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Chapter VII

Contents

CHAPTER VII

PROFESSIONAL SCHOOLS IN MILITARY AND NONMILITARY INSTITUTIONS

    In making plans for the care of the wounded overseas it was realized, especially with respect to fractures, that the treatment should be so systematized that the wounded soldier would be under one method from the time he was injured until he left the hospital. In order to accomplish this it was important (1) that there be adopted a standard method of treatment; (2) that medical officers be trained in the use of standard appliances and methods. The latter was the more formidable of the undertakings. This was accomplished, in part, by establishing classes, under eminent surgeons, in various medical centers and sending them, upon the completion of the courses, to the medical officers’ training camps and base hospitals to assist in the instruction along the given line.

    To this end there were organized, in military and nonmilitary institutions, exclusive of medical officers’ training camps, divisional camps, posts, and base and general hospitals, schools for the instruction of medical officers in the diagnosis and treatment of conditions coming within the range of certain of time medical and surgical specialties.

    United States Army Auxiliary Hospital No. 1 (war demonstration hospital), Rockefeller Institute, New York City, may be said to occupy an intermnediary position, since it was, so to speak, a military organization engrafted upon a nonmilitary institution.

MILITARY INSTITUTIONS

SPECIAL SCHOOLS FOR TRAINING IN DIAGNOSIS AND TREATMENT

PNEUMONIA SCHOOL, BASE HOSPITAL, CAMP JACKSON, S. C . a

   With the concentration of large numbers of men in Army camps, acute respiratory disease was immediately recognized as a very important problem confronting the Medical Department of the Army. Measures were instituted which aimed to prevent the spread of infection by contact with those showing evidence of mild inflammation of the upper air passages. Attempts were made to protect soldiers who volunteered for the purpose against pneumonia by prophylactic vaccination. In addition, efforts were made to discover the bacteriological agent responsible for each individual infection, in order that epidemiological measures might be more intelligently formulated and serum therapy instituted if the type of infection could be influenced by it.

    This program required the cooperation of trained epidemiologists, bacteriologists, and clinicians. Courses in bacteriology were arranged and medical officers detailed to them for periods of study. An opportunity for clinical and laboratory training in the care of acute respiratory diseases was offered by the

a Based on: ClinicalInstruction in Acute Respiratory Disease, Camp Jackson, S. C., by Henry T. Chickering and James H. Park, jr., Copy on file, Board of Publications, Surgeon General’s Office.


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hospital of the Rockefeller Institute (q.v.p. 493), which received patients suffering with pneumonia for treatment and study. Beginning November 1, 1917, medical officers were detailed to that hospital for instruction. They served as internes, were responsible for the ordinary clinical care of the patients, and in addition they performed all the laboratory work in connection with their patients.

    In May, 1918, in addition to the instruction offered at the hospital of the Rockefeller Institute, a similar course of study was begun at the base hospital, Camp Jackson, under the direction of a medical officer who had assisted in the training at the Rockefeller Institute. 1 This camp, with a population of from 30,000 to 60,000 men, furnished ample clinical material throughout the summer months.

    To facilitate this study of acute respiratory diseases, the chief of the laboratory provided one room which became known as the laboratory of the pneumonia school. A special appropriation was granted by the Surgeon General to equip this laboratory and to purchase the necessary supplies, materials for culture media, and laboratory animals. Here it became possible for every officer to become familiar with the cultural characteristics and pathogenicity of the common bacterial flora of the nose, throat, and deep respiratory passages. Cultures were made from the secretions of the nose and throat and from the sputum, on blood agar and Avery medium. Mouse inoculations with sputum to facilitate the determination of the type of pneumococcus were made in each case. In addition lectures were given on the bacteriology of the respiratory tract and the clinical application of the laboratory study of acute infections.

    During the summer two wards, of 32 beds each, were provided for the treatment of cases of acute respiratory disease. Upon admission to the base hospital all patients were held in reception wards until a tentative diagnosis allowed of their proper distribution.

    The observation wards were situated close to the bacteriological and Roentgen laboratories. Fluoroscopic examination of the chest proved of diagnostic value in the very early stages of bronchopneumonia and lobar pneumonia and was always resorted to when patients complained of symptoms referable to the respiratory tract, even though by physical examination no signs of pulmonary involvement could be detected. When clinical examination was unsatisfactory, the fluoroscope frequently revealed increase in density in localized areas of the lung and restriction of the movement of the diaphragm on the affected side. In addition, specimens of sputum and blood could often be obtained for examination a day or more before signs of definite consolidation were evident.

    At Camp Jackson officers were detailed to the pneumonia school for instruction for periods of one month, there being usually 6 or 7 men in each class. The patients were assigned in rotation, so that ordinarily each physician would have not more than 10 or at most 12 under his care at once. Each student learned to recognize the difficulties incident to the accurate study of the bacterial flora of the nose, throat and pulmonary infection. In order to insure an intelligent prognosis, emphasis was placed upon repeated sputum examinations when only a pneumococcus of Type IV was found.


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     When serum treatment was indicated, instruction in the proper method of intravenous administration was given, together with the technique of determining the individual’s sensitiveness or lack of sensitiveness to horse serum. By attention to these details no accidents attributable to serum were experienced.

    From May 27 to September 15, 1918, upon which latter date the so-called influenza epidemic commenced at Camp Jackson, 192 cases of pneumonia were treated in the pneumonia wards by officers detailed for duty in the pneumonia school, and 20 officers were given instruction. The mortality of the cases treated was 7.7 percent.

SCHOOL FOR THE DIAGNOSIS AND TREATMENT OF TUBERCULOSIS AND THE ADMINISTRATION OF TUBERCULOSIS HOSPITALS, UNITED STATES ARMY GENERAL HOSPITAL NO. 16, NEW HAVEN, CONN.

     In February, 1918, the Surgeon General recommended leasing, for use as a general hospital for the treatment of tuberculosis, the William Wirt Winchester Memorial Tuberculosis Hospital, situated 2 miles west of New Haven. Conn., and then just nearing completion.2 This suggestion was approved by the Secretary of War, and the lease was executed.3 The hospital was opened for sick soldiers on March 7, 1918,4 and on March 21, 1918, it was designated General Hospital No. 16.5

    A school of instruction was organized in this hospital for the training of medical officers in the physical diagnosis and treatment of tuberculosis and in the administration of general hospitals, including the duties of officers assigned to the various departments of general hospitals especially those for the treatment of tuberculosis, with the view of training medical officers for service at tuberculosis hospitals.4

    The courses covered a period of six weeks. The instruction was largely practical. The microscopical appearance of tuberculous lesions was presented and the relation of these lesions to the clinical course and to the physical signs. The interpretation of X-ray plates was stressed particularly from the clinician’s point of view.

    The following subjects were covered: (1) Physical diagnosis (normal and pathological chest). (2) Administration of wards in a general hospital. especial attention being given to treatment and record work. (3) Routine laboratory work. (4) Interpretation of X-ray plates. (5) Diagnosis and treatment of nasopharyngeal conditions. (6) General pathology, with special attention to the lung, with capital autopsy study. (7) Treatment of tuberculosis. (8) General administration of a military hospital, with practical work by: (a) Commanding officer, (b) supply officer, (c) mess officer, (d) adjutant. (e) registrar. (9) Military instructions by the detachment commander: (a) Management of a medical detachment, (b) drill, (c) setting-up exercises. (10) Reconstruction work. (11) Special instructions in the rapid examination of recruits.

    The number of medical officers who took the course was 257.4 The distribution of medical officers who attended the school was as follows: 4 Assigned to other hospitals as ward surgeons, 103; to special examining boards, 77; to base hospitals as specialists in lung diseases, 4; commanding officer in general


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hospital, 3; medical chief in general hospitals, 2 of whom later became commanding officers, 7; other assignments, 18; discharged or transferred to other sections of the Medical Department as not suitable for this section, 24.

    Some medical officers of the Regular Medical Corps took this course of instruction, which was more comprehensive and of longer duration than any of the similar courses given. The principal benefits arising from the course were the standardization of methods, the learning of the exact meaning of the terms employed in tuberculosis work, the manner of making diagnosis, the interpretation of physical signs, and the common method of treatment.

    All courses of instruction were discontinued on October 7, 1918, on account of the influenza epidemic, and the instructors used as consultants in the influenza wards.6

SCHOOL FOR INSTRUCTION IN CARDIOVASCULAR DISEASES, UNITED STATES GENERAL HOSPITAL NO. 9, LAKEWOOD, N. J.

    It was early determined by the Surgeon General that the medical staff of each of the large base hospitals should include a cardiovascular specialist; that is, an officer with adequate training in the modern aspects of cardiac diagnosis, including a familiarity with the use of the polygraph and the electrocardiograph. In order to supplement the supply of officers with these qualifications a course of instruction was given at the hospital of the Rockefeller Institute in the summer and autumn of 1917.

    Considerable difficulty was experienced in securing a sufficient number of properly qualified cardiovascular examiners, and it was soon found necessary to establish at the medical officers’ training camps at Fort Riley and Fort Oglethorpe special courses of training for such examiners. These were short intensive courses, taking only from two to three weeks and designed to meet the special diagnostic requirements of the cardiovascular examinations.

    Upon the opening, in June, 1918, of General Hospital No. 9, at Lakewood, N. J., with its special heart service, courses of instruction in cardiac diagnosis and also in the management and physical training of the functional heart disorders were begun there and were continued up until the time of the closing of the hospital.7
     
    The need for specially trained officers to take over the management of the great number of cases of irritable heart which were accumulating in the camps of this country and of France became very great, for the results of treatment were found to depend largely upon the skill and special training of the officer assigned to their care. By an arrangement made with the British authorities. a certain number of our medical officers, selected for such special work in the American Expeditionary Forces were given a few months of valuable training at the Army heart hospital at Colchester, England, before proceeding to their stations in France.7

    The problem of the hospital care of the heart cases, especially of those cases returned from overseas, came in for much consideration and discussion and was finally met by the decision not to attempt to concentrate all heart cases in special heart hospitals, but to designate a number of general hospitals to which heart cases might be sent, and to use one hospital (General Hospital


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No. 9, Lakewood, N. J.) for the special study of the form of heart disorders which constituted the real heart problem of the Army, namely, the functional disorders known as the irritable heart of the soldier.7

    For this purpose a special heart service was established in the hospital, which was supplied with thoroughly equipped laboratories and a staff of especially trained assistants. Much valuable information was obtained from the study of these cases and, following the lead of the British Army, methods of treatment by means of graded physical exercises were developed and standardized.7

    The following outline issued by the Surgeon General ‘s Office for use at the medical officers’ training camps was enlarged upon, the course extending, at first, over a period of three weeks and later including an additional week’s instruction in nephritis and arthritis.8

OUTLINE OF CURRICULUM FOR A COURSE IN PHYSICAL DIAGNOSIS OF THE CARDIOVASCULAR SYSTEM AND OF HEART DISEASE, OF TWO WEEKS’ DURATION

   One hour, anatomy of the normal heart and physiology of the circulation.

    Eight hours, physical examination of the normal cardiovascular system. Attention in these eight hours of practical exercises should he given to the following subjects:
1. Inspection of the heart and all peripheral vessels.
2. Palpation of the cardiac impulse and of the peripheral vessels.
3. Outlining by percussion the area of cardiac dullness and of dullness over the great vessels.
4. Auscultation of the heart, with special reference to the quality of the first sound.
5. Estimation of pulse rate and of blood pressure.

    (The examinations indicated in 1, 2, 3, 4, and 5 should be made both in the upright and in the dorsal position; those in 2 and 4 should be made likewise when the patient is lying, first, on the right, and then on the left side. The examinations indicated in 1, 2, 4, and 5 should he made before and after varying degrees of exercise, and particular attention should be paid to the alterations induced by exercise.)

    Eight hours, study, by methods indicated above, of such functional deviations from the theoreticallv normal as - 
(a) Cardiorespiratory murmurs.
(b)Systolic murmurs in the absence of hypertrophy.
(c) Sinus arrhythmia.

    One hour, consideration of Circular No. 21.

    Four hours, consideration of irregularities. (Here stress should be laid upon such irregularities as those produced by sinus arrhythmia and premature contractions, since these are irregularities which occur most commonly in young men and are of military importance.)

    Twenty-six hours, practical examination of abnormal cardiac lesions with special reference to diagnosis and military prognosis. During this period, one hour should be devoted to the significance of the history of infectious diseases such as rheumatism, chorea, tonsillitis. and of such incidental complaints as growing pains, in estimating the importance of the physical signs which are present; consideration of the subjective symptoms of heart failure and to a discussion of the physiology of heart failure and its early and late physical signs. Two hours should be devoted to functional cardiac disorders (the “irritable heart of soldiers,” Da Costa; “effort syndrome” or “D. A. H.” of Lewis.)

    One hour, special differentiation of this functional cardiovascular disorder from mitral stenosis.

    One hour, treatment of functional cardiovascular disorder.

    Thorough history taking was regarded as a very important part in the study, classification, and grouping of cases. The following is an outline for history taking, as used in the instructions to new ward men:9


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HISTORY TAKING

    I. Family history. Aside from the routine history, inquire for evidence of neurological. neurotic, or hysterical disturbances. Also history of alcoholism, drug habits, etc.
    II. History of infancy and childhood. Diseases; conditions that might have influence on later development; early nervous manifestations; eneuresis, chorea, fainting attacks, etc.
    III School history. Progress in studies; final grade and at what age; leaving school; games and sports; if sedentary, learn why.
    IV. Occupational history. If there has been a frequent change of work, learn why; nature of last work before military service; heavy or light work, with or without symptoms; time lost from illness or symptoms.
    V. Personal history. Sexual; alcohol; tobacco, etc.
    VI. Military History. Date of entrance; enlistment or induction; history of service in American camps; full or light duty; if latter, why; dates of transfer to various camps in United States; overseas service--after O. S. examination or not; date of sailing; overseas service (where performed; full or light duty; if latter, why; illnesses and hospitals entered; give dates and names; date of return to United States; record after landing in United States; date of entrance into No. 9).
    VII. Present symptoms, with duration and asserted cause.
    VIII. Anything in the general attitude, mental or otherwise, that might be an aid in analyzing an existing nervous condition.

    NOTE . - Organic as well as functional cases should be analyzed for evidence of any form of inferiority; as, intelligence defects; chronic invalidism; neurotic or hysterical manifestations; focal disturbances; reactions of the emotionally sensitive; etc.

GROUPING OF THE NONORGANIC CASES BY MEANS OF HISTORY STUDY

    I. Nonorganic cases; effort syndrome.
a. Physical strain. Have carried on well at the beginning of training, but gave out on severe effort; normal history previous to service; may occur after a return to full duty following too short postoperative convalescence.
        b. Postinfections.
    (a) Following rheumatic fever.
(b) Following other infections. Careful study fails to show any signs of organic disease.
    c. Constitutional inferiority.
(a) Intelligence defects. May not be physically weak; lack ambition and push.
(b)Physical inferiors; chronic invalidism; may show full normal mentality; often have associated neurotic characteristics.
    d. Emotionally sensitive. Break under severe, sudden nervous strain; retention of fears for long period; previous history usually normal.
    e. Neurotic. Somatic manifestations; fainting, vomiting, etc.      f. Neurological. Basis of organic disease; epilepsy, old meningitis, etc.

     The most common types in cases from the American camps are the physical inferiors and the primarily neurotic.

    The following exercises were in use in the cardiovascular service in the treatment of cases and instructing personnel for cardiovascular work:9

GRADED EXERCISES FOR THE CARDIOVASCULAR SERVICE, GENERAL HOSPITAL No. 9, LAKEWOOD, N. J.

     These graded excercises are used in the study of both organic heart disease and in those cases showing the symptom-complex of the effort syndrome. The exercises are arranged on a basis of eight units in the following order: (1) Arms; (2) head and chest; (3) balancing; (4) trunk bending forward and backward; (5) arms, legs, and feet; (6) trunk bending sideward; (7) marching, running, etc.; (8) breathing. The order of the units is the same in each grade. In the lowest grade, the movements are given slowly. With the advancement


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through the grades, the movements are given in faster time and with increased snap to the commands. By use of this unit plan the exercises are easily graded from the most simple to the complex. All exercises are given twice a day. The sixth, highest grade, includes work in double time, with a period for games.

    A medical officer is present at all exercises. It is his duty to detect the earliest signs of effort on the part of the organic cases and immediately refer them for examination. By encouragement, discipline, and general talks on physical development to the functional cases, he is able to keep them up to their full effort. Repeated examinations of functional eases is avoided. This medical officer has charge of the strength tests. This test is made on each patient when he first begins exercises, and is repeated every four weeks until the man is discharged from the hospital.

INTERPRETATION OF THE COMMANDS

    Arms forward: Arms straight, shoulder high and shoulder width apart, palms inward.
    Arms fore upward: Arms raised upward by passing through arms upward position.
    Arms sideward: Arms shoulder high, hands slightly behind the line of the shoulders, palms downward.
    Arms side upward: Arms raised through arms-upward position, palms turned inward as the arms are raised upward above the shoulders.
    Arms backward: Arms raised over head and backward as far as possible, with chest raised.
    Hands on hips: Hands firmly on hips, thumbs to rear, elbows and shoulders well back.
    Arms bent for thrust: Arms bent, elbows close to sides, forearms vertical, hands clenched at side of shoulder, knuckles outward.
    Arms bent for strike: Hands clenched over shoulders, knuckles to the rear, elbows shoulder high and well back.
    Support line frontways: Weight supported on hands and toes, the arms, trunk, and legs straight.
    Trunk bent forward; Back bent as much as possible, head up, knees straight. Heads lead in return movement.
    Trunk lowered one-half forward: Back flat, head up, trunk carried midway between vertical and horizontal positions.
    Trunk lowered forward: Back flat, trunk to horizontal, head up.
    Trunk bent backward: Chest raised, head and neck lowered backward as a unit, chin in, knees straight. The bending is in the upper spine.
    Trunk bent sideward: Body bent directly sideward, knees straight, feet flat on the floor.
    Chest raised: The chin drawn in and the chest raised upward and forward.
    Heels raised: Heels raised, ankles fully extended, weight on toes, heels slightly separated.
    Knees bent: Heels raised and slightly separated, knees bent outward, body erect, head up.
    Leg raised: Body held erect, chest raised, leg raised as high as possible, knee and ankle extended.
    Foot placed: Foot placed in given direction, toes touching floor, leg straight, weight on stationary foot. Feet about 18 inches apart.
    Stride: Weight equally divided on both feet, feet flat on floor. Feet about 24 inches apart.
    Side step: In given direction, weight transferred to stepping leg, heel of stationary foot raised. Distance about 24 inches.
    Lunge: Leg raised and step taken in given direction, knee of stepping leg bent, feet flat on floor, body erect. Distance about 24 inches.
    Feet closed: Inner edges of feet together, knees pressed together.
    Head lowered backward: Chin drawn in, head and neck lowered backward as a unit.


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 RHYTHM OF MOVEMENTS

    Arm and leg movements are usually taken in fast rhythm.
    Trunk and head movements are always taken in slow rhythm.
    The balancing exercises are done on count or command. These are the third exercises in each group.
    In compound exercises, the rhythm is that of the slowest movement.

UNITS OF EXERCISES

    Each lesson consists of eight exercises or units and the order of these should not be changed.
    1. Arm, leg, and foot. 5. Same as unit 1.
    2. Head and chest. 6. Trunk sideward.
    3. Balancing. 7. Marching, running, etc.
    4. Trunk forward and backward. 8. Breathing.

