel would be required 
for that purpose* ULRICIfs scheme lacks any indication con- 
cerning the extension of the tuberculous processes and ob- 
servations concerning the therapeutic treatment* 
GRASS: A classification scheme must be compiled in such 
a way that everybody who has to use it can distinguish the 
different types of tuberculosis without ambiguity. The sym- 
bolism of the scheme of ULRICI and BACMEISTER is much more 
practical than the figures of a HOLLERITH-system. Both 
systems must be combined in such a way that the symbols oS 
the scheme can be transferred to the figures of the HOLLERITH- 
system later. In doing so some difficulties must be taken 
into consideration because the complete diagnosis must corre- 
spond to the sum of the different symptoms* 
6. Classification of findings made by the X-ray projection 
method. 
Oberstabsargt (ka.jor. MC) HEIN, 
The scheme for the evaluation of the X-ray projection 
findings developed by the Army Medical Inspection does not 
permit an exact diagnosis of the lung processes. First of 
all it is not possible to arrive at an exact diagnosis con- 
cerning the specific changes of the lungs. On the other hand 
the non-specific changes of the lungs or the changes which 
cannot be explained with certainty cannot be classified, so 
that we are not in a position to work precisely enough to 
use these findings for statistics. 
The X-ray projection method should serve to secure a 
true diagnosis and classification of fitness besides the 
picking out of tuberculous persons and the elimination of 
infectious tuberculous patients. Therefore an X-ray pro- 
jection method should be compiled accordingly. The diag- 
nosis must be so precise and clear? that it is possible to 
compare findings and alterations without difficulty. All 
these demands can be fulfilled by means of the minature 
X-ray projection. As to the demands regarding the diag- 
nosis we must not ask too much. This seems to be necessary 
because of lack of especially skilled medical officers and 
the quick procedure with regard to the evaluation of the 
different screen pictures. We must try to prevent a diag- 
nosis which lies beyond the possibilities of an X-ray pro- 
jection. On the other hand a control and comparison of the 
results of other examiners must be possible. Therefore 
it is requested that the following scheme be adopted: 
1* A simple and clear description and localization 
of the finding 
2. Marking those findings which were based only on an 
X-ray projection. 
3* Classification of the findings according to 
military fitness. 4, A space must be reserved for the entry of 
the final diagnosis. 
5, The course and the prognosis of the tubercu- 
losis should be set forth. 
The symbols of the proposed scheme are as 
follows: 
r,l refer to the side of the picture, I, II, 
III, IT, and T stand for apex, infraclavicular ' 
zone, middle zone, base zone and hilus. With 
these symbols it will be possible to determine 
the extent of the process as to the space, sub- 
sidence and activity. Further symbols ares 
L 1 no pathologic changes of the lungs 
L 2 changes which cannot be evaluated by X-ray 
projection alone 
L 3 non-tuberculous changes of the lungs 
L 4 refers to positively old tuberculous 
changes which do not affect military 
fitness (healed pulmonary tuberculosis) 
L 5 are changes which affect military fitness 
L 6 are changes which exclude fitness for the 
time being (as f.i. formation of cavities) 
P mean* pleura. To this group belong all 
kinds of thickened pleura, the seropneu- 
mothorax under P 7, pneumothorax under P 8 
separately, 
G means external influence and effect of 
operative measures i.e. gunshots, dislocation 
of diaphragm, pneumolysis, plastic operation, 
thoracotomy 
H is the symbol for the he a. • Changes which 
can be diagnosed with certainty are set in 
columns here. 
S is the symbol for skeleton. Here we have 
to designate the curvature of the spine, 
costo-anomalies and fractures 
The actual conditions are characterized by the fact that 
a special importance is given to the diagnosis. The judgement 
of military fitenss is also indicated. So, under L 4 we have 
defects belonging to group A 47, under L 5 defects of groups 
B 47, and L 47, under L 6 Z 47 and vlJ 47 deficiencies. 
The attempt to bring this scheme into relation to the 
general scheme for the varieties of tuberculosis failed. The 
attempt to incorporate X-ray projection findings in a general 
scheme of diagnosis for pulmonary tuberculosis with a view to 
secure a possibility of a uniform registration and statist- 
ical evaluation, and, at the sane tine in order to make a 
count by the HOLLERITH* system possible, aggregate parts of the X-ray projection have 
been adopted as f.i. numbers L-l, - L-3, P,G,H,S. 
anatomic and clinical points of view are the basis of this 
scheme. The descriptive representation already used in the 
X-ray projection scheme assures a close relation to the 
clinical classification. The clinical diagnosis as well as 
the localization, activation, possibility of transmission* 
progress, and regress etc. are connoted by a figure. If the 
HOLLERITH-system is going to be adopted, the symbol used in 
the general scheme will serve as a basis for the counting 
system. Particularities of the finding, of course, of the 
constitution etc** ahe presented by adding further figures. 
Necessary supplements are easily incorporated. Practical 
experiences were not yet gained in the use of this new scheme. 
Discussion: 
PICKHAN; The classification scheme provided for the X-ray 
projection findings of the navy takes into consideration the 
X-ray anatomical finding of the tuberculous pulmonary changes* 
JANFER: A frame scheme as simple as possible is desired, 
which may be extended to special requirements. 
GRASS: HEIN’s scheme underlines the diagnosis of the 
X-ray projection i*e. it brings medical experience in reach 
of scientific evaluation. If the number of X-ray projections 
is high, this means much additional work to the surgeon who 
does not concentrate his attention on the X-ray projection 
findings in the classification of military fitness, appraisal 
of necessary treatment and control and, in case of prisoners 
of war, their suitability for labor. 
ULRICIs The X-ray projection system used by HEIN as a 
basis of the diagnosis should be used only as a method of 
indication and not as a method of diagnosis as we have in the 
past. HEINfs scheme is rather complicated, it is Impressive 
because of its versatility. 
_Fitness for active service in case of tuberculosis 
according to the new definitions of fitness. 
Oberstarzt (Colonel MG) DEIST 
The observations made in the classification of regist- 
rants afflicted with tuberculosis reveal that, in spite of 
the exceptional severity of the war and in spite of repeated 
appeals to keep the scarcity of personnel in mind, many a 
surgeon does not realize the seriousness of the^situation 
and does not proceed with the necessary rigour in the evalu- 
ation of the minimum requirements for military service. Some 
of the surgeons are of the opinion that it must be prevented 
that a doubtfully active tuberculosis or a tuberculosis which 
has been inactive for a very long time becomes active again 
under the influence of active service. This point of view is contrary to the orders given. If we take into consideration 
that several hundred young and sound soldiers pay their tri- 
bute by dying for their fatherland during the cruel fighting 
on the eastern front each day, we must accept the possibility 
that the situation of a soldier afflicted with tuberculoses 
may be aggravated. 
This hesitant attitude cannot be sustained from the 
scientific point of view as it is not possible to prove if and 
which form of tuberculosis is aggravated in case of a change 
of surroundings and if the patient is exposed to different 
conditions. 
When classifying fitness for active service it is not 
important to disqualify because of the possibility of an 
activation or reactivation of tuberculosis. We rather must 
try to find the actual condition by means of well established 
procedures. Therefore it is useless to evaluate the case on 
the basis of a future possibility but rather it must be on • 
the basis of the actual condition. 
For that purpose we have available quite a number of 
reliable criteria: 
1. The anamnesis (f.i. consecutive relapses) 
2* The age of the patient. According to the obser- 
vation in the X-ray findings* small centers in 
adolescents under 22 years of age, which are of 
no importance in adults may easily lead to large 
infiltrative outbursts. 
3* The X-ray picture. Comparative evaluation of 
roentgenograms at different times* 
4. Number and type of the formation centers in the 
lungs and other parts of the body. 
The directive Is still valid according to which a 
registrant may be deferred as temporarily unfit if during 
the preceding period of five years an infectious pulmonary 
tuberculosis was objectively proved or if, either in a 
hospital or sanatorium, operative interventions have been 
carried through. 
No further comment is required with regard to para .4? 
of the ("Index of Constitutional Ailments for Classification 
of Fitness" para. 2 of the XXVII of Army Manual 209/1 tfavy 
Manual No* 284* Air Force Manual 800) except on the follow- 
ing points: Under B and L 47 we find the description "Healed 
with or without defect". In this connection a few questions 
have arisen. By "Healed with or without defect" the clinical 
functional reaction is understood. If the tuberculosis was 
healed vrith an impairing effect upon the functions of the lung 
l.e. the ability of respiration, the pulmonary tuberculosis 
mentioned under L 4? must be defined as follows: Chronic, 
clinically healed with defect, compensated, predominantly 
one-sided productive pulmonary tuberculosis of moderate ex- 
tent, Here, it would have been better to insert the word 
"Inactive", The expert, however, will find that understand- 
able regarding the details of the diagnostic notes. The description: "Healed with defect for a long time" 
should not depend on the anamnesis alone, but also on the 
finding (X-ray) at the time in question. 
The classification of fitness for active service ac- 
cording to the new Classification of fitness reads as follows: 
According to the new classification schedule A- and B-defects 
are classified "fit for active service" and may be used in 
the field unconditionally. U-defects are classified as "fit 
for labor duty or use in home defense". vU-defects are 
classified "unfit for military service" and Z-defects "tempo- 
rarily fit" as in the past. So far, changes have not taken 
place in comparison to the previous procedure. 
A modification has been introduced in that L-defects 
are henceforth subdivided and those defects which permit the 
classification "fit for active service" are especially marked. 
This, however, does not concern tuberculosis since defect 
L 47 does not provide for any differentiation in this case. 
Therefore each L-4? must be classified "fit for garrison 
service in the field". The classification "fit for labor 
duty, but not fit for military service" as in the past is 
no longer possible. 
Soldiers classified as "fit for garrison service in the 
field" may be used either in the field army or in the train- 
ing army according to their age and their physical condition. 
In the field army soldiers classified as "fit for garrison 
service in the field" should not be used in combat. He should 
rather-be used by the supnly centers (as f.i. as a cook, as a 
tailor, etc.) in supply institutions or defense units in the 
homeland. 
Therefore the classification "fit for garrison service 
in the field" should be subdivided into field army”and supply 
army. 
It is not possible to give any general directions for the 
single case as to usability of those soldiers mentioned in annex 
XXVII under L 47 either in supply centers of the field army or 
in the training army in the homeland. Each single case must 
be considered separately. Under consideration of the present 
situation the responsibility of the medical officer requires 
him to be strict, which still must be based upon objective 
findings. Of utmost importance will be the regulation that 
all soldiers classified "fit for garrison duty in the field" 
have to stay with the training army if he is no asset to the 
field units. 
In all cases of pulmonary disease which were healed 
"with defect" it win be necessary to classify those soldiers 
as "fit for garrison duty in the homeland". According to 
the orders given a medical re-examination must take place 
three months later and if changes have not taken place those 
soldiers may be classified as "fit for garrison duty in the 
field". 
From a general point of view it should be^possible to 
classify registrants falling under L 47 , especially the old 
pleuritis cases as "fit for garrison duty in the field" in in the first examination. In this connection I refer to typi- 
cal old pleural^thickenings without simultaneous pulmonary 
tuberculosis which have been in existance for many years and 
which do not show a tendency to relapse* 
As far as tuberculosis is concerned it may be said in 
brief, that the new scheme is facilitating the classification 
process in that the classification "fit for labor duty but 
not fit for military service" will no longer be possible for 
deficiencies of that category. The classification "fit for 
garrison duty field"and "fit for garrison duty at hone" which 
were not clearly enough defined have now been modified into 
"conditionally fit for active duty" or "conditionally fit for 
active duty in the homeland". The regulations provide that 
a soldier so classified will not be used in combat. He will 
be used by the supply units etc* These changes will facilitate 
the decisions of the medical officer. 
Discussion: 
GRASS: Registrants afflicted with tuberculosis of pleu- 
ritis will be deferred for a period sufficient to ensure in- 
activity of the pathologic process, observation of which can 
be obtained by means of the roentgenogram. Deferment is justi- 
fied in adolescents with slight formation of foci, in elder 
registrants in case of fresh foci or extensive foci which may 
include centers of active tuberculosis. That deferment is 
unobjectionable because the person in Question remains in the 
general labor pool. Within the Armed Forces the tuberculous • 
and pleuritic soldiers as well should be used according to 
their fitness and be kept under observation if an active pro- 
cess cannot be clearly proved. 
Directions regarding fitness for active service in cases 
of tuberculosis according to the new classification 
system* 
When judging registrants afflicted with tuberculosis it 
should be born in mind that it is rather the object of the 
examination to determine the actual present state of the 
disease, i.e. to diagnose objectively existing symptoms of 
active tuberculosis, than to make sure that the process has 
come to a standstill or to exclude the possibility of a re- 
lapse. The anamnesis, the age of the soldier and his clinic- 
al and his roentgenologic symptomatic picture will help the 
medical officer in the evaluation of cases of tuberculosis. 
Details concerning number 47 of the list of defects are 
given in annex XXVII of Army Manual 209/1, Navy Manual Nr.284 
and Air Force Manual 800. 
According to the new classification, A-and B-defects 
justify a classification as "fit for unlimited active service", 
vll-defects must be judged as "unfit for active duty", Z-defects as "temporarily unfit for military service". Defect L 47 will 
be judged exclusively as "fit for garrison duty in the field." 
8. Acute tuberculosis in youth. 
Stabsarzt (Captain MC) SIXT. 
In juvenile tuberculosis the chronic varieties need not 
be considered at all. 
Its characteristic appearance is the acute type. In more 
than 73 £cr cent of all reported cases the central process is 
already in an advanced condition. 
Juveniles show a special tendency to hematogenous dis- 
persion which seems to be increased by the influence of the 
surroundings due to war conditions. 
These varieties of dispersion exhibit the picture of 
exudative destructive tuberculosis and take a rapidly fatal 
course. 
The quota of the tuberculous infectious diseases in young 
soldiers is relatively small. So we must expect a high per- 
centage of primary infections because there nre many possi- 
bilities for an infection in various forms. If, beside the 
fresh infiltrates, the isolated pleuritis and acute miliary 
tuberculosis are added to the group of primary infections - 
as proposed by ULRICI in one of his reports - the primary 
infections will include more than half of all the cases. 
Even in peace time juveniles are especially endangered 
by tuberculosis and during a war which requires a ruthless 
use of our young people, tuberculosis has every chance for 
an anfadorable course. 
The fact that it has been possible to bar a spreading 
of tuberculosis in the fifth year of war in the military 
and civilian sectors i3 not mere chance but the result of 
systematic and careful planning and is in contrast to the 
experiences of World War I, 1914-1938. 
9. Acute tuberculosis in adolescents* 
Stabsarzt (Captain MC) WURM 
The actual situation of tuberculosis in juveniles is 
characterized by widespread contagion of approximately 50-70 
percent and a highly accelerated spread of contagion caused 
bv the war with its stirring up of the masses of the people thus 
spreading the infectious sources. The pathologic anatomical 
analysis of fatal cases of tuberculosis may contribute to the 
problem of late tuberculous primary infection. Out of 108 
fatal cases of generalized tuberculosis belonging to the age group foa 18 up to 39, 50 cases or 46,8 per cent were due 
to early spread, 54 cases or 54 per cent to late spread. 
If sacre# of post-mortem examinations made by the Armed Forces 
ivhion are included in the above number of fatalities, show 
that the percentage of fearly spread with 43 cases or 55,8 per 
cent is somewhat higher. In 70 cases which resulted in mili- 
ary tuberculosis meningitis the percentage of early spread 
amounted to §1,4 per cent, in the cases of the Armed Forces, 
however, to 62 per cent. Amongst the late spreading cases, 
7 cases of persons older than 28 years who had shown old 
caseous primary complexes must probably be traced back to 
a later primary infection. The numerically greatest group 
of early spread was found in ages between 18 and 25. 
Contradictory reports have been received regarding the 
peculiarities of the tuberculous picture of the late primary 
infection. The erythema nodosum, which in northern countries 
Is often found as the initial symptom is of no importance here. 
Uhe localization of the primary complex is the same as in the 
primary infection of the children. The changes of the regional 
lymph nodes resulted in a complete caseation in only 46 percent 
of the cases, in case of the late spread, however, only 5*5 
per cent. 
The most important symptom of the progressive late primary 
infection is the exudative tuberculous pleuritis which, with 6o 
per cent of the cases, was nearly twice as frequent as in the 
late spread after an infection in infancy. In a considerable 
number of the cases the pleuritis was the consequence of a 
hematogenous dissemination. 
Progressive tuberculous changes as for instance the 
primary infectious tuberculosis and the hamatogenous cavernous 
pulmonary tuberculosis were found in a small number of the 
cases. 
In the case of the isolated pulmonary tuberculosis of 
juveniles no symptoms of a late primary infection were seen 
which fact seems to be contrary to results observed else- 
where (Switzerland), The frequency of progressive tuber- 
culous pulmonary changes in case of late spread is noteworthy. 
The picture of the extrapulmonary hematogenous metastasis 
is dominated by the tuberculous meningitis in case of the group 
showing early spread and in 64 per cent of the cases it was 
the cause of death. In the case of the late spreading the 
frequency of meningitis amounted to 50 per cent# The acute 
disseminated miliary tuberculosis with its 28 per cent was 
nearly twice as frequent as in the case of late 
Extrapulmonary caseous metastasis in the organs was found in 
early spreading as well as in late spreading with 3® (resp, 
48 per cent) of the cases. 
In 50 cases of early spreading the course of the disease 
was characterized by one or several onsets of hematogenous 
type. Meningitis as well as miliary tuberculosis were domi- 
nant as causes of death. In case of several points of attack, 
the first one usually appeared as serositis, especially as 
pleuritis# 
It was not possible to ascertain the duration of the disease form the primary infection to the fatality. There 
is no doubt that tuberculous primary infection is especially 
dangerous at an juvenile age when special physical and 
psychic strain is imposed on the body. It is more dangerous 
at that age than in adolescents and school children. This 
is especially true under war time conditions. 
Discussion; 
LYDTIN: Our concept of tuberculous .contagion was re- 
vised by the tuberculin-tests of Bruno LANGE. The inter- 
pretation of LANGE is confirmed by pathologists as well as 
clinicians by the fact that the clinican finds in soldiers 
those varieties of tuberculosis which belong to the group 
of primary infections. 
GRAEFF: Autopsies made during the last three years 
proved that the total number of persons infected by tuber- 
culosis has decreased. 
AMMICH: T he unfavorable course of the late primary 
infection which is proved by the autopsy material of the army 
on the southern part of the eastern front, covering the period 
of April to September 1943, must be explained by the strain of 
combat besides climatical and constitutional factors. Late 
primary infections amounted to 2.8 to 3*8 per cent and about 20 
to 30 per cent ot these resulted in the death of the patient 
either by miliary tuberculosis or tuberculous meningitis* 
BACMEISTER: The frequency and virulent course of the 
late primary infection in sailors is caused by influences of 
the environment on sea and ashore. 
DEI°T: It is of no avail to search for the origin of 
each case of exudative pleuritis inihe respective units. 
An examination into the possible influence of the surround- 
ings will be worth while only when several soldiers of the 
same unit have been infected. 
GRASS; Clinical and epidemiological experiences, as 
well as experiences made with X-ray projection examinations 
proved, that the onset of new cases, apart from a few 
exceptions, were observed in juveniles as well as in adults 
and they are due neither to fresh primary infection nor to 
secondly infection but rather to- a sensitiveness of the 
patient submitted to extreme physical or psychic strain* 
Directions regarding acute tuberculosis of .juveniles 
1* In the fid-d army as well as in the training army 
an increase of the variety of the onset of acute tubercu- 
losis was observed with or without a marked involvement 
of the lungs* 2, The reason for this is: 
under physical and psychic strain due to war con*» 
ditions old centers of tuberculosis are reactivated* 
b) the number of late tuberculous primary infections 
h-s increased considerably* 
.. The increase in primary infections is explained by 
the fact, that p.t present only 50 - 70 per cent of the 18 year 
olds have had their primary infection. Those Fho are not yet 
infected wil1 be infected very quickly because the sources of 
infection which always exist have a effect owing to the 
crowding of population caused by the war. The number of evi- 
dent cases following a late nrimary infection is largely in- 
fluenced by the stress of the war. 
4* The varieties of tuberculosis which have come into 
existence after a late primary infection are, after al", the 
same as in the primary infections of the child. The acute 
hematogenous onset predominates and the quick development of 
a progressive pulmonary tuberculosis is rarely observed* It 
is surprising to see the great incidence of initial exudative 
tuberculous pleuritis. 
5» From the clinical point of view the pcute tuberculosa 
is in juveniles appears as pulmonary tuberculosis with infilt- 
rates which are more or wide spread and with infiltrative 
casous centers which frequently subside quickly. Therefore, 
75 per cent of the patients coming to the hospital because of 
subjective complaints exhibit cavities# Exudative pleuritis 
is frequently seen as symptom associated 
with pulmonary tuberculosis. Af an early date hematogenous 
spread frequently appears in either single centers the 
body or as miliary tuberculosis. Either of these may be 
associated with an extensive pulmonary tuberculosis, or in 
some cases even without considerable changes of the lungs. The 
great number of cases of meningitis is striking. Finally we 
observe caseous swellings of the lymph nodes frequently locat- 
ed in the neck# 
6, In order to combat acute juvenile tuberculosis it is 
necessary to diminish the possibilities of infection and to 
reduce the physical-strain on'the body. 
In order to diminish a spread of infection, soldiers 
afflicted with tuberculosis must be separated from the Armed 
Forces. This result will be attained by the 2-ray projection 
method to be applied in the examination of registrants, when 
drafted and during the service. Less than 1/1000 of infect- 
ious tuberculosis cases were observed in field units and so 
we may say that the above method has proved satisfactory. 
The damages caused by excessive strain on the body are 
prevented in such a way that soldiers who show tuberculous foci 
must be used according to their fitness which must be estab- 
lished according to the degree of transmissability of their 
tuberculosis. By repeated observation a reactivation of the lnbfhnf1(?u* fentFs Is either Prevented or recognized early, 
so that the treatment may be started successfully. v ’ 
—The conservative treatment of open pulmonary tuberculosis. 
Stabsarzt (Captain M,C.) DOHMF.N 
The conservative therapy mentioned here differs fundament- 
ally from what most of the sanatoriums understand by that term. 
Here, the patient is set at rest and all harmful influences 
are kept away from him. duration of such a complete rest, 
lasting sometimes 3? 4 and 5 months depends on the type of 
During this period of rest any interruption which 
might arise for personal reasons must not be allowed. It is 
a matter of course that not every patient may efficiently be 
subjected to this kind of treatment. His psychic attitude re- 
quires permanent supervision and interest on the part of the 
surgeon at the beginning as well as during treatment, The 
patient himself should be interested in his proper case and he 
is fully aware of his condition. After recovery has been 
achieved, the patient will be brought to a rest cure at a hos- 
pital where the treatment is less strict. The patient after 
having passed three stations will finally be brought to the 
fourth where the period of the rest-cure will be gradually 
reduced. If further symptoms of activity cannot be observed 
or if they have edno to a fcestwe start with subjecting the 
patient to some strain of the body. At the end of the cure we 
even begin with the labor duty of the patient in his own 
or similar profession under constant medical supervision. In 
this way 
299 soldiers suffering from open pulmonary tubercu- 
losis were treated in the air force hospital 
VDomfront" (near Paris)# 
193 or 65#5 per cent of the cases showed a consider# 
able change for the better. 
Symptoms of activity could not be observed anymore. The 
sedimentation rate was normal. The sputum which had been ex- 
amined six times in different weeks was negative and the 
gastric contents were negative too (three times). There were 
no serious complaints and corresponding X-ray findings. 
A spread was found only twice in approximately 300 sold- 
iers who h'd been treated conservatively. Massive hemorrhages 
did not occur. 140 soldiers were discharged as cases of 
closed tuberculosis, among them wore 80 natients with cavities. 
64 cases of late examinations by the competent medical 
services are available which revealed only four cases of ag- 
gravation. (X-ray pictures of spontaneous recoveries of open 
pulmonary diseases with cavity were shown). 
Discussion: 
KJUKlERs 65 selected cases which had been treated by ab- 
solute confinement to bed showed primary success in 44 cases 34 nf them resulted in a closure of the cavity. Early 
cavities and others as well should be treated conservatively 
in the beginning. If, after a lapse of 8 weeks, they have 
ne>t become smaller, a spontaneous healing must not be ex- 
pected anymore. The biological cavity MONALDI is excluded from 
this therapy (refers to MONALDI1s suction drainage of the ca- 
vitiesi* 351 
XIT, 
Z«R_0_C_E_F _p_I_N__G__S 0_F T„H_F C_0_N_S_U_L_T_a_N_TJ3j. 
0_N I_0_L_0_ _G_Y 
Translation prepared by; 
U, S. Naval Technical Unit, Furope, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government (U, S.) las is„£nd„actU3l_state„of_t]ie_objeciivp_ adapt ornery 
(See Section II, Article l) 
(See Section II, Article 2) 
n.§ijL on_ of __the_c ire ulatorY_f unction, 
Xs'ee Section VIII, Article 8) 
inder, .operators 
G esc hwaderar z t_X2 o lo 0£psJ._HEI NS IUS 
The navy has always paid special attention to the 
selection and training of Qualified range finder operators. 
So, we have available the experience lasting over decades 
as far back as World War I, which were published by OLOFF 
and HEINE, Later studies by CAANITZ, PAUL, KRaHNERT, and 
HEINSIUS have proved the usefulness of the classifications 
already existing. This is demonstrated by thc fact that 
•nly 10 per cent of the participants of courses of instructior 
for range finder operators did not meet the requirements. 
Suddenly in 1939*4-0 - 60% of the applicants did not come up 
to the standard after th° navy had to be enlarged. This is 
due to the fact that we had to entrust ophthalmologists 
with the examination of fitness who were not sufficiently 
Qualified in that field. Proper measures have been adopted 
in the meantime. Special directions havp been published 
with detailed regulations regarding examination and classi- 
fication, special forms for the examination of range find- 
ers have been introduced as well as special courses for 
ophthalmologists in order to secure a coordination of the 
technioue of examination. Upon th° introduction of these 
measures the number of participants who did not come up 
to the standard declined to the former percentage. Because 
of the good result achieved the officers in charge of those 
courses as well as the combatant units reou°sted further 
improvements of the methods regarding selection and train- 
ing. All this resulted in the foundation of the "Research 
Department for Sensory Medicine" (SIMFA) attached to the 
Medical Department of the Naval High Command "Ostsee", 
("Baltic Sea"). 
The instructions concerning the ophthalmological 
examination of fitness of range finders are reviewed in 
detail and as they have proved to be efficient it is re- 
commended that they be adopted by the other branches of 
the Armed Forces, 
Research work is under way regarding the improvement 
of i|he methods of examination for persistence of fusion, 
sensitivity of sensory fusion (TSCHERMAK-H 'Ir’SIUS) and of 
the sensory competition (HAMBURGER) 
Dr, KRUEMMFL is going to report about experiences 
gathered with the stereoeidometer which has been devel- 
oped after systematic examinations in collaboration with 
MONJE and HEINSIUS. The problem of visual capacity at dusk has not yet 
solved. According to the examinations of MONJF and 
HEINSIUS, we must suppose that th°re are individual var- 
iations of the limit up to which range finder operators 
are able to perform good measurements. This is the only 
explanation for the varying results of measurements per- 
formed in daylight and dusk. 
2.*. Stereoscopic methods of examination ih ran.°:e finder 
Ofieratorjg, 
Ma£li3estabs^rzi_iLieui^_M^C^^_NaVyl_KRUErMrL 
The usp of stereoscopic range finders, despite the 
keen competition of the electronic measuring instruments, 
has not lost its importance as the most essential auxiliary- 
instrument of artillery observation. These instruments 
require excellent stereoscopic vision and even a special 
type of stereoscopic vision. It must be born in mind that 
all empirical factors of vision of objects in space such 
as strength of vision, perspective and color perception 
are secondary and even have to be pushed in the background 
intentionally in order to give way to the stereoscopic effect 
of the diagonal disparity. 
After it was learned that the capability for this kind 
of space-perception varies individually, aln methods suit- 
able for measuring this ability have gained more and more 
interest. The nature of this space perception consists 
in a centrally controlled sense mo tory r'asicn which auto- 
matically changes the lateral differences of the retinal 
irritant complexes into steretscopic pictures of different 
depth. 
This report is limited to the methods applied by the 
navy and practiced on a large scale. 
The following instruments have been used: 
1, mit Pulf ri c h-Taf el11 
(Zeiss-stereoscope with Pulfrich-table) 
2, nRaumseh-Pruefgeraet" by Koch 
(Apparatus to determine stereoscopic vision) 
• The " stereoeidometer" by MO IT JE 
The "Pulfrich”-table proved to be extremely useful 
because of its excellent calibration of space in steps of 
15 sec, from 150 sec, down to 15<y_sec. of parallact- 
ic difference i.e, down to the minimum separable by stereo- 
scopic vision. 
It is a necessary condition that the apparatus be well 
adjusted and that n» psychic difficulties will interfere 
in the examination. The distance of the oculars must not 
be less than 64.,0 millimeters and the testing picture must 
be placed at the focal point of the ocular lenses. Other- 
wise in conformity with the laws of optics, diverging or converging cones would fall into the eye and indivi- 
dual would necessarily by diverging or converging 
m»vdments. The diverging movements must be 
in the first place because they are unohysiological. A 
graphic scheme was shown wh:'ch demonstrated the excellent 
correlation between the efficiency of individuals in 
the stereoscope and range finder test. 
The stereoscope test instrument by KOCH is based on 
the color haploscope and its physiological basis is there- 
fore labile. We must examine the limits of stereo-fusion 
and not the sensitivity of the finer diagonal disparate 
space vision which must be examined from the opnosite 
direction with smallest angles of parallax differences. 
From the scientific point of view, however, it is inter- 
esting to find out whether the motor limit tested by 
the apparatus of KOCH has a positive correlation to the 
acuity of stereoscopic vision or not. According to the 
experiences gathered by the Air Defense School II this seems 
to be the case. 
The stereoeidometer constructed by MONJE, another new 
test instrument, is based on the HDrei-Stab”-method (method 
of the three bars). The arrangement of the bars may be 
rotated ISO degrees within a circular testing field. The 
diagonal disparity originating from the movement of the 
middle hairline is null if the bars are in a horizontal 
position. The acuity rises with the increasing angle and 
its maximum is attained at 90 degrees. The difficulties 
of space perception may thus be increased either by a con- 
tinuous or gradual progression which allows one to deter- 
mine the particular angle at which the result of the exa- 
mination and the actual result in range finding enter into 
positive correlation. This angle has about 6 degrees. 
The aperture of the angle is of importance in this connection. 
An angle open to the right assures a more uniform gra- 
duation of correlation. This result demonstrates the in- 
fluence of the anomalies of the horopter which is the main 
source of the so-called "personal-defects". These anomalies 
were analysed more precisely in special horopter instruments. 
Their description, however, would be too involved,- 
D erninp;_ experience s_£ained_in_ the 
J£lection_of_railLe-£in^(5£_.o2erato££j. 
HE INS IUS; The necessity of the examination »f range 
finder operators being restricted to the clinical-physio- 
logical examination is emphasized. The physician must not 
perform technical psychological tests which should be re- 
served to the military instructor or to the psychologist. 
HAMBURGERj The most important condition for a reliable 
and continuous stereoscopy is the continuous participation 
of both eyes in the binocular act of seeing. If the range 
finder student has no space perception for a long period of 
time - a circumstance which is freeuently observed by all 
range finder instructors - or, if in the case of another 
range finder operator the euality of the range determination 
is inferior because of a temporary loss of the stereoscopic 
effect we must take for granted that one of the eyes dees 
not take part in the process in both cases. The loss of the stereoscopic impression moans the exclusion of one 
of the eyes in the binocular act of seeing. I have ob- 
served that even little refractive defects (esp, anisome- 
trophy and astigmatism) although not necessarily the direct 
cause, may favor a strabismus concomitans. Therefore I 
have examined the refraction of the range finder operators 
skiascopically and, in fact, it could be proved that a 
certain correlation exists, between minor refractive de- 
fects and bad range finding results. This concerns re- 
fractive defects which may easily escape notice in the 
subiective deterrinati. on of the refraction as well as in 
the usual skiascopy with narrow pupil of eye and peri- 
pheral fixation. 
In spite of this we w-re not satisfied with the re- 
sults achieved so far. There were too many exceptions 
with which in spite of a "bad" refraction good range 
finding results and in spite of a ’’good'1 refraction bad 
range finding results were achieved, I had to suppose that 
soldiers who in spite of a normal focal depth had. failed 
during the ran'-.e finding course would show symptoms of the 
domination of one eye. This presumption could not be 
verified. My own examinations showed, however, that 
another factor is of utmost - probably decisive importance. 
It is generally known that haploscopically if similar 
pictures different in color are presented the so-called 
competition t>f colors will occur. This observation is 
proved amorig others by the post stamp test of SC HE NX- 
STIRLING* If the ranps finders are examined as to the 
frequency with which the two colors change we observe a 
great variety. In extreme cases we may observe a rather 
auick change (once or twice/sec.) or the changing may 
not occur during a couple of minutes, or, it may even fail 
to appear. The post stamp is always seen in mixed colors. 
This means that are individuals who are either sen- 
sitive or indifferent to that competition of colors. In 
certain individuals the slightest differentiation of bin- 
ocular pictures will give rise to the said competition of 
colors, in other individuals, however, this competition 
will not appear at all even in case of a stronger different- 
ial on. 
At equal focal depth individuals who are sensitive 
to the competition will be good range finder operators,, 
those who are not sensitive will be bad range finder 
operators. These facts are applicable with only few ex- 
ceptions and therefore I would like to suggest that the 
post stamp test be included in the examination of range 
finder operators. The fact that the sensitiveness to the 
competition is of such importance is explained in that 
even in stereoscopy both eyes receive different pictures 
and that evidently this difference is easier to perteive 
in the case of a stronger competition. This subject was 
dealt with in detail in one of my publications which, how- 
ever, will not come into your hands very soon and there- 
fore I would like to mention it here. In case of an ex- 
act haploscopic examination of range finder operators 
other characteristics were observed as for instance inci- 
pient stage of "Horror fusionis’1. All these details can 
only be mentioned here in passing. VAN BEUNINGFN: The principal condition for each 
examination of stereoscopic vision is without doubt a norm- 
al acuity of vision on the one hand and th« roast exact 
measurement of the distance of the eyes and an examination 
of the objective focal depth according tc the physiological 
minimum defect on the other hand. 
During some courses of instruction at th*' Army Range 
Finder School at Weimar, to which a department for stereo- 
scopic vision is attached, it was frequently observed that 
sene soldier# did net attain the necessary ran e finding 
results - demonstrated by ainirma defects, - in spite of 
the fast that they had «hen teed a emits under the cix» 
euaataitcee aentiaaed avpre* After having studied that 
Masttea thereughly we ease te the follewlng cenelv.sion: 
The beginner has special difficulties to adapt the 
aidpolnt to the target if th~ target is moving. It is much 
easier f6r him to carry through the measurement if the mid- 
point is stationary. 
There is no doubt that the parallax movement of the 
midpoint makes the stereoscopic movement difficult. 
On the other hand the soldier handling the range 
finder has particular trouble caused by the fluctuating 
light in the landscape and especially secondary targets 
which interfere with the main target. We see that, those 
facts which sire useful and advantageous for the astimation 
of distances present a handicap in stereoscopic range 
finding. 
Therefore w- must not aim at getting the student 
accustomed to the apparatus nor introduce exercises in the 
mere physiologic focal depth of vision but w~ should rather 
practice with the moving parallax and eventually try to 
overcome the above mentioned disturbing impressions of the 
landscape such as the contrasts of light and dark and the 
secondary targets. The range finder operator will get 
accustomed to glittering air and current of air in general 
and he will be able to overcome th°s~ difficulties by pract- 
ice, The disturbing factors arising in this way must there- 
fore not be exarihed in the preliminary examination. 
As to the selection of the apparatus for range find- 
ing purposes we may say at present that the FMA-ap>arat- 
us net only gives us a survey of the absolute physiologic 
depth of vision but at the same time it gives us the means 
to evaluate the efficiency in case of a moving midpoint 
(parallax movement). It might be supposed that the differ- 
ence in the evaluation of the results obtained with EMA- 
apparatus and the EM 0.9 apparatus are due to the inter- 
ference of disturbing targets and that this difference 
offers a standard for the measurement of the different tend- 
ency to failures of the soldier in the field of stereoscopic 
vision. 
V' 
According to the measurements at hand aOCH’s stereo- 
scopic space pfi test instrument shows many advant- 
ages because of the many possibilities of accommodating the 
eye more and more to stereoscopic vision. It is, however. too tedious for the purposes of the'army because each train- 
ing course (up to 300 men) does not last than three 
weeks. Furthermore this apparatus reeuires color vj 
(color stereoscopy), stereoscopic vision and manual ability 
too, so that it takes too much time to train the personnel 
and to initiate th'' soldier in mass tests, 
MONJkMs instrument is efficient and handy. Its 
disadvantages are that it does not measure the focal depth 
directly. By rotating the three bars a rough method of 
measurement is improved and the evaluation of stereoscopic 
vision is achieved in the indirect way. Besides this a 
sufficient correlation with the school finding not be 
obtained when using angles of 25, 15, and 7.5 degrees. In 
the following course we therefore shall reduce th- angles 
to 20, 10, and 5 degrees in order to obtain good measur- 
ing results, 
Zeiss ( stereoscope shews ad lusting errors ar- soon 
as the interpupillary distance of the oculars is less than 
60 or 61 millimeter, which is due t» the construction of 
the apparatus. "ith the Pulfr?ch-tableswe arrive 
at an underestimation of the examined soldier. 
The following factors must be taken into consideration 
or examined during the preliminary examination of stereo- 
scopic vision: 
1, normal sharpness of vision (objective and sub- 
jective) , 
2* distance of the eyes to be measured as precise- 
ly as possible when looking at far distances, 
3. purely objective physiological focal depth, 
U. attitude towards the mobile midpoint (parallax 
movement), 
5* proneness to disturbances caused by differences 
of light density within th* measuring range. 
The addition of all th"SQ findings will probably re- 
sult in a better estimation of the situation. It will be 
better than the one achieved by the correlation of the 
judgement of the school and all the other range finding 
test instruments w° have available,. 
As to the selection of range finder operators of the 
aavy and air ce on the one hand and. thoso for the army 
An the $ther I must say that the range finders for the army 
must meet all requirements of the other branches. The diffi- 
culties with which range finder operators have to deal in the 
ajpmy are different from those of the other branches of the 
Armed Forces but they are still comparable. We must not 
underestimate the fact that the navy and the air force depend 
largely and exclusively on an optical instrument, i,e. in 
this case on a ran ‘ e finder as soon as radio range finding is 
not practicable, for it must be realized that a mere estimat- 
ion of distance on sea and in the air is not sufficient. The army meeds good finders too in mobile warfare, This 
is the only way to arrive at a ouick and reliable range 
determination within about five minutes in contrast to* ' . 
the routine methods of the artillery which takes about an 
hour. The great advantage of the army and navy coast ar- 
tillery in relation to the army range finder must be seen 
in the fact that the calibration plate may be viewed with- 
out interference by secondary targets. The range finder 
operator of the army must in the first olace learn that 
the calibration plate can penetrate the many interfering 
target on land. On the other hand the tendency to physical 
derangements probably is not so important in the above men- 
tioned two branches of the Armed Forces in cd-pafison to the 
army. The physical tendency to derangements is under study 
in the Army Range Finder School, 
Directions for tfoe .selection Qf, rq.flge. finderis. 