EXERCISES

Grade I (15 minutes)

    1. Raise arms side upward (1). Return (2).
    2. Arms bent for thrust: Straighten arms sideward and raise chest (1). Return (2).
    3. Bend arms for thrust: Raise heels and chest (1). Return (2).
    4. Hands on hips: Lower trunk one-half forward and exhale (1). Return (2).
    5. Bend arms for thrust (1). Straighten arms upward (2). Return (3, 4).
    6. Hands on hips: Bend trunk left (1). Return (2). Right (3, 4).
    7. March in place (1 minute).
    8. Raise arms sideward and inhale. Lower and exhale.

Grade II (15 minutes)

    1. Arms bent for thrust: Thrust arms forward (1). Return (2).2. Raise heels and chest. Inhale (1). Return (2).
    3. Bend knees one-half deep (1). Return (2). (Hands on hips.)
    4. Hands on hips: Raise chest and inhale (1). Lower trunk one-half forward and exhale (2). Return (3, 4).
    5. Arms bent for thrust: Swing left leg forward (1). Return (2). Right (3, 4). Trunk kept erect.
    6. Side stride stand: Bend trunk left sideward and raise right arm side upward (1). Return (2). Left (3, 4).
    7. March in place (2 minutes).
    8. Raise arms fore upward amid inhale. Lower side downward and exhale.

Grade III (20 minutes)

    1. Raise arms fore upward (1). Return (2). Raise arms side upward (3). Return (4).
    2. Raise arms forward (1). Move arms sideward, raise chest and inhale (2). Return (4).
    3. Bend knees and raise arms sideward (1). Return (2).
    4. Side stride stand: Hands on hips. Lower trunk forward (1). Return (2).
    5. Arms bent for thrust: Swing left leg sideward (1). Return (2). Right (3, 4).
    6. Arms bent for thrust, feet closed: Turn trunk left (1). Return (2).

Grade IV (25 minutes)

    1. Raise arms backward (1). Swing arms fore upward (2). Return (3, 4).
    2. Bend arms for thrust and lower head backward (1). Return (2).
    3. Raise left leg forward and arms sideward (1). Return (2). Right (3, 4).
    4. Side stride stand: Swing arms fore upward (1). Bend trunk forward and touch floor (2). Return (3, 4).
    5. Raise heels and raise arms side upward (1). Bend knees, arms sideward (2). Return (3, 4)


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    6. Feet closed, arms sideward: Turn trunk left (1). Return (2). Right (3, 4).
    7. Hike (15 minutes).
    8. Hands front of shoulders: Straighten arms sideward, palms up, and inhale (1) Return and exhale (2).

Grade V (35 minutes)

    1. Feet closed, arms bent for thrust: Turn trunk left and thrust right arm forward (1). Return (2). Right (3, 4).
    2. Arms bent for thrust: Straighten arms sideward, palms up, raised chest, and inhale (1). Return (2).
    3. Raise arms sideward and left leg forward (1). Move left leg backward and lower trunk one-half forward (2). Return (3, 4).
    4. Hands front of shoulders: Lower trunk one-half forward and exhale (1). Raise trunk, raise arms sideward, and inhale (2).
    5. Arms bent for thrust: Lunge left and thrust sideward (1). Return (2). Right (3, 4).
    6. Hands on hips: Turn trunk left (1). Bend trunk forward (2). Return (3, 4).
    7. Run in place (20 seconds). Breathing exercises. Repeat the run.
    8. Raise arms forward and inhale. Lower sideward and exhale.

    The free exercises cover about 20 minutes and should be taken in full time with brisk, snappy rhythm.

Grade VI (60 minutes)

    1. Bend arms for thrust and place left foot back inward (1). Lunge left sideward and thrust arms sideward (2). Return (3, 4).
    2. Stop left forward, raise arms sideward, raise chest and inhale (1). Return (3).
    3. Raise left leg backward, hands front of shoulders (1). Lower trunk forward, arms sideward (2). Return (3, 4).
    4. Lunge left sideward and bend arms for thrust (1). Thrust arms sideward and lower trunk forward (2). Return (3, 4).
    5. Bend knees and place hands on floor (1). Support line frontways (2). Bend arms (3). Return (4, 5, 6).
    6. Side stride stand, hands on hips: Bend trunk forward (1). Circle trunk left (2). Backward (3). Right (4). Forward (5). Raise trunk (6). Repeat, with circle trunk right.
    7. Run in place (1 minute).
    8. Raise arms fore upward and inhale. Lower side clowmiward and exhale. Vigorous games (15 minutes). Games: Dodge ball, cage ball, volley ball, relay races, basket ball, tag games, etc. Hike (20 minutes). Part of hike in double time and rest in quick time. A swim may be substituted for part of hike.

UNITED STATES ARMY AUXILIARY HOSPITAL NO. 1, WAR DEMONSTRATION HOSPITAL, ROCKEFELLER INSTITUTE FOR MEDICAL RESEARCH, NEW YORK CITY

     The various war activities of the Rockefeller Institute for Medical Research were made possible on the large scale on which they were conducted through the aid of the Rockefeller Foundation, which supplemented the available funds of the institute in a generous manner. Through the large appropriations mnade to the institute by the foundation for war purposes, the institute was enabled to undertake certain teaching and other activities which it was in a position to conduct with advantage.

b The statements of fact appearing herein are based, in the main, on the "History of United States Army Auxiliary Hospital No. 1, New York City,” by Maj. George A. Stewart, NI. C., United States Army, while on duty as a member of the stall of that hospital. The material used by him in the compilation of the history comprised official reports from the various divisions of the hospital. The history is on file in the Historical Division, Surgeon General’s Office, Washington, D. C. - Ed.


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    These war activities, for the most part, were outside the normal work of the institute as designated by its founder and board of trustees; however, the imminence of war with and then later the actual declaration of war against Germany, led the corporation of the institute to readjust its general kinds of activities, in order to place the facilities of the institution on a war basis.

    Fortunately, the institute had made contributions looking toward the prevention and curative treatment of disease which offered immediate application to some of the medical problems likely to arise in connection with the greatly enlarged personnel of the Army and Navy, and with the inevitable casualties of large training camps in actual warfare. For example, the institute had worked out curative sera for epidemic meningitis and one of the forms of pneumonia, both of which diseases have always appeared in greater or less force in large military organizations; also, under the support of the Rockefeller Foundation, Carrel, in conjunction with Dakin, had perfected, at Compeigne, France, a method of treating surgically infected wounds which had come to have wide applicability in practice. It seemed right and proper, therefore, that the Rockefeller Institute should employ its resources in men and facilities in the service of the Surgeon Generals of the Army and Navy in dealing with their large and important problems.

    Meanwhile, the personnel of the institute suffered considerable depletion, as a considerable number of the scientific staff insisted on going into active service with the expeditionary force; but a nucleus of the staff was reserved, through cooperation with the Government, and indeed even augmented by special consignments made by the Surgeon General of the Army, in order that the particular service which the institute could render the Government might be carried out.

    The war demonstration hospital of the Rockefeller Institute was planned as a school in which to teach military surgeons the principles of and art of applying the Carrel-Dakin treatment. The idea of a teaching hospital of this kind was conceived after the diplomatic break of this country with Germany occurred, and before war was actually declared against that country. It was also thought of as a model of a base hospital which might be studied by military authorities in the United States; and hence it was constructed on what was regarded as the best plan for such hospitals as developed on the Western Front. The hospital was essentially a portable structure, including two wards of 24 beds each and all the necessary subsidiary units. The unique feature was a large laboratory for teaching the technique of bacteriological control of the wounds, and for research on problems arising out of cases admitted or suggested by the general subject of wound infection.

    In order to arrange for the admission to the hospital of wounded soldiers from overseas it was necessary for the war demonstration hospital to have an Army status. Therefore, on August 24, 1918, the hospital, in connection with the United States Auxiliary Laboratory No. 1, was reorganized as United States Army Auxiliary Hospital No. 1 and placed under the command of the port of embarkation, Hoboken, N. J., with a captain of the Medical Corps as commanding officer, a captain of the Sanitary Corps as adjutant, and a


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sergeant of the Medical Department in charge of the sick and wounded records 10 No other change in the staff was made.

INSTRUCTION

    Instruction was given to medical officers of the Army and Navy, to enlisted men in both services, to civilian surgeons, and to female nurses of the Red Cross and civil hospitals. The classes were conducted in the wards, in the operating room, and in the laboratory; and various devices were used to illustrate and enforce the teaching. The medical officers and others (e. g., chemists and bacteriologists) were taught the principles of the Carrel-Dakin method of the treatment of war wounds and were required to cover, by personal observation or operation, all the essential points involved in its proper application. They learned to prepare and to titrate the Dakin solution, to make microscopical examinations in the bacteriological laboratory, and to prepare the wound and apply the treatment in the operating room and at the bedside.

    The course of instruction for medical officers covered ordinarily a period of two weeks. Two classes, therefore, were conducted each month. At first the patients were civilians suffering from a wide variety of infected wounds. After the American Army had begun active military operations in France and the wounded began to he returned to the United States, the soldiers suffering from infected war wounds displaced the civilians. The first overseas case was received on August 31, 1918. The first class reported for instruction on August 2, 1917, and the last class completed its work on March 29, 1919.

    The following is a detailed account of the number of courses given, and the number of persons receiving instruction:

[table]

c This course was organized on April 1, 1918. It consisted of three days’ instruction in the chemistry of antiseptics.
d This course was organized July 1, 1918. One week’s instruction given in laboratory methods used in conjunction with treatment of wound infection.


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    The complete surgical course embraced the following three subjects:

Surgical clinic; laboratory methods; chemistry of antiseptics. The following schedule outlines the complete course:

Complete Surgical Course


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Complete Surgical Course-Continued.

    In carrying out this schedule from the clinical side, ward rounds were made, operative and dressing clinics held, lantern slides and motion pictures shown to demonstrate the necessity for an exact method of treating infections and the importance of following the four essential principles of the CarrelDakin method—mechanical or surgical cleansing, chemical sterilization, bacteriological control, and closure. The routine of teaching followed is briefly summarized.

    Mechanical cleansing. - Using careful surgical technique, the surrounding skin was cleansed. In some superficial wounds it was possible to sterilize by mechanical means, scrubbing with neutral soap and water being sufficient at times. In the more highly infected wounds, involving the deeper structures, it was not only necessary that the outside be cleansed, but that a thorough, careful surgical operation be performed. Faulty mechanical cleansing can lead to only one result--continued infection, with loss of function, or in many cases loss of life. It was impossible to teach men surgery and surgical judgment in the brief space of two weeks, but it was possible to emphasize the principles of thorough and careful preparation as to the stages of treatment, if the condition of the patient made this necessary.
    Chemical sterilization. - Chemicalscould not, of course, be expected to dissolve out and thus remove foreign bodies such as fragments of shell, clothing, bone, etc. The proper clinical use of the chlorine was demonstrated to the classes, and emphasis was laid on the point that in the employment of antiseptics the three cardinal principles of time, concentration, and contact must be observed at all times.
    Control. - Observation with the eye alone would not tell the true condition of a wound. To assist in this work, two methods were available: The curve of cicatrization, and the bacteriological control by means of smears and cultures. The former was intended mainly for scientific purposes and not for everyday clinical use. It indicated what effect an antiseptic or method of treatment had upon the rate of growth of epithelium. For practical purposes, the bacteriological smear control of the wound was of greater value. If mechanical and chemical sterilization had been carried out properly, the bacterial count would fall. If there was a rise or irregularity, the cause was usually a fault in the mechanical cleansing or in the application of the antiseptic, rather than in the method itself.


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    Closure. - Afterthe control had shown the wound to be sterile, it might be safely closed by any surgical procedure, such as a simple suture, fat transplant, skin flap, skin graft, or other method suited to the case.

    The total number of cases admitted to the hospital during the periods of its active service was 325.

LECTURES AND DEMONSTRATIONS

    Resuscitation. - Thelectures on the methods of resuscitation consisted in an experimental demonstration on animals of the efficiency of the method of pharyngeal insufflation. The thorax of etherized or curarized dogs was either transversely split or the walls completely removed, thus exposing lungs and heart to full view of the entire class. Without the aid of artificial respiration the lungs, of course, collapsed and as a consequence the heart slowed up. Shortly after the heart stopped beating, pharyngeal insufflation was instituted, which caused immediately the rhythmical distention of the lungs, and the heart recovered, sometimes in less than one minute. The experiment was always a success and made a profound impression upon the classes.

    Tetanus. - Regarding the treatment of tetanus, three points were discussed:
    (1) The removal of the primary cause by proper surgical methods; (2) the neutralization of the free toxin in the blood and the lymph by means of a thorough serum treatment; (3) the treatment of the tetanic manifestations after the toxin was once fixed in the nerve cells and thus was not amenable to the neutralizing action of the antiserum. Here chiefly the treatment by magnesium was indicated. The action of magnesium was demonstrated by actual experiments on tetanic dogs: (a)Animals in a severe and dangerous state of tetanus were relieved and restored to nearly normal within a few minutes by a judicious intravenous injection of magnesium sulphate; (b)in another experiment it was shown that an injudicious administration of the magnesium salt might endanger the animal’s life; (c)it was finally shown that tetanic animals which received intentionally too much magnesium and thus were in imminent danger could be saved in a few minutes by an intravenous injection of a normal solution of calcium chloride. There were animals in which after receiving a very large dose of magnesium the respiration was completely abolished and the heart’s action could not be felt any more; they were nevertheless resuscitated by means of calcium and with pharyngeal insufflation.

SPECIAL INVESTIGATIONS

    A number of specific problems which arose in the course of the work of the hospital were studied and several papers published. The following observations were made: (1) It was found that hypochlorite solutions, even if neutral, have the ability to dissolve necrotic tissue, plasma clot, or exudate and pus cells, whence their power of “clearing” the wound and of more efficient bactericidal action, since the bacteria, otherwise protected by the debris or exudate, are readily exposed to the antiseptic effect of the hypochlorite. (2) The chlorine content of hypochlorite solutions diminished more rapidly when in contact with necrotic tissue than with intact normal tissue. On the other hand, chloramine-T solutions are not only more stable, but deteriorate a little


485

more rapidly in the presence of necrotic than of normal tissue. (3) Dakin’s hypochlorite solutions and chloramine-T solutions quickly destroy the exotoxin (Bull) of B. welchii. (4) The following antiseptics were tested for poisonous effects on animals and showed decreasing toxicity in the order given: Eucalyptol, brilliant green, mercurophen, mercuric chloride, chloramine-T, dichloramine-T, proflavine, hychlorite, Dakin’s hypochlorite, javelle water, magnesium hypochlorite, iodine, phenol.

    In addition to these main points, subsidiary ones to which some attention was given were studied. It was found that of the solutions of hypochlorites and allied chlorine compounds available for clinical use, none showed an appreciable solvent action on blood clot. Hence arose the advisability of proper mechanical cleansing and treatment of wounds, in order to remove and prevent blood clots which might harbor bacteria.

    Beginning in August, 1918, instruction was given convalescent patients by aides in reconstruction and occupational therapy.

    At the request of the Surgeon General of the Army, the courses in rnstruction for medical officers were continued until April 1, 1919. The last class completed its work on March 29, after which the patients remaining were evacuated as rapidly as possible and the hospital was closed on April 15, 1919.

UNITED STATES ARMY AUXILIARY LABORATORY NO. 1

    The fact was early recognized, once we were at war, that the Surgeon General would make heavy demands upon the personnel of the bacteriological and clinical chemical laboratories of the country. It was thought probable that the existing highly-trained personnel would prove inadequate to meet the needs. On the other hand, it was believed that the recent general addition to the medical curriculum, of bacteriology and its handmaiden, serology, and the corresponding improvement in the teaching of chemistry in medical schools, as well as the creation of many diagnostic laboratories in hospitals, would provide a large number of partially-trained laboratory workers who could readily and quickly be prepared to carry out, either alone or under supervision, diagnostic work in camp laboratories. Other potential sources of workers were the schools of agriculture in which instruction in bacteriology was given. Hence it was proposed to establish training courses in bacteriology, serology, and (later) medical chemistry for this class of students. The Surgeon General approved the project, the laboratory was organized and the Surgeon General assigned medical officers and others to the Rockefeller Institute for instruction.

COURSE IN BACTERIOLOGY

    The first requisite was a teaching laboratory. In view of what was stated of the nature of the institute, namely, an institution of pure research for already trained workers, no general instructional laboratory had ever been called for. Fortunately, a new laboratory building of the institute had been recently occupied and contained a large, undivided, and unoccupied space on a convenient floor which could be utilized. The necessary desks and apparatus were quickly assembled and installed, and the first course of instruction opened on June 25, 1917. The instruction covered a period of four weeks (28


486

days), and the course was repeated once a month. In July, 1918, one week’s instruction in surgical bacteriology was added, and in the fall of 1918 one week was set aside for the study of anaerobes. Hence when the classes were discontinued, the instruction covered a period of six weeks. At the outset an arrangement was made for 20 places in the laboratory; later the number was increased to 53. Eligible persons were accepted from the Army and Navy, and when space was available a few civilians who proposed to enter the service were admitted. Eligibility consisted of previous training in laboratory methods, with special reference to bacteriology and serology (immunology).

    The course of instruction was planned to be intensive and strictly practical, and to cover a selected set of subjects which it was believed would dominate the demands made on the diagnostic bacteriological laboratory. The work was practical, the student carrying out under the direction of instructors the entire series of operations which he would be called upon to perform in the diagnostic laboratory. A series of brief lectures and demonstrations was designated in order to make the object of the various steps clear to the student, and to connect the operation with the present state of our knowledge and to point out to him the readily accessible articles and books for his further guidance. The schedule which follows represents the subjects taught and the period given to each when the course had been fully developed. In order that the nature and manner of the instruction may be easily apprehended, the plan of instruction in a few of the main subjects is given in some detail.


487

FIRST WEEK - THYPHOID AND DYSENTERY


488

SECOND WEEK - PNEUMONIA


489

 THIRD WEEK - MENINGITIS


490

ANAEROBIC - FOURTH WEEK


491

MISCELLANEOUS SUBJECTS


492

BACTERIOLOGY OF WOUNDS AND TECHNIC OF TREATMENT OF INFECTED WOUNDS


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    Each class in bacteriology was sent for half a day to the Willard Parker Hospital, for instruction in the hospitalization of contagious diseases.

    The number of persons receiving instruction in the courses in bacteriology was 480: they were distributed as follows:

Officers of the Army...........................................382
Enlisted men of the Army........................................32
Officers of the Navy............................................44
Female technicians...............................................4
Civilians.......................................................18
Total..........................................................480

COURSE IN CHEMISTRY

    The course in clinical chemistry was begun April 1, 1918. At first it included only methods of use in clinical diagnosis, but later it was extended to include also the methods of sanitary chemistry which were most called for in the camps. A regular four-year university course in chemistry was required for entrance, with a few exceptions in the cases of Medical Reserve Corps officers sent by the Surgeon General. Part of the men had also completed postgraduate courses for higher degrees. Because the students selected were already familiar with general chemical technique, they were able to complete the following course in one month.

    The course included quantitative and qualitative chemical analysis and microscopic examination of urine; quantitative analysis of blood for the determination of acetone, acetoacetic acid, non-protein nitrogen, urea, chlorides, bicarbonate, oxygen, hemoglobin, and sugar; detection of blood in feces; analysis of gastric contents; functional tests of glucose tolerance in diabetes, bicarbonate retention in acidosis, and phenolsulphonephthalein test for kidney function: sanitary analysis of water, and qualitative tests for poisonous metals and alkaloids; the preparation and standardization of Dakin‘s solution.
Nine courses in all were given, and the following persons received this instruction:

Officers of the Army.......................................44
Enlisted men of the Army...................................75
Civilians...................................................7
Total.....................................................126

COURSES IN THE DIAGNOSIS AND TREATMENT OF PNEUMONIA

    Soldiers suffering from pneumonia were admitted to the hospital of the Rockefeller Institute for treatment to as great an extent as the facilities permitted. The Surgeon General of the Army assigned medical officers to the hospital, where they were taught the methods of pneumonia diagnosis and treatment as perfected there. These officers lived in the hospital and served as mternes; they remained for a period of six weeks to several months. After leaving the hospital, in many instances, they served in the pneumonia wards of camp base and general hospitals. The total number of medical officers assigned to this duty was 26. In May, 1918, as the number of pneumonia cases entering time hospital became very few, this instruction was largely transferred to Camp Jackson, S. C., where it was conducted under the direction of a medical officer who had previously been assisting in the work at the Rockefeller Institute.


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COURSES FOR TECHNICIANS

    Toward the end of the period during which instruction in bacteriology was given, the increasing requirement for technical aid in the Army laboratories suggested the advisability of training a certain number of women in the making of culture media and section cutting and staining. Hence classes were formed consisting of six women who spent two weeks in the preparation room of the institute, in which all the culture media were prepared, and two weeks in acquiring the technique of fixing, hardening, embedding, cutting, and staining of sections of tissue. Forty women availed themselves of this instruction. The course in media making covered the following operations:

Schedule of instruction for women technicians

NONMILITARY INSTITUTIONS

SCHOOLS OF FRACTURES AND WAR SURGERY

    Late in July, 1917, arrangements were completed whereby officers attached to the division of general surgery of the Surgeon Gneral's Office were enabled to receive intensive instruction along various lines.11Beginning August 1, 1917,


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at Rockefeller Institute (United States Army Auxiliary Hospital No.1), as noted, the principle of wound healing and the treatment of wounds were demonstrated to classes of approximately 15 men, over a period of 2 weeks for each class. These classes of intensive instructions were made up of officers of the Medical Reserve Corps, men of surgical training, destined for future general surgical activity.

    In October, 1917, courses of intensive instruction in the treatment of fractures were suggested:12

MEMORANDUM FOR THE SURGEON GENERAL

   1. Permission is requested from the Surgeon General to inaugurate courses of intensive instruction in the treatment of fractures of from two to four weeks’ duration, in the following cities: Chicago, Boston, Cleveland, Baltimore, Philadelphia, New York, Omaha, Denver, San Francisco, Pittsburgh. Arrangements will be made with clinical teachers who have large traumatic services which include many severe complicated fractures. Many prominent teachers have signified their willingness to cooperate in this work.

    2. These courses of special instruction in fractures are for the benefit of a large group of well-qualified surgeons who have been actively engaged in the practice of general surgery during the past 10 years and whose services would be made more valuable if they could receive special instruction in the modern, efficient methods of treating fractures.

    3. These courses are also greatly desired for many surgeons who earnestly wish active duty but who can not at present be assigned to training camps because their quota is complete. It is most desirable to keep these surgeons actively occupied in the service and this can be accomplished by assigning them to these courses of instruction, on the completion of which they may be assigned to cantonments, and in turn teach those who have not had the opportunity of receiving the special course of instruction.

(Signed)    
WILLIAM H. MONCRIEF,
Lieutenant Colonel, Medical Corps.

Approved: By direction of the Surgeon General.
(Signed)   
C. L. FURBUSH,
Major, Medical Reserve Corps.

    About the time that these courses of instruction in fractures were being established it was realized that it was not practicable to give courses of instruction in fractures alone, because it was difficult to secure sufficient clinical material to take up the full time of the students, and besides, it was considered desirable to give instruction in the treatment of war wounds in connection with the treatment of fractures; therefore, the courses were arranged to embrace instruction in war surgery and fractures.11

    Arrangements were finally made for the establishment of courses, variously designated, in the following cities:11 New York City (exclusive of Rockefeller Institute): Bellevue Hospital (2), Cornell University Medical College (1), Roosevelt Hospital (1). Boston, Mass.: Massachusetts General Hospital (1), Boston City Hospital (1). Philadelphia, Pa.: University of Pennsylvania (1). Pittsburgh, Pa.: Carnegie Building (1). Cleveland, Ohio: Lakeside Hospital (1). Chicago: Rush Medical College (1), Cook County Hospital (1), Presbyterian Hospital (1). New Orleans, La.: Charity Hospital (1). San Francisco, Calif.: Stanford University (1), University of California (1). Rochester, Minn.: Mayo Clinic (1).

    The directors of the schools were prominent surgeons in the communities in which the schools were located and the teaching staffs were principally members of the staffs of the institutions in which the instruction was given.


496

    An adjutant, and in some instances an assistant adjutant, was selected from the students by the director to assist in the keeping of records and the rendering of reports of the schools.13 At the completion of the courses the students were classified and a detailed report rendered to the Surgeon General showing the qualifications of each man. Weekly and monthly reports were also rendered showing the progress of the classes.

    The first classes to be ordered to these schools were principally from the medical officers’ training camps. Approximately 70 men were ordered from Fort Benjamin Harrison in November, 1917.13 The classes for January. 1918, were selected almost entirely from ambulance and field hospital companies, the idea being for these men to return to their organizations and act as instructors for other members of their units.13

    The Surgeon General furnished to each school a set of standard splints, which had been adopted for general use in the Army, including a Bradford frame for each school.13

    A syllabus of the abstracts of War Surgery was sent to each school by the Surgeon General, as indicated by the following circular letter which was used by all schools as a basis for the instruction given.14 The instruction, therefore, was basically the same in all schools except that at the Rockefeller Institute (q. v.) where the instruction was largely devoted to the treatment of wounds, and at the Mayo Clinic (q. v.) where the courses were along the lines of general surgery.

   1. Under separate cover we are sending to you a syllabus containing abstracts of War Surgery. It is hoped that the material it contains may be of value to you and the surgical personnel.

    2. Great care should be exercised to preserve this copy. You will acknowledge its receipt since they will be checked against you as part of the property sent for the course, and in case your class is taken over by some one this copy should go to the new instructor as part of the property of the Government.
    The abstracts are primarily designed as a basis for, the lectures, and the following are suggested as among the subjects which would be of interest to your class: (a) War wounds: The circular of November 1 contains an outline of this subject. Considerable emphasis should be placed upon (1) excision; (2) sepsis; (3) tetanus; (4) gas bacillus infection; (5) shock; (6) hemorrhage and aneurysm, primary and secondary; (7) ligation of vessels with a study of collateral circulation; (8) location of nerves (of importance because of excision of wounds). (b) Wounds of special locations (should have intensive study), e. g.: (1) Joints; (2) chest; (3) abdomen; (4) brain and spinal cord; (5) oral and neck surgery; (6) nerves. (c) Amputations: Form, site of election, especially after treatment. (d) Fractures. (e) Burns and gas injury.

    3. If any further help can be given, communicate with this office, attention of the surgical division.

   The following is a copy of a syllabus inclosed in the above letter and sent to the schools by the Surgeon General to aid in the teaching of the treatment of war wounds: 14

THE TREATMENT OF WAR WOUNDS

    (1) Arranged by the division of surgery, under authority of the Surgeon General, United States Army, for surgical teaching.
    (2) In fighting pests apply antiseptic and protect wounds. Treat mortal complications only--do not scrub or explore.
    (3) In front area: Don’t suture wound! Don’t scrub wound! Don’t evacuate with tourniquet in place! Don’t put on tight bandages! Don’t probe!


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    (4) In front area: Do give antitetanic serum. Do arrest bleeding (a) by tying vessel, (b) by bandage over cone of gauze. N. B. Be sure circulation of limb is not cut off. Do apply splint to fractures without removing clothes.
    (5) Antiseptics will cleanse wounds locally and control suppuration but will not affect bacteria after they have entered the circulation.

WOUND TREATMENT AT EVACUATION AND BASE HOSPITALS

    (6) Excision with foreign body removal and drainage when necessary are fundamental principles.
   (7) If wound is excised within six hours immediate closure is often possible.
   (8) Various other antiseptics have been used: Flavine, brilliant green, ‘Bipp,” eusol, dichloramine-T., picric acid, iodine, and many others.
   (9) Eusol: A type of hypochlorous acid; is extensively used by the British. Probably less efficient than Dakins solution.
    (10) Bipp”--Morison’s method: Bismuth subnitrate, 1 ounce; iodoforrn, 2 ounces; paraffin, quantity sufficient to make paste. Excise and cleanse wound. Apply minimum amount Bipp.’’
   (11) ‘‘Bipp"--danger: Poisoning from bismuth or iodoform. Advantage: Little dressing of wound necessary.
    (12) Hypertonic salt solution (Wright): Theory of use--osmosis from wound (lymphatic drainage), now little used by British.
    (13) Flavine compound (Browning) : Kills bacteria in wounds. Complete sterilization not so often secured. Fairly satisfactory but seems to inhibit repair after a time.
    (14) Picric acid: Five per cent picric acid in alcohol--not so irritating as iodine and proobably as efficient.
    (15) Closing of wounds. -
    First. Primary closing of a fresh wound after mechanical sterilization may be made if patient is afterwards closely watched.
Second. Secondary closing is made after mechanical and chemical sterilization and under bacteriological control. A wound may be sutured when surgical asepsis is obtained (1 bacterium per 5 fields).
    (16) To-day suppuration of wounds can be surely prevented or stopped. There must be no pus in a hospital.
   (17) Most of the amputations due to infection can be avoided.
   (18) Septicemia generally can be prevented. The length of treatment of each wound can he reduced to one-third of what it is at present.
    (19) These results can not be obtained without precise technique. No chemical suhstance has the power, by itself, to sterilize a wound, if proper surgical treatment is not applied.
   (20) Burns. - Arranged by the division of surgery under authority of the Surgeon General, United States Army, for surgical teaching.
    (21) Burns are treated by the following approved methods: Paraffin wax, open air, under bed tent, adhesive plaster, strapping, dichloramine-T.
   (22) Do not scrub burns or apply antiseptics to them; scrubbing and antiseptics destroy essential epithelium.
    (23) Fundamental principles underlying treatment of burns are: Asepsis, protection, conservation of epithelium, prevention and treatment of shock.
    (24) Paraffin wax is combined with, various ingredients and marketed under the trade names: Cerelene, ambrine, parresine, radintol, standlind, etc.
    (25) Paraffin wax must be anhydrous. Guard against the boiling water of the water bath mixing with it.
    (26) Paraffin wax is prepared acid free with or without addition of mild drugs.
    (27) Paraffin wax should be solid when cold, and 140 ° F.; heating at 250 ° F. for 10 minutes renders aseptic.
    (28) Paraffin wax furnishes favorable conditions for repair by acting mechanically as a protective.


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    (29) Burns of first degree should have open-air treatment. One application of paraffin or oil may be made at first dressing.
   (30) Application by atomizer is safest and best method of avoiding pain. If brush is used wax must not be over 150̊ F.
   (31) Puncture blebs. Preserve overlying epithehium. Dry thoroughly with gauze, pledgets, or dry air. Apply dressing rapidly while wax is liquid.
   (32) Apply layer of wax, then layers of cotton and wax alternately. Avoid direct contact of cotton with burn, which causes pain in applying and removing. At subsequent dressings, wound may be washed with saline solution or weak antiseptic applied as spray; do not rub with cotton or gauze.
   (33) Dressing changed once daily. Fetid odor is of no serious import and disappears rapidly under proper aseptic treatment.
   (34) Clinical evidence of toxic absorption requires use of hot moist dressings (aseptic or antiseptic); do not use wax dressings under such circumstances.
   (35) Burns in neighborhood of joints should be treated with the idea of preserving joint function. Beware of contractures.
   (36) If large areas are denuded of epithelium, prevent scar tissue contraction by skin grafting.
(37) Burned fingers and toes will web permanently unless separated by gauze during healing.
(38) Burns may be treated by open method, exposed to air and protected only by gauze-covered wire frame.
(39) Treatment of burns by dichloramine-T.

   The following syllabus of instruction in the standard methods for treating fractures was also sent to all the schools: 15

    The purpose of this course of instruction is to familiarize medical officers with standard methods in the treatment of fractures. It is intended that officers so trained will not only serve in the special fracture hospital, but in field, base, and general hospitals, and as regimental officers as well, so that a continuity in the methods for treating fractures can be maintained. By this means it is proposed to establish team work on the part of medical officers throughout the Army, in order that the wounded soldier will receive promptly the most efficient treatment, whether at the regimental aid station, the dressing station, the field hospital, the evacuation hospital, or the base hospital, as well as along the lines of transportation. The logical result of this cooperation will be to secure early recovery, lessen deformity, and reduce the number of soldiers permanently disabled to a minimum. It is realized that the exigencies of the service in the zone of the advance will frequently be such as to render the standard aids impracticable, but by indicating clearly the desideratum it is hoped that the difficulties in the field will act not so much as an obstacle, as a stimulus to the ingenuity of the medical officers.

    Fractures in war are usually compound and will be much more prevalent than the simple, so that any treatment which considers merely the fracture and not the wound and the soldier would be quite ineffective. Consequently, the course of instruction will be initiated with a brief but thorough presentation of wounds, from a military standpoint, their causes, and their treatment. This will be followed by the course in standard methods for treating fractures proper. The instruction will be intensely practical in nature, consisting in the demonstration of the splints, their adaptability and application, and in clinics.

Causes and varieties of wounds:

    1. Bullet wounds: (a) Shrapnel, (b) rifle, (c) pistol.
    2. Shell wounds: (a) Shell fragments, (b) shell fuse, (c) hand grenade.
    3. Bayonet wound, sword wound.
    4. Burns.
    5. Gas.
    6. Varieties of wounds: (a) Abrasion, (b) contusion, (c)laceration, (d)puncture--complete or incomplete.


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Condition of wounded men:
    1. Hemorrhage, excesssive (shock).
    2. Exposure, wet, cold; hunger.
    3. Shell shock.
    4. Gas.
    5. Visceral injury; abdominal, thoracic, and head.
    6. Infection; pyogenic, tetanus, gas bacillus.
    7. Suppuration.

Treatment:
    General -
1. Water administered: (a) Mouth, (b) rectum, (c)hypodermoclysis, (d)intravenous, dangers.
2. Food and hot drinks.
3. Medication.
    Local -
1. Wound antisepsis: (a)Excision, necrotic tissue; (b) wound cleansing; foreign body removal; (c)tincture of iodine, (d) Dakin-Carrel method, (e)dichloramin-T.
2. Hemorrhage: (a)Pressure by bandage, cautious; (b) packed, cautious; (c)tourniquet, cautious; (d)ligation of artery, cautious; (e)amputation;. indications.
3. Dressings: (a) Dry antiseptic gauze, (b) suture; indications.
4. Infection: (a)Suppuration, (b)gangrene, (c) drainage.
    Fractures (at the dressing station):
1. General treatment.
2. Wound antiseptic; 2 per cent iodine, superficial.
3. Wound cleansing.
4. Immobilization and extension methods -
    I. Fractures of the upper extremity: (a)Simplest splint, arm to chest; (b) screen wire and wood splints; (c)if practicable, Thomas arm splint; elbow splint.
    II. Fractures of the lower extremity: (a)Rifle down the side of leg with coat between legs, and then lashed together; (b) screen wire and wooden splints, (c)femur, Thomas knee splint for fracture of femur; in fracture of femur, the soldier once placed on litter is not to be removed therefrom.
    III. Fracture of rib; immobilization.
    IV.  Fracture of pelvis, fixation; not removed from litter.
    V. Joints.
5. Infection; special treatment: (a)Tetanus-serum, (b) Gas bacillus, seration; antitoxin; (c)pyogenic.
6. Amputations, contraindications; indications.
7. Anesthesia.
8. Diagnosis tags. These must be kept up to date, particularly with fractures.
    Transportation:
1. Cases sorted into transportable and nontransportable.
2. Maintenance of immobilization and extension, where practicable, methods. Not more than 12 hours should elapse without the splint being inspected by a surgeon, and necessary adjustments made.
3. Femur, special treatment for fractures of, in transit: Not to be removed from litter; Thomas knee splint inspected once every 12 hours.
    Evacuation hospital, special fracture hospital, base hospital:
1. Early and adequate surgery.
2. Wound antisepsis.
3. Wound cleansing.
4. Conservation of fragments.


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    Evacuation hospital, special fracture hospital, base hospital- - Continued.
5. Immobilization and extension; standard methods.
    I. Fracture of upper extremity: (a) Humerus, (1) Jones humerus extension splint, (2) Jones abduction splint; (b) elbow splint, (c)radius and ulna, Jones forearm and wrist splint.
    II. Fracture of lower extremity: (a) Femur, Thomas knee splint; Hodgen splint overhead suspension and extension from Balkan frame, or on special fracture bed; (b) tibia and fibula, Jones leg splint and Cabot splint.
    III. Fracture of rib; immobilization.
    IV. Fracture of pelvis; fixation; Bradford frame.
    V. Joints; operative indications; foreign body removal; drainage.
6. Malunion and nonunion--caution--late tetanus and infection.
7. Infections; special treatment.
8. Operative treatment--indications for; standard methods.
9. Amputation; special.
10. Anesthesia; ether, drop method, chloroform; nitrous oxicle spinal, tropococaine.
11. Examinations, special methods: (a)Roentgen-ray, (b) bacteriological.
12. Massage and baking.
13. Hydrotherapy.
14. Curative workshop--reconstruction.

   The number of officers given instruction by these institutions in these subjects up to the signing of the armistice was 1,195,16 exclusive of those given instruction at the Rockefeller Institute and at the Mayo Clinic.

    As an example of the courses of instruction given at these institutions, an abstract of the history of the instruction given at Cornell University is presented.

CORNELL IJNIVERSITY MEDICAL COLLEGE, YEW YORK CITY e

     The course of instruction in fractures and war surgery followed by Cornell University Medical College was planned to give a practical working knowledge of fractures and their complicating wounds as seen in military practice. With this in view, the first two weeks, and to a less extent the third week, were occupied for a considerable part of the time with the study of basic subjects, such as anatomy, chemistry, bacteriology, and pathology, an understanding of which was essential. These were taught entirely in the laboratories, and officers took an active part in the demonstrations. The balance of the time in these weeks, and the entire fourth week, was given over to clinical study in the hospital wards and operating room. In this way, the relation between the lectures and the laboratory work, on the one hand, and the practical application of facts thus studied to wounds and fractures, on the other hand, was presented throughout the course, and received more emphasis as the course advanced. It will be seen on examining the schedule of exercises that the entire course was based upon practical work, and that didactic instruction was minimized.

    The college library, on the fourth floor of the college building, was open at all hours. It was well supplied with current and textbook literature on all the subjects discussed in the course. The library of the New York Academy of Medicine was open throughout the day and evening to all medical officers. Ample facilities were thus available for the necessary supplementary reading.

   c The statements of fact appearing herein are based on: “Cornell University Medical College Course of Instruction on Fractures and War Surgery for Officers of the Medical Reserve Corps.” Copy on file, Historical Division, Surgeon General’s Office.


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CHEMISTRY

SUMMARY OF LECTURES AND LABORATORY DEMONSTRATIONS

    1. Considerations of general properties, methods of use, mode of action, stability, etc., of the more common antiseptics.

The discussion includes:
a. Inorganic antiseptics
b.Organic antiseptics
Hydrogen peroxide
Alcohol
Potassium permanganate
Aldehydes -
Heavy metals -
Formaldehyde.
Mercury.
Paraform
Silver.
Halogen derivatives -
Halogens
- Iodoform.
     Iodine
Chloramine-T.
     Hypochlorites.
Dichloramine-T.
     Eupad.
Phenols -
     Eusol.
Carbolic acid.
    Boric acid.
Lysol.