Fxp-'riences of various branches of the service show 
that a preliminary examination is necessary regarding those 
soldiers to be used as range finder operators. This must 
be done in order to assure that no physically uneualified 
soldiers attend the courses. The examination must be made 
by medical experts who w°re especially trained for that 
purpose, Fxaminations carried out by troops physicians 
will not be reliable because do not have the necessary 
instruments available. The organization of those prelimin- 
ary examinations to be done by medical specialists is a 
responsibility of the different branches of service because 
of the variety of the organization of the units. Thm exist- 
ing instructions of the different branches of service are 
obligatory to its memebers even if the examination is done 
by medical specialists of other branches of service. As a 
result of the collaboration of all concerned the following 
rules concerning the examination of the functions of the 
eye have been considered indispensable: 
1, The power of vision and the condition of refract- 
ion must be determined objectively and subjective- 
ly with and without correcting glasses and for 
each eye separately. It must be tested up to 
6/4,, As long as there are no difficulties re- 
garding replacements, full pow°r of vision should 
be reouested. If there is, however, a lack of 
personnel we may go as far as 6/8, if an equival- 
ent up to 6/6 can be obtained by use of spheric 
lenses. Variations in the refraction of more 
than 1 diopter must alv/ays be excluded, those of 
more than 0,5 diopter, however, only if possible. 
The method used must always be mentioned in the 
report, 
2, Diseases of the eye: 
The tendency to diseases of the eyelids and of the 
conjunctiva and especially hayfever must be given 
serious attention. Soldiers suffering from ptosis, 
chronic diseases of the eyelids and of the conjunc- 
tiva are unfit* 3. Movements of the eyes: 
The healthy condition of the eye muscles must be 
assured by movements of the eyes. The reaction 
of the pupils and the accommodation must be ex- 
amined by simple methods without any measuring. 
4. Latent strabismus: 
The requirements of the different branches of 
service vary. In each single case the procedure 
applied must be mentioned in the findings. 
5. Fundus: 
In general any changes of the fundus caused by 
disease exclude the candidates from employment as 
a range finder operator. 
6. Capacity of dark adaption: 
This capacity must be examined according to the 
directions which have been given for this purpose. 
Details will be entered into the record only in 
exceptional cases. 
7. Interpupillary distance must be measured when 
the soldier is looking at distant objects. The 
soldieU must know the interpuoillary distance 
of his eyes as an item of personal data. 
8, Stereoscopic vision: 
The physiologic focal depth must be examined by 
means of one of the methods described in detail 
in the appropriate directions. Beyond that spec- 
ial reruests of the different branches of service 
must be taken into consideration according to the 
corresponding procedures, In the report of find- 
ings not only the methods applied in each case 
must be noted but in addition the judgement, the 
number of examinations performed and the defects 
found. There is no other possibility for compar- 
ing the findings of the different methods. The 
most common procedures of examination are set 
forth in the appendix. 
9* Special observations: 
Besides the medical observation special attention 
will be paid to those factors which af 'ect fitness 
for active service, as for instance diseases of the 
nervoud system and other organic systems. To 
this category belong nervous, restless and easily 
diverted persons. It is not the task of the 
examining surgeon to give a psychological analysis 
of such disturbances. 10, Final judgement regarding fitness: 
The different branches of service are respons- 
ible for the publication of directions regard- 
ing classification. The medical classification 
should mention the capacity of night vision. The 
classification of fitness must always bo put down 
in writing in the record. 
Appendix: 
For the examination of focal depth the following methods 
are in uSe besides the real ran?e finding instruments: 
1, Pulfrlch tables: 
The Pulfrich tables are inaccurate and this fact 
must be taken into consideration when counting 
the number of defects and judging fitness. 
2, MOHJF’s apparatus: 
MONJE's apparatus, only a small number of which 
are available, must still be calibrated for use 
in the evaluation of defects in series examinat- 
ions. It is possible to measure the focal depth 
if the picture is immobile and if disturbing in- 
fluences do not interfere. This apparatus, how- 
ever, does not permit any measurement of predis- 
posed disturbances of parallax movements on the 
one hand and varying contrasts on the oth^r. 
3. The EMA-apparatus (range finding training instru- 
ment) constructed by ZEISS; 
According to the experiences made so far this 
apparatus allows the measurement of all necessary 
factors for the judgement of stereoscopic vision, 
if, by the introduction of light contrasts the 
predisposed disturbances may also be measured. 
4-. Other apparatuses proposed for this purpose have 
not proven to be efficient according to the ex- 
periences made so far and they therefore need 
not to be mentioned. The range finders, proper- 
ly speaking, are suitable for the determination 
of the focal depth only under consideration of 
many facts unknown to the troops. 
1m. 4i2:ui_lil£-Possibiilties_to_p£3cii^£_night„yi£i2rjJl. 
15sililJ£Stabsar^t_XLiSIJtJ.jt_M-tCJ>_>NayyJ._V0ELKEL 
- 6 
In night vision light intensities of 10 stilb, are 
fixed centrally, darkness is more complete paracentral 
fixation replaces central fixation. Paracentral fixation 
vision may be learned and practised. In order to practise 
and examine night vision several apparatuses were construct 361 
ed during the recent time, especially the NOVAK-NETTHAUER 
apparatus which renuires the perception of a large LaNDOLT’g 
ring at A meters distance. Progress was achioved by the 
so-called "Nyptoskop" constructed by VON TSCHT'RMAK and HEIN- 
SIUS which vision tests with' luminous paint. This 
instrument is a simple and efficient means of testing the 
acuity of night vision in large scale examinations. In 
addition it is suitable for night vision practise. It con- 
sists of a graduated rod 1 meter long provided with a scale 
of luminoms paint, A sliding frame is attached to this rod 
in which card-board discs, the center of which are painted 
with luminous paint of different strength may be inserted. 
By means of this apparatus w1 have examined 200 night fighter 
pilots in a test series. Moreover, the "Nyktoscop” was used 
in the examination of 1B0 night observers among submarine 
conning bridge personnel who at the same time examined by 
means of the adaptometer, nyktometer and the apparatus con- 
structed by NOVAK-WETTHAUER. The procedure for this examin- 
ation proved to be satisfactory in pilots (where special 
speed is imperative) and submarine personnel (who corld 
not be submitted to tedious examinations lasting 3i hours.) 
The testing disc was slowly brought toward the eyes of the 
examinee until ke finally was able to recognize part of the 
letter E, After that the letter was moved backward until 
the E could not be distinguished any longer. By moving 
the disc forward the value of increase could be clearly 
determined. The difference between the first value which 
was termed recognition value and the threshold-value, pre- 
sents a valuable criterion in the evaluation of adaptability 
and fatigue. Encouraged by the fact that the influence of 
adaptability was clearly recognizable in the very beginning 
additional series of examinations were carried through in 
small groups of night observers including 10 consecutive 
days of schooling with the Nyktoskop, The results obtained 
were very favorable because in most of the cases an increase 
in the power of night vision of 100 percent was observed i.e. 
an increase from 0,1 to 0,2, The fatigue was reduced pro- 
portionally with the increase in the power of night vision. 
To some extent this result is certainly due to adaption or 
the ability to improve the sensitiveness of the retina i.e, 
the contrast function of the dark adapted eye. The greater 
part of the impovement of the power of night vision is due 
to a change from a central to paracentral vision. In tests 
made to determine the subjective fixing point in darkness 
it was observed that the fixing point approaches the macula 
with an increasing light for instance 10 and 10** , where- 
as the fixation point moves away from the center to the 
periphery in case of light densities. After training 
the observations are much mire precise and more regular. 
All soldiers trained in this way declared that their power 
of night vision was improved. Therefore we propose to make 
use of these results objectively with the ni~ht reconnais- 
sance of airplanes and ships. As to the night observers, 
whose, task is ef special importance for th° troops we re- 
commend practising night reconnaissance by means of the 
Nyktoscop and the newly constructed apparatus as well, with 
which the reconnaissance of air and sea targets may be prac- 
tised in dim light. The power of night vision of the persons 
in charge should be examined from time to time with varying 
densities of light especially regarding the progress of 
practise. The examinations made so far wh:ch have caused much trouble to the physicians and night observers as 
well seems to be justified. The early detection of the 
enemy may protect a vehicle or airplane against sudden 
night attacks. 
Discussion: 
HAMBURGER: According to my own observations the acuity 
of vision of the dark adapted retina is in fact somewhat 
better in the uoper part than at the bottom for ectual dist- 
ance fron the middle of the fovea. 
EC KEL: Comparative examinations regarding practical 
night vision in connection with air targets and regarding 
the evaluation of tested personnel carried through with 
different night vision instruments at the AFS V (Pilot 
Training School of Air Group Command V) Baden near Vienna, 
showed surprisingly low concordance of the results of 
different examinations. In practical night vision tests, 
as well as in different test instruments, considerable in- 
dividual variations were observed. Those variations made 
it more difficult to find a seouence for the results obtained 
in the sight setting of air targets because the tested per- 
sons showed individual variations to an extent which al- 
most covered the entire range of Possible variations. These 
test persons examined with the constructed 
by ENGELKING-HARTUNG and showed a normal of adaption. 
HARMS: According to my own experience the zone of 
highest sensitivity to light moves more and more toward the 
periphery with increasing dark adaption. In case of ident- 
ical conditions of dark adaption there probably exists indi- 
vidual differences as to the distance of the optimal zone 
from the center. 
VAN BEUNINGFN: hen judging the Nyktoskop we must 
emphasize that the fluorescence diminishes the acuity of 
night vision considerably and is responsible for the quick 
fatigue observed. 
KRUEMMFL; Very recently observations of the constancy 
df light were made with the Nyktometer by the "Kaiser Wilhelm 
Institute 1 for Work Physiology" (Prof, GRAF). In these tests 
deviations of the density of light up to 40 Lux were ob- 
served in spite of constant ampere values (fatigue of the 
filament). In connection with thorough examinations of 
visual thesholds this observation considerably affects the 
racact-itude of the results. 
BRAUN; The introduction of radio measuring instruments 
should hever lead us into the temptation to attach less 
significance to the capability of night vision of the eye. 
Night vision will always be of decisive importance for night 
ebservers and night fighters even if the best radio measur- 
ing instrumentsr are available.  
I^jor_OSTERHANN 
This report is unsuitable for publication. 
(Omitted from original report). 
Medical examination for fitness for assignment a.S 
listening sentry, 
Oberfeldarzt (Lt. Col., M.C,) Prof, RANKE 
I would like to make some preliminary remarks before 
dealing with the description of the apparatus. At all times 
the physician has an important role in selecting from among 
the registrants the right man for the right job in the ser- 
vice, Just as in civilian life special branches of service 
require a full productive in special fields exceeding 
the normal physical fitness, With the exception of the 
flying personnel of the airforce this selection has been 
undertaken by the units themselves without the participation 
of any physicians,' Psychologi sts temporarily have been 
consulted and thus changed the above situation. They were 
unsuccessful, however, because they attached too much im- 
portance to the character of the registrant whrch cannot be 
determined well enough during a short examination. Never- 
theless the selection of specialists without the participation 
•f experts seems to be an inefficient procedure, VAN BEU- 
NINGEN has observed that among soldiers detailed to a train- 
ing course of range finder operators there were not only 
many astigmatics with typical near v:sion but even soldiers 
with a. one-sided highgrade vision. 
If, in this connection, we want to assist the t:-oops 
we have to propose simple methods which may be applied 
easily in a short time for the examination of specific capa- 
bilities which are of importance in the selection of special- 
ists, Here we have especially to deal with sensory powers 
whereas the mental assimilation depends largely on training 
so that considerable errors may result from the methods in 
use so far. It is a fact, however, that the examination of 
the sensory powers is quite suitable for excluding the 
majority of unfit soldiers. 
As to these specialists in which sharp vision is of 
special importance we are fortunate enough to dispose of 
adeouate ecuipment for the examination of the capacities of 
the eye separately because of the well-known physiology of 
the eye. Defects of refraction, accomodation, adaption, 
acuity of vision, colorvision, the latent and manifested 
strabismus and, as far as the mental elaboration is concerned, 
the stereoscopic fusioh may easily and ouickly be examined. 
It is much more difficult, however, to obtain a true 
evaluation of special:sts with particular auditory powers 
and I am convineed that this is due to the lac1: of a recog- 
nized physiology of the auditory Process, In all text-books we find the theory of hearing but nothing or a few words 
only about the physiology of the auditory process. There 
is some knowledge regarding adaption, fitjrue and accommod- 
ation but next to nothing is found about the physiologic 
conditions of sound location. Therefore we do not know well 
enough if and to what extent the auditory threshold con- 
stitutes an independent partial function in connection with 
volume of sound, differences of volume of sound and frecuency 
in connection with the sound location, or, if in proceeding 
this way we leave uncohsidered the most important functions 
of the auditory organs. As to radio operators and listening 
posts the acoustic memory and the ability to concentrate one's 
attention on certain kinds of sound may be of much greater 
importanc e, 
We are, however, in a position to establish a negative 
judgement; in case of elevated, auditory thresholds - regard- 
less of whether it is present in one ear or in both, whether 
the entire freouency is concerned or only an essential part 
of it - registrants will be considered as unfit for assign- 
ments in which the ear plays an important part. Therefore 
it will be of decisive importance for the development of 
suitable methods for the selection of soldiers for such 
assignments to examine the auditory thresholds. Therefore 
we have to put on the agenda the general demand for apparat- 
uses suitable for the determination of the auditory thres- 
hold, For the purposes of preassignment examination such an 
instrument must answer the following r-ruirements; 
1* certain calibration which may be checked even 
under changing conditions as for instance con- 
nection to different voltages, 
2, handy size and easy transportability, 
3, frequency bands of about 100 to 8000 Hertz with 
intervals not greater than one octave. 
U* easy graduation of th« volume of sound of about 
5 to 5 ph»n. 
Only the mass production of such instruments will make 
it possible to compare examinations made at different places. 
Therefore we are greatly interested in the development of an 
instrument which is also suitable for the aurist and not 
only for scientific examinations. Only in this way will it 
be possible to make sufficient observations and evaluate them, 
I would appreciate it very much if some assistance would be 
given to us by rhinolaryngologists. Apart from bulky scien- 
tific instruments we ourselves have only one Otaudion 
L0RENI of a Copenhagen firm. That instrument has some bad 
features but nevertheless Oberregierungsrat (Government 
Counsellor) Dr. FLIK has obtained some fairly rood results 
in connection with the examination of sound locators. 365 
fixfisxifius£jS-Jsiih-fll££ixifi_a2idiaiD£i£Ea* 
Oberf (Lt,. CqX.w ,.¥.*£ ) Prof. . &UEN?RMANN 
The medical examination of soldiers to be selected 
for listening posts is, first of all, a matter of the 
examination of the ears, of the nose and of the acessory 
nasal cavities. In an anti-aircraft artillery school after 
a mass preliminary medical examination, soldiers detailed 
to such courses wnre, for the first time submitted to 
special medical examinations at their replacement-units 
with regard to their new assignments. In general no gross 
defects were observed in soldiers detailed to such courses. 
Nevertheless it may happen that soldiers suffering from 
chronic catarrh of the acessory nasal cavities and Fstachian 
tubes and one-sided deafness are assigned to those courses. 
Those soldiers must be ciuickly discharged so that we do not 
waste precious tine on them, I was informed that an auditory 
examination of all applicants does not take place but only 
in those cases which do not give a clear picture to the 
troop physician. The course of the examination is as follows-. 
After examining the tympanic reflex, for which purpose it 
may be necessary to rinse the auditory canals, the perception 
of whispered speech is examined. If the hearing capacity is 
less than U meters the hearing must be examined, by means of 
the tuning fork or he must be sent to a specialist for final 
decision* Then follows the inspection of th' tons:'Is, of the 
teeth, of the nose (septum, turbinates) and, according to the 
finding, the soldiefs are classified into fo • r "rorps. No, 1 
is the normal finding, Mb* 2 minor defects, No. 3 diminished 
perception of whispered speech and a tendency to tonsillitis 
and catarrh of the Fustachiaia tubes, and under No, A will 
be classified all those who must be rejected as unfit because 
of deafness and eczemas* It was observed that by this rough 
examination it is possible to separate unoualified registrants. 
This became clear by the fact that about 90% of all regist- 
rants selected for the course came up to the standard. How 
strong the influence of the will to be efficient and the 
inner disposition is for the performance of the strenuous 
duty of a sound locator may be seen in the fact that during 
the preliminary examination 2 - % % of all newly assigned 
candiates feigned incorrect hearing in order to escape from 
the course. On the other hand it was furthermore observed 
that a women’s auxiliary battery recruited from volunteers 
showed much better results in comparison to one consisting 
of drafted women. Out of this comes the conclusion that in 
addition to the real auditory efficiency psychological con- 
siderations have a great influence upon the efficiency of 
hearing. The above outlines rough auditory examination may 
be satisfactory in connection with the practical reeuirements 
in general. The troop physicians of the schools and search- 
light troops, however, would appreciate it very much if they 
could dispose of an instrument which would enable them to 
determine the auditory efficiency objectively. Therefore 
I suggested three years ago that electric audiometers simi- 
lar to those constructed by Western Electric which are 
handy, efficient, resistant and easily connected, to the 
lighting current should be made available, A Nig electric 
firm has been entrusted with the corresponding preliminary 
work. That firm, however, has showed just as little inter- 
est in that work as before the war. This is amazing because If the fact that even civilian physicians are highly 
interested in an instrument like that and, on the other 
hand, nearly all of the Otoaudion-instruments are out of 
order and cannot be repaired. Therefore I was very inter- 
ested rn seeing at the clinic ff UNTFRBFRGFR an instrument 
developed by the medical assistant Dr, BLAUFNIT "IN which 
is not larger than an audiometer and which probably is suit- 
able for eliminating the above mentioned shortcomings. I 
would like to describe it her'' in a few words and to suggest 
having it tested by higher authorities and to bring about 
its construction. This will be all the easier because it 
consists of ordinary radio parts which have only to be 
assembled according to the directions of Dr. BLAUFFSTEIN, 
The audiometer makes it possible to operate with n the 
limits of 16 - 16 000 Hertz whereas the audiometer of the 
Western Eelctric has a freruency band of only 128 - 9700 
Hertz. The zero point adjustment is controlled by a cathode 
ray tufco so that it is possible to Sf t even low frceuonces 
correctly, Th- tone may bo interrupted without additional 
noise by means of a push button and the volume of sound 
adjusted from 0 - 120 decibels. The audiogram nay bo traced 
either as a tyoical presentation of impair d hearing or 
as a diagram of the absolute hearing capacity. The control 
of the initial voltage is controlled by an incandescent 
lamp. As a sound-transrm ttor wo use a Western Electric 
electrr-dynamic-head phone. Estimates of the firm producing 
this apparatus figure at about 5 - 600 marks for each 
apparatus. The special advantage of the introduction of an 
electric audiometer for the examination of listening posts is 
the possibility of obtaining a more precise testing. On 
the hand it will be possible to check feigned state- 
ments and above all, to examine in a more precise manner 
than would be possible with a tuning fork. Furthermore we 
shall be in a position to find out to what extent a loss 
of the hearing capacity of sound locators progresses with 
such an assignment. According to SCHMIDT this drop in the 
efficiency originated either from organic injuries or in- 
ternal, mostly psychic, reasons rather than from fatigue. 
I could imagine that an exact testing of hearing capacity 
is likewise affected by the possibility of hypersensitive 
hearing capacities of the sound locators. The possibility 
of elimination of these errors alone justifies the expenditure 
for this apparatus which will render inestimable services not 
only to the clinician, but first of all, in connection with 
the otoneurologic examinations of head traumatologists, I 
have succeeded in getting two audiometers, one for Brussels 
the other one for Berlin. Many hundreds of examinations 
have been performed by qualified medical personnel who 
had been trained for a short time for this purpose. They 
have shown the value of the electric audiometers which in 
foreign countries arc generally adopted and every radio 
dealer takes advantage of them, I am submitting herewith 
some curves to you demonstrating the results of hearing 
tests # 
In Germany the diagnostic value of the audiometer 
was first put on a broader basis by RUFF and L,.NG NBFCKf 
Its main value cohsists in the possibility of achieving 
more objective and uniform values than with the tuning fork 
and BFZOLD's tonometry. First of all the 
of the bone for high and low tones is much easier tested 
with tho elctrie audiometer than with the tunlng fork. In 
spite of all advantages these apparatuses, which technically are not far developed in Germany, were not generally introduced,. 
It is getting high time to make up for this unfavorable situatio. 
md therefore it is recommended to evaluate the apparatus con- 
structed by BLAUENSTEIN, There is an urgent demand, first of 
all in connection with the exam-nation of sound locators, but 
also in relation to diagnostic purposes in other otologic fields. 
Ijl Selection of sound locators in the Navv bv medical experts. 