2. Detailed consideration of recent halogen antiseptics, with special reference to Dakin’s solution and the chloramine derivatives. The discussion includes common names of substances used, methods of preparation, calculations involved in correcting Dakin’s solution, f stability, products formed on decomposition, etc.

   *    *     *    *    *     *

BACTERIOLOGY OF WOUND INFECTIONS.

GENERAL CONSIDERATIONS

Influence of type of wound on infection.
    Punctured, shattered, superficial, punched-out wo smnrl.
Probabilities of infection.
Sources of infection.
    Direct--projectile, bayonet; material carried into wounds; clothing, splinters, skin fragments, etc.
    Indirect--earth and feces.
Subsequent infection.
    Influence of dressings - (a) transmission of infection from skin; (b) on anaerobes.
Character of infection usually found; reasons.
Bacteriological analyses of clothing (chart).
    New, soiled, and sterilized clothing.
Local mechanical conditions in wound affecting infection.
(a)Destruction of tissue; (b) interference with blood supply.
General body conditions affecting infection.
    (a) Health; (b)age; (c)degenerative factors; (d) shock; (e)bleeding; (f)fatigue.
Physiological processes in wounds and effect on infection.
    Differences in punctured and shattered types.
    Influence of unaltered serum and lymph on bacteria.
    Influence of altered serum and lymph on bacteria.
    Influence of living and dead leucocytes on bacteria; on serum and lymph.
    Influence of the presence of dead tissue.
(a)On growth of organisms; (b)on production of deleterious products.

    f At the time the course was given, Dakin’s solution was prepared from bleaching powder, but a demonstration of its preparation from chlorine gas and also from common salt was included. A description of the preparation and action of this solution may be found in Vol. XI, pt. 2, p. 201 et seq., of this history.


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Reaction that usually takes place in wounds.
    Up to fifth hour, no reaction; microscopic findings.
    Fifth to ninth hour, reaction begins; migrating elements; degeneration of injured tissues.
    Ninth to twelfth hour, appearance of bacteria; anaerobes near bits of clothing.
    Twelve hours, bacteria multiply and spread; some phagocytes appear; small amount of pus appears.
    Twentieth to thirtieth hour, pus more abundant and fetid.
    Forty-eight hours, anaerobes associated with aerobes.
Flora of wounds; stages (chart); types present in first stage.
    General activities and dangers.
    Distribution in wound; Wright’s wet leech; streptococcus in wall.
    Types of organisms taking part in chronic infections.
    Persistence of anaerobic types; relation to dressings.
    Relative unimportance of staphylococcus infection; source.
    Contributing factors influencing type of infection.
    Mechanical influence of oxygen and blood supply and food conditions; viability of tissues.
    Symbiotic growth; anaerobic and facultative anaerobic putrefactive organisms. Various pathogenic organisms; favorable and unfavorable effect.
Practical.
    Methods of making films from wounds for bacteriological examination; stains employed and methods of staining.
    Examination of stained films and methods of checking up the Carrel-Dakin treatment

B. AEROGENES CAPSULATUS (B. PERFRINGENS)

Group; occurrence in nature; faecal Baelinea; morphological description.
Pathogenicity; causative relation to gas gangrene; charts and citations.
Food supply; dead tissue, muscle, glycogen; anaerobiosis.
Staining qualities in body and in cultures; capsule formation.
Spores; in feces and dirt; in wounds; in cultures; size, shape, position in bacterial body, and resistance.
Cultural description with exhibition of cultures.
Influence of foreign bodies in growth (cloth, metal).
Method of isolation (sources of error).
Symbiotic growth; charts and citations.
Production of poisonous products of growth; necessary factors; previous failures and Bull’s method; effect of toxic products; local; general; on growth of organisms in tissue; antisera, Bull’s; neutralizing value against toxic products; therapeutic value, prophylactic and curative; against toxic products; against growth of organisms; antisera, Weinberg.
Natural references of body against this organism.
Methods of increasing; active and passive immunization.
Logical methods of combating this infection.
Prophylactic; curative.
Practical: Staining and examination of materials from wounds and cultures.

B. MALIGNANT EDEMA (VIBR0N SEPTIQUE)

Group; occurrence in nature; general description; pathogenicity; occurrence in gas gangrene; nature of lesions; food supply; anaerobiosis; staining qualities; motility, flagella; spores, size, shape, position in bacterial body, resistance; cultural description with exhibition of cultures; other organisms resembling; methods of differentiation.
Production of poisonous growth products; Bargue and Doli, Weinberg, Roux; nature and effect; production of putrefactive substances.
Antisera, Weinberg; symbiosis in war wounds.
Practical: Examination of films and hanging drop preparation.


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B. TETANI

Group; general description; occurrence in war wounds; incidence.
Morphology; staining qualities; motility, flagella; spores; pathogenicity; causation; presence without symptoms; retention in wounds over long periods; cryptogenic infections; effect of injection of washed spores.
Cultural description with exhibition of cultures.
Recognition in films; distinction from tetanuslike organisms.
Toxin production; method.
Toxin; strength; mode of action; path of entry; reasons for failure of cures with antisera.
Antitoxin; use; methods; prophylactic; curative; chart of English results.
Practical: Examination of films for recognition of; examination of films; of hanging drops for motility.

OTHER ORGANISMS PRESENT REQUIRING ANAEROBIC CONDITIONS

B. fallax of Weinberg. Short description; activities; percentage of incidence.
B. edematiens of Weinberg. Short description; activities; percentage of incidence.
Coeur jaune of Weinberg. Short description; activities; percentage of incidence.
B. sporogenes. Short description; activities; percentage of incidence.
Bacillus X of Fleming. Short description; activities.
Bacillus Y of Fleming. Short description; activities.
Bacillus “Hibler IX” of Robertson. Short description; activities.
Anaerobic streptococcus.

STREPTOCOCCUS

Types of this organism causing infection.
    Streptococcus hemolyticus.
    Streptococcus viridans.
Type causing wound infection; enterococcus; description.
Special importance of streptococcus in wounds; growth in granulation tissue and unaltered serum.
Types of primary and secondary infection caused by streptococcus.
Pathogenicity of various types.
Interrelationship; immunilogical--protective, agglutins.
Morphological description.
Capsulation.
Staining qualities.
Cultural description with exhibition of cultures.
Products of streptococcal growth--toxins, hemolysius.
Discussion of body defenses--bacteriolysins, opsonins.
Immune sera.
Use of vaccines; favorable and unfavorable conditions.
Practical: Examination of films.

STAPHYLOCOCCUS

General description with habitat.
Occurrence in nature.
Relative importance.
Varieties present in wounds; source.
Relative pathogenicity of varieties.
Pathogenicity.
Cultural description with exhibition of cultures.
Products of growth--hemolysins (soluble and fixed), leucocytic, lepase, gelatinase, proteolytic, depressing factors.
Discussion of body defenses and use of vaccines.
Practical: Examination of films.


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GENERAL DISCUSSION OF OTHER ORGANISMS FOUND IN WOUNDS AND THEIR IMPORTANCE

Colon group.
Proteus group.
Pyocyaneus.
Diphtheroids.

GENERAL RESUME OF WHOLE SUBJECT OF WOUNDS

Discussion of sterilization of wounds--mechanical, physiological, chemical.
Discussion of subject of disinfectants as applied to Wounds, with exhibition tests.
Practical: Examination of films to check Carrel-Dakin method.

PNEUMOCOCCUS

Group; morphology and staining reactions; pathogenicity; types with mortality statistics; types, recognition; technique, usual method, demonstration; technique, Mitchell method, demonstration; cultural reactions, exhibition; serum treatment.

MENINGOCOCCUS

(Same presentation as pneumococcus.)

COURSE IN PATHOLOGY OF BONES AND WOUND INFECTION

GENERAL DISEASES OF BONE

   1. Simple osteoporosis. - (a)Best example is absorption of bone by cancer metastasis. Here bone is passively absorbed without cellular reaction, without cell ferment action, by pressure on bone, on vessels, and by local and general abstraction of nutriment. Spontaneous regression of cancer followed by spontaneous replacement of bone and healing of fractures. Gross and microscopic specimens.
  (b) Simple osteoporosis also occurs as a spontaneous disease of adult bone without known cause; may be progressive, and local or universal. Cause, general malnutrition, or local disturbance of circulation.
   (c) Osteoporosis occurs in various combinations-in many other diseases of bone; e. g., tubercle. Gross and microscopic specimens.
  Look out for preexistent osteoporosis in all adult subjects.
  (d) Exhibition of humerus in case of universal extreme osteoporosis, practically no bone being left in skeleton. Senile marantic atrophy.

   2. Osteomalacia. - Gestational;senile; infantile; local; universal; pure or associated with other bone changes.
  Gross effects are softening, bending, deformities. Progressive, but with usual definite limit. Peculiar constitutional disturbance in nutrition of formed bone. General cause is failure of calcium metabolism in general malnutrition, to which contribute excessive demands of fetus, calcium deficiency in diet, and probably originally defective bone.
   Microscopic: Soft, rounded bone trabeculae, deficient in calcium, basic staining, with striae of mucinous material, lacunar absorption. May be associated with much churning up of bone, new imperfect bone replacing old. Picture more or less specific.

  3.Osteitis fibrosa. - Progressive disturbance of bone, with absorption and then excessive replacement by poorly ossified bone, with growth of soft, fibrous tissue throughout marrow. Tendency to form cysts in marrow.
  Gross: Great thickening and softening of bone, which becomes chalky, cuts easily, bends, and breaks; skull first, long bones later; may be localized anywhere. - Exhibition of three skulls.
    Microscopic: Shows broad trabeculae of poorly ossified bone, some absorbing, others actively growing; may resemble osteomalacia; soft cellular, fibrous, vascular, marrow tissue; great reduction in red marrow; indirect sequels; bone cysts, benign giant cell sarcoma, fractures, and deformities.

  4.Rickets, congenital. - Infantileforms. A constitutional nutritional disorder, with general anemia, and special defect of bone ossification, strictly connected with deficient calcium absorption and appropriation. Experimentally produced by calcium poor diet.


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  Gross: Overactivity of epiphyseal ends, with swelling of ends of bone, but poor ossification; pigeon breast; rosary; deformities; frequent unabsorbed islands of cartilage in marrow cavities; great irregularity of chalky ossification zones; exhibition of skeletons; anemia, marasmus, enteritis.
  Microscopic: Overgrowth of cartilage with poor absorption; failure of periosteal bone; hyperemia.

  5.Syphilis, congenital. - Interfereswith growths of long bones; characteristic saw-tooth line of ossification; large liver, large spleen; early death of fetus, or dwarfing.
   Acquired; necessity of requiring spirochaeta and not relying on Wassermann. In general affects periosteum and causes thickening of bone shaft and narrowing of medulla. Circumscribed areas of absorption may be associated, but less common. Exhibition of honeycombed skull. Look out for confusion with multiple myeloma. Often gives gummatous infiltration of muscles and soft parts. Exhibition of forearm, amputated for tubercle, which never thickens shaft.
   Gummatous periostitis and osteitis not common, may result in much thickening and coarse honeycombing of entire shafts or of circumscribed portions of shaft; caries sicca; dry specimens.
   Microscopic: Syphilitic granuloma, in periosteum, bone, or marrow; bone growth predominating over loss.
  No excuse for amputating syphilitic limbs.

  6.Tubercle. - Differs from lues in affecting chiefly joint surfaces and ends, always causing absorption, almost never growth; early involving soft parts, and giving much exudate, hyperemia, wide suppurating tracts and sinuses; very wide superficial skin invasion in late stages; hectic fever, anemia, emaciation; usually many tubercle bacilli in pus.
  Miscroscopic: Typical; exhibition of gross specimens, wet and dry.

  7.Rheumatism, rheumatoid arthritis, gouty arthritis. - Alldue to underlying metabolic disorder sometimes associated with low’ grade of bacterial (streptococcus) infection. Miscellaneous bacterial infections of low grade or chronic course may contribute.
  All tend to produce chronic, progressive, productive periostitis about joints, with productive periarthritis. General results are absorption of joint surfaces, eburnation, osteophytes, stiffening of joints, partial ankylosis, complete anchylosis. Affects any or all joints of spine, chiefly large joints. Exhibition of gross specimens.

TUMORS OF BONE

   Osteoma is comparatively rare, occurs chiefly in bones of skull, is of slow growth, and little present interest.

  Exostoses occur at ends of long bones, show central core of cancellous tissue with marrow, are often covered with cartilage derived from joint surfaces, and slowly growing. - Two gross specimens.

  Osteophytes occur at ends of bones, along tendon and muscle insertions, are elongated, pointed, solid bone, and of inflammatory or traumatic origin.

  Angioma occurs spontaneously, and follows trauma or fractures as a disturbance of healing process. Type cavernous. Two cases, one following trauma to head of humerus, giving massive enlargement, recurring once after curettage. One case spontaneous, in body of lumbar vertebra, causing absorption and collapse of spine with paraplegia.
   Angioendothelioma. - A malignant, rapidly growing tumor arising in bone shaft or marrow cavity, absorbing bone and invading soft parts, with metastases. Not osteogenic. Structure resembles hypernephroma (adenocarcinoma of kidney), with blood spaces lined by high cylindrical cells with clear cytoplasm, and requiring separation from hypernephroma, by search for primary renal (or adrenal) tumor. Gross specimen from lower end of humerus.

  Osteogenic sarcoma. - A specific disease of bone, always essentially the same, but occurring in three main gross forms:
  1.Spindle cell, fibrous, or cellular periosteal sarcoma, shaft long preserved, grows to large size slowly. produces metastases, and is usually fatal. Several gross specimens, early and late.


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   2. Telangiectatic osteogenic sarcoma. - Veryvascular, most vascular forms producing malignant bone aneurisms (gross specimen from humerus). Destroys shaft early, invades soft parts as vascular, cystic, pulsating tumor in which new bone is scanty but present. Rapid course, early metastases, practically always fatal. Operated on frequently after occurrence of pulmonary metastases. Always X ray the lungs. Ten gross specimens.

   3. Sclerosing osteogenic sarcoma produces ivorylike bone filling marrow cavity and thickening shaft. Pure and very slow, but often associated with vascular or cellular sarcoma. Very malignant. Specimens.
   Bone sarcoma affects chiefly ends of long bones arising centrally from epiphyseal line, and rather seldom invading joints. Specimens.
   Metastases pass readily through blood vessels, enter lungs, and grow to large bulk. Two cases.
Benign giant cell sarcoma. - Medullary or central sarcoma or sarcoid. A specific disease of bone marrow, usually associated and sequel of osteitis fibrosa, arising in cysts of this disease; often multiple, slow, without cachexia, never producing metastases; rarely breaking into joints. Absorbs bone shaft slowly but often steadily, sometimes with advancing bony capsule, which may crepitate. Structure shows typical cellular vascular granulation tissue in which are many large giant cells with very many small separate nuclei, quite different from giant cells of malignant sarcoma. This same structure may be acquired in the sinuses leading to malignant sarcoma. Treatment conservative. Gross and microscopic specimens.
Multiple myeloma. - A characteristic disease of bone marrow, consisting of a very mild or very malignant neoplastic growth of marrow cells. Usually chronic, multiple, with numerous perforating tumors of ribs, skull, sternum, spine, or long bones. Early signs are boring pains, X-ray picture, and Bence-Jones albuminuria.
Four main types. - (1)Plasma cell tumors. Typical plasma cells, usual show type may be mixed with myxoma. Prognosis bad. Two cases.
   (2) Lymphocytoma. Small lymphocytes. May involve whole of long bone and be mistaken for very malignant “round-cell sarcoma.” Case involving whole of humerus, recovering under X ray.
  (3) Malignant large cell types. Large round cells, probably derivatives of granular l.eucocytes. Produces metastases and bulky tumors.
   (4) Erythroblastoma. Rare. Small round cells with dense nuclei; malignant. Cells contain much or little hemoglobin. One case.
    Myeloma thus varies widely in prognosis and should be distinguished from osteogenic sarcoma.
    Exhibition of case developing three months after fracture of clavicle.

FRACTURES

    Types. - Complete; green-stick; linear; chipping; perforation; impacted; comminuted. With dislocation. Determined by type of trauma and character of bone injured. Illustrative specimens.
Fate of fragments. - Favorablewhen periosteum, endosteum, and nutrition are intact. Bridges of periosteum may suffice. Usually necessary to remove all small loose fragments, leaving periosteum.
Fate of bone transplants. - Depends on age of subject. Most favorable when periosteum and endosteum are transferred. Bone and periosteum may suffice. Bone alone probably always absorbed. New vessels penetrate old Haversian canals and seem to keep alive the transplant, but there is nearly always gradual absorption and replacement by new bone.
    Microscropic section (B. Brooks, A. 5., 65, 66).
Healing of fracture. - Blood clot soon organized by fibroblasts and endothelium, forming a central cavity about ends which gradually shrinks in one to two weeks. General reactive process affects periosteal tissues, fascia, muscle over a wide area. Much new cartilage promptly laid down from all these sources, giving fusiform provisional callus. Extremely active growth of bone trabeculae throughout callus, with calcification and absorption of cartilage, giving definitive callus. Condensation of bony callus follows gradually, with firm


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bone always somewhat excessive. Usually reopening of marrow cavity early filled with callus. Osteoporosis affects ends to variable, usually considerable degree, sometimes excessive with marked shortening.
    Specimens illustrating excessive provisional callus at two weeks and later. Structure approaches that of osteogenic sarcoma.
Nonunion. - Chiefcause is lack of osteogenic momentum, or excessive osteoporosis. Usually attended by failure to absorb cartilage which may remain surrounding a central cavity. Suppuration, common. Syphilis a rare factor. Wide stripping of periosteum may figure. Results: Fibrous union, or no union, or pseudoarthrosis. Dry specimens of each. Inclusion of muscle, or nerves may occur.
Complications of fractures. - Injury to muscles--widespread in military work. Forward, wavy, spiral movement of high-velocity projectiles. Wide contusion and killing of tissues due to hydraulic laws. Wide dissemination of fragments. Necessary to remove all loose fragments and all contused tissue in which circulation fails.
    Injury to nerves and brain, a special topic.
   Injury to vessels; arteries highly resistant. Rupture leads to gangrene. Partial integrity followed by thrombosis, secondary sloughing, and hemorrhage. Traumatic aneurism.
Infection. - Practically constant in compound fractures; bacterial content of clothing and dirt; open treatment; importance of blood masses; course of hemorrhage along fasciae and within muscle sheaths; effects of suppurative osteomyehitis, with involucrum about old fractures (many specimens). Dead bone as harbinger of bacteria. (K. Taylor, A. S., 66, 522.)

ACUTE INFECTIOUS PERIOSTITIS, OSTEOMYELITIS, AND OSTEITIS

     Modes of infection. - (a) Metastatic from abscess in distant area, during septicemic, infectious diseases, scarlet, variola, typhoid, etc.; (b) pyemic, from septic emboli; (c) direct infection, in compound fractures.
Bacteria. - Staphylococcus, commonest agent; produces abundant suppuration; tends to involve whole of marrow with large sequestra. Streptococcus, tends to affect epiphyses and joints, or periosteum, with less pus, and more necrosis. Typhoid gives late, localized cortical infection, little pus, seldom bulky sequestra.  

    Blood supply of long bones. - Three groups: Epiphyseal, from joint vessels; metaphyseal, from periostium supplying ends of shafts (these two sets are end arteries); central nutrient artery supplying most of shaft. Experimental osteomyelitis shows dominance of these sets of vessels.

    Gross pathology. - (a) Periostitis: Serous, fibrinous, or phlegmonous exudate gathers between bone and periosteum, strips up periosteum for short distance, gives localized abscess, and superficial necrosis of bone. Or entire shaft is affected with soft parts with fatal pyemia. Or marrow is penetrated through Haversian canals, marrow filled with localized or diffuse purulent exudate, leading to total necrosis of shaft. Pus beneath periosteum usually means pus in marrow cavity and calls for opening marrow.
    (b) Osteomyelitis: Infection begins in marrow, extends variable distance, giving local abscess or diffuse suppuration. Necrosis follows when blood supply fails over a segment of bone, and always involves whole of bone.
    Sequels, sequestrum formation, involucrum formation, death from pyemia, etc., or restitution.
     Sequestrum: Hard, white, bathed in pus; undergoes some absorption; may be completely absorbed, but suppuration continues as long as sequestrum remains. Bacteria protected and persist in dead hone. Sequestrum may involve any portion of shaft, or whole long bone and both joint surfaces. (Specimens.)
     Involucrum forms most freely in suppurative periostitis, may be bulky, very thick, spongy, condensing after recovery from infection, often riddled with cloacae. Remarkably extensive examples of involucrum may form, covering whole of shaft of femur and both joint surfaces (specimen); or whole of inferior maxilla in phosphorus necrosis (specimen).
Demonstrations of dry bones specimens of fractures. - Simplewithout reaction; transverse, oblique, splintered, green-stick, comminuted, impacted. Thirty specimens.
     Infected fractures with suppuration, large and small. Complete necrosis of entire shaft with involucrum. Three specimens.


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     Simple fractures healed, in various positioms. Femur, 10; forearm, one or both bones; Colles, with dislocation at elbow; vertebras; clavicle, one or both; sternum; humerus; one or both bones of leg; foot; pelvis; ribs; skull; etc. Numerous rarer forms of fractures and healing.
    Nonunion with osteoporosis. Fibrous union. Pseudarthrosis.
     Moist specimens with analysis. Effects on skin, subcutaneous hemorrhage.
     Muscles, crushing, infiltrating hemorrhage throughout sheaths.
    State of blood vessels, tearing, thrombosis, gangrene, secondary hemorrhage. Hemolysis in muscles, and inclosed blood clots.
    State of bone and bone marrow. Fate of nerve trunks.
     Course of infection as determined by course of hemorrhage, and injury to soft parts, with special reference to gas gangrene.
    Treatment of fractures (Le Riche). - Urges thorough cleaning away of all broken fragments, and extreme care in preserving periosteum. (1) In young subjects, if one removes bone, but leaves periosteum, it will always produce enough bone to fill defect. (2) In subjects past growth period (22 to 23), periosteum gradually loses activity, but under trauma, violent, or repeated slight, or infection, it regains power of producing bone. The regeneration from periosteum is then slightly less than the bone removed if operation is subperiosteal; it is poor and insufficient if operation is incompletely subperiosteal; it is nil if operation is extraperiosteal. In infected fractures, two to four days old, subperiosteal esquillectomy is always followed by admirable reproduction of bone after control of infection. Extreme care with fine instruments, avoiding trauma, is secret of success.
   Most war fractures are infected. Few infections where there are no muscles. Injury to muscle is widespread from concussion and thrombosis of vessels. Swollen muscles close wound of entrance and retain broken-down tissue, while excluding air and circulation.
   In infected fractures, all loose fragments die. Attached fragments usually harbor bacteria, become source of continuous infection and seat of inflammation, and eventually die. In mild infection, marrow is destroyed for short distance and becomes clear to X ray. In had infection, marrow destroyed to ends of bone or even into joints. Extensive sequestrums result. Thorough drainage necessary. Removal of all dead bone, recognized by white color and increased density. Dead bone may consist of outer shell or splinter involving only portion of shaft, or whole thickness of shaft, or whole bone.
Complications of fracture and accompanying injuries. - Fat embolism: Comparatively frequent occurrence, after fractures of long bones involving fluidification of marrow, crushing of fat tissues. After clean operations, sometimes trivial, on fat subjects, as breast of hernia, etc. Pathogenesis. Fluid fat drawn in venous channels reaches pulmonary capillaries anti arterioles, fails to pass, and causes obstruction of blood flow. Right heart distended, pressure high. Symptoms of dyspnea rapidly increasing, cyanosis, labored pulse, coma. Fat may be forced through lungs and lodge in brain amid other organs, giving intense capillary congestion with agglutination thrombi with appropriate symptoms. Minor grades of fat embolism, not fatal, probably common. Not to be confused with shock, in which the patient bleeds into his own veins and capillaries, and blood pressure in right heart is low. In fat embolism, patient dies from asphyxia.
    Case report after fracture of tibia. Experimental lesions in dogs receiving olive oil. Gross and microscopic demonstrations from each.
Pulmonary embolism. - Thrombosis of veins, especially varicose veins, superficial or deep, occurs spontaneously or after injury. Thrombus extends into some large vein, as femoral, and eventually end breaks off and is carried to lungs, lodging in large pulmonary artery. Here it may cause rapid death, or, death being delayed, it may set up local thrombosis, clot ramifying to variable extent in pulmonary vessels. Infarction fails in rapidly fatal cases, but may occur and befollowed by pneumonia. Anatomical diagnosis requires demonstration of broken end of original thrombus, loose embolus in pulmonary artery. Death by asphyxia.
   Case report and gross specimens of pulmonary embolus from slight injury of calf, with varicose veins and Hebrews’ disease.
Shell shock. - Best to assume anatomical lesions arid not to attribute condition to nervousness. Concussion from shell explosion often sufficient to produce miliary hemor-


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rhages in brain substance. Mott has found such lesions in brains of shell shock. Lesser lesions on fine nerve fibrils and gemmules, or nerve cells may reasonably be postulated. Many cases complicated with CO poisoning. Exhibition of Mott ‘s findings.

WOUND INFECTION

GENERAL

    Types of reaction. - (1)All pyogenic bacteria produce leucocytic exudate and simple suppurative inflammation of varying extent, bacteria remaining on superficial layers of cells. All produce and heal by granulation tissue, and leave scars.
Grades of reaction. - (a) Catarrhal inflammation: Occurs on wound surfaces, mucous and serous membranes, and in organs and tissues. Lymph nodes, kidney, joints. Essential features are exudation thrown out on a surface and exfoliation of lining cells. Exudate may be serum fibrin, blood, or pus. Little or no interstitial exudate. Complete healing usually follows.
    (b)Phlegmonous inflammation: Exudative process with very rich, diffuse, leucocytic infiltration. Leaves deposit of mucin in tissues and stiffening may lead to pus pockets.
    (c) Necrotic inflammation: Characterized by death of tissue from pressure of exudate or necrotic action of bacteria. On surfaces produces ulcer; in closed tissues abscesses. Always leaves permanent changes in tissue.
(d)Diphtheritic inflammation: Characterized by widespread and superficial necrosis from bacterial toxins. May affect surfaces or deeper tissues. Usually streptococcus or Klebs-Loeffler bacillus. Leaves ulcers, abscesses, scars, deformities.
    (e)Gangrenous inflammation: Death of tissue in bulk, from thrombosis of vessels, large or small, and secondary putrefactive changes, with foul odor. Necrotizing action of bacterial toxins may be prominent. Moist gangrene. 
     (f) Septicemia: Much or little local reaction fails to stop entrance of bacteria to blood stream and bacteria circulate and grow in blood. 
(g)Sapremia: Absorption of products of tissue decomposition, with or without bacteria. Retained secundines. 
(h)Pyemia: Multiple abscesses from emboli of infected blood clot of bacterial colonies. Usually from infected thromboplebitis. 
     (i) Syntoxic parasitism: Absorption of aggressins, together with their specific bacteria, produces great increase in virulence of infection, increasing invasive properties by paralysis of leucocytes, proliferative properties, and toxicity of bacteria.
     (j) Aggressins are specific substances developed by bacteria growing in living tissues, which paralyze leucocytes and facilitate growth invasion and toxicity of bacteria.  
Sources of intoxication. - (a)Diffusible toxins: Specific poisonous ferments readily diffusing from bacteria in cultures and tissues, acting on nerve cells (tetanus), or on local tissue cells (diphtheria), or both, producing characteristic symptoms. 
(b)Endotoxins: Less specific or nonspecific poisonous proteins derived from bacterial cell bodies upon their solution in body fluids, acting chiefly on nervous system, also on most organ cells, producing nonspecific symptoms very similar in all infectious diseases. Diffusible toxins produce antibodies and immunity endotoxins do not.
    (c) Hemolysins, nonspecific blood-dissolving substaces, of complex origin and nature, derived from toxins, endotoxins, and products of tissue change. e. g., streptococcus, Bacilli aerogenes. S. P. A.
   (d) Toxic products of tissue change, generally repelling leucocytes, derived by various changes in splitting of protein molecule and fats. Ptomaines. very toxic alkaloids, as cholin, cadaverin. Nitrogenous bases, as leucin, tyrosin. Fatty acids, lactic, formic, butyric. Aromatic products, as indol, phenol. Simple chemicals, NH3, H2S, CO2, H2. Most of these may probably be reduced by cleansing surface of wounds and removing dead or infected tissue. Bacilli edematis maligni produces an ammonia salt of a fatty acid which is extremely toxic. (Barger, Dale, Lancet, 1917.)   
Sources of defense. - Mainsource of defense in all wound infections is polynuclear leucocyte. Significance of leucocytosis, local, general. Mode of action of leucocytes is by phagocytosis. Extracellular destruction of bacteria in acute pyogenic infection is quite


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subordinate. Mechanical, flushing of wound by serum, and pus carries off surface bacteria. Fibrin membrane entangles and inhibits entrance of surface bacteria. Mucus generally antagonistic to bacterial growth and movement. Endothelial cells are actively phagocytic at most stages, especially later phases. Chief period of spread of bacteria is in early stages before capillaries become filled with leucocytes. Too great congestion not favorable to emigration of leucocytes, while stasis in vessels completely inhibits leucocytosis. Granulation tissue a specially effective barrier on account of its active circulation bringing abundance of actively emigrating leucocytes. Clotting blood is a strong antiseptic, while hemolyzed blood greatly favors growth of bacteria, and produces intoxication, and should he removed. Any agent injurring or inhibiting granulation tissue or procedure involving its removal is to be avoided. Postoperative “flares.”    
Action of local antiseptics. - Nolocal antiseptic can penetrate inflamed tissues in bactericidal strength without damaging natural defenses. Their action, if favorable, must be the removal of surface bacteria and accumulated material which is favorable to growth of bacteria on surface and to formation of toxic products of tissue decomposition. They may also carry in oxygen and relieve anaerobic conditions. They may act as chemotactic agents drawing more leumcocytes to surface. Their administration may call for more detailed general attention to wound and patient and thus relieve some unfavorable conditions commonly existing about neglected wounds. They act as mental stimulis to patient and physician. They fail with true tissue parasites like bac. tuberculosis. 
Gangrene. - Alwaysinvolves closure of vessels, usually of large vessels, by any means, usually thrombosis, or endarteritis, possibly only by spasm, rarely by pressure. 
     Dry gangrene, unattended by spreading infections or exudate, and secondary to arterial occlusion. 
     Moist gangrene, an acute infectious process resulting in gangrene simultaneous with occlusion of vessels. 
     Senile gangrene, toes, feet, fingers. Follows arterial sclerosis. Gross and microscopic specimens showing lesion in vessels. 
     Thromboangeitins obliterans: Erythromelalgia. Hebrews’ disease. Specific course with pain from neuritis, erythema, and other vasomotor disturbances, and gangrene of extremities. Progressive. Specimens showing gross and microscopic lesions. 
     Gangrene from crushing injury, severing main artery, or causing thrombosis. May be immediate or delayed. Gross specimens.
     Gaseous gangrene, specific, usually mixed, infection of wound, to be considered later. Specimens. 
     Diabetic gangrene, perforating ulcer of foot. Severe exudative inflammation of pyogenic type in specially susceptible tissues. 
     Spontaneous gangrene: Acroesthesia. No demonstrable lesion occluding vessel. Case history and specimen of leg. 
     Gangrene of frost bite and trench foot: Occurs only after vessels have become occluded by thrombosis (very rapid cases), or obliterating endarteritis which may develop within a few days of exposure. Effects of cold include edema, serous exudation, venous stasis with vasomotor paralysis, followed by very active proliferation of fixed tissue cells. Illustrative section from frost gangrene of toe, showing endarteritis, productive neuritis, and great cellular overgrowth.
     Streptococcus is the main bacterium. Many clinical types.
Erysipelas. - Usual form is a superficial, rapidly spreading infection of subepithelial lymphatics, hyperemia giving erythema. Chills, fever, intoxication, occasional bacteremia, local or general, single attack or recurrent, slight exudation, no permanent changes. 
    Or erysipelas may be subcutaneous, with or without cutaneous erythema, and then it is usually more severe. Exudate may then be slight and serous, or phlegmonous (many polynuclears), or diphtheritic. Bacteremia common, septicemia may occur, often fatal. These types occur with gas gangrene, hospital gangrene, etc. 
    Local cellulitis with lymphangitis: Common type of streptoccoccus infection. Early involvement of lymphatic nodes which require excision if purulent. 
    Superficial diphtheritic inflammation of open wounds usually caused by streptococcus:
    Surface covered by whitish or gray membrane, coherent and opaque if mixed with fibrin. True diphtheria of wounds also occurs.


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     Streptococcus tends to produce relatively little pus, extends rapidly through lymphatics rather than blood vessels, produces more intoxication than local reaction, and often lodges in serous membranes (joints), and leads to septicemia, not pyemia. Local process often diphtheritic. Staphylococcus produces much local reaction, much pus, seldom diphtheritic lesions, invades local vessels with infected thrombi, giving pyemia.
    Tetanus. - Allsoil, and most foreign materials, contain Bacilli tetani. Hence wounds must be made unfavorable for anaerobic growth. Tetanus develops in slightly punctured, or deep penetrating, or widely lacerated wounds, where virus is protected from air. May appear at once, or weeks after wound is healed. Very slight or no noticeable local reaction. Bacteria remain localized, or travel up nerve sheaths. Symptoms due to diffusible toxin. Appearing after 12 days, prognosis favorable. Prophylactic antitoxin regularly indicated. One of the chief grounds for wide-open treatment of wounds.
Gas gangrene. - Anold and well-known wound infection, very common and fatal in early days of the war; now less common and rather effectively handled by open treatment and early and thorough removal of dead tissues and blood clot. B. aerogenes grows vigorously when there is food for it, but disappears when there is nothing to feed upon.
   Two main factors determine incidence in civil practice, fecal contamination and watery blood. Specimens. Abortion. Transfusion of infected stale saline. Terminal anemias. 
     Sources: Constant in feces. A saprophyte of nearly universal distribution. Samples of fresh Belgian uniform fabrics constantly infected.
     Clinical types: General character of that of infective sapremia, or syntoxic parasitism.(1) Bronzed erysipelas. (2) Subcutaneous and fascial. (3) General involvement of muscles. (4) Infection of isolated muscles. (5) Delayed or latent forms, excited by operations on old wounds. (6) Metastatic. Developing in distant parts not affected by wound.  (7) Septicemic. Sometimes in fulminant cases, more often a terminal invasion in anemic subject. (8) Toxic. Intoxication out of line with local lesion. (Probably mixed infection.) (9) Benign. Favorable course, with little general reaction. May be found in simple pleurisy. (10) Gaseous and nongaseous forms.
     Course: Peracute; acute; chronic.

    Development of lesion: (a)Preparatory--main factor is injury of muscles, direct or from splinters of bone, or from shutting off blood supply; equally important is blood clot, especially haemolyzed blood. Intramuscular hemorrhage ballons out the muscles from end to end and ocludes vessels. (b)Infection--cadaveric rigidity said to mark line of advance in infected muscle, a true coagulation of myosinogen. Serous exudate abundant precedes leucocytes. Rich and effective leucocyte exudate in favorable cases, little in bad cases. Gas infiltration often splits up tissues and facilitates spread of bacteria. Yet in dead rabbit muscle bacillus travels in muscle planes 2 cm. in 24 hours. Thrombosis of vessels sets in promptly and favors growth of bacilli. Hemolysis proceeds rapidly and destroys protective power of blood. Necrosis of muscle results from infarction. (c)Putrefaction--secondary changes a complex process, many bacteria being usually concerned. Muscles dark red when first infected, later change to yellowish brown or chocolate black. Fibers homogeneous, then fragmented, swollen, disintegrated, giving rise to many toxic products of tissue change, of which little is known. 

     Biochemistry: (Henry, B. M. J., 1917, i, 806.) First stage. - Active growth in muscles clue to abundance of glycogen which is split by saccharolytic action of B. aerogenes. Glycogen converted into lactose and maltose, these again into acids and gas. Gases are CO2 and H2. Excess acids tend to limit growth of bacillus, but these are neutralized by alkaline fluids and blood. Wright’s treatment by intravenous sodium bicarbonate designed to limit supposed acidosis, not very effective. 
Second stage - acid formation succeeded by proteolytic action which dissolves muscle and yields ammonia compounds. H2S is given off and muscles darken. In this stage, more severe systematic intoxication appears. In acid stage, muscles are brick red.   
Treatment: Principles suggested by known pathology of diseases are thorough removal of bacterial nutriment, contused muscles, dissecting out muscles infiltrated with blood, removal of blood clot, cleaning out bone fragments and all foreign material. Maintenance of circulation. Blood transfer for anemia. Oxygen. No evidence appears of true toxin pro-


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duction, but reports of serum treatment, theories to contrary, are encouraging, and should be watched with caution. Bacteriology of disease is usually complex and involves bacteria for which no immunity has thus far been produced for man; e. g., streptococcus, endotoxins, tissue products, ptomaines, ammonia compounds.

     Results of serum treatment: (Weinberg, Royal Soc., July, 1916). - Three sera from B. perfringens, B. edematiens malignans, and Vibrion septique gave immediate good effects in 10 of 15 cases. In 5 septicemic cases, there was no benefit. Thinks antitoxic sera will have better preventive than curative effect against B. edematiens malignans and Vibrion septique. These toxins rapidly combine with nervous tissue in one hour. Recommends immediate injections in and about wound of three mixed sera, then, from results of bacterial culture, choose the one most indicated.

ANATOMY OF THE EXTREMITIES, WITH SPECIAL REFERENCE TO THE STRUCTURES INVOLVED IN FRACTURES AND DISLOCATIONS

     This course consists of six demonstration conferences, during which a very extensive collection of fractured bones and old joint dislocations, ankyloses, and dissections of muscles about bent and stiff joints are examined. Dissections of the joints and soft parts of the limbs, as well as models and charts, are used extensively.
    First lecture. - Themuscular and bony attachments of the arm to the neck and trunk. It is brought out, by means of models and specimens, that the arm is chiefly held to the body by extensive muscular attachments. Posteriorly, these muscular attachments begin at the occipital bone of the skull by means of the trapezius muscle and extend throughout the length of the vertebral column, and finally through the latissimus dorsi the arm is actually attached to the posterior part of the iliac crest or the girdle of the lower extremity. The arm posteriorly is held to the body by means of muscle attachments from the head to the sacrum. Anteriorly the muscular connection is much less extensive, yet, by means of the omohyoid, it begins at the hyoid bone and extends through the pectoralis major and other muscles to the breastbone and ribs. The numerous muscles, all of which are demonstrated, hold the arm by means of insertion into the arm girdle, the clavicle and scapula, as well as by insertion into the humerus or arm bone itself. The toughness, or strength, of these muscles is responsible for holding the arm to the trunk against violent pulls and forces, tending to tear it away. Should these muscles be broken or ripped away, the only bony or joint connection between the arm and the trunk is the small sterno-clavicular articulation. This joint owes its strength solely to its capsular ligament. The possible injuries and dislocations of this joint are considered.