The American " Sonotond*-;~et er", which is at the dis- 
posal of the Navy, » as recently used in connection with the 
scientific examination of injuries caused by detonations. It 
has not yet been used as an instrument for the selection of 
sound locators in the Navy* The selection of sound locators 
by experts in the Navy is proceeded by a spychological test in- 
cluding the detection of sound direction and the maxi urn hearing 
capacity below water. Formerly the selection by specialists was 
Limited to examihg the tympanicmembiane reflex and the perception 
of whispered and conversational speech; In this way an exact 
examination as to the capacity of sound location and binaural 
cearing was not guaranteed. Up to 30 - 1+0% of the applicants 
of a number of groups at sound locator schools did not attain 
:he reeuired efficiency. This may be partically due to the 
’act that unintelligent candidates unfit for other careers 
ave been detailed without bearing in mind that this kind of 
service requires intelligence, ability to concentrate and resist- 
.nce against weather conditions. 
The supplements to the classification regulations published 
•y the Research Department for Sensory Medicine one year ago 
roved to be satisfactory. These regulations prescribe not 
nly a careful examination of the ears but also an examination 
f the nos' and throat ih order to find out whether the regist- 
ant shows a tendency to colds and chronic infections of the 
ucous membrane. The prescribed examination concerning the 
taring capacity with regard to the upper and lower freouency 
s well as the time of nerceotion of the c9 tone constitutes an 
mportant advantage of these regulations. The failures which 
ere at freouent in the courses were reduced to a minimum, 
'esides this an ear-specialist was assigned as the chief medical 
fficer of the Navy Anti-aircraft Defense School which is.in 
harge of the training of sound locators and the snp.rchlight 
ersonnel. In this way it is guaranteed that all sailors de- 
al 1 ed to these special courses are submitted to another examina- 
ion by a medical specialist at the veryr beginning of the course. 
The introduction of daily test series of the extended audi- 
ory examination, however, takes much time and therefore can be 
sed only as a makeshift solution. In consideration of this 
act the Research Department for Sensory Medicine (of the Navy), 
n cooperation with the Physiological Institute of the Univers- 
ty of Innsbruck suggested the construction of a very simple 
M nd handy auditory threshold-measuring -instrument. It should 
,e constructed in such a way that STENGER’s apparatus may be 
ttached in order to be able to examine sound location. Because of the war conditions the so-called MGOERICKE-ap aratus" could 
no% be demonstrated here, A report about its construction 
and functioning was submitted instead* This auditory-threshold 
measuring-instrument, is relatively small (20 x 20 x 4.0 centime- 
ters). It may be connected to the light current and provides 
frenuencies from 10 to 30 000 Hertz, The adjustment of the 
volume of sound may be set in decibels from 0 up to 115 dbs. 
in intervals of 5 dbs. The instrument permits the reading of 
the absolute value of sound pressure in millibars and the examin- 
ation of hearing capacity br means of both continuous and Inter- 
rupted sound. 
This simplified and efficient apparatus may be used not 
only for the selection of sound locators for the air defense 
forces and submarine personnel but also for clinical examinations, 
simulation tests and scientific research work. 
Discussion concerning examination of fitness: 
RANKE: Objective audiometry is necessary in order to 
determine objectively a decrease due to fatigue and injury, 
H0LZL0EHNFR: The practical experiences gained in sound 
locators of anti-aircraft artillery apparently showed that in 
this case fitness depends less on the auditory threshold which 
m$ty be measured, bv means of the audiometer but more on the 
binaural hearing. This circumstance had to be expected theo- 
retically, The apparatuses for the examination of values 
seem to be suitable and worthy of improvement, 
VON EICKEN; I would like to ->oint to the tuning rod men- 
tioned by Prof, WHTHL0, It is made of duraluminum and its 
vibration lasts much longer than the - tuning fork. Only 
registrants who hear very well can hear the very last vibrations 
of this tuning rod. 
PERWITZSCHKY: The const uction of audiometers will be 
very difficult if the apparatus is to answer to technical 
renuirements. The ouestion is whether or not such a precisely 
working instrument, which of course must be remained for the 
physical research work, is necessary for the examination of 
hearing capacity. 
It is my opinion that for purposes of sound location 
the practical examination is much more valuable than the 
measurement of the acuity of hearing. 
Directions for the examination of hearing capacities 
s £ e c i £ l.jjn X 
The units demand the cooperation of medical officers in 
connection with the selection of soldiers for soecial pur- 
poses, So far it has not been possible to co-e to a complete 
agreement regarding the results of the medical examination and 
the reeuirements of the units. Therefore it is necessary to 
further develop this method. An exception of this is the deter- 
mination of the unilateral or bilateral deafness. In accordance 
with the clinical reeuirements of •tologists it is very necessary 
that a handy and sturdy audiometer be developed which may be 
calibrated at any time in order to find the number of auditory 369 
thresholds in the entire range of frequency. The hitherto ex- 
isting eouipment does not correspond to the necessary reouire- 
ments neither regarding their number nor their efficiency. The 
cooperation between clinicians and the physiologists must be 
guaranteed so that further progress may be achieved regarding 
the development of these instruments. 
&X t ec t iy e_d evi c eA 
Qber stabsar ? t .joy ,) Prof. PEREITZSCH KY 
Prof, PERWITZSCHKY has constructed an apparatus with which 
it is possible to protect the ear against the pressure of explosion 
and, at the same time, to prevent impairments of the ear and thus 
secure the safety of the soldier. This apparatus tak°s advantage 
of the physical peculiarities of the wave of detonation and of 
the acoustic wave. 
Discussion: 
U’* ' VFFENORDE : More than 100 arti llerynen of the Navy have 
been tested in anti-aircraft schools a to the external ear. 
Calibers of 2, 3*7 and 12*8 centimet rs had been used. Com- 
parative examinations of the ear drum and of the hearing wrre 
made with normal and whispered speech, further- ere, c5 -continu- 
ance of hearing after applying the ear-phone, THIELE<g plug ana 
by plugging the ears with the fingers, the same tima all 
test groups had to examine whether or not the head straps 
proved to be a hinderance when carrying steel helmet and gas-mask 
at the same time. 
NOACK; The Navy needs the ear protecting capsule princip- 
ally for the gun crews of capital ships. 
RANKE: Discussed the volumes of sound which actually 
exist In gun-tests , At the same time the ouestion is raised 
whether these circumstances alone cause combat fatigue. 
VAN BEUNINGEN: In some ear adaption tests in the institute 
we have exposed the ear to a sound of 1000 Hertz and to a pres- 
sure of about 1 dyn/socm during varying periods of time. We 
have observed that the ear reacts in the following way: In the 
beginning its threshold stays constant after the sound has been 
switched off. After several repetitions the threshold of hear- 
ing decreased to about 6 decibels during the test-period after 
a lapse of 10 - 15 mi nutes and the time of recovery was shorter. 
In continuance of the same test the threshold increased consider- 
ably about 4-0 minutes later, A specific phase of sensitivity is 
followed by a phase of fatigue. ;‘h~n considering the t.i no re- 
ouired for the recovery of the threshold, duri nr the course of the 
entire test we see a direct relation between the time of adaption 
and readaption in the phases of "constancy11 and "sensitivity1' of 
the threshold. In the phase of fatigue, however, such a clear 
relation cannot be observed. The practical significance of thus 
finding is the following: A sound locator who during a certain 
period of time has to listen to a sound of certain volume which 
is near to the threshold volume shows, after a lapse of 40 - 50 
minutes, symptoms of fatigue to such an extent that a decrease in efficiency must be taken into considnrat:on, Therefore the 
limit for the hearing of sound? near the threshold is from the 
point of view of time about 50 minutes. It srpms to be imprud- 
ent to employ a sound locator for such special tasks longer than 
that time. On the contrary he should be allowed an acoustic re- 
laxation for at least one hour. 
2ji Calcium requirements in soldi erfcs diet^ 
pberfeldarzt (Lt. Cpl.t M.C.) _Prof,_LANG 
It is not easy to the calcium requirements of 
the human body. More than 99% of about 1200grams of calcium 
contained in the human body is contained in the skeleton. This 
large depot of calcium makes it difficult to determine the 
calcium requirements of the body by means of a differential 
analysis. Under the influence of vitamins or hormones and entire- 
ly dependent from the supply of food either an increased storing 
or a deduction from the depot may occur. It is a matter of 
course that it is impossible to determine the calcium reouirements 
of the body by means of blood calcium examinati "ns because the 
cuantity of calcium actually contained in the blood is largely 
independent from the supply of calcium. The blood calcium level 
is the resultant of all regulations and counter regulations, 
which govern the processes of movements, storage and mobilization 
of calcium, Therefore the only possibility to determine the 
calcium reouirements If the body is to institute long lasting 
close observations. 
Everybody knows that the metabolism of calcium must be 
considered only in connection with the entire metabolism of 
minerals. It is, however, of special importance to examine the 
metabolism of phosphorus at the same time. Numerous tests under 
most varying conditions (study of balances, graph of growth, 
growth of later generations, analysis of animals, development of 
rickets) all have proved that all the functions of life show an 
optimal course if not more than two mol, of phosphate are added 
to each mol, of calcium. 
All factors influencing absorption are highly inportant. 
It is surprising, however, that both soluble and insoluble cal- 
cium salts are fairly well absorbed. Two exceptions from this 
rule, however, must be noted; Calcium oxalate and calcium phos- 
phate. The,, oxalate is found in many green vegetables. There- 
fore they are of secondary importance with regard to the supply 
of the organism with calcium. 
, r ;■ . • r.'- e e . " ■ , 11 " 
Cereals contain much phytin which causes rickets. This ef- 
fect was observed by MALLEWBY, The largest quantity of it is 
contained in the ingredients of bran. It has been well known 
for a very long time that the human body absorbs calcium poorly 
in the presence of phytin and at the same time that phytin-phos- 
phorus is used up only with difficulty. Rats, however, easily 
absorb calcium-phosphate because their bowel contains phytase - 
a fermant that causes a splitting of phytin. In different tests McCANYE and WIDDARSEN proved that 
the absorption of the calcium contained in whole wheat broad 
is much more difficult than that in rye bread. This is due to 
the higher percentage of phytin contained in rye bread. Our 
experiments have proved that the greater part of phytin contained 
in German rye-bread is split enzymatically during the process 
of fermentation. So much phytin is left over, however, that 
with regard to the soldier’s actual daily bread ration 0,1 up to 
0,15 grams of calcium may be withheld from absorption. 
The quantity of protein greatly influences the extent of 
the calcium absorption. The findings of McCANYE, according to 
which the absorption of calcium is improved with increased con- 
tents of protein, could not be confirmed by our own scries of 
experiments. This fact, may lead to the conclusion that calcium 
is absorbed by way of an amino-acid-calcium salt complex, re- 
spectively peptic-calciurn salt which can be proved by 
numerous other findings. 
There are only a few food-stuffs which are of great import- 
ance as to supplying the human body with calcium, most import- 
ant of which arc milk and cheese. According to the analysis 
by F, HOLTZ the calcium contents of the different food-stuffs 
varies so much that it is impossible to determine the exact 
quantity of calcium contained in the different food-stuffs out 
of tables. Conclusions may bo drawn only from the analysis 
of the food itself. By using water varying quantities of calcium 
are added to the food but these amounts are generally negligible. 
In repeated balance-tosts made at my institute SCHUETTE 
has fetund that the necessary supply of calcium is froeuently 
not covered by the soldier’s food. The daily deficiency amount- 
ing to about 0,1 up to 0,2 gram of calcium is duo to the followin 
factors: 
1, the diminished supply of milk and dairy-products; 
2, the large quantities of finely ground flour which 
amounts to 50% and more of the soldier’s daily 
diet. This bread contains much phytin and its un- 
favorable calcium-phosphatc-relation is detrimental 
to the calcium economy of the body. 
If we suppose a daily calcium deficiency amounting to 0,2 
gram then, 70 to 75 grams of calcium ar" withdrawn from the 
body in a year, i.e, 5% of its own balance. Such a deficiency 
may last a long period of time before any recognizable damage 
may be observed. It is a matter of course that there exists 
great regional variations according to the sum''lies of the troops 
and the possibility to obtain additional food-stuff (vegetables, 
milk), 
It is realized that steps must be taken to increase the 
calcium sup dy, Therefore during the las. conference of the 
committee for food control of the Armed Forces we made pro- 
posals to eliminate the calcium deficiency by admixing cal- 
cium in the soldier’s bread (0,5 gram of Calcium - 1 kilogram 
of br~ad). In this connection it does make any difference 
which type of calcium salt is added and the choice depends on 
the possibility of supply. Our own thoraugh examinations have 
proved that in this way an immediate balance i.e, a positive 
calcium balance is secured. The taste of tread prepared in the 
above way does not differ from ordinary br^ad. 372 
Discussion: 
GUTZEIT: Advises carrying out the proposed admixture »f 
calcium in the soldiered food. This seems to me to be the more 
useful as our own findings in paradentosis-examinations in German 
soldiers stationed in Norway revealed a slight prophylactic ef- 
fect in those troops which had been given calcium in the drink- 
ing water. At the same time this addition of calcium obviously 
diminished the susceptibility to minor infections, 
VOLLHARDs I would also like to recommend the admixture 
of calcium, especially in Norway. I am personally inclined 
to see a clos-1 relation between the paradentosis and calcium 
defici ency, 
HORSTFRS; Report on the effect of the admixture of cal- 
cium in PWfs, An increase in the capacity for and little 
increase of weight was observed. 
LANG: There is no calcium-deficiency in the civilian 
population. The actual rations of bread and skimmed milk 
which contain much absorbable calcium guarantee a sufficient 
calcium supply. There is no evidence that a calcium deficiency 
can be proved only during certain seasons because all of our 
tests were made all the year round, 
KATSCH: Contrary to the experiences made during the first 
World War, late rachitis and osteomalacia changes in old women 
have been rarely observed so far in my own field of research. 
During the last years, however, tetany v/hich in general was rare- 
ly observed at the Baltic Sea has become more frecuent. It is, 
however, not verified that this is due to the changed calcium 
balance in the foods, A calcium shift in the body caused by 
pathological conditions may result in an increase of the bloud- 
calcium levels therefore one cannot rely on the blood calcium 
levels as an indication of the calcium reserves in the body 
(for example: the very rare clinical picture of the general- 
ized muscle petrification with accompanying decalcification of 
the bone). 
GUTZEIT: With a total of 1200 grams of calcium in the 
human body, l/3 of the calcium reserves of the body would have 
been used up in $ years of war. So important a loss of calcium 
would necessarily be visible in X-ray examinations of the bones 
in the form of decalcifications and curvatures of the bones. 
Nothing of this kind has been observed in my clinic and the 
affiliated hospital although special attention has been given 
to this matter* 
VOLLHARD: Does the admixture of calcium influence the 
taste of the bread? In me farm on the Bergstrasse, 5 milk 
cows had to be slaughtered because of osteomalacia and because 
"Vigantol11 could not be obtained, for this may be 
the lack of calcium in the pasture caused by the very serious 
drought during the last Fall, 
* 
SCHENCK: Clinical observations did not show any signs of 
calcium deficiency in soldiers and prisoners. Allusion is made 
of the possibility of observing the calcium metabolism in the 
formation of callus. Further, calcium propionate is mentioned as a means of dis- 
infecting bread. The question is raised whether the calcium 
balance is not influenced by the seasons and whether this de- 
ficiency is not existent under different conditions of nutrition 
and time. 
Finally he shows that it is possible to find the calcium 
content of the body by the quotient calcium-defecation/cal*ium- 
urine. 
i. 
BOHNFNKAMPj The significance of calcium cannot be over- 
estimated, especially regarding sensitivity of the nervous systems 
and conditions of permeability, As to the blood it is not poss- 
ible to speak of a fixed and constant level in the blood. This 
was demonstrated by many tests made during the late years which 
revealed the dependence of the blood picture on gastric-secret- 
ions, vegetative structure, periods of rest, work, nourishment, 
procedure of absorption or intestinal trouble etc. We have de- 
veloped a new method for this type of research to be applied in 
future tests. This method makes it possible to nuickly find out 
the exact amounts of Ca, K and Na, by using only small Quantities 
of blood. Hundreds of tests were made and we found considerable 
calcium-variations. On the other hand we found numerous, and in 
some cases very impressive conditions of tetany which were caused 
by reduction of calcium. Such latent conditions of tetany are 
indeed very freouently observed. Special attention must be paid 
in this respect. 
It is proposed to examine thn influence of calcium deficiency 
by means of the so-called A,T, 10 tests, the measurement of the 
time of hypoventilation until the onset of tetany, furthermore, 
calcium determination, appreciation of the clinical symptoms of 
tetany and X-ray examination of the skeleton. 
Conclusions regarding calcium deficiency in soldierfes diet, 
Extended balance tests have shown the existence of a small 
calcium deficiency in the soldier’s diet. it was pro- 
posed to cover this deficiency by adding calcium to the bread. 
M2ifiJb£ii£iB_cI_cncrgy_in_case_of„Xexcos£iye.l_iie3tJU 
P£of esspr._WEZLER 
As an introduction he reviewed the importance of the in- 
crease of the metabolism under the influence of extreme cold 
(1st chemical regulation of heat), which, together with measures 
to eliminate the radiation of heat efficiently protects the body 
aga-' nst cooling. Then the euestion was raised whether in a simil- 
ar way in case of excessive heat a regulative functional decrease 
of the formation of heat ( 2nd chemical regulation) can be 
proved which, besides stimulating the physical reaction of an in- 
creased heat radiation,, impedes the transfer of heat. This quest 
ion and others, such as a change of energy under the influence 
of heat were studied with the help of his findings and those ob- 
tained in collaboration with R, THAUER regarding the tolerance 
to heat by using the climate chamber of the Institute for Animal 
Physiology at Frankfurt, Nine diagrams were discussed in detail. 374 
The consumption of O2 and the body temperature are shown as a 
function of time if the exposure lasts several hours during 
which time the air temperature is at 30, 4-0 and 50 degrees Cel- 
sius with 50 % relative humidity. After that he described how the 
chancre of gas depends in conformity with physical laws, on the 
outside temperature, at least up t»‘b50 degrees Celsius, A 
closer analysis of the curve of the O2 consumption as a function 
of the body temperature allows the deiTionstrati on that the in- 
creased metabolism, amounting to 16 - 17% per degree of increased 
body temperature, must be interpreted as a slight decrease of the 
regulation of the combustion process in the sense of the 2nd re- 
gulation of heat and that this arrears if the total increase of 
metabolism in the range of the stored heat is decreased by that 
amount which, as a minimum, is inherent to the physical mechanisms 
of regulation, i.e, to the increase of the function of the heart, 
of the respiratory muscles and perspiration glands. 
The curve that represents the body temperature as a 
function of the outside temperature at 50 and 90% relative 
humidity allows the recognition of the range of efficiency of 
all regulative functions under the influence of heat and besides 
that the specific influence of the ambient humidity at constant 
temperatures, A higher degree of ambient humidity will cause a 
morr marked retention of heat even if the other conditions are 
the same. This, however, causes an intense increase of the 0£ 
consumption. Finally in two examples it is demonstrated in 
which way additional strain on the organs i.e* work of the musc- 
les and O2 deficiency-breathing (12% O2 mixture) - cause an 
increase of the O2 reeuirements thus impeding the function or 
the regulative mechanism under the influence of heat as a con- 
seouence of an increased generation) of heat, respectively 
accelerating the process of heat storage in a general manner. 
In some final remarks the essence of the discussion is 
summarized as follows: The human organism is capable of pro- 
tecting itself much more efficiently against cold than against 
heat. This is especially due, in contrast to the 1st regul- 
ation of heat, to the low regulative potencies of the so-called 
2nd regulation of heat. The adverse increase of metabolism 
connected with the increase of the body temperature increases 
the storage of the heat. 