    The fractures of the clavicle are then considered. The parts of the bone more likely to be broken are pointed out, and in every case a consideration of the muscle pull on the broken parts is gone into. The possible injuries of the soft parts, such as the nerves and vessels that lie beneath the bone, are discussed and the exact position of these structures is shown on the specimens. The Valuable role of the subclavian muscle is recognized as often protecting the large subclavian artery and vein, as well as the brachial plexus of nerves, all passing between the clavicle and the first rib. 

    The joint between the clavicle and scapula is briefly described and shown with specimens. Fractures of the scapula are demonstrated, and the resulting derangement of muscle pull and muscle positions are analyzed. 

    Dislocations of the shoulder joint: The most common dislocation of this joint are takemi up in their order of frequency. The muscles, passing from the scapula to the tuberces of the humerus, are described as holding the head of the humerus close into the glenoid fossa of the scapula. In all dislocations some of the muscles are stretched or torn, and it is demonstrated which muscles are affected in shoulder dislocations passing in given directions. The mechanics of the joint, its freedom of movement and strength in different positions, are reviewed. The relationships of large vessels and nerves in the shoulder and axillary regions are fully demonstrated. 
Second lecture. - Thearm, as a whole, is divided into ventral and dorsal surfaces, separated by preaxial and postaxial borders. On this basis the muscles may be grouped according to their positions and actions. The muscles of the ventral surface being flexors, those of the


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dorsal surface very largely extensors. The arrangement of the cutaneous nerves, and also the innervation of the muscles, may be simple analyzed in connection with these surfaces and borders. The muscles are thus treated in functional groups, and their innervation corresponds with the group arrangement. This view of the subject enables the surgeon to understand and to know the muscles and nerves without attempting to burden his memory with the details of anatomy. The complexities of given movements are briefly considered so as to show the various muscle groups involved in performing a certain action of the arm. By the use of these analyses, it is shown how paralysis of certain muscles and fractures at different places in a bone might be diagnosed.
 
    The humerus is studied in regard to the strength of the bone in its various parts, and the attachments of muscles were found to correspond with certain changes in strength in the different parts of the bone. The upper epiphysis is considered from the standpoint of possible epiphyseal fractures in young men, and the pull of the scapular muscles on the tubercles as part of the epiphysis is pointed out. A large collection of humeri that had been fractured in various places during life are shown, and the displacement and shortening of the bone is explained from the standpoint of the direction and force of muscular pull on the parts of these specimens. The relationships of the large nerves and vessels of the arm to the bone are reviewed, with special reference to the most favorable points for compressing the brachial artery against the humerus.

    The regional anatomy of the elbow joint is discussed, after which a full consideration of dislocations and fractures in the region of this joint is undertaken. A number of old fractured and ankylosed elbow joints are demonstrated. The movement of the forearm on the upper arm at this joint is analyzed from a mechanical standpoint. The obtuse (carrying) angle formed between the upper and forearm is shown; and the significance of this bend, on the line of pull is demonstrated. 
Third lecture. - The forearm and hand: The movements of pronation and supination are analyzed; and the general relationships between the radius amid ulna are shown in the various phases of these movements. The arrangement of the muscles on the radius and ulna and the influence of these muscles on the fragments resulting from fractures of the radius and ulna are discussed. The arteries and nerves of the forearm are demonstrated in their relationships to the muscles and bones. Fractures and dislocations of the wrist and carpal joints are discussed, and a number of specimens showing fractures of these regions are demonstrated. The fascial compartments and tendon sheaths in the hands and wrists are reviewed in connection with possible distribution of infections, etc., in the fingers and hand. The general anatomy of the vessels and nerves, tendons and muscles in the hand are briefly summarized and the useful landmarks and method of locating the internal structures are pointed out. 
Fourth lecture. - Thesupport of the trunk on the pelvic girdle: The strong and close connection of the trunk with the pelvic girdle is contrasted with the loose muscular attachment of the pectoral girdle to the trunk, which was considered in the first lecture. The regional anatomy of the pelvic girdle is briefly reviewed. The main and tie arches of the girdle are then considered. The femoro-sacral, or standing arch, and its tie arch are discussed in connection with certain fractures and the strength of the pelvic girdle in general. The ischio-sacral, or sitting arch, and its tie arch are considered in a similar manner, and dislocation which might occur in the pelvic girdle are then briefly reviewed. 

    The mechanics and strength of the hip joint are analyzed with the view of more fully understanding the conditions following the different dislocations of this joint. With ligament preparations, it is shown what positions the head of the femur would occupy in the several hip joint dislocations. In each case the muscles that may be stretched and torn are discussed. The ligaments of the capsule are described in connection with their behavior in the various dislocations, and the uses of these various ligaments and muscles in reducing the dislocation are described. 

    A large number of specimens are then used to demonstrate various fractures of the neck and upper parts of the femur. The collection available for this purpose is extensive and extremely elucidating in a consideration of the various compacted conditions of the head of the femur, resulting from severe injuries to the hip joint.


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    Fifth lecture. - Thethigh and knee: The thigh and leg, as a whole, are divided into ventral and dorsal surfaces, separated by pre and post axial borders, as was done in the case of the arm. The thigh and leg, however, have been rotated to such a degree in development that their dorsal surfaces are forward or toward the ventral surface of the trunk. Keeping this in mind, the muscles of the thigh and leg may be arranged in functional groups similar to those of the arm, the extensor muscles being found on the front or dorsal surface of the limb, and the flexor muscles are on the ventral surface of the limb which is toward the back of the body. The distribution of the cutaneous nerves is also rendered simple by this division of the limb into surfaces. The innervation of the muscle groups here again as in the arm makes it possible for the surgeon to understand their function and arrangement without depending upon the details of anatomy. A large collection of fractured femurs are shown, and the line of union between the two fragments indicates the direction of muscular pull which has been exerted on the lower fragment. The places on the femur most frequently fractured and the muscle pulls on the fragments during various degrees of flexion at the knee are pointed out.

    The regional anatomy of the knee joint is briefly reviewed, with a careful consideration of the synovial cavities of the joint and the neighboring tendon sheaths and bursae. Dislocations of the knee joint are then discussed from an anatomical standpoint.

    Sixth lecture. - The leg and foot: The general anatomy of the leg and foot is briefly reviewed on dissected specimens. Fractures of the tibia and fibula are demonstrated with a considerable number of these fractured bones, and the displacement of the fragments is discussed in the light of the muscle pulls involved. 

    The ankle and tarsal joints are reviewed and the dislocations and fractures of these joints and bones considered. 

    The arches of the foot are carefully analyzed and the conditions of fallen arch and flat foot thoroughly discussed from the anatomical standpoint. The competition between the tibialis and peronaeus muscles is discussed in connection with time normal position and direction of the foot in standing and walking.

   The tendon sheaths and fascial compartments of the foot are described in connection with their importance as influencing the distribution of infections, etc. The general arrangements of the vessels and nerves and the relationships of the tendons and bones in the ankle and foot are demonstrated on dissected specimens. Finally, the foot is considered from a mechanical standpoint, as the pedestal or basis on which the body must stand and move.

SYLLABUS OF THE COURSE OF INSTRUCTION GIVEN IN BELLEVUE HOSPITAL

    The object of this course is twofold: (1) The practical treatment of fractures; (2) the practical treatment of infection.

    1. Instruction is given in the principles, the structure and the application of the standard splints adopted by the United States Army. In this work the officers are required to become entirely familiar with the various splints and their uses. In order that they may practically learn those factors which tend to comfort or discomfort on the part of the patient, the first instruction is carried on with some of their own number acting as patients. Later they used uninjured patients in the wards and finally apply the splints and various apparatus to patients whose injuries demand their use for therapeutic reasons. The service affords from 30 to 40 such patients for each class. This work includes the setting up of the Balkan frame, and using it as a means of putting into effect the principles of suspension and traction in compound fractures of baths the upper and lower extremities. This work is closely supervised, and is accompanied by lectures based on the work of Silver, Flint, Blake, Jones, and LeRiche.

    2. Instruction was given in the operating rooms and wards in the practical lessons which military surgery has taught in the treatment of baths contaminated and suppurating wounds of the soft tissues and bones. Emphasis is laid throughout upon the principles which are coincidently being taught in the laboratory courses, in anatomy, chemistry, bacteriology, and pathology. Necessarily, there is some variation in this part of the work with different classes, because of the variation in clinical material in the wards, but in general the same plan is followed. The purpose of this plan is to demonstrate those facts in treatment which all authors agree the war bias proved.


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    (a)Severe contaminated wounds may be rendered clean if proper attention is paid to the elimination of all foreign matter, including that resulting from blood and tissues which have been damaged beyond hope of repair. Attention is given to the mechanical and chemical cleansing of the wound within the first six or eight hours. The teachings of Moynihan, Carrel and Dakin, Wright, Depage, Tuffier, Blake, Dunham, Le Compte, Lee and Furness, and others are followed in this. For this purpose all proper traumatic cases are operated upon before the class, particular attention being given to the principles involved.
 (b)Badly infected and suppurating wounds may be rendered surgically clean by proper application of the above principles, associated with the use of physiological and chemical antiseptics. In teaching this phase of the subject, intensive instruction is given in the technique of using Carrel tubes, the dichloramine-T-oil spray, and the principles underlying the use of the Wright hypertonic salt solution and salt pack. The officers are permitted to do the actual dressings in this part of the work, and insistence is laid upon correct technique in each step. 
(c)Wounds thus rendered surgically clean may be sutured or grafted, and the period of convalescence much shortened by this means. In this work the officers study the bacterial count and determine when the suturing shall be done. They then witness the latter and follow the results. Throughout this course the endeavor is made to emphasize the underlying principles of pathology and bacteriology which control wound healing, with the practical technical application of therapeutic measures which tend to overcome those factors that lead to continued disability. The object to be attained is the most prompt return of the wounded man to the most nearly normal condition possible. Further instruction is given along these lines by Captain Butler in the demonstrating room and by didactic lectures. 

    Another phase of the course has to do with the treatment of burns. The service furnishes a large material for this subject, and the officers are taught the use of the dichloramine-T oil, the paraffin compounds, the hot-air treatment, and the comparative value of the alkaline and the acid dressings. For the latter, an unpublished method is used. The surface of the burn is first covered with one layer of coarse gauze impregnated with the vaseline-resin-paraffin (see under Carrel treatment), used to protect the skin against sodium hypochlorite solution, and over this is applied a gauze dressing continuously wet with a 0.5 per cent solution of acetic acid. This results in a very prompt digestion of all necrotic tissue, and the establishment of healthy, clean granulations. If kept thoroughly wet, the dressing causes very little pain, and by many patients is pronounced more comfortable than any other form of treatment. The vaseline gauze permits the daily change of dressing without damage to epithelial islands. But two precautions are necessary; the vaseline gauze must be coarse mesh, about 16 by 20, must be applied in but one thickness, and the outside dressing must be kept well wet, but not dripping, the entire time. To this latter need the patient himself, or any ward attendant can attend, as dryness results in pain, indicating when more solution should be used.

INFECTED WAR WOUNDS  f

a. The general problem of infection in this war.
    I. Comparison with other wars.
    II. Remarks by various writers.
    III. What infection meant in the early part of the war.
b. Causes of such widespread infection.
c. The steps employed to combat infection, and the results therefrom.
    I. Pure surgical steps--mechanical sterilization.
(a) The exponents and their results.
    II. The physiological process.
(a)Wright’s hypertonic salt solution.
(b)Various techniques for employing the hypertonic salt-.
(c)Added use of vaccines.

f For full discussion of this subject see Vol. XI, pt. 1. Details of course of instruction are omitted here. - Ed.


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    III. Chemical sterilization.
(a)Past history of chemical sterilization.
(b)Requirements for good antiseptics, and natural limitations of chemical procedures.
(c)The varied possibilities in chemical compounds.
    1. Phenol, etc.
    2. Salts of the heavy metals.
    3. Oxidizing agents, and other varied types.
    4. The dyes.
    5. The chlorine group.
    6. Hypochlorites.
    (1) Early history.
        (2) The physical and chemical characteristics.
Strength of watery solution.
Reaction and stability.
Length of time in which work is done.
    (3) Special technique necessary.
    (4) Apparatus necessary for the method.
    For preparation.
    For checking up on wards.
    For each individual patient.
    For dressing carriage.
    For bacteriological study of wound.
    For surgical supply room.
    (5) Team work an essential.
    (6) Method of doing the dressing.
    (7) Objections to the hypochlorite sterilization.
7. Dicloramine.
  (1) Early History.
    (2) The physical and chemical characteristics.
    Strength of oily solution.
    Stability.
    (3) Solvents for dichloramine.
    Eucalyptol.
    Paraffin oil.
    Chlorcosane.
    Necessity for chlorination.
    (4) Method of preparing the solution.
    (5) Apparatus necessary for the technique.
    For preparation of the solution.
    For the dressing.
    For the surgical supply room.
    (6) Objections and comparison with hypochlorites.
d. Certain special types of infection.
I. Tetanus(a)Mode of action of B. tetanus.
(b)Observations made during war.
    1. Report of R. A. M. C.
    2.  Atypical tetanus.
    II. Gas infection and gas gangrene.

WAR WOUNDS IN GENERAL
aThe physiologic concept of the soldier.
b.General statistics regarding war casualties.
I.  Other wars. 
    II. Present


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c. Causes of injuries and surgical conditions.
    I. Cases other than battle casualties.
    II. Missiles and other weapons.
    III. Poison gas, fire, etc.
d.Transportation of wounded, and question of speed.
e.Complications of wounds.
    I. Exposure to cold and weather.
    II. Lack of food and water.
    III. Shock and hemorrhage.
    IV. Trench foot.
    V. Physical fatigue.
    VI. Psychic fatigue and shell shock.
    VII. Asphyxiation.
    VIII. Burns.
    IX. Other complications.
Special types of injuries.
    I. Fractures.
    II. Head injuries.
    III. Abdominal injuries.
    IV. Chest injuries.
    V. Other special injuries.

    *    *    *    *    *    *

    Not alone have the pyogenic organisms attracted attention in this war, but also the great class of the fecal anaerobes. This group embraces, among others: Tetanus bacillus, gas bacillus, bacillus of malignant edema, B. edematiens.

    Two in particular have been causes of great mortality in the early part of the war, anti have been the subjects of much study: Tetanus (quickly overcome), gas bacillus (still a serious condition).

    Tetanus had been exhaustively studied prior to the war, and been controlled under conditions of civil life. At the beginning of the war, it was a serious problem chiefly because no adequate system had been provided for giving the wounded prophylactic treatment. As soon as provision was made for supplying the advanced dressing stations with enough antitoxin, it ceased to be such a serious problem.

    Mode of action of tetanus bacillus.
Found in the richly manured soil.
    Normal inhabitant of the intestinal tract of horse.
    Carried into the wound on foreign bodies.
    Anaerobic life.
    Localized growth of the organisms.
    Production of exotoxin.
    Toxin reaches cord through the nerve trunks from the wound.
    Secondary importance of spread through blood stream.
    Clinical signs of infection.
    No local reaction, as with pyogenic organisms.
     Incubation period, and relation between the length of the period and the severity of the case.
    Classical symptoms.
     Recent observations on the earliest symptoms.
  General irritability.
    Increased reflex irritability and muscle spasm in the affected extremity. (Relation between the mode of reaching the cord and the part first affected.)
   Atypical tetanus, and the relationship between the amount of toxin and antitoxin in the cases with localized symptoms.
     Delayed tetanus.
  Factors causing sudden flare-ups.
    Mortality statistics.


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Various methods of treatment.
    Surgical--prophylactic.
Wound cleansing and institution of adequate antisepsis.
    Surgical--therapeutic.
Amputation--reasons why; poor results.
Nerve drainage--reasons why; poor results.
    Drugs--therapeutic.
Opiates and sedatives--reason why; limits.
    Mag. sulph.--mode of action; results.
    Antitoxin--prophylactic.
       Number of “units” necessary--American, British.
       Duration of immunity, and optimum periodicity of injections.
  Question of anaphylaxis--methods of guarding against it and treatment.
  Prophylaxis for delayed tetanus.
  Time necessary for absorption from different parts.
    Antitoxin--therapeutic.
Time to institute treatment.
Points for administration.
Number of “units” to give, frequency, etc.
General statistics regarding gas bacillus.
The Bacillus aerogenes capsulatus has long been known, but it has never been conquered in civil life, as has B. tetanus.
Very great incidence of “gas infection,” with much lower incidence of “gas gangrene.”
Mode of action of organism.
    Occurrence in nature, and mode of access.
    Influence of foreign bodies on growth.
    Early localization, and later widespread.
    Theory of symbiosis.
Association with streptococcus.
Preparation by streptococcus or other organism for the spread of B. aerogenes.
Intoxication from products of necrosis.
Roll of gas in opening channels.
    Theory of Bull.
Production of exotoxin in vitro.
Experimental evidence.
Nature of toxin.
Antitoxin, and experimental results.
Ability of B. aerogenes to prepare its own soil for grow-tim.
Clinical signs and symptoms.
    Earliest--muscle rigor.
    Cutaneous changes.
    Crepitation.
    Odor.
    Incubation period.
    Toxemia.
    Morbidity and mortality.
Treatment.
    Surgical-- prophylactic.
Early adequate surgery, especially the removal of all foreign bodies and devitalized tissue.
    Surgical--therapeutic.
Very radical surgery, amputation if necessary, excision of all affected muscles.
    Antiseptic--prophylactic.
Early use of antiseptics.
Oxidizing agents.


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Treatment--Continued.
    Antiseptic--therapeutic.
Dakin’s solution, detoxicating effect.
One per cent chlorohydrate of quinine.
Oxygen needled into involved tissue.
    Antitoxin--prophylactic.
Still subjudice.
    Antitoxin--therapeutic.
Still subjudice.
General statistics.

    *    *    *    *    *    *

THE SURGERY OF FRACTURES

Fractures, types of:
    1. Closed or simple.
    2. Open or compound--special type gunshot.
Mechanism:
    Direct violence.
    Indirect violence.
    (Special type, muscular action.)
Symptoms:
    Pain - 
1. On direct pressure--digital.
2. On indirect pressure.
3. On cross strain.
    Deformity - 
1. Long axis.
2. Transverse axis.
3. Axial rotation, etc.
    Abnormal motion.
    Crepitus.
    Change in soft parts, ecchymosis, skims blebs, laceration of muscles, injuries to blood vessels, nerves, etc.
    Shock.
    Fat embolism.
Treatment:
    First aid -
Weight bearing--nonweight bearing bones.
Closed or open fractures - 
    First essential is rest. Avoid unnecessary examination and manipulation.
    Remove clothing, splint injured part with apparatus at hand in axis of limb.
    Give morphine.
Upper extremity - 
    Arm to chest--axillary pad.
    Screen-wire and wood splints.
    Thomas arm splint--elbow splint.
Lower extremity -
    Rifle down side of leg--folded coat or blanket between leg and bind legs together.
    Wooden splints, wire or metal splints.
    Thomas knee splint.
Open (compound) fractures - 
    By direct violence, gunshot - 
        Transportable.
    Nontransportable.
    By indirect violence.


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Treatment--Continued.
    First aid--Continued.
Cut away clothing.
Treatment of the wound--iodine over skin and projecting bone.
Dressing--sterile dressing or alcohol dressing.
Immobilization in long axis, avoiding unnecessary handling.
Hemorrhage - 
    Elevation.
    Pressure.
    Tourniquet.
    Ligation of vessels.
    Immediate amputation.
Treatment of wound in soft parts in fractures by direct violence and gunshot fractures:
    Inspection to determine - 
If transportable.
If not transportable.
Early adequate surgery:
    Wide opening and exposure, leaving no pockets; removal of foreign niaterial; emit away dead and contaminated tissues; remove loose bone fragments.
    Sterilization of wound - 
Before six hours.
After six hours.
Formalin 1 per cent, H2O2, saline.
Iodine.
Dakin-Carrel.
Dichloramine-T, in chlorinated eucalyptol.
Clumsky solution, etc.
Modern method of treating fractures:
    1. By massage and mobilization.
    2. Manipulation with fixation by external device after reduction.
    3. Splints - 
Wooden, wire, tin, etc.
Plaster splints, molded plaster.
More complicated and orthopedic splints, Thomas type.
    4. Extension methods - 
1. With straight limb -
    Buck’s extension with Volkman sliding rest. (Bardenheuer and Cologne school.)
2. With flexed limb - 
    Hodgen splint (with combined traction of Stimson).
    Zuppinger, inclined plane, etc.
    Balkan splint.
    By transfixing nails, rods, etc.
    5. Open operation.

GENERAL CONCEPTIONS

    1. Unnecessary manipulation under improper surroundings should be avoided. Splint the fractured area (in the long axis of the limb, if an extremity) and transport the patient to a place suitable for the handling of the injury in question. If the patient is in shock or pain, use morphine. If an open fracture, iodine on skin, sterile dressing. Treat major injuries (blood vessels) at once. Otherwise prepare for transportation to fully equipped station.

    2. Reduce the fracture as soon as possible after the injury. This reduction should not be delayed beyond two hours. In open fractures, before six hours, excise loose fragments, remove foreign material, excise contaminated and devitalized tissues, sterilize wound. If possible to close, insert sutures to be tied if wound remains clean. After six hours, treat as above, except leave wound open and close later when wound has become free from infection.


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    3. Reduction and the proper and complete examination to determine the type and character of the fracture should be done under an anesthetic. (Naturally the same general contraindications to the use of an anesthetic apply here as are found to apply in other fields of surgery.)

    4. Have an X-ray plate made if such a plate can be made without unnecessary delay. No reduction should be delayed, however, beyond the time set in paragraph 2 to await X ray. An X ray must always be made after a reduction and should be made the day of the injury. it is, perhaps, superfluous to add that the surgeon should interpret the X-ray plates himself.

   5. Every fracture treated by traction should have an X ray taken with the traction apparatus in position and in full operation.

    6. Every fracture of the long bone should have the proximal and distal joints included in and immobilized by the fixation apparatus.

    7. The fixation apparatus used should be easily removable, procurable everywhere. and should not be applied too tightly.

    8. If the fracture is obviously irreducible, or if the X ray taken after the supposed reduction slows that that reduction is unsatisfactory, other treatment should be institute promptly.

    9. Operation should be done within the first 14 days; 4 to 7 days for the smaller bones.  9 to 11 days for the larger bones. All cases operated upon later than two weeks should he considered as late operations. (Obviously operation may be done immediately for complicated injuries to the soft parts.) Open fractures should be operated upon as early as possible. (See par. 2.)
    Use of X ray in fractures.
    Delayed union; nonunion; pseudoarthrosis.
    Process of repair in bone.
Effect of suppuration upon repair.
    Regional fractures.

    *    *    *    *    *    *

INJURIES OF SKULL, SPINE, AND PERIPHERAL NERVES

INJURIES OF SKULL

    Injuries. - Menaceof infected wounds of skull coverings. Contusions of skull, causing hematoma, epidural hemorrhage, contusions of brain. Punctate hemorrhages, possible subsequent degenerative changes.
    Symptoms. - Symptoms due to fracture proper, plus hemorrhage, brain trauma; immediate, secondary, infection.
    Treatment and operative technique. - Woundsof skull; incised; puncture; fractures of vault of skull (simple or compound); fissured; inner table only; depressed, comminuted; gunshot.
   Fractures of the base of the skull (simple or compound). - Symptoms due to hemorrhage, escape of spinal fluid, injury to brain, injury to cranial nerves; infection.
    Treatment. - Operative technique of subtemporal decompression.

INJURIES OF SPINE

    Contusions. - Local symptoms; possible cord symptoms, from punctate hemmorhages hematomyelia.
    Treatment.
    Sprains. - Gradually induced by heavy load; suddenly induced by heavy lifting, falling, or impact of falling weight.      Treatment.
    Dislocations. - Usuallyassociated with fractures; otherwise usually without cord symptoms.
    Fractures and fracture dislocations(with or without cord injuries). - Direct violence, involving usually, spinous processes and laminas; any portion of vertebra when due to projectile; indirect violence, involving, usually, crushing of bodies, plus, in severe cases, dislocation. with possible fracture of articular processes and arches.


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    Symptoms. - Without cord involvement, local signs of fracture; with cord involvement, local signs of fracture, plus cord symptoms varying with level of the lesion and completeness of damage to cord; immediate; remote.
    Treatment. - Operative technique.

INJURIES OF PERIPHERAL NERVES

    General consideration as to nerve properties. - Trophiccenters; degeneration; time involved; lapse of time after which regeneration may occur; result of nerve paralysis on muscle.
Division of nerve. - Incomplete and complete; physiological; anatomical; nerve bulbs on proximal and distal stumps.
    Pathology. - Innerves, early; in muscles, late.
    Symptoms. - Varywith site of lesions and completeness of division; primary roots, motor; peripheral trunks, sensory; lapse of time after injury; early; late.
    Treatment. - Rendering wounds sterile; preventing overstretching of paralyzed muscles; nerve repair as soon as is feasible; physical therapeutics before and after operation.
    Types of operations. - Neurolysis; end to end suture; various implantations; transposition; transplantation; bridging; suture materials; protection with cargile membrane.
    After treatment. - Physicaltherapeutics; reeducation.
    Results. - Immediate; remote.

PATHOLOGY OF TRAUMA OF THE SKULL AND CONTENTS

    Three lectures, with demonstration of specimens illustrating injury to the skull, brain, and its membranes, with consideration of the mechanism and clinical history as an aid to diagnosis, localization, and treatment.

    1. The mechanism of fractures of the skull. - Direct fractures of the vault at place of contact of violence. Localization of the fracture in relation to associated intracranial hemorrhage. Fracture without wound or abrasion of scalp; localization by hematoma of scalp at place of contact and extracranial hemorrhage into scalp from fracture.

    2. Traumatic intracranial hemorrhages. - Clot from laceration of the middle meningeal artery by fracture. Subdural clot from laceration of the brain. Anatomy and mechanism of indirect laceration of the brain an aid to the localization where focal symptoms are absent.

    3. Compression of the brain. - (a)Compression by traumatic hemorrhage. Disease associated with hemorrhage producing compression. Internal hemorrhagic pachymeningitis, central cerebral hemorrhage (apoplexy), ruptured aneurysm of circle of Willis and branches. (b)Compression by suppurative inflammation. Internal suppurative pachymeningitis from punctured wound of skull (subdural empyema). Suppurative meningitis (leptomeningitis) from infection through fracture. Traumatic suppurative meningitis without fracture. Abscess of brain. The cerebrospinal fluid obtained by lumbar puncture an essential aid in diagnosis and treatment.

TRANSFUSION g

    The life-saving effect of transfusion upon patients who have passed into a serious condition as a result, in whole or in part, of hemorrhage, is universally acknowledged.

    *    *    *    *    *    *

    As regards the indications for transfusion, the more the condition of the patient is due to a loss of blood, the greater is the benefit which may be expected from transfusion. No fact so emphasizes the importance of this indication for transfusion as the difference between the results following the use of transfusion in depressed states of vitality due to pure hemorrhage and to pure shock.

    In contrast to the almost literal resurrections following transfusion after hemorrhage, the results in conditions due to shock alone are disappointing. This is a fact which has been confirmed by a number of observers, notably in a recent article by Archibald and McLean (Shock in War Surgery, Annals of Surgery, September, 1917, lxvi, No. 3, 280). It is a fact supported by animal experimentation, and one quite in accord with the best accepted theories of the nature of shock.

g For a full discussion of this subject see Vol. XI, pt. 1, Chap. VII, p. 185. Details of course of instruction are omitted here. - Ed.


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     The symptomatology of the states produced by both shock and hemorrhage is so similar that only the history may enable one to determine to which of the two causes the depressed condition of the patient is due. The distinction, however, is of greater theoretical than practical importance, because hemorrhage and shock are more often combined in the same patient than otherwise, and the patient should then be treated as a case of hemorrhage. The favorable result of the transfusion will be directly proportional to the degree with which the symptoms are due to hemorrhage.
  
    Unquestionably the loss of blood when it occurs early, as it usually does, protects the patient against the internal sequestration of a large proportion of the circulating blood, upon which sequestration the development of shock depends. This fact is, doubtless, the explanation in a large degree for the favorable results following transfusion after hemorrhage in patients also subjected to causes of shock. It is, however, desirable to recognize the usual ineffectualness of transfusion in shocked patients who have not suffered from hemorrhage. 

    While hemorrhage is the usual indication for transfusion in war surgery, it is not the only indication. Instances of poisoning by carbon monoxide occur in the Army, and the usual beneficent results have followed transfusion of patients so poisoned. (Robertson and Watson.) Transfusion is of great value in anemic conditions preceding serious operations. 

    Other indications for transfusion chiefly concern medical cases. They include the various anemias: 
  Secondary anemia.
  Pernicious anemia.
  Leukemia.
  Bacteremia.
And as a last resort in desperately ill medical cases.

    The following are some of the specific conditions for which transfusion has been used in a series of 165 instances reported by Unger:
1. Hemorrhage:
    Gastric and duodenal ulcer.
    Typhoid fever.
    Postoperative hemorrhage.
    Ectopic gestation.
    Uterine hemorrhage.
    Ulcerative colitis.
    Jaundice.
    Hemorrhage associated with blood diseases.
    Micellaneous cases - 
        Hematemesis of unknown origin.
    Intestinal hemorrhage of unknown origin
    Multiple hereditary telangiectases.
    2. Blood diseases:
Secondary anemia.
Pernicious anemia.
Hemophilia.
Purpura hemorrhagica.
Leukemia.
Bleeding of new born.
Banti disease.
Von Jaksch’s anemia.
Henoch’s purpura.
    3. Toxemias:
Pneumonia.
Pyogenic infections with extreme toxemia.
Coal-gas poisoning.
Morphine poisoning.
Uremia.
Scurvy.
Toxemia of pregnancy.


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    4. Infections:
Localized pyogenic infections.
Bacteremia.
    5. Shock.
    6. General debility, previous to operation.

    Meleney, Steerns, Fortune, and Ferry (American Journal of Medical Science, Nov., 1917, cliv, No. 5, 733) have concluded, as a result of a review of 64 of these medical cases, that the treatment was merely palliative in the majority, but to a degree which in no way detracts from the value of the procedure; for many incurable patients have been given months of fairly good health, and, in many instances, spontaneous remissions have been definitely hastened. Of the medical cases, the pernicious anemias have been most benefited.

    *    *    *    *    *    *

X-RAY DIAGNOSIS

LECTURE I

    Introductory:
The production of X rays. - Phenomena of electric discharges in air; in vacuo. The energizing current. Cathode stream. X rays. Gas tube. Coolidge tube. Properties of  X rays. Penetration. Fluorescence. Ionization; chemical effects. Absorption by various tissues. Record of densities as shown on fluorescent screen; on plate. Central ray. Divergent rays. Distortion. Technical axioms. Application. Methods of X-ray examination:
Fluoroscopy - general.
Orthoradioscopy - examination with central ray.
Radiography.
Stereography.
Teleradiography.
Serial radiography.
Posture. - Positions.Centric examination. Sagittal views. Frontal views. Oblique views. Exeentric examination. Methods of immobilization. Use of contrast media esophagus, gastrointestinal tract, sinuses.

LECTURE II

    Interpretation: Tissue density as shown on plate. Determination of posture, position, side, age, sex.
1. Appearance due to artifacts--plate, developer, movement of part.
2. Appearances due to foreign bodies--clothes, buttons, teeth filling, bandages, immobilizations apparatus.
3. Appearances due to soft tissues--muscles, tendons, ligaments, breasts, buttocks.
4. Normal Roentgen anatomy--epiphyses, developmental variations. Interpretation of pathological findings on clinical and pathological basis.
5. Variations--in relation to clinical symptoms.
6. Accidental findings.
7. Negative examinations.
8. Limitations of the X-ray examination. Methods of analysis--fractures and dislocations, bone diseases, joint diseases, thoracic diseases, gastrointestinal diseases.

LECTURE III

    Fractures. - Fluoroscopy, radiography, technique of arrangement for various views of various joints. Sources of error, study of deformity; study of callus.


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    Scheme of analysis

Bone
R. L.

...............cm. from............................................(Bony landmark)

    Variety:
Simple.
Sprain.    
Multiple.
Comminuted.
Epiphyseal.
    Line of fracture:
Complete.
Incomplete.
Green stick.
Fissure.
    Direction:
Oblique.
Longitudinal.
Transverse.
Spiral.
T-shaped.
V-shaped.
Stellate.
Irregular.
    Displaced fragment (degree) (0, 1, 2, 3).
    Upper fragment}
    Lower fragment} direction
    Overlapping.
    Union.
    Associated fractures.
    Complications:
Inflammation.
Tumors.
Syphilis.
Foreign bodies.
    Operative procedures.

LECTURE IV
Bone inflammations. - Normalbone markings - Haversian system as shown on plate; pathological basis of radiographic appearances in periostitis, ostitis, osteomyelitis.

Scheme of analysis for radiographic study of bones

    Periost. (periosteal shadow is to be differentiated from time cortical shadow only under pathological conditions):
1. Exudative.
2. Productive.
3. Destructive - periosteal; subperiosteal.
    Cortex.
1. Atrophy (shown as loss of bone density) -
    Lamellar--lamellae intact.
    Lacunar--lamellae perforated.
2. Sclerosis--productive process--general; localized.
3. Necrosis--destructive process--inclosed by sclerosis; not inclosed by sclerosis.
    Erosions.
    Defects.


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    Medulla -
Atrophy.
Widened.
Narrowed.
    Soft tissue:
1. Infiltration--localized; general.
2. Sinus formation; air -
    Macular--in connective tissue.
    Linear--in muscle tissue.
3. Calcification--sequestral, interstitial, arthritic. Diagnosis.

LECTURE V

    Study of chest.
    Relation of air content to illumination of pulmonic fields.
    Relation of vascular content to number, size and density of pulmonic markings.
    Relation of heart shape to valvular defects.
Analysis of thorax picture - Scheme for Roentgenological study of the chest

    1. Pulmonic fields.
Shape--triangular, rounded, irregular.
Size--height, width; equal, unequal; large, medium, small.
Illumination--bright, brilliant, deficient, absent; general, local; location, borders; sharp (concave, convex, horizontal), indefinite, mobile, immobile.
Expansion--equal, unequal, diminished.
    2. Hilum shadows.
Shape.
Size.
Structure.
Density.
Calcification.
Pulsation.
    3. Pulmonic markings.
Number.
Size.
Shape.
Extension.
Density.
Distribution--general, local.
    4. Tracheal and bronchial outlines - air content.
Trachea--size, shape, position, bifurcation (site).
Main bronchi.
    Relation to hilum shadow.
    Relation to aortic arch.
    5. Diaphragm.
Position (relative).
Shape.
Contour--regular, irregular, concave, wavy; convex, billowy.
Movement.
    6. Vertebra, ribs and spaces.
Structure.
Direction.
Width.
    7. Cotodiaphragmatic space.
Size.
Shape.
Illumination.


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    8.Median shadow.
Outline--left aorta, pulmonary artery, left auricle, left ventricle, right auricle, right aorta.
Size--small, normal, large.
M.R.--Maximum deviation of the heart shadow to right of median line.
M.L.--Maximum deviation of heart shadow to left of median line.
T.--Total heart width=M. R.+M. L.
P.--Total pneumonic field radius.
L.--Heart length, “apex to base.”
V.--Angle of ventricular line to horizontal=45
    Position--normal, transposed, displaced.
Axis--vertical, oblique, transverse.
Shape--normal, spherical, oval, triangular, rectangular.
Movements--as a whole, its individual chambers, the great vessels.
    9.Aorta.
Size--small, normal, large; length from junction of right auricle to summit of arcus; width at base, at arcus.
Shape--ascending, arcus, descending.
Position.
Density.
Movement.
    10. Upper mediastinal shadow.
Size.
Shape.
Outline.
Position.
Tracheal position.
    11. Retrosternal space.
Size.
Shape.
Illumination.
    12. Retrocardia space.
Calcification.
Shadows.
    13. Esophagus.
Pathological findings.
Interpretation.
Diagnosis.

METHOD OF REPORT

    A radiographic examination of the chest gives the following results.

[table]


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[table continued]

The pathologcal finds are ...............................

This would indicate the presence of......................................

LECTURE VI

    Localization of foreign bodies:
Principles and general methods.
Plate localization.
Fluoroscopic localization.
Stereoscopic localization.
Localization of foreign bodies in the eye.

Practical lessons

    Lesson 1. - A demonstration of laboratory organization: Equipment; units; laboratory routine; radiographic technique.
    Lesson II.  -  Fluoroscopy: Advantages; disadvantages; ray quality and quantity; screen under suspension; sensitization of the eye; protective measures--operator, patient; limits of safety.
Manipulative procedures--palpation--magnification.
Study of bony system: Chest; gastrointestinal tract.
Placing the patient in postures, positions.
Demonstration of the causes of distortion and how to obviate them.
    Lesson III. - Fractures, upper extremities. Reports of cases by students according to scheme outlined, these reports being subjected to general criticism and comment.
    Lesson IV. - Fractures, lower extremities.
    Lesson V. - Study of the head and spine, normal and pathological: Suture markings; vascular markings; air sinuses; sella turcica.
Study of air or gas in soft tissues--detection--localization.
    Lesson VI. - Study of osteomyelitis. Reports of cases by students on the basis of scheme outlined, these reports subjected to general criticism and comment-.
    Lesson VII. - Study of differential diagnosis of inflammatory bone diseases from syphilis, tumor, and systemic bone conditions.
    Lesson VIII. - Study of chest conditions--pneumothorax, effusions, consolidations.
    Lesson IX. - Localization of foreign bodies. Practical demonstration.

MAYO CLINIC, ROCHESTER, MINN.

    The courses of instruction in war surgery at the Mayo Clinic, Rochester, Minn., for officers and other Medical Department personnel, included the officers’ school of general and war surgery; courses of instruction in anesthesia for nurses; courses of instruction for enlisted men for operating-room assistants. The courses were begun in November, 1917,17and were discontinued in the spring of 1919.18 As originally planned, the courses were to extend over a period four weeks,19 but this was soon changed, and the later courses covered a period of six weeks.20 An outline of the course extending from December 9, 1918, to January 18, 1919, follows:21


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ANNOUNCEMENT

    Class was divided into six sections. Sections were required to follow- schedule. Members of sections required to report on work assigned.
    St. Mary’s Hospital. - General and special surgical and pathological clinics were given every morning; orthopedic surgery, Thursday morning; neurological surgery, Saturday morning.

    Colonial Hospital. - Orthopedic surgery, every morning except Monday and Thursday; ear, nose, and throat surgery, every morning; plastic and oral surgery; general surgery, every afternoon.