21* m_of_ energy, und lye nce„of_]ies t.t 
ffp-frprarzt (Warrant Officer, MPC.) FJ ITPIR 
In connection with the Question of the 2nd chemical regulation 
of heat, i,e, the question of the decreas- of the metabolism 
of energy in heat, nine persons tested in climate chambers 
of the Institute for General and Military Physiology, On the 
one hand we wwe interested in learning the reaction of the 
metabolism of energy during the change, during the stay in 
tke same climate and th~ ext-nt of an eventually occurring 
decrease of metabolism. The results were the following: the 
reaction of the metabolism varied during the change into higher 
temperatures (4.0 and 50 degrees Ceisj_us with a little relative 
humidity), A number of persons showed an immediate increase, in 
others, however, the metabolism decreased distinctly in the be- 
ginning and increased later beyond the initial temperature. This 375 
varying picture may bo explained by the buffer action of the 
skin as was mentioned by KOENIG, It can be proved that a de- 
crease of the metabolism occurs during the change into higher 
temperatures if the skin was cooled pr'viously. A decrease of 
the metabolism, however, cannot be observed in general if the 
skin of the body is exposed to heat at the beginning of the 
influence of the test climat-. In this case a buffer action 
exists and the temperature increases immediately and the 
physical regulation begins much earlier. 
During a longer stay in unchanged climate, in most of 
the bases an increase of the metabolism was observed after 
l-J- hours in high temperatures. It cannot be determined to 
which extent its height is influenced by a decrease of com- 
bustion in the sense of the 2nd chemical regulation of heat. 
In two persons, one of whom suffered from bronchial asthma, the 
metabolism constantly stayed under the initial value during the 
entire time of the experiment or it increased only to a neglig- 
ible extent. In these two cases, in which the whole regulation 
of heat is greatly influenced by the chemical regulation of heat, 
a certain release from stress of the physical regulation of heat* 
and with this of the circulation The decrease of meta- 
bolism in heat is in no case so great that a reduction of the 
daily reouirements of calorics seems to be justified in hot 
territories, 
Discussion concerning loss of energy in hi h temperatures: 
SCHWIEGK; In asthmatics, hyperthermy often causes relaxat- 
ion of the bronchial spasm and at the same time a reduction of 
the respiration which would explain the decrease of the metabolism 
in the sense of the 2nd regulation of heat. 
WEZLER: The results achieved by H, MEITNER were confirmed 
by my own tests of cooling and warming of the persons used for 
the experiments. Also in these dynamic experiments the ex- 
tent of the 2nd chemical regulation of heat was not essentially 
higher than 10% of the basal metabolism. This finding supports a 
genuine regulative decrease of metabolism, which for practical 
purposes is almost insignificant. 
BUETTNER: The inverse course of the temperature of the 
center of the body and of the main temperature in case of strain 
caused by climate has been well known to me since my joint experi- 
ments with PFLEIDERFR and KOENIG, There also occurred regular 
variations at intervals of about 10 minutes for almost one hours. 
The temperature of the center of the body is surpassed by the aver- 
age skin temperature only in case of heat waves, in which the 
a#ldest spot lies anywhere below the hypoderma or if the humid- 
ity and temperature of the skin drop 1 alow the corresponding 
values of the air. By applying excessive humid heat the course 
was in general as follows: Constancy of the central temperature 
of the body until the average skin temperature increases to 
35 - 36 degress Celsius. After that both temperatures rise 
together with a difference of 0,5 degrees Celsius between them. 12a Circulation ..and niotr.bolism .jp case of local freezing^. 
Stnbs^rzt_lC^£tain_^_C^l_H^_SCHWIEGK 
The development of local damage by cold does not depend 
on the degree of cold to which the tissue in nuestion was ex- 
posed. On the one hand damages by cold may occur at temperatures 
varying from 5 *- 8 degrees minus Celsius, on the other hand a 
damage may not occur at all in case of freezings of the 
tissue caused by temperatures below zero. It is obvious that the 
reason for these damages by cold are due to special changes of the 
metabolism during exposure to cold. In this connection one especial- 
ly thought of a suffocation-metabolism during the exposure to cold 
with the formation of lactic acid. This is understandable be- 
cause of the fact that during the exposure to cold and even hours 
and days later a very marked diminution of the blood circulation 
can be observed, by animal tests the question was 
studied as to what changes take place in the blood and in the 
muscles of an extremity which is exposed to temperatures down 
to 0 degree Celsius. At the same time we measured the content 
of oxygen and carbonic acid, the content of lactic acid, water 
and albumin, blood sugar and phosphate fractions and the alkal- 
line reserves in the arterial and venous blood, furthermore, 
the contents of glycogen, total amount of sugar and phosphate 
fractions of the extremity in nuestion. The tests proved that 
together with a marked decrease of the circulation during the 
exposure to cold there is a decrease of the consumption of 
oxygen down to l/5 to l/8 and a decrease of the arterio-venous 
blood sugar and lactic acid difference. Therefore during the ex- 
posure to cold not only a suffocation-metabolism could not be proved 
but neither was there an increased formation of lactic acid. The 
requirements of energy are covered by the oxidative metabolism. 
This may be traced back to the fact that the metabolism is 
significantly lowered according to the ,rR, G . T ,M-rule . Further- 
more these tests have proved that tissues which are exposed 
to cold can absorb considerable quantities of oxygen from the 
arterial blood in spite of the changed dissociatioh of the 
graph of oxygen. With this the theory that the escape of oxy- 
gen which is rendered more difficult in low temperatures is 
the cause of a suffocation of th° tissue is no longer sound. 
Tests with ESMARCH13 bandage during which the ligated 
parts were exposed to cold and warmed up again have proved 
that a complete ligature of the regions, up to 9 hours, can 
be endured by the tissue without considerable damage. If, 
however, the ligated parts are warmed up at the same time 
most serious capillary damages occur even within two hours. 
They lead to disorder of thrt permeability, formation, of edema, 
condensation of the blood and all this results in a collapse 
of the circulation. From these experiments the conclusion must 
be drawn that with local freezings the onset of the damage 
of the vessel and of the tissue occurs in the phase of warm- 
ing up. During that phase the metabolism is already increased, 
the circulation oS blood, however, is still seriously decreased 
because of the significant narrowing of the vessel. Therefore, 
in case of local freezings, the therapy to be applied must 
first of all increase the circulation of the blood in the dam- 
aged parts which must itself be kept cool. This can be achieved 
by preventing a general exposure to cold, by massage of the 
affected parts which must be kept cool and the elimination of 
the vaso-constrictor sympathetic tonus by eliminating the sympathetic nerve by means of novocain. The results will net 
be so good by eliminating the peri-arterial nerve in the fossa 
ovalis by means of novocain. 
Discussion: 
HOLZLOEHNER: Special attention must constantly be paid 
to the differences in the causes of the symptoms and also to 
the treatment existing between the effects of a general ex- 
posure to cold and the local freezing. Otherwise a progress 
in the one field would cause serious damage in the other. 
WEZLER; In my own experiments we have also observed an 
increased utilization of the blood in cold. 
During the exposure to cold the spasm of the vessels, up 
to the medium sized arteries, lasted several hours even under 
an intense warring of the skin which was proved bv my own ex- 
periments during which parts of the body exposed to cold 
and heat. 
DRUCKREY; Have any therapeutic tests been ma e with 
alcohol, caffein, or nitrite in order to a spasm of 
the vessel after an exposure to cold? 
BROCK: I suggest elii inating these spasms of the vessels 
by using a centrifuge in conformity with the improvement of 
REYNAUD t s gangrene by using centrifuges. 
-DANG: The findings that the nature of metabolism is 
much the same during the exposure to cold as in general, i,e, 
oxidative, is of fundamental significance. It removes many 
speculations concerning freezings being due to suffocation., 
Physicians frequently speak of a suffocation-metabolism oven 
if this is not possible because of the C2 pressure. XV. 
P R_0_C_E_E_D_I_N_G_S 0_F T_H_E C_0_N_S_U_L_T A_J_T_Sg 
C_0_M_M_I_T_T_E_E 0_N D_ I_S_E_A__S_E__S 0_F 
EJLL.2JL LO-LI A_J_D I__A_X__ I_L_L_A 
Translation prepeared bys 
U, S. Naval Technical Unit, Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government (U* S , ) I* £icja£_jui££l££l_aiid_2riJ2£ssdl£-l££a£i3£i&_A£.AazillA..aiid 
.£a£fi_llUil£ie.2,* 
0 ber atftfcflftr.21 (Major MrQ,) RFICHENBACH 
The first aid for soldiers with face and jaw injuries 
should be in a special hospital near the front lines to 
which the injured should be brought as soon as possible and 
without having received previous surgical treatment. 
Cooperation with the associated specialities (eyes, throat, 
nose and ears) has to be available in one and the same hospital. 
The treatment of patients with jaw and face injuries should 
be performed by one surgeon (surgical and orthopedic treatment). 
According to the experiences of this war there are pract- 
ically no limits to the early surgical treatment. The surgical 
wound treatment with the aim of closing the wound is the method 
of choice in the region of the jaw and the face. In case of 
wounds on the surface of the brain, open pneumo-thorax, and 
opening'of the joint cavities as well as with jaw and face in- 
juries, the approximation suture should not be used to produce 
a total closing of the wound. When first aid is given in the 
front lines the effected parts should be kept at rest. If the 
patient has lost teeth and suffered fractures, bandages similar 
to a prosthesis have to be applied. 
The most suitable material for the sutures is stainless 
steel wire. The suture with wire plates and the sutut-e in the 
deep tissues according to WAS5MUND also proved to be very good. 
It is best to differentiate between immediate suture (in- 
stead of primary suture), early suture, late suture, (instead 
of secondary suture). 
We must warn against a complete immobilization for a long 
period of time. It is mueless to wind a bandage round and round 
the head but a many tailed bandage or one secured by wrapping 
under the jaw, even using paper tissue, are suitable. 
Z*, £ixai-.jsjiE5isal-.aai-.j2xaaili£ii£-i£j2aiiD£iii-££-.ia2-aiii-l!asfi 
iaiii Ll&&* 
1, Contrary to the first World War where the injured 
soldier arrived after much delay in the homeland hospitals, we 
now accomplish the surgical and prosthetic first aid of jaw and 
face injuries by specialists in the immediate vicinity of the 
front lines, either as provisional aid in the advanced main 
dressing station or as definite treatment in the maxillary 
surgery department of the Army, 
2, It is desirable that all special departments be com- 
bined in one hospital. 3, It was always poss:ble to establish our own technical 
laboratory in the medical departments behind the front lines. 
J+, Before establishing the course of treatment we made 
X-ray pictures in two planes and here the *$1feraens ball" 
(property of the department, refers to a compact type of X-ray 
tube) with darkroom was very helpful. 
5, We did not always use the same method of splinting. 
The majority of the wme treated with wiresplint. With 
linear fractures and defect fractures we used combined prosthes- 
is with wire arches secured to the individual teeth by wrapping. 
In case of toothless jaws the so-called Mummel-splint with 
supporting head and jawcap bandage is used. 
6, For the advanced main dressing station we r'commend 
the use of bandages similar to a prosthesis and for the maxillary 
surgery department of a hospital splints made according to im- 
pressions are recommended. 
7. Generally we first perform the and then 
the surgical treatment. 
8* Within the first three days we ha"' th° best success in 
healing with the surgical treatment and followin'- immediate 
suture. After the lapse of th?s time we waited, for the wound 
to clean up and then made an early suture, according to GANZFR, 
A successful suture recmires adenuat'1 drainage. Drainage 
to the outside, at the lowest point and to the corner of the 
mouth has turned out better than drainage towards the oral cavity. 
As material for the suture we use stainless steel wire almost 
7/ithout exception. For the lips we use it 0,1 and 0,15 milli- 
meter thick, for the rest of the soft tissues 0,2 and for the 
wire tension sutures 0,3 millimeter. 
9k Complications ar '■ first of all secondary hemorrhage 
and aspiration pneumonia and besides this erysipelas and diph 
theria* 
it* Tracheotomy is a very severe operation in case of 
demolition of jaw and face. The medical detachments perform 
tracheotomies too frenuently in the front lines according to 
our experience. 
11, The tranfer of patients to a homeland hospital bef»re> 
a lapse of 2 weeks is always endangered by secondary hemorrhage. 
12* Freshly operated patients should be attended by doc- 
tors for at least 8 days and cared for by trained nurses, and 
sometimes even feeding by nose-gavage is necessary. 
IJa^Iiflal^r^imexit.pf^^pe^nd^jaw.iniuri-.^ 
The lecturer denounces, as regards face and jaw injuries, 
both the common surgical wound treatment and the delayed con- servative treatment. believes that they classification 
as special war wounds which call for special wound preparation 
and closure by the use of carefully placed approximation sutures 
(cerebral, pleural and joint injuries). 
The cause of concern is not the occurrence of serious in- 
fection; it is rather found in the unfavorable course of re- 
covery in case of a spontaneous healing. Surgical wound treat- 
ment favors the course much more. It eliminates the almost 
certain infection of the wound with its profuse suppuration. 
The development of senuestration of the bone will be limited or 
even avoided. Foreign bodies within easy reach can be removed. 
The course »f recovery will be much shorter, physical strength 
is preserved and bandage material can be saved to a large degree. 
Sometimes the bother of drooling and disfiguration can be elimin- 
ated at once, Freouently delayed plastic operations can be 
avoided or in any event they are simplified. The objections 
to this procedure are without foundation. They originate from 
the erroneous supposition that the surgical wound treatment i s 
identical with the method of treatment described by FRIEDRICH 
(radical excision of the wound and complete closure by suture). 
These two methods of treatment do not have anything in 
common. The procedure according to FRIEDRICH is possible only 
in case of small and superficial wounds, as FRIEDRICH states 
himself that it cannot be used with large wounds. The exact 
time limit, which FRIEDRICH established for his method of treat- 
ment (the 6 to 8 hour limit) cannot be put into effect for the 
surgical wound treatment, purpose of the latter is the 
basic improvement of the wound conditions which will permit the 
accurate approximation by suture. This effect can be obtained 
at any date. The surgical wound therefore 
does n«t depend upon a shirt period of time: PICHLFR states 
that it is effective at any time, LINDFMANN thinks that it is 
dangerous; but it is not. Erroneous transfer of FRIEDRICH1s 
method of treatment can become dangerous, that means the com- 
plete closure by suture of large wounds in the field of the 
maxilla but without the previous surgical treatment of the wound, 
which assures a healing without infections by keeping it open 
sufficiently. surgical wound, treatment with accurate 
approximation suture is not to be made in the front lines, but 
in the special departments behind the front lines. In this 
case a thorough knowledge of the matter has to be presumed. Thu 
objection that no special aid is necessary for the execution 
of the surgical wound treatment (LINDFMANN) is not entirely 
correct. Damaging losses of tissue and nerve lesion*in the 
preparation of the wound can always be avoided, if it is proper- 
ly executed. 
Disadvantages of this method are non existant and the ad- 
vantages are great. The demand for the final wound care should 
be expressed as follows: Fnllnwing the dental and jaw ortho- 
pedic preparation the surgical wound treatment is followed by 
partial suture which is performed to reinstate form and funct- 
ion. L* Final treatment »f iaw-face injuries. 
SiaJ25aE4iJ[fiajBje&ifl-U*cA^<-.scHUCHARDT 
The indication to use adjacent o»d distant flaps t• cover do 
fects in the area of the maxilla and face is discussed in the 
beginning. The plastic preparation of adjacent flaps which 
should be preferred, is limited by the size of the defect and 
by the formation of new scars. The use of visor and pistol 
grip flaps is denounced, as by using the new scars are made 
in visible places. As a distnat flap the author prefers the 
tube graft which makes it possible, by avoiding open wound areas, 
to transplant the necessary tissue taken from th® neck, arms, 
chest, or flank, to cover the defect. In numerous examples 
successes obtained, by treatment with adjacent and distant flap 
operations from the field of plastic surgery of the face were 
shown. Most interesting cases of t»tal orbital plastic re- 
pair and replacement of chin structure by new methods of treat- 
ment using tube grafts shown. For some cases of •stee- 
plastics of the upper and lower jaw the tube graft is used, 
the bone transplant is imbedded into it, and is thus brought to 
the defect together with the graft. 
The goal of each final treatment in case of injuries of 
the jaw and. face is to cover the defect with tissue originating 
from the same body and to make the patient independent from 
prosthesis as much as possible. 
iU IIa.Slic„re£air_of_t he_jQose„wit]i_a_tube_£rolf t. 
Stabsarzt (Captain M,C.) SCHUCHARDT 
We will briefly discuss the possibilities of soft part 
substitution with free and pedunculated, grafts in defects of 
the nose. For all partial plastic operations on the nose, flaps 
of the forehead and cheek are very suitable, SCHUGHARDT, how- 
ever, used only flaps from the face if the dtnor site could be 
closed again by suture without disfigurin'*7 deformaty of the 
mouth, lower eyelid and eye brow. In case of large flaps from 
the forehead the covering of the donor site is possible only 
by free transplantations of skin. As this always causes the 
development »f ugly scars, SCHUGHARDT denounces the total and 
subtotal plastic operations »f the nase using skin from the 
forehead. The ideal means for t»tal and subtotal plastics of 
the nose is the tube graft. On the me hand it has t# be chosen 
according to the extent of the defect and on the other hand 
according to the suitability of the donor sit®, the upper arm, 
the chest or flank. It is bettor to rebuilt an individual 
nice with the abundant material offered by the tube graft than 
by using an adjacent flap from the face, A special advantage 
of tke tube graft is the complete avoidance of visible second- 
ary scars. The technicue for forming a profile frame and the 
importance of using orthopedic methods of support and pressure 
bandages in cases of large plastic reconstruction of the nose 
was demonstrated. Pressure dressing for shaping the trans- 
planted soft-part tissue is pointed out. Discussion »f the lecturers tho first and final 
gurglcal and orthopedic ox ia^’_anj 
IaP.e„injuriesJL 
WASSMUND*, Exhibition of a new extension damp was 
developed by WASSMUND for the extension of the lower jaw, 
BRUHN'sextension foreceps used up to date took hold of the teeth 
of the jaw with one arm, the other arm is a one prong 
hook which adapts to the lingual surface of the lower iaw. 
The individual manufacture of these extension forceus reeuires 
some working time in a laboratory. The cap-splint which over- 
lies the teeth, disturbs an °xact adjustment of the bite and 
its examination. If only a few teeth are left,the capsplint 
cannot find any support; also not if the aveolar process is 
broken in the front area. With a toothless lower jaw BRUHN 
substituted the capsplint by a second hook, which, lying in 
the oral cavity, grasps the aveolar process from above. But 
in this case the use of a prosthesis is impossible. It was 
my desire to make the extension ap aratus in the simplest 
way and without work in the laboratory. It has to be suitable 
for every jaw and even a toothless lower jaw. This 
can be accomplished by using a 3 prong extension clamp. Two 
prongs apply to the lingual of the jaw, the third one is 
made like a screw and applies to the font area of the ch:n. 
By this the chin is firmly fixed and can be extended as desired. 
The clamp was worn for months in about 15 cases without causing 
any inflammation of the soft parts or the bone. Up to now, we 
have manufactured the extension clamp ourselves in the laboratory 
from 3 mm thick stainless steel wire. 
Its mode of application iw shown in the case of a serious 
comminuted fracture on both sides of the lower jaw. Both 
horizontal branches were demolished, the small middle piece of 
the chin was toothless. It was markedly dislocated in the 
direction of the hyoid bone to the back and downward, A closing 
of the lips thereby becomes impossible. The chin was grasped 
with the extension clamp which was extended to a head-splint. 
It was kept at rest in the right position for about 5 months. By 
achieving th° extension and the resting position in this way 
a bony consolidation of both side defects was obtained whech 
was about U to 5 cm large. It has been said that by combined 
efforts of extension and resting position a spontaneous bony 
regeneration can be gained, even in case of very large bilateral 
defects of the lower jaw, so that a further #steo-plastic 
operation will be unnecessary, and the period of treatment 
is considerably shortened. 
PERWITSCHKY: The method of early wound treatment in 
my maxillary surgery hospital differs in two r 'gar "s from the 
points of view of the speaker: 
1, Fixed time of the wound treatment, 
2, uninterrupted suture, respectively partial suture and 
suture with drainage. 
Comments to #2: I treated all cases by an early suture 
with the exception of those where the extent of the defect did 
not allow a connection of the wound on account of a loss 
of substance. Furthermore the joining on the edges of the wound in their whole extent becomes so solid th.it th°y com- 
pletely, In no case did I have to put in a drain and in no 
case did an infection occur which would have forced me to re- 
open the suture. 
Comments to #1: I closed all cases as soon as possible 
without exception by suture, i.e. as soon as th° fracture was 
put in a resting; position br a splint in case of a fvacture of 
the lower jaw. Only the necrotic shreds macroscopically vis- 
ible, arc removed (foreign bodies and bone splinters lying loose 
in the tissue,too of course). How is it possible to explain 
the contradiction between the experiences of the speaker and 
Mr, WASSMUND and my own? The answer may be that I always closed 
the wound early without keeping any portion of the wound edges 
apart artificially by insertion of a drain or a tampon to faci- 
litate an outflow of the wound secretion. It is probable by 
this that the damaged cells located close to the wound edge 
ar-> preserved or that their necrosis escapes an observation with 
the naked eye. 
Bn account of WASSMUND*s operations I watched throughout 
the last year for a different manner of wound healing and did 
not find any differences in case of wounds which were closed 
on the second, tenth or even the 2Bth day, A limit is made only 
through cpithclializing the edges of the wound. 
According to my opinion my experiences are specially im- 
portant for the surgeon in the front lines, because they do 
not limit him to the imitation position with regard to the 
suture, 
Comments to SCHUCHARDT's dissertation: Lately I preferred 
the tubegrafts from the back pedunculated on a level "rith the 
shoulder, method of treatment will bring pain to the 
patient such as I observed, with the fixation of the arm in case 
of a transfer of a flap from the flank, Fxceptions are made only 
with smaller defects of the face where I find that a tube graft 
originating from the neck is ouite sufficient. Furthermore the 
tube graft from the back has the advantage that it is possible, 
on account of its thick muscular apparatus, to take a thick flap 
oven from skinny patients, and furthermore the skin is loss hairy 
than on the chest. 
FLOHR: The oucstion of active surgical or conservative 
treatment in case of face and jaw wounds, which was not ru? te 
clear in 'Vorid War I and at the beginning of this war, has, 
according to our experience, been determined in favor of the 
surgical wound treatment. In spite of the persistency with 
which some schools stick to the conservative open wound treat- 
ment, we decline this method as unfavorable and less successful 
for the patient, as it freouently leads to extensive plastic 
operations and unnecessary prolongation of the time of treat- 
ment on account of the bad functional results and mutilation of 
the face. 
According to our experiences those cases, which were given 
only first aid by the medical units in the front lines, i.e, 
wh-re lust the hemorrhage was controlled or a debridement of the 
wound was made, showed the best results. Therefore, contrary 
to the methods applied during the first .orId War, the first 
special treatment should be made in a maxillary surgery hospital 
near the front lines. The most freouently observed mistakes violating the principles of the first treatment of soft parts 
and bones of the face arcs 
1. too extensive excision of wounds, 
2. neglect to suture the mucous membrane, 
3. bone suturing and 
4-. lately, marrow nailing of the jaw bones. 
It is justified to forbid the suture of gun shot wounds 
of the trunk and the extremities. But in the of the face 
we should like to consider it as a logical measure after the 
surgical preparation of the wound, It would be contrary to 
common sense to excise the wound and later on expose it again 
to the oral fluids with all tis germs and residual food. In 
our field wo do not excise because wo dread an extension of 
the infection, but to gain an approximation of thr facial 
parts with a suture, by creating clean ’.rounds. Our experience of 
many years showed very clearly that a suture sho'uld be striven 
for, although the decision, whether a co1 pl~te or partial, im- 
mediate or primary suture, if approximation suture or delayed 
suture under open granulation should be made defends on the 
age, kind and state of the wound, as well as the experience 
of the surgeon. 
Special consideration was given to the use of mucous mem- 
brane for closing off the source of infection coming from the 
mouth and by this to exclude the disastrous adherence of soft 
tissues of the face to a wrong part of the jaw hone. This 
very important point is not much discussed in our professional 
literature although the bad functional results and the diffi- 
culties which meets later when fr'eing such scarred deformities 
are very well known to every maxillo-facial surgeon. 
Comment on the treatment of fractures: The Bauer-SCHROJ‘DDR*s 
wiresplint bandages used for treatment of jaw fractures and 
modified according to WASSMUND, still dominates the field today. 
In the first year of the last war I recommended a United use 
of wiresplint bandages. According to a well based explanation 
by RFICHPNBACH, he too reco "ends that the wire bandages be 
substituted by splints, similar to a prosthesis, if one has to 
deal with defect fractures in the horizontal ramus of the jay; 
and fractures in a jaw with too few t~eth, Shortly after the 
beginning of the war we declined the use of wire formed into 
a loop according to HAUPTMFYFR as a splint for jaw fractures. It 
proved to be a failure. In his latest publication RFICilbUBACH 
took a similar, although not so completely adverse standpoint. 
We did not consider the SCHLAMPP-splint as favorable as several 
ethers simply because its application with special ligaments 
is complicated, time consuming and depends upon the use of 
special instruments* 
Wire Suture in Case of Bone-Plastics, 
The skillful fitting of the implanations into the defect, 
the pointing and making of impaction holes sometimes creates 
the possibility of an infection on account of the length of time 
of the operation and th extension of the bone stumps. For these reasons the operation is frcoucntly without succors. If 
possible wo nowadays expos*.; only tiro edge of the low or jaw, 
freshen it to a. large dogr and fix the implantation securely 
by two wire sutures. To shorten th l»ng waiting time from 
the day of injury till the osteoolasty, i.c, U - 6 months 
after the injury, we exooso the edges of the bones around the 
defect about 1+ w~ ks before the operation is supposed to take 
place, cut out all infectious tissue and eliminate th*' ulcerating 
edges of the bones. In this case we do not rely on the X-ray 
picture, 4, weeks later th? real transplantation of bone with 
wire suture is performed. By this procedure we gain about 4- - 
6 months time. If fragments cannot be supported by a prosthesis 
we successfully bridge over thr defect by means of ivory sticks of 
the thickness of a pencil and cover the defect itself by broed, 
flexible tibia chips. Up to now we heve op-ratod about 30 cases 
in this manner and gained healing and consolidation almost 
without exception. The ivory sticks healed in and coasolid .ted 
almost universally according to our experiences ov r 4- y w.rs, 
UNTERBFRGERs A thorough, special and immediate treatment 
of gunshot injuries in the uuper jaw is essential to avoid second- 
ary suppuration of the injured area and furthermore it is the 
best prophylaxis against the occurrence of dangerous and even life 
endangering complications, originating thereform. On account cf 
our experiences in many cases with injuries in the middle section 
of the face, of which injuries of the upper jaw and Highmore1s 
antrum take the first place, a surgical aft«r treatment was 
necessary chiefly for the following reasons: 
1# Secondary ■treatment yfas most frequently caused by re- 
»condary_infect ipus_fpc i_pf_ shat ter ed_bpne__ wit h continuous 
suppuration externally (formation of fistulae)j 
2« .second to mention' are opepatio.ns on accoppt_pf eon- 
£ll.gatlpns._caus e_d_by_.inf ect ions . ext endi ng from the focus off 
£hatt^jone_towards_the_putsidea Several complications were 
observed: 
a) Purulent infections in the area of the ch'eks origin- 
ating from the shattered maxillary sinus. The channel of infect- 
ion is exposed down to the maxilla :n this cas°, abscess drainage 
tow rds the maxillary sinus is made. If possible, an incision from 
the outside should be made too, 
b) Orbital complications. First of all removal of splint- 
ers in the area of the roof of the maxillary sinus should be made. 
Furthermore one should try to find site of entry of the in- 
fection into the orbit. Finally an opening and drainage of the in- 
fected parts of tissue is necessary. In case of serious processes 
with danger to the eyeball it is advisabl- to combine the operation 
with drainage of the orbit cavity towards the outside, by removal 
of either the lateral or medial wall of the orbit. 
c ) Pp-gsibi jtj.ties pf ,ipf ectgops gf t,hg„. back wall ,tJa.§ - 
siThe infection tends into the £sa1 nfratemporal- 
is towards the outside if the back wal1 is injured. The larger 
outer part of the fossa is formed by the fossa infratemooralisf the 
smaller inner part is formed by the f o s eyyg.o o^l^iirja,, If 
the infeetion extends within the fossa, infratemporalis it is poss- 
ible that it spreads into the parapharyngeal space and extends 
bv gravity into the mediastinum, (mediastinitis), If the infection 387 
rises from the fossa infratemporalis the route of spread of the 
infection passes subt errporally and thereby causes a spelling 
of the temporal area. The best way to reach the focus of in- 
fection in case of such a subtemporal oxters:on of the infection 
is to make an incision from the outside into the soft parts 
according to KROENLEIN and with a descending way of infection, 
o£enin£_pf_the_naranharyngea 1_J3pace and of necessity 
di.a._sot_omay be necessary. 
If the infection proceeds by way of the iniured back v/al" 
medial’y through the fossa pterygopalatina, the infection spread- 
ing from the fascia pharyngea causes an infiltration or c ,! 
the pharyngeal wal , and furthermore can extend as an infiltrat- 
ion of the larynx and oesophagus wall and even become an abscessP 
As the formation of an abscess is usually superficial it fre- 
quently occurs that it spontaneously ruptures into the pharynx 
and thereby heals completely; on the other hand an incision 
from the inside may be necessary on account of increasing diffi- 
culties of swallowing or dyspnoea. In especially grave cases 
the danger of suffocation has to be feared and can be met only 
by an immediate tracheotomy. Seen from the oral cavity the in- 
fectious focus of extension, originated in this way, shows up 
as a swelling in the area of the lateral pharynx, the soft 
palate ou:te frequently shows considerable diminution of the 
mavability of the soft palate, and thereby the pronounciation 
becomes nasal and. swallowing becomes more difficult oh account 
of regurgitation of the liquid through the nose. If the infect- 
ion extends towards the ostium pharyngeum, secondary ear symp- 
toms occur. 
A parapharyngeal abscesc can be caused by an abscess of the 
pharynx wall penetrating into the pharyngeal space, so that an 
necessary only in case o? an abscess of the 
parapharyngeal space;may have to be considered. 
3) Complications following sudden severe hemorrhages. The 
Beollnue tamponade is the best auxiliary procedure in case of 
sudden hemorrhages from mouth and nos . Complications as a se- 
quence of injuries of the middle part of the face skull are re- 
ported about by my assistant, Stabsarzt Dr, KRETSCHMER in 
ZIMMER*g Monograph, Wehrmedizin, Kriegserfahrungen, c2lL1* 
I Band. Kriegschirurgie, Verlag DFUTICKE, 
WASSMUND : All- lecturers agree that an early closure of face 
wounds is desired. PERWITZSCHKY1s conception deserves a closer 
examination. I think we lay too much stress upon the freshening 
of the wounds in case of an early suture. The extensive and 
snug closing of the revised wounds of the face as performed by 
PERWITZSCHKY is, according to my opinion, not favorable, as it 
serves secondary hemorrhage in case of wound areas still oozing 
or bleeding. If the wound areas are cleaned on the 10-12 day 
and wheh granulation has started, it is not necessary anymore to 
freshen them; the condition of the wound and the power of resist- 
ance of granulating areas is very good and does not reouire im- 
provement, It occurs frequently that wounds of the face are ex- 
cised in the main dressing station and the field hospital with- 
out even intending or executing a partial suture. This proce- 
dure, that turns out well in case of shot wounds on other parts 
Of the body cannot be accented for the face and should be for- 
bidden, as it sacrifices precious tissue without need and 
necessity. An excision of face wounds jo sensible only if a partial suture follows immediately. As a rule this world be 
performed only after orthopedic treatment of the bone fractures 
and therefore should be executed in the special department for 
maxillo-facial injuries, 
I use the tube graft from the back as observed by PFR ITZ* 
SCHKY with some of my patients, only in special cas°s5 for 
instance if ehest and abdomen are too hairy, I would not pre- 
fer to take a tube graft from the back as a general procedure, as 
the skin of the back is very thick and cannot be fitted into 
the tender skin of the face as well as other material, 
SEIFERTHs From the point of view of a maxilla, nose and 
ear specialist I am sup orting an early surgical treatment of 
jaw injuries inflicted b * gunshot on account of the danger of 
rising infections in the inner space of the skull. It is 
possible that damage due to impact may be caused by the explosive 
effect on the base of the skull in case of jaw and maxillary 
sinus gunshot wounds which in rarp cases even causes dura and 
brain injuries. Therefore a revision of the maxillary sinus 
has to be made to avoid intracranial complications. 
SCHUCHARDT; I am surprised about PFRWITZSCHKY declining 
the use of the tube graft from the flank. The bother to the 
patient, which is connected with the use of the long tube graft 
flap from the back is considerably more than that caused by the 
use of tube grafts from the flank. The patient is very much 
hindered in lying if the tube graft from the back is used. 
I 
A fixation of the head, lasting for several weeks, dees 
not damage the sound shoulder joint and the patient easily 
gets accustomed to the forced position within 1 or 2 days. If 
the tube graft is separated from the upper arm, the pains in 
the joints will decrease shortly thereafter. I very rarely 
could find, a reason to use a tube graft from the back. 
It is a disadvantage of the tube graft the neck 
that keloid scars develop after the peduncular flap is taken. 
He there fore prefer the acromio-pectoreal round peduncular 
flap to the round peduncular flap from the neck. 
The Cause and .Tre^tment_pf_Life_oj^d^ngering_second.ary 
Hemorrhage s_in_C^se_of_lnjuries^.pf__the_Face-sku.llA 
Stabsarzt (Captain M.C.) K..W. SCHNEIDER 
Extensive hemorrhages in cas'1 of face injuries almost 
regularily reeuire a ligation of the external carotid, because 
control of hemorrhage in the area of injuries very seldom 
succeeds, A total of 21 (20%) mostly severe secondary hemorr- 
hages occurred in case of 106 ligations w« trace the causes 
of these sedondary hemorrhages. In addition to the knowledge 
we have up to now about larger anastomosis of the head arteries 
it was proved by experimental experiences that all head arteries 
on both sides are in close connection among themselves. By 
arteriograms of corpses and preparatory examinations of the 
vessels it :as possible to detect two large direct connections 
between the two internal maxillary arteries and several anasto- 
moses of the internal maxillary artery with the internal cartoid 
of the same side. 389 
Our experiences gained from clinical observations and 
postmortem examinations prove that secondary hemorrhages 
can basically be traced back to the large anastomoses bet- 
ween all head arteries which make a retrograde refilling of 
vessels possible. Besides this, the meningeal reflex, started 
by the ligation of the carotid externa (70-100$ increase of 
the blood circulation in the carotid arteries on both sides) 
increases the danger of starting secondary hemorrhages. 
Hemorrhages following injuries of the inside of the 
nose, especially of the ethmoid - sphenoid sinus area frequently 
originate from the vessels of the internal carotid artery, but 
w« always have to take into account diagnostic difficulties, 
especially in case of hemorrhages from the upper part of the 
nose. 
The treatment of hemorrhages and secondary hemorrhages 
wMch follow injuries of the face-skull always has to take into 
account these close connections between all head arteries. The 
most ouccessful staunching of hemorrhages in the area of injury 
cannot be made most of the time as structure of the face- 
skull makes the location of vessels exceedingly difficult 
of access. Besides making a pressure tarnoonade, the supporting 
main-vessel, which in most cases is the external carotid artery 
has to be interrpted too. The secondary hemorrhages starting 
thereafter can generally be traced back to the supply over the 
same sided internal carotid, rarely over the contralateral extern- 
al carotid. The supply over the internal carotid can bo stopped 
effectively only by eliminating the direct connections. 
7. Hemorrhages in th<* maxillo-facial ar^a. 
0 z t_Xli3s 
Late hemorrhages of the face-skull differ functionally 
but not orincipally from oth~r large hemorrhages on account of 
their extensive collateral circulation and this has to be taken 
into consideration in attempts to control such hemorrhages. The 
collateral circulation of the Internal carotid artery in case 
of late hemorrhages is of minor importance, but there is an 
important anastomosis between the artery and the 
artery occipitalis. 
Guiding principles: 
Every minor, unimportant secondary hemorrhage can 
lead to a life endangering and therefore revision 
of the wound, respectively the wound extensions, is re- 
quired , 
2, To apuly a tampon to a wound in case of late hemorr- 
hages does not bear any success, but only precious 
time, 
3* The only secure method of hemostasis in case of late 
hemorrhages of the face-skull is control of the hemorrhage 
at the very place of the blooding. 390 
4. If* it is rot possible to discover the origin of the 
hemorrhage, or if the additional operation appears more 
difficult than a ligation of the external carotid, the 
carotid can be tied off. If the hemorrhage recurs, it 
would not serve any purpose to tie up the carotis com- 
munis, hemostasis has to b° accomplished at the site of 
bleeding and one should not hesitate to perform a tre- 
panation or resection of the maxilla. If there is a 
repeated hemorrhage with penetrating injuries of the face- 
skull after a ligature is applied to the carotid and it 
cannot clearly be recognized from whi ch side it origin- 
ates, then the external carotid on th~ side can 
be ligated. 
5. Either before or during each operation a blood- 
transfusion has to be made. 
Discussion concerning hemorrhages in the maxille*facial 
WASSMUNDj The number of 106 ligations of the external 
carotid as reported by SCHNEIDER is curte high. It is not 
quite clear why the common carotid is ligated prophylactic - 
ally in this case. When the ligation is made at the place 
of choice, a hemorrhage of the external carotid is not to be 
expected. It is surprising that, in sp:te of this, SCHNEIDER 
reports 20% secondary hemorrhages, I myself observed second- 
ary hemorrhages of the arterial system only in very rare cases. 
By the same token it is possible that veins are injured or 
can be erode* from which secondary hemorrhages can start* 
Therefore as a rule it is reruired to make a ligation not at 
the place of choice, but at the olace of the hemorrhage. The 
gunshot wound is to be opened widely and has to be kept wide 
open after the bleeding vessels am ligated. It must stay 
wide open, be taraponaded and has to heal under granulation* 
Only if this procedure is not Possible or fails, should a 
ligation of the carotid be made. 
BECK: in spite of a ligature apolied to the external 
carotid, secondary arterial hemorrhages can occur out of its 
anastomoses. One example showed that the hemorrhage stopped 
after a ligation was applied to the spheno-palatina, 
In some cases an existing aneurysma of the carotid has 
to be considered. The picture of an autopsy specimen is 
shown, demonstrating an aneurysma of the internal carotid on 
a level with the naso-pharyngeal area. The patient i ed on 
account of hemorrhages and asphyxia. If an aneurysm is sus- 
pected, an arteriograohy with lodsol or Vasoselectan is 
recommended. We refer to PHILIPPIDES article in "Der Chirurg11, 
1942, Heft 19. 
SCHNEIDER: First of all I should like to make certain 
corrections: We have to distinguish between hemorrhage and 
secondary hemorrhage. By secondary hemorrhage I understand a ' 
hemorrhage subsequent to or succeeding a v°srel-ligaturr, 
Secondary hemorrhages occurring with a ligature of the external 
carotid naturally have originated from the of injury and 
not from the ligature of the vessel having injured the vessel 
itself. I think that the ligation of the common carotid is 
necessary as in case hemorrhages arise I have immediate control of it by a tenporary ligature of the vessel. This ligation will 
never present any danger for the wall of the v-ess#l„ A tamjwnade cf 
the wound bed is necessary, as the influence of the anastom- 
osis with th<= other vessels has always to be considered. The 
knowledge of the physiology of the flow of blood in the head 
is the basis for treatment of such hemorrhages and secondary 
hemorrhages. During my speech I always stressed that on 
account of a ligature of the external carotid a continuous 
increased flow of blood of about 70 - 100$ is caused in the 
carotid on both sides. As the blood pressure regulation of 
the arteries of the head is completely independent from the 
bl»od pressure of the body .by self regulation, therapy intended 
to increase the blood pressure does not have any influence 
on the blood pressure of the head, A ligature of the common 
carotid artery stimulates the carotis sinus at the same time 
and thereby causes an increase of blcod-pressure by vaso- 
constriction in the head. 
iL* Gpnshot injuries of the joint ox the iavf. 
Ofrprstftbsap?t (Mfl, ,1 Q£_J^C.grpf, k'ASSkUMD 
Gunshot injuries of the joint of the jaw are frequently 
connected with injuries of the auditory canal and auditory 
organ; and succeeded by a suppurative inflamration of the au- 
ditory organ. Fractures of the base of skull and souamous 
portion of th° temporal bone sometimes exist at the same time. 