    Mayo Clinic Building. - Genitourinary clinic, second floor, every morning, 8.30 o’clock; eye, ear, nose, throat, and oral surgery clinic, second floor; orthopedic department, annex, clinical laboratory, second floor, experimental laboratory, fifth floor, Roentgenology clinic, second floor, every afternoon.

OUTLINE OF COURSE FOR SIX WEEKS

St. Mary’s Hospital:
Hours
Surgical and pathological clinics.......................136
Colonial Hospital
Surgical and pathological clinics.........................}
Orthopedic surgery........................................} 76
Eye, ear, nose, and throat surgery............................}
Mayo Clinic Building:
X-ray clinics..................................................3
Genitourinary............................................6
Experimental laboratory..................................6
Clinical laboratory......................................3
Eye, ear, nose, and throat clinics.......................6
Orthopedic clinics.......................................6
Lectures................................................39
69
Total......................................281

    The classes and demonstrations were conducted by the staff of the Mayo Clinic, most of whom were members of the Officers’ Reserve Corps, on the inactive list, receiving no salary from the Government. Thirteen classes and a total of 226 officers received instruction at the clinic.20

   In addition to the officers who were given instruction in the Mayo Clinic, classes of enlisted men were ordered there for training as operating room orderlies and classes of nurses were trained there as anesthetists.20 Five classes of enlisted men, totaling 116, took the course.20 The first course began in April, 1918, and was completed on June 5.22 A noncommissioned officer was detailed to the director of the school as his assistant in looking after the details of the clothing, subsistence, etc., of the enlisted men.22

    The following is a copy of the schedule of instruction given the enlisted men: 20

SCHEDULE OF LECTURES AND PRACTICAL DEMONSTRATIONS FOR THE ENLISTED MEN:  (OCTOBER 21 TO NOVEMBER 29, 1918)

    Practical anatomy and physiology (3 lectures--Monday, October 21, October 28, November 4, 1918).
(1) Bone and muscles.
(2) Blood and central nervous system.
(3) Internal organs; position and formation.
    Report at St. Mary’s Hospital lecture room, 4 p. m.; sections A and B.


530

    Practical hygiene (3 lectures - Monday November 11, November 18, November 25, 1918). Report at St. Mary’s Hospital lecture room, 4 p. m.; sections A and B.
    Bandaging (3 lectures - Tuesday, October 22, October 29, November 5, 1918).
    Each private required to learn to make the following: 1 circular, 2 oblique, 3 spiral reverse, spica of finger, spica of thumb, construct a sling, figure-of-eight for knee and elbow, Barton bandage, four-tail bandage for head.
Report at St. Mary’s Hospital lecture room, 4 p. m.; section A.
    Bandaging (3 lectures - Tuesday, November 12, November 19, November 26, 1918).
    (Same as shown above for section A.)
Report at St. Mary’s Hospital lecture room, 4 p. m.; section B.
    Dressing of wounds (3 lectures - Tuesday, October 22, October 29, November 5, 1918).
    (1) Types of wounds, burns, and frost bites.
    (2)  Immediate treatment; antitetanic serum, control of hemorrhage, cleansing of wounds, first-aid dressings.
    (3) Drainage; antiseptics, dressings, special care.
Report at Desk C--b, Mayo Clinic, 4 p. m.; section B.
    Dressing of wounds (3 lectures - Tuesday, November 12, November 19, November 26, 1918). (Same as section B, shown above.)
Report at Desk C--b, Mayo Clinic, 4 p. m.; section A.
    Sepsis and antisepsis (4 lectures - Wednesday, October 23, October 30, Novemnber 6, November 13, 1918).
Report at St. Mary’s Hospital lecture room, 4 p. m.; sections A and B.
    Usages of common drugs (2 lectures - Wednesday, November 20, November 27, 1918).
    Description, dosage, demonstration of the following: Sedatives--Morphine, codine, heroin, aspirin, bromide, veronal. Stimulants--Ammonia, aromatic spirits; camphorated oil, atropin, coffee, digitalis. Cathartics--Castor oil, licorice powder, pills, etc.
Report at St. Mary’s Hospital lecture room, 4 p. m.; sections A and B.
    Operating room technique - sisters, anesthetists, surgeons (6 lectures - Thursday, October 24, October 31, November 7, November 14, November 21, November 28, 1918).
        (1) Importance of hospital to the sick; lifting a patient on cart; dressing and undressing patient; how to give a patient water and food; temperature, baths, urinal; how to assist; disinfectants; bedpan; enemata; bed making.
        (2) Asepsis; sterilization (a)scrubbing, (b)boiling and steam, (c)antiseptics; practical demonstration of preparation of sponges, pack, and salts, and sterilization of the same.
        (3) Lecture 15 minutes on the care and sterilization of instruments; familiarization of instruments.
    (4) Care and sterilization of ligatures; contents of emergency kit; Red Cross hospital supplies; review of instruments.
        (5) Operating-room technique: (a)Care of sterile instruments and supplies; (b)preparation of surgical assistants; (c)preparation of patient; (d)anesthetics.
        (6) Mock operation with review of operating-room technique.
Report at St. Mary’s Hospital operating rooms, 4 p. m.; sections A and B.
    Discussion of gas poisoning, drowning, shock (section A - Friday, October 25, November 1, November 8, 1918; section B - Friday, November 15, November 22, November 29, 1918).
Report at St. Mary’s Hospital operating rooms, 4 p. m.
    Demonstration of blood transfusion, intravenous saline, hypodermoclysis (section B - Friday, October 25, November 1, November 8, 1918; section A - Friday, November 15, November 22, November 29, 1918).
Report to Colonial operating rooms, 4 p. m.
    Use of splints and plaster of Paris casts (9 lectures - section A, Monday, October 21, October 28, November 4, 1918; Wednesday, October 23, October 30, November 6, 1918; Friday October 25, November 1, November 8, 1918. Section B, Monday, November 11, November 18, November 25, 1918; Wednesday, November 13, November 20, November 27, 1918; Friday, November 15, November 22, November 29, 1918).
Report at desk E 1 Mayo Clinic, 7 p. m.


531

    Technique in genitourinary preparation, (6 lectures--section B, Tuesday, October 22, October 29, November 5, 1918; Thursday, October 24, October 31, November 7, 1918. Section A, Tuesday, November 12, November 19, November 26, 1918; Thursday, November 14, November 21, November 28, 1918).
Report at desk A2, Mayo Clinic, 7 p. m.
NOTE. --At the end of the course, each man was given a written and an oral examinations.

    The classes in the course in anesthesia were conducted for nurses beginning in April, 1918. Twenty nurses were trained in this work. The following is a copy of the schedule of instruction in anesthesia :20

LECTURES

    1. Circulation. - The course, purpose, and mechanism of the circulation of the blood. The physiological significance of blood pressure, the pulse, etc. The importance of this to anesthesia.
    2. Respiration. - The purpose and mechanism of respiration. The physiological change that takes place in the lungs, etc. Relation of respiration to etherization.
    3. The nerve mechanism in connection with the circulation and respiration. The nerve control of the circulation and respiration. How etherization modifies this.
    4. Physiology of anesthesia. - Effect of the anesthetic upon blood pressure and respiration. The different stages of anesthesia.
    5. Physiological compensation during anesthesia. - The adaptation of the anesthetic to the surgical procedure.
    6. Accidents occurring during anesthesia. - Overetherization, shock, hemorrhage, etc.
    7. Quiz.

DEMONSTRATIONS

    1. A graphic study of the circulation and respiration. Attempts were made to demonstrate all of the important points emphasized in the first four lectures.
    2. A study of the accidents occurring during anesthesia and the methods of combating them.

DIVISION OF GENERAL SURGERY

(a)Practical work:
1. Each nurse had five general anesthesias under the supervision of the regular anesthetist.
2. Practical demonstrations each day.
3. Ether by the drop method.
4. Induction; maintenance.
    (b) Respiration and circulation during maintenance:
1. Complications during induction.
2. Complications during maintenance.
3.  Artificial respiration; demonstrations.
    (c) Blood pressure:
1. General principles and theoretical considerations.
2. Practical demonstration.
(d)Quiz.

SCHOOLS OF PLASTIC AND ORAL SURGERY

    It became apparent to the Surgeon General, in July, 1917, that there was this command an inadequate number of general and dental surgeons sufficiently experienced in plastic and oral surgery to take care of the cases of maxillofacial injuries that we were likely to encounter.23 He planned, therefore, to secure the services of surgeons of the highest type and of considerable experience in plastic and bone surgery, and also of qualified dental surgeons, and to give both of these classes a course of instruction in plastic and oral surgery,


532

conducted by qualified instructors. These surgeons and dentists were to work and be trained together so that units, to be composed of a surgeon and a dental surgeon, could be formed which would give to the patients to be treated the skill of the two professions. The Surgeon General accordingly authorized the establishment of three medical schools to give special courses of insruction in plastic and oral surgery for officers assigned to that work.

    Letters were then sent, through the Council of National Defense, to more than 200 prominent surgeons in the United States, to more than 800 teachers in dental colleges, and to other prominent dental surgeons, asking for suggestions as to individual men whose training and practice were such as to make them especially fitted for plastic and oral surgery.23 In this way a long list was obtained to whom questionnaires and letters of inquiry were sent. Students for the schools were selected in the main, after a careful study of the answers to these questionnaires and letters. An advisory board, consisting of five prominent surgeons was called to meet with the subsection of the section of plastic and oral surgery, Surgeon General’s Office, September 6, 1917, and it was decided at this meeting to open the first school in St. Louis.23 The medical and dental departments of Washington University, St. Louis, offered their facilities unrestrictedly to the Surgeon General, without charge for the materials used. Two other schools were later established, one at the University of Pennsylvania, Philadelphia, and the other at Northwestern University, Chicago, 111.24 

    The schools were under the control of the Surgeon General, who designated the teaching staff and outlined the curriculum. The courses of instruction varied from 16 days to 4 weeks, and extended from October 15, 1917, to March 30, 1918.23 All assignments of students were made from the Surgeon General’s Office, after first making satisfactory arrangements with each student by correspondence or conference. Reports of efficiency and class standing were made to the Surgeon General at the close of each course and many reports and recommendations were unofficially made to the chief of the section in the Surgeon General’s Office. In this way it was possible to obtain a very fair knowledge of each man’s ability and qualifications at the end of his course of instruction.

    It was customary, after the completion by these students of the courses of instruction, to assign a surgeon and a dental surgeon together to a base or evacuation hospital, the two composing a unit which constituted a division of the section of head surgery in the hospital. This unit, unless otherwise specified, had charge of injuries and surgical diseases of the mouth and its essential structures, including the bony framework and the soft tissues of the face, and also of the neck, with the exception of diseases and injuries that properly come under the specialties of ophthalmology, otolaryngology, neurologic surgery, and diseases of the thyroid gland. The instructors of the schools were selected from the staffs of the schools giving the courses and from the staffs of the affiliated institutions. Many of these institutions, as well as many of the students, were not on active duty and received no pay from the Government. Others were appointed contract surgeons, some of whom donated their pay to help defray the expenses of the courses of instruction. Following the plan inaugurated in the Chicago school, mimeographed copies of references to all obtainable


533

war literature were made and sent to the other schools in sufficient number to allow each student officer to have a complete copy. Students were required to furnish many of their own books. The schools were closed in March, 1918, the instruction being continued at the medical officers’ training camps.23 25
 
    The numbers of officers who attended the courses in these schools were: Medical officers, 164; dental officers, 123.26
 
    Three courses were given in Philadelphia at the Thomas A. Evans Museum and Dental Institute of the School of Dentistry of the University of Pennsylvania, and the facilities of the following institutions were placed at the disposal of the director: Jefferson Medical College and Hospital; Medico-Chirurgical College and Hospital; Philadelphia General Hospital; Pennsylvania Hospital; Hahnemann Hospital; and Temple University.27

    The institutions affiliated with the Chicago school were as follows: Wesley, St. Lukes, Cook County, Presbyterian, Augustana, and Francis Willard Memorial Hospitals, and John Crerar Library. The teaching staffs of these schools were selected principally from the staff of the institutions in which the instruction was given and from the institutions associated with them. Two courses of instruction were given at the Chicago school.28 

    The courses were similar in the three schools. The one conducted in St. Louis is given here as an example.

SCHOOL OF NEUROLOGICAL, PLASTIC, AND ORAL SURGERY, ST. LOUIS, MO.

    This school was attended by surgeons and dentists, and courses in neurological surgery were given in conjunction with those in oral and plastic surgery beginning with the second course. During the first two weeks the morning sessions of the two groups were separate. Both groups together participated in the afternoon sessions. The courses occupied 16 working days, from 9 a. m. to 6 p. m.29

SCOPE
     (a)To teach cooperation between surgeons and dentists.
(b)To demonstrate the methods of immediate immobilization of mandibular fractures, the repair of soft parts with free drainage, the construction and use of emergency splints, and the care of complicating injuries.
(c)To instruct in the treatment of face and oral injuries during the healing stage; repair of defects of bone and soft parts by plastic operations; construction of permanent prosthetic apparatus.

COURSES

    Anatomy (51 hours); dentists attended the demonstrations only.
    (a) Dissection: Complete detailed dissection of head and neck by each surgeon (35 hours).
    (b) Demonstration daily reviewing the ground covered by that day’s dissection.
(c)Surgical anatomy of the head and neck emphasizing landmarks, surgically important structures, regions prone to harbor infections, surgical relations.

    Numerous skulls, model dissections, and permanent specimens were at the disposal of the students.
    Infective processes about mouth, face, and neck (7 hours).
    (a) Oral and dental infections: The recognition and treatment of diseases of the mouth and teeth, bacterial flora of the mouth peridental infection, their sequelae and influence upon injuries.
(b)Infections of soft tissues and bones: Erysipelas, traumatic and nontraumatic inflammation of the salivary glands, adjacent regions involved by infection, complications due to extension of inflammation (intracranial) thromboses, meningitis, edema of glottis, angina Ludovici, cervical infections, etc.


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(c)Infections of maxillary antrum: Anatomy, diseases, symptoms, injuries, standard operations.
(d)Salivary infections and fistulae: Symptoms, treatment.
    Fractures (4 hours).
    The recognition and treatment of fractures of upper and lower jaw; surgical anatomy; importance of restoring dental occlusion; avoidance of deformity; complications noted in gunshot wounds; drainage of submaxillary region. The diagnosis and treatment was further illustrated in operative course “a.” Treatment of temporomaxillary ankylosis.
    Splints (7 hours).
(a)Demonstrations of the forms of temporary and permanent dental splints used for immobilization of mandibular fractures, special value of individual forms, selection of type to be employed.
(b)Demonstration; preparation of dental splints in presence of surgeons.
    Operative course (27 hours); surgeons assisted by dentists.
(a)Plastic methods on the cadaver: Preliminary lectures preceded each day’s laboratory work covering the operations to be performed that day. Students working in groups of three.
    Repair of defects of the soft parts of the face by sliding and pedunculated flaps; reconstruction of lips and cheeks; repair of scar deformities of lips and eyelids; Thiersch and Wolff grafting; immobilization of fractured mandible by wiring of teeth; repair of gunshot defects of soft parts and bone with preparation of emergency splints; rib grafts; enucleation of eye.
    Demonstration of repair of partial and complete loss of nose and ear by Indian and Italian method. Transplantation of finger to restore nose.
(b)Blood transfusion (3 hours). Transfusion by citrate method performed on dogs by students in groups of four.
(c) Demonstration of bone grafting (3 ½ hours). Tibial graft transplanted into jaw defect of dog; technique.
    Anesthesia (3 hours).
    Lectures detailing precautions necessary and special technique. Insufflation intracheal ether anesthesia, local regional anesthesia (conduction anesthesia, peridental, etc.).
    Postoperative care (4 hours).
    Inspection of postoperative cases and wounds. Massage and mechanotherapy.
    Roentgenology (2 hours).
    Interpretation of radiographs showing dental and peridental abnormalities, fracture of jaws, foreign bodies, etc.
    Clinical demonstrations (12 hours).
    Varying with the material available, mainly consisting of fractured mandibles, operations for repair of defects of soft parts and scar contractures, cartilage and bone grafts, drainage of oral infections.
    Extraction of teeth (4 hours). Demonstration.

    Making and application of special forms of splints for the dentists (30 hours).

    Each dentist constructed and retained for future reference the splints most applicable to the treatment of fractured mandibles. These exercises occupied the morning hours of the dentists for the first 10 days of the course.

    At the completion of the first course the curriculum was changed and extended to include the following neurological surgery:29

    Neuropathology.
    (a) Lectures and demonstrations (4 hours).
    (b) Autopsies (6 hours).
Physiology of the nervous system; lectures and demonstrations (12 hours).
    Clinical neurology.
(a)Lectures, dispensary, and ward work (23 hours).
    (b) Eye and ear (7 hours).


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    This intensive course dealt in great detail with all aspects of the surgery of the soft and bony parts of the face, jaws, and neck, enabling both the surgeon and the dentist to grasp the manifold problems which would confront him from the time the recently wounded patient required his care to the final period of discharge. The present war surgery appeared to demonstrate that almost miraculous restoration of function and repair of hideous defects with but minor final disfigurement could be attained if the proper measures were immediately instituted and if the subsequent treatment were carried out according to well-defined principles. The course was designed to teach these fundamental and essential facts and to prepare the surgeon for their application in practice.

    The first course began October 15, and the fourth, February 11, 1918. The first course covered a period of three weeks. The instruction in the second course for the dentists was completed on November 22, 1917, and instruction for the surgeons was completed on December 7; the later courses covered a period of four weeks. The expenses connected with the running of the school were handled by the Washington University and no bill was presented to the Government.23

SCHOOL OF PLASTIC AND ORAL SURGERY, UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA, PA.

   This school was conducted at the Thomas W. Evans Museum and Dental Institute of the School of Dentistry of the University of Pennsylvania.23 A conference was held in the Surgeon General’s Office on October 17, 1917, at which were representatives of the University of Pennsylvania and other medical schools and hospitals in Philadelphia and at this conference the course of instruction which had already been established in St. Louis was discussed, after which the facilities of the hospitals in Philadelphia were placed at the disposal of the Surgeon General, for the establishment of a similar course. A school at Philadelphia was authorized by the Surgeon General.23 Three courses of instruction were completed at this school, the first session beginning November 5, 1917, the second on December 3, 1917, and the third on February 11, 1918.24 The courses were attended by groups of surgeons and dentists, part of the course being arranged for both groups jointly, each group receiving instruction separately on subjects which pertained to that group.24 The following is a synopsis of the courses given and the schedules of instruction by hours for each week in each course :    27

SYNOPSIS OF THE COURSE OF STUDY BEGINNING NOVEMBER 5, 1917

Anatomy: Hours
(a)Dissections(surgeons).......................................36
(b)Demonstrations(dentists).........................................12
(c)Surgical anatomy lectures.........................................4
Infection processes about mouth, face and neck:
(a)Mouth infection (bacteriology)...............................4
(b)Infections of the neck and face—cellulitis-..................2
(c)Surgical infections of the face...................................1
(d)Infection and treatment of maxillary sinus........................1
(e)Diseases of mouth.............................................3
(f)Diagnosis and treatment of mouth diseases.....................1


536

Wounds and injuries; evening lectures.
Fractures: Hours
(a) Diagnosis and treatment of old and new fractures...................3
(b) Clinic on treatment of old fractures...............................1
Splints: Making and application of special forms:
(a) Lectures and demonstrations (surgeons and dentists)................1
(Dentists only).............................................................2
(b)Laboratory