The danger of cerebral complications is to be considered. The 
otologist and neurologist have to be consulted in time. In 
spite of an undamaged covering of the soft parts over the fract- 
ure of the joint, it is possible that the injury in the joint 
is infected, as the missile passed through germ containing 
cavities of the face-skull (oral cavity, pharyngeal cavity, 
maxillary sinus) or because the wound in the joint communicates 
with the auditory canal, A closed, infected injury of the 
joint demands an early opening and undisturbed outflow of the 
secretion. In case of an open injury of the joint a suture 
cf the capsule within the first 24 hours may prove very use- 
ful. An injury of the joint, closed and without inflammation 
(adeptic) should not be touched. 
It is necessary to put the lower jaw in a resting position 
for the duration of the inflammation (4-6 weeks). Fello'ring 
thereafter active and passive movement has to be started. 
Trismus (Kieferklemme) has to be •vercome by stretching - 
exercises, other wise a scarred contraction or ankylosis cannot 
be avoided. A deviation of the low r jaw towards the Injured, 
joint has to be prevented by an plane or a splint 
(applied to the sound side). 
The indication and th° danger of injuries has 
to be examined before missiles close to the joint removed, 
A missile in an infected missile-bed has to be removed. A 
chronic suppuration from i fistula in the’area of the joint as 
well as- a chronic suppuration from the war dan possibly originate 
and 'be*' supported by the missile, .--Ac •ncapsulated missile■ oafi re- 
main in its place. Small»missiles should be left alone? while 
large onfcs have to be removed if: they disturb the movements of-.the 
joint 6r if they cause pains. The physiological reaction ha# to 
be considered. Some soldiers are not fit for service, 392 
Maiil3^£b£i£i^b<g^rit_XiiACmdrJ1._MJ>CJkJ.].IS2Yl„BECK 
The roentgenological picture of the dis-as'-'d joint of th-" 
jaw can be made by the possibility of opening V'\r mouth during 
the exposure according to PARMA-PORDES, In cas- of a closed 
jaw the most certain view of the joint of the jaw is possible 
by using the modified SCHUELLFR -position, w!*ich at thp :same 
time allows an exact interpretation of th*- conditions of the 
joints. Traumatic conditions of the joint of the jaw reouiro 
an additional occieito-frontal picture of the skull, which, 
in case of insufficient results with tho usual positions have 
to be made with perorbital presentation of the joint of the 
jaw, A new modus of X-ray photography will be introduced. 
Secondary changes of the joints are of importance for jaw 
surgery' in wartime. The various operations of the joint, of-'the 
jaw are being disoassod, starting with experiences made with 
the treatment of fractures of the jaw. 
In case of ankylosis a broad resect:on of the joint of 
the jaw should be made, Orthopedic aft^rtreatm:nt to overcome 
muscular contraction can be started immediately aft'-'r the 
operation. The incision according to AXHAUSEN-BOCKENHEIMER 
should be chosen- to gain access to the joint of the jaw. 
The intermediate grating #f the joints is part of the 
clinical picture of deforming arthropathy, Chondreal changes 
demand the excision of tho disk. Osseous diseases of the head 
of the joint, combined with severe disturbances of function, 
reeuire the resection of the diseased of the joint. 
The habitual luxation can be removed by of splitting 
open the articular eminence according to LII'DEMAFl or by an 
osteoplasty. Very often the formation sear-tissue between 
the articular eminence and the joint of th~ jaw by openin'? this 
space, and a subsecuent prolonged tamponade are ,quite sufficient. 
Injection-treatments are rejected. 
. . The displacement of th'' disk towards the front according 
to KONJFTZKY is recommended only in case of simultaneous disease 
changes of tho disk of the joint. (terminal and intermediate 
grating of the joints). 
If the head of the joint is fixed firmly between the cart- 
ilage disk and the articular eminence, in other words, if a 
subluxation exists, it is sufficient to make a slanting excision 
of tho front part of the disk to remove the mechanical obstacle. 
If there is a luxation at t same time this measure will bo 
pre “cdod by a plastic elevation ~f tho body of the joint. There- 
by it is' possible to avoid tho inadeeuate use of tho cartilage 
aroas of the head of the joint and its counter-beds in case of a 
loss- of the disk. 
In case of loss of the joint of the jaw the disturbances 
•f occlusion can be balanced by an extension of the jaw-arch 
according to TRAUNER’s method, A sliding plastic operation 
behind the crest, of the ascending lower branch of. the maxilla 
is mentioned. If large defects of thr lower jaw a covering by 
plastic operation, short fragments of the joint should be 
left alone. -*-t is advisable to fasten the proximal end of 
the transplant in the soft carts. 
Dis£ussi3ri_conc or nin£.,guns hot-wound s_a£d_dis 03s 
JLb£_ joint_o f _tj}e_ jaw.* 
SCHUCHARDT: The functional after-treatment of diseases 
of the joint are very often »f decisive importance for the 
final result. To avoid a deviation towards th~ side it :1s not 
sufficient to contrive an inclined plane on the sound side* 
Much more important than this is systematic ex-rc:se therapy, 
which, if proper instruction is can easily learned 
by the patient. When he makes ex'-rcis'S of opening and closing 
the mouth in front of the mirror for instance, he should be 
told to watch that with a maximum opening of the mouth, the 
middle of his lower jaw should remain in th" mid-line of the 
face. 
BECK: There are situations which force us to remove even 
splinters remaining in the surroundings of the joint of the 
jaw. The following cas shows a patient wounded at the northern 
front, 
The X-ray pictures show splinters lodged medially to the 
joint of the jaw next to the base of the skull, * or 3 years 
ho had fistulae in the tight side of the necv and neuralgia. 
We declined removing the foreign bodies by making the operation 
inside the mouth on account of the danger of injuring important 
vessels and eventual formation of scars in the area of the inner 
masticatory muscle. An osteotomy was made In the ascend4 ng 
ramus and access was gained to the splintbers lodging in the 
joint of the jaw, which could now bo removed easily. 
PERWITZSCHKY: Comment to Wassmund’s lectures: I am very 
conservative when it comes to the removal of gun-shot splinters 
laying the joints. I operate only if by a series of X-ray 
pictures it can be proven beyond doubt, that the foreign body 
presents a mechanical obstacle for the movement of the joints. 
Lockjaw is caused freouently by scars of missiles which 
have penetrated deeply. If in this case an operation is made, 
I necessarily have tc consider that the scar made by the operation 
will always be larger then the one made by the missile itself, 
and furthermore the disadvantageous effect has to be considered. 
Directives for the Treatment of Injuries to the Facp 
arid... Jaw, 
General Comments, 
1, The medical units in the front lines (medical company, 
field hospital) should limit their activities to the 
first aid of injuries to the jaw and face anch as: 
operations for saving life (hemostasis, tracheotomy), 
putting the fractures in a resting position by simple 
methods, dressing of wounds. Any kind of surgical 
treatment even excision of wounds, should not be 
made. The most important thing to do is to transport 
the injured to the nearest special department as prompt- 
ly as possible. 394 
2# The special maxillary and face department of the 
medical establishments in the rear areas are res- 
ponsible for the final treatment. As a rule they 
start with the orthopedic treatment of the fract- 
ures, which then is succeeded by the surgical wound- 
treatment, The latter one consists in the surgical 
preparation of the wound followed by a partial suture, 
depending on whether or not the condition of the 
wound allows or demands it. A complete closure should 
not be made, as the undisturbed outflow of secretion 
has to be assured. In case of large los es of sub- 
stance a suture tension and plastic coverage 
are unsuitable. Plastic operations should be made by 
the special department for maxi 11o-facial surgery 
(Restoration-Surgery), In of a possibility of 
injuring the accessory organs the competent special 
surgeon should be consulted. 
3, If it is not oossible to send the injured to a special 
maxillo-facial surgery hospital within the first week 
after the injury the final treatment has to be given 
by the medical units in the front lines according 
to the above mentioned rules. 
x Particular Details. 
Gunshot Injuries to the Joint of the Jawt 
If the joint of the jaw is injured by gunshot, very 
frecuently an injury to the base of the skul , th" temporal 
bone and the auditory organ is inflicted at the same time. 
It is advisable to have th^1 patient examined at the earliest 
date by an otologist and neurologist. 
A closed injury of the joint without inflammation 
should be left alone. In case of an open injury of the 
joint a suture of the capsule with:n the first 24 hours 
may prove useful in some cases. 
If an acute infection arises, the closed ioint has to 
be opened immediately by an incision in'front of the tragus 
(edge of the auricle). 
After gunshot injuries it is necessary to keep the 
lower jaw in a resting position for approximately 4-6 
weeks. Immediately thereafter active and passive movement 
has to start on account of threatening contraction and 
ankylosis, 
The head of the joint may be removed only if it is in- 
fected and necrotic. 10- ypotfr. .diseases in th,g Forces .and .their 
i££erejQC e, f c r_t|ie_D nr vie e^. 
2b£r£eiaarzi_iLi^_C2lJ,„MJ.CJll_STUCK 
Taking into account the records of tr<*atm®nt of about 
1,600< ,000 soldiers w® si onld like to define our attitude 
regarding the dental care of the troops. we prefer an 
extensive dental treatment to a limited tr®at,™®nt, in which 
latter case special consideration is rd.ven to combating ex- 
tensive foci of inf ction, caries and paradentosis and further- 
more' to the matter of skill as regards the dental treatment. It 
is determined, that only highly skilled dental care assures a 
long lasting health of the oral cavity. An increase of the 
range of dental care has been taken into consideration, but 
it was rejected as detrimental, as the success of dental treat- 
ments depends on the exact execution of ®ach phase of the treat- 
ment, even the smallest one. This cannot be achieved, if the 
dentist’s time for treatment is li’ited. 
Emphasizing th® matter of skill does not m®an that larger 
numbers of soldiers needing dental care cannot be treated, but 
it reeu res a certain chan e of dental methods from the treat- 
ment of roots, which does not offer much success, and prostheses 
which are not essentially necessary, to an intensive treatment 
against caries and paradentosis, as well as surgical treat- 
ments (extractions and apical osteotomy) for focal 
which freouently originate from apical foci. 
In order to accomplish this, we suggest the introduction 
of new directives concerning together with suggestions 
concerning organization. 
1, Removal of all roots as well as all teeth if a focal 
infection exists and a cure can- at be guaranteed on 
account of apical dis as°s or adiacent dns iruction 
which extends deep into t guns and Is associated 
with suppurative inflammation#or decayed pulp. 
2, Simple methods of filling for all t®eth with new 
caries, Special consideration should be given to 
interdental spaces. The time consumed for this 
task can be justified as it is only a fraction of 
the time that would be needed for treating a tooth 
with an inflammation of the pulp. 
3, Treatment of dental pulp is justified if in the 
particular case the teeth are still of value funct- 
ionally, The treatment has to be done according 
to rules which exclude apical complications. 
Insertion of dental nlates or dentures is to be 
undertaken where the general health is seriously- 
endangered without them. 11 jl S © n 1 al-.i-aierial^Jl> 
z t_Xlja jorJL_MJ.C o f^_FALK 
Of the new materials generally used in the German Army 
the most suitable ones are those obtained from the basic substanc- 
es of carbon, lime and wat°r, and developed into polymerizations*- 
mixtures such as Paladcn and Palapont, As a basic substance for 
prosthesis we prefer Paladon to caoutchouc not only on account 
of its better cosmetic effect, but especially because it adheres 
better to the tissues. 
If proper indications are followed, Palapont may be used for 
single crowns, connecting links for bridges and a<. a substitute 
for metal all remirements and saves the preparation 
of amalgams and of metal teeth, and in addition it saves time 
because of its simple method of manufacture. Teeth made of 
Palapont adhere better to the basic material made of Paladon 
than teeth with button-pins. Press-dies for manufacture at the 
clinic should be available in every large dental hospital, be- 
cause they help to overcome difficulties in supplies. 
Silver-tin amalgams used as a substitute for prteious 
metals are only a temporary solution. Silver-tin amalcams are 
very suitable for fillings, crowns and bridges, provided the 
directives for manufacture are properly observed an-1 fin- 
ished material is submitted to the hard or "fusions adjustment. 
As* a partly finished material as well as raw materials, precious 
steels are a valuable additional material to our armamentarium, 
espcially for plates, clasps of metal, crowns, bridges and 
clamps which are to be manufactured in the laboratories. 
steel especially has become an indisoensa’le means on account 
of its relatively simple method of preparation and its attributes. 
As the manufacture requires certain knowledge of the pecu- 
liarities of the material it should be used only by skilled 
personnel. Inapororiate procedures impair the resistance and 
firmness of the material. Parts of steel should be connected 
only by . i soldering with gold-steel-solder, the obtaining 
of which is, according to my experience, a matter of consider- 
able difficulty. The welding together of parts of steel re- 
auires further trials and experience. 
IZjl concerning , Tooth-Subst ituteg witfc_reg_^rd_to 
Preservation and Restoration of Fitness for Front- 
Siab3£rst_l£l_XC3£t£iri_Mj2^R£se£yel_ISSEL 
The lecturer discussed the meaning of "fitness for duty 
in the front lines", as concerns the function of mastication. 
Complete fitness for frontline duty not exist, if the 
Td-tions which ar° available for the troops are insufficient, 
or can be made into small Sits only by a largo expenditure of 
time and energy. Here wo have to consider the special troops, 
such as crews of submarines, flying personnel, air-borne 
troops and parachuters who ha’e to depend on hard, special rations 
sometimes for days, and furthermore musicians, playing brass in- 
struments belong to this group. In special cases a disturbance of tho function of speech can reduce tho fitness for frontline 
service, (Transmission of orders verbally and by telephone)* 
In order to establish clear directives wh ch should serve 
the restoration of fitness for frontline duty we discussed 
critically the fixed and removable dentures and their indications* 
Special consideration was given to the materials available 
in war-time. 
New materials of metal and non-metal (steel and Palapont) 
were subjected to a critical examination, and the indications 
for their use w~re established* The construction of dentures 
with these materials in order to preserve the fitness for front- 
line duty was rejected because they were not found suitable by 
the experience of the last 3r years. Among others, large steel 
bridges extending over th ' area of thrt front teeth and there 
fastened by pin-crowns were rejected. The peculiarity 6f the 
steel and the way it has to be treated does not assure an exact 
fit of the pin-crowns with or without a ring. If st-el crowns 
were used as anchors steel was suitable, if the denture was made 
properly * 
As regards Palapont, the lecturer firmly 
fixed replacements of t-eth (crowns and bridges) r be made in 
such a way that the Palapont can easily be replaced if repairs 
are necessary, without rnmoving the bridge r<- r.;cti th" 
metal structure of th"' crown from the mouth, Theso ree’ i 
are not met with scaffold bridges and for f s reason they 
should not be made. 
Firmly fixed replacements of teeth have limited to 
those cases where only by this means will the fitness fo* 
frontline duty be restored or retained; and furthermore toJ 
those cases where existing replacements of teeth have been 
destroyed or teeth been lost by a disability due to tho war. 
In all cases an X-ray control of all the pressure lines is 
essential, 
The crown with attachments was rejected as an unsuccessful 
construction. 
Setting aside the special cases mentioned above, removable 
dentures are indicated in case of insufficient ability to mastic- 
ate. The ability to masticate is looked upon as sufficient if 
4 pairs of masticators articulate with one another in the side 
of the dental arch. In many cases the normal time for recovery 
of about B-12 weeks had to'be reduced to 4-6 weeks in order to 
serve the interest of an early restoration of fitness for frontline 
duty. In special cases a provisional arrangement can bo made 
immediately aft "r the extraction. We have learned by experience 
that such provisional arran rirmnts function for quite some 
time (RFICHBNBAGH), 
Prostheses which can be removed have to b-> manufactured as 
simple plat "-pros t hesi s with simple and >ur p<-> p ~f ul clamp-f astoninrs , 
The use of the lingual bar without a simultaneous ns •- of continu- 
ing clamps was rejected for the free-end worn on both 
sides only gingivally on the lower jaw. Here the base plate 
is indicated which adheres to the front t"eth with its upper ed- 
ge and thus opposes the tilting up of tho free-end saddle. Prostheses for jaw defects take an exceptional position for 
soldiers in jured by gunshots, as here not only the missing 
but also parts of the jaw have to be replaced. The fast- 
ening of these prostheses was discussed and explained by pic- 
tures. In order to preserve the remaining teeth the lecturer 
strongly urges, as a result of his experiences during .’orId 
War I, regarding the late prosthetic treatment of soldiers in- 
jured in the jaw by gunshot, that clamp-tectK should bo connected 
by crowns, respectively bridges with one another and. the defect 
prosthesis should be suspended on them with some flexibility. 
So-called clamp-crosses, made of steel-wire, render valuable 
aid. If appropriate arrangements ar- made, they can be used as 
splints and so servo for the fastening of defect prosthesis, if 
in sore cases the stiffening of crowns is not necessary, a clamp 
system has to bo chosen for fastening the prosthesis, which at 
the same time has to have the characteristics of a splint. 
Concluding, .the lecturer pointed out that a cooperation 
between the maxillo-surgeon and the prosthetic surgeon is 
necessary. By" this cooperation lost time can be avoided in fit- 
ting the prosthesis by avoiding later correction of the olveolar- 
is crest. 
l Urgent Elimination of gaips flt tho Front Lipo?, 
0boraX3i_L2l_Il£t 
e,s_er::e LUTZF 
The word 11 front-linesn as used in th* title of my lecture dot - 
not moan the transverse section of the medical unite on duty 
in the front lines, but actually the field of firr of heavy 
arms, I collected my experiences for the main mart in this zone 
and should like to give a short account of them. 
In case of an offensive, the elimination of pain is the 
primary purpose of our treatment. In contrast to major surgery 
in our field the elimination of wain is accomplished in the same 
manner in mobile warfare as in static warfare. 
Because of a generally relatively bad condition of the 
t'-'eth of the troops, the main activity of dentist in the 
front-lines is taken up by conservative treatment. 
From the very start of may career I not only performed 
therapy to eliminate pain, but if it was possible - and it is 
possible in static warfare - I restored every set of teeth aft~r 
having discussed the matter with the competnnt medical officer of 
the troops. 
In order to preserve a healthy and useful set of teeth, it is 
essential that every conservative treatment is made exactly and in 
a neat manner. Special consideration should be given to the 
treatment of roots. As the time available for t’*i s treatment 
is limited, it was sometimes very difficult to determine the 
proper therapeutic treatment. The deciding factor, besides 
elimination of pain was always the ouest:on whether or not the 
tooth was worth preserving. With the various diseases of the pulp an exact diagnosis has 
to bo made according to the anamnesis and the clinical report. 
The pulp »f all single rooted teeth was extirpated, canal 
dilated, cleaned and filled (Lontulo, Hoot-filling paste, gutta- 
percha-points, cement). If a partial ppilpitis could be recognized 
the crown of the oulp of all molars and multi-rooted pre-molars 
was amputated, the infection had already seized the oulp of 
the root and the tooth had to be preserved for reasons of 
mastication I amputated, although the incompleteness of such 
treatment was clear to me. In most cases it is less dangerous 
to tr at the pulp of a root medicinally, than to have a half cr 
an unfilled canal of a root. By trying to fill roots which arc 
either difficult to penetrate or arc bent, our manipulations 
will cause the greater damage. We will always carry the infect .n 
to a place where is should not be and do much damage in the 
apical paradentium. Molars which w~re carious and not worth 
preserving, with gangrenous, decayed pulp and such teeth where 
no apical osteotomy could be ma.de, ?rero extracted. 
Not all teeth could be preserved by conservative methods, 
therefore the forceps had to be used fronucntly, In case of 
each surgica.l treatment wo to mak~ either an ana *• a 
esthesia #r at least try to reduce the pain. For eliminating 
pains completely in most cases, we now ha the ideal proce- 
dures of terminal and regional anaesthesia and the treatment 
with ethylene chloride (causing freezing). I always used 
the record syringe, it is simply to pack, easy to sterilise 
and transport. As injection fluid I used Novocaln-Suprarenin 
in ampules ready for use, containing a 2',- solution. In a few 
exceptions I used a solution. It is doslr-'d and often 
necessary that of certain instruments, such as bayonetforecexs- 
and levers, several are at hand so that a sterilization of 
the i ns trumont s does not haVve to be made each operation 
especially if large parts of the jaw have to bo cloned. In 
order to alleviate the fitting in of false teeth, I surgica ny 
removed and smoothed the edges of the bones aft~r having 
extracted roots of teeth which not worth preserving* 
In advanced dental stations of the frontlines, operations 
of the medium dental surgery can be executed besides extract- 
ions and incisions. In most cas~s the wounds he-\l normally and 
without complications, if the wound is properly dressed.. In 
cases where a primary or secondary infection of the blood coag- 
ulum occurred, the empty avoolaris should be loosely tanponaded 
with Marfanil-powder or with a piece of gauze soaked with 
chlorphenol-camphor, With only a few exceptions the patients 
were free of wain at the next visit and a normal wound-healing 
rj 1 
took place, ihis local therapy could be supported favorably 
with the application of heat. Incisions and operations of 
abscesses could be performed relatively painless, if they were 
frozen with ethylene chloride beforehand. Larger operations 
like the removal of difficult and displaced wisdom-teeth, 
operations of large cysts abd resection of points of roots should 
bo made at the main dressing station. Such an operate on . usual- 
ly reouires a relief froyn out door duty and furthermore second- 
ary treatment for about a week. In order to achieve a bettor 
and faster healing of the wounds it is advisable to hospitalize 
the patient. The best systematic car'' c ui at the 
main dressing station. If in the begi nning of my lecture I maintained that a local 
or intraoral regional anaesthesia is sufficient, this was only 
in relation to the general dental treatment. With the treat- 
ment of people, injured in the jaws this method failed in 
most cases. Hero experience was our best teacher. The 
first patients injured by gunshot wounds in the jaws wore treat- 
ed with a provisional splint under anaesthesia of a 2% Norocain - 
Supraronin solution. Cases of severe destruction of the facie 
were marc ready for transportati n by applying a temporary 
or adhesive-plaster dressing. If the anaesthesia and the re- 
sorption of the injection fluid connected with it had subsided, 
we freouently observed secondary hemorrhages in the demolished 
and distended tissue, which could hardly be controlled, Very 
soon we rejected this regional anaesthesia in the ar a.of the 
face and gave an S.F.17. injection (Scopalamlne, ‘"ukodal, 
Fphetonin) intramuscularly to the patients, The patients fell in- 
to a twilight, sleep and we could work undisturbed. According 
to our experiences it is essential for the transportation of 
the eatients to apply a provisional oplint to the jaw, i,e, 
to put the fragments into a resting position with a temporary 
dressing after.the manner of SAUER in order to prevent extensive 
dislocations and save pain for the patient, and after this the 
wounds of the face can be treated. If this is done, ’these in- 
jured should be sent by air transport to a specialist in a field 
hospital or a station hospital in the homeland for further' 
o,nd final treatment and cure, 
u*.. Focpl infection - Treatment of roots and apical Osteotomy, 
In case of focal infections every thoughtless muti- 
lation of the sot of by extraction of all dead toet& 
has to be avoided, as the restoration of the ability to 
masticate by falsa tooth roenines a long ecried of time 
and by this the soldier will not be fit for duty for months. 
At the same time we decline the attempt to preserve badly infect- 
ed te'-'th by long conservative treatment, especially in the case 
of poly-rooted teeth, as success can probably not bn gained. 
The/ treatment of an infected tooth, especially a mono-rooted 
tooth w: ln promise success .if it is-made conscientiously and all 
therapeutic means available arc applied. 
In case of osteitic processes originating from the tooth 
system, the removal of the focus of granulation, iS not suffi- 
cient, it has to be proceeded by a thorough treatment of the 
canals of the roots with fillings that cannot1 bogpenetrated by 
bacteria; a resection of th~ point <bf the root has to be made, 
which has to be followed by an apical osteotomy, if the lo- 
cation and form of the focus in the bone is favorable, Viith 
focal infections of mono-rooted a successful surgical 
operation can be made. 
The chlorine-tablet, which corresponds to a ouantity of 
2.25 cubic centimeters of chlorine (-12,5 cubic centimeter 20% 
chlorine mixture) proved to b*e excellent for the treatment of roots (air corps), Use 0f chlorine tablets makes it 
possible to prepare a dis ased tooth clinically without re- 
<aon, within the first session of treatment up to the 
Foramen apicale, Furthrmore a thorough mechanical and 
chemical cleansing was possible and thm tooth could be closed. 
Gangrenous teeth can be tr ated and finished in 3 sessions 
within 3 days, 
••rith chronic and apical paradentitis an apical osteotomy 
succeeds the treatment of the root, if the location and the 
size of the bone-focus is favorable* Teeth with more than one 
root cannot bo treated this way, because their complicated 
anatomical structure and the unfavorable location of their 
roots does not promise a full success. 
With severe focal infections where the state of the 
patient demands prompt aid, it is justified to remove the 
tooth and then make a thorough currettagc, of the alveolari s 
if possible an exposure of the alvcolaris and clransing of 
the ostcitic process. 
In case of chronic, marginal infections, which can be 
evaluated as foci, a radical removal of the infected tissue 
as well as removal of the deep pockets of the gums by radical 
operation is necessary. 
Discussion concerning dental diseases. 
t The army does not reeuest a report of treat- 
ments in order to control the performances of each single den- 
tist, but to give the higher echelons a survey of the entire 
situation. Besides this it facilitates a better distribution 
of material and instruments according to the reouirements of 
the different dental stations. The scheme of panel-account 
wsich is known to all panel dentists has been chosen in order 
to enable a financial calculation of the treatments and by this 
to draw a comparison with the treatments of the civilian dent- 
ists. The dental stations of the army stated that the writing 
out of reports of treatment do«s not mean an additional task 
for them. 
A uniform regulation for all parts of the Armed Forces 
concerning dental replacements is appreciated. However, it has 
to be requested, that the same regulations will be issued for 
the civilian sector, because otherwise the soldier will be 
worse off than the civilian and this would cause discord. The 
directives published on 10 October 194-2 for the Army proved to 
be good, (Reading of the directives in the irmy 
Bulletin part B, 194-2, # 734--). 
With the army, permission for dental replacements are 
given by the director of the dental station of the army, dental 
replacements which are made by a contract-dentist have to be 
approved by the physician of the troop. As the approved applic- 
ation for dental replacements serves as the dentist's voucher 
for the KZVD (German Society for Panel Dentists) and prosthetic 
treatment can be given only in very rare cases during the first 
session, no further delay in the treatment and no further burden 
as regards writing is included for the contract-dentist. Only 
applications for bridges and metal plates the approval 
of'the physician of the corps area, who performs this job in line with his other tasks. Regarding the necessary limitation 
of time consuming metal work we cannot denounce this control, 
as part of our dentists still do not act according to circum- 
stances and prefer time-consuming but lucrative dental 
replacement to the economical plat'-replacement, We do not 
consider it useful to prohibit the use of gold furnished by 
the patient, as such a prohibition could be ordered in a 
justified way only if the civilian patient would have to under- 
go the same restrictions. Besides this the use Of gold is al- 
ways simpler and not so complicated and can therefor-' be made 
with less expenditure of time than by using st^el. 
Large laboratories did not prove successful ti the 
army, as the organization and aim nistrat:on of them 
too much personnel. Besides this too much time would be lest 
by sending the models to and fro; a local cooperation between 
dentist and technician assures a more individual treatment 
of the patient, 
BICHLMAYR; The directives are excellent and we cannot 
understand a layman in the NaVy (a physician or some other 
aid station)should decide, whether a removable or firmly fixed 
prosthesis, if silea-metal or gold, or which method of splint 
should be made or chosen. Only a specialist, in this case 
the dentist himself, is able to judge these ruestions, 
Paladon is excellent, but it proved a failure with partial 
dentures, for instance, if the third teeth left and right in 
the upper jaw or in the lower jaw still exist, the danger of 
breakage is too great, 
LENTRODT j S.F, F. (Scophedal, Fucodal, weak and 
carefully administered up to 1,5 cubic centimeters and injected 
subcutaneously, intra-muscularly and intravenously have prroved 
to be very good in thousands of cases. If S.F,E, strong, 
1 cubic centimeter, was im'ected intravenously it caused pro- 
nounced disturbances of respiration in cases of severe maxillo- 
facial injuries so that in many cases we were obliged to inject 
it only subcutaneously. In casaof aepeated injections of S,F,E, 
weak within several hours, we freruently observed a motor rest- 
lessness and preferred to give a morphine derivative after the 
first S.3T.F, effect had subsided. S,Tr,r, proved to be v'ry 
good in the treatment of maxillo-facial fractures for the re- 
duction as well as for splinting. Fvipan is used almost ex- 
clusively for the removal of splinters supplemented by S.Etr, 
weak intravenously. Contrary to otorhinolaryngolo i°ts we 
reject the use of Fvipan with inflammatory processes of the 
floor of the mouth and with acute pyogenic infections in the 
area of th° maxilla, 
I once saw a Hovocain-poisoning with a badly wounded 
Hussion prisoner of war ?/ho had a short period of excitement 
and convulsion which gradually passed into a paralysis asso- 
ciated with paleness, profuse perspiration and epileptic 
spasms, With the use of Suprarenin special precaution should 
be taken if diphtheria and possible myocardial-damage has 
occurred recently. MADLFNFR reports an acute arrest of heart 
action after 10 cubic centimers of Novocain-Adrenalin solution 
had been given without any preceding S.F.E, or morphine; the 
diagnosis was severe chanp;es of the myocardium and diphtheria. 15 A Gingivitis^and_Paradentosis• 
The lecturer refers to the endeavour of the medical 
authorities to clarify the etiology of paradental pathology 
and stresses the importance of chronic inflammation of the 
gums which is harmless in itself, but leads to the develop- 
ment of severe damage of th° paradental tissues, stomato- 
gingivi,tis ulcero-necrotica and to paradentosis, The field 
medical officer can accomplish a lot to keep the soldiers free 
from paradentosis by instructing them about the importance 
of a rational care for the teeth and its control. The diagnostic 
importance of bleeding gums for recognition of early para- 
dentosis is stressed ' ecause it allows the field medical officer 
to institute an opportune prophylactic treatment in case of al- 
ready existing severe degrees of gingivitis and paradentosis. 
It is appropriate and recommended that special places for pro- 
phylactic dental treatments bo established. 
Zanies nt th_t he_ Fro nt_Line_Tr oops A 
tg,bsar z t (Mo, j o f A„P-J.ICHF NBAC H 
In winter 194-1/4-2 the cases where soldiers had to be 
transferred to the reserve-army on account of paradentosis in- 
creased ih the area of an army. The medical officer of the 
Army reouested that a hospital for exoert-opinion on paraden- 
tosis and a station for paradentosis treatment should be at- 
tached to the maxillo-fiospital near the front-lines. The 
examination of the material - we had approximately 100 new 
cases per month - resulted in the necessity of dividing the 
patients into three groups. 
The first groups, which amounted to 12% had only marginal 
inflammations. The second group with 84% had additional 
pathological pockets in the gums, outflow of secretion and 
loosening of the teeth. Only in a small group of about 4% 
we did not have any indications of inflammations or Inosen- 
ing of the teeth, but striking signs exposure of parts 
of the roots of the tooth and sides of dental groove. The 
examinations showed that it is useful for reasons of exploring 
pathogenesis and its treatment not to name diseases of the 
tooth supporting apparatus as paradentosis, but to separate 
from them the inflammatory forms of paradentitis which apparent- 
ly occur more freeuently in the front lines. They cm be 
treated without difficulty beoenso we could snnd back for 
front-line duty about 96% of our entire patients, and only 
4,% had of necessity to be transferred to the because 
splint treatment was indicated, which could not be performed 
in the front lines. 
On account of th°se facts we can draw the conclusion that 
even in the front lin°s an exam nation and uniform export 
opinion and treatment of the diseases of the tooth supporting 
apparatus is necessary. The word paradentosis and the imagin- 
ation of a complete loss of teeth connected therewith is a 
widespread opinion amongst laymen, so that with an improper 
diagnosis, as happens often with the troops, an unneccessary 
severe psychic strain can be aroused. On the other hand the patients would like to go to their homeland because they 
think that only there can they get proper treatment* 
Discussion concerning paradental diseases, 
BICHLMAYR: Most of the dentists state that improper 
hygienic conditions of the mouth are the cause of gingivitis and 
stomatitis. In addition to this, it is the lack of Vitamin 
C and B. The therapy has not changed during the last years. 
Aside from the usual local treatment, where iodoform-glycerin- 
lactic-acid pulp is especially preferred, intravenous or sub- 
cutaneous injections of Cebion or Redoxon were and by 
this means a quick fading away of the disease was accomplished. 
The results gained in Norway are especially interesting, as 
according to former uoints of view many diseases should have 
originated there. This is not true according to the r-ports 
on hand* Food, lacking vitamins, lack of sun-light end further- 
more the lack of lime in th° water are not responsible for 
these diseascs, but as already mentioned before, unhygienic con- 
ditions of the mouth. Ship-test: no fresh wat~r, only distilled 
sea-water for drinking water, lacking lime. Result: dirt para- 
dentosis, no other treatment but supuly of vitamins, etc, was 
made, furthermore care of systematically und°r control 
and all signs disappeared. I learned that vitamins and lime 
are no longer looked upon as cause of para'1 entosis since the 
Third Conference of the Military Medical Academy, This results 
in three final conclusions: 
1, Gingivitis should be treated only dentists, and 
as happened frequently, for many weeks by physicians. 
Immediate transfer to the dentist is accessary, 
2, As long as no better therapeutic means are available, 
it is recommended to instruct the soldiers about groper 
function of mastication and care of teeth by a specialist 
(dentist), 
3, All reports regarding danger of paradentosis and 
loss of teeth in Norway and on submarines are exaggerated. 
The diagnosis were made by laymen. The Norway and sub- 
marine psychosis is overcome, 
BLASCHKE : It is suggested that a tooth-brush be made 
which is approved by th'- German Dental Society in order to 
eliminate the unsuitable and material wasting typos made by 
the industry* 
A toothbrush should supplied and given to th- solHior 
as a part of his equipment. The medical officer in the 
front linos and the dentist should force the soldier by ex- 
planation and ord°r to use it properly and regularly, 
STUCK: The Director of the German Society for Dentists 
supports BLASCHKE*s suggestion for introduction of a standard 
toothbrush for the Ajmed Forces , 
LENTRODT: Genuine paradentosis as a chronic degenerative 
process and gradual atrophy of the paradentium was observed 
in a few cases only with old soldiers, mostly uartjcipants in 
the First World War. In those cases neither splints nor radi- 
cal operation caid help, but only extraction of the teeth. Very frequently patients were transferred to our hospital 
on account of stomatitis, and the diagnosis of the medical 
officer in the front lines was "paradentosis", According to 
an order of the medical officer of the army all patients 
with paradento athies were transferred to out hospital fir 
either treatment or opinion as regards the method of treatment. 
Neither an officer nor a soldier ever left the area of our 
army because of genuine or false oaradentosis, According to our 
experiences insufficient care for teeth is the cause for the 
rapid spreading of gingivitis among the troops. This con- 
clusion can be drawn by the fact that inflammatory symptoms 
disappear quickly after a thorough cleaning of the oral cavity 
has been made, was striking in Esthonia that most cases 
of stomatitis occurred in the oil-shale area. Only a small 
percentage of the patients required a long treatment in the 
maxillary department of out hospital. Here we saw severe sto- 
matitis with extensive ulcers. As most of our -patients were 
relatively young, the ulcerative stomatitis healed, completely 
on account of the treatment, without leaving any defective 
tissue in the paradentium. On the floor of a paradentosis 
the ulcerative stomatitis became chronic and lead to re- 
lapses, GROSS' pointed this out some time rwo. In case of 
pressure dystrophies we made a compensation of articulation 
and removed badly fitting or faulty articulating crowns and 
bridges. As regards extractions w- very cautious if we 
to deal with acutely inflamed areas. A* a rule we waited 
for the fading away of the stormy symptoms and then followed 
SLAUK’s proposals as regards the medicinal early treatment, 
RTith severe stomatitis and especially in cafe of hemorrhages of 
the gum without visible signs of an inflammation we gave doses 
of vitamin C either orally or intravenously. In all stomatitis 
cases we examined the tonsils and accessory cavities very care- 
fully and established a temperature curve , V/ith every 
stomatitis with increased temperature we made a blond picture 
and consulted an internist. Owing to an intensive sanitation 
even with the medical units in the front lines, we were able 
to meet severe difficulties proohylactically, The establish- 
ment of tooth and prosthesis hosoitals at the front lines stood 
the test as well as employment of a special maxillofacial 
deparmtant, 
o r_T£££Ame nt_o f_D i spo.5 t h g„T£ e t 
According to records of treatment of 1,600 ,000 
soldiers we should like to define ou; attitude regarding the 
dental care of the troops. Should we prefer an extensive cent- 
al treatment to a limited treatment, in which latter case 
special consideration is given to combating rxt foci of 
infection, caries and paradentosis and furthermore to the 
matter of skill as regards the dental treatment. It is deter- 
mined that only highly skilled dental care assures a long 
lasting health of the oral cavity. An increase of the range of 
dental care has been taken into consideration, but is was re- 
jected as detrimental as the success of dental treatments 
depends on the exact execution of each phase of the treatment, 
oven t]he smallest one. This cannot be achieved, if the dent- 
ist’s time for treatment is limited. 
Emphasizing the matter of skill, does not mean that larger 
numbers of soldiers needing dental care cannot be treated, but 
it rcouires a certain change of dental methods. The treatment 406 
of roots, which does not offer much success and prostheses 
which ar - not essentially necessary must be set aside for an 
intensive campaign against caries and paradentosis, as well as 
surgical treatments (extractions and apical osteotomy) for 
focal infections which frequently originate from apical foci. 
In order to accomplish this, we suggest the introduction 
of near directions concerning therapy with suggestions concerning 
organi zati on, 
1, If apical osteotomy is not indicated with mono-rooted 
teeth, extractions and furthermore removal of all 
roots as well as all teeth should be made when a 
focal infection exists and a cure cannot b :• guarant- 
• eed because of arncal diseases of adjacent destruct- 
ion which extends deep into the arms and is asso- 
ciated with suppurative inflammation or decayed pulp, 
2j Treatment of dental pulp is justified, if in the 
particular case the teeth are of functional 
value. The treatment has to be done according to 
rules which exludo epical complications, 
3 i Simple methods of filling for all with new 
caries. Special consideration should be given to 
interdental spaces, 
Paradentosi s s 
1, The "leaflet for medical officers of troops about 
treatment of paradental damages"informs the medical 
officer of the troops to strive for closer cooperation 
with the dentist, 
2, In regular health-inspections the troops should be in- 
formed - possibly by the dentist - of the proper use 
of the tooth brush and the proper execution of 
mastication. In most cases this may prevent the 
occurrence of paradental damages, 
3, The treatment of chronic gingivitis is a matter per- 
taining only to the dentist, 
4, It is suggested that a standard tooth-brush be in- 
troduced for the Armed Forces as a part of the e- 
ouipment. The industry should be induced to produce 
standard tooth-brushes according to forms examined 
a,nd suggested by the Armed Forces, 
££os t he.si^JL 
In order to secure dentures for older soldiers who have 
to join the Armed Forces now to a large extent, certain-limi- 
tations of the up to now us-d methods are essential. Removable 
dentures can be made only if less than L molars are left in the 
upper jaw which fit into U molars in the lower jaw in the act 
of mastication; or if front tenth or lost by disability 
due to the war, respectively damaged teeth, have to be replaced. 
Fixed dentures should be made only if teeth damaged by 
disabil ty due to the war have to be restored and at the same 
time spaces between have to be bridged over; especially 407 
if those dentures are for flying personnel, parachuters, crews 
of submarines and musicians playing brass instruments. Other 
acceptable cases are if badly destroyed teeth can be preserved 
only by crowns or pin-troth (even if not essentially n cessary 
for preserving or restoring fitness for duty). If these crowns 
respectively pin-teeth with an intermediate link can be com- 
bined into a bridge, these bridges can be made, if by this ira .ns 
a space up to two teeth can be closed, 
It is the supposition for inserting fixed dentures, that 
in every case a roentgenological examination of holding 
t°eth an apical inflammation or co sidora le atr ophy 
of the avoolar-bone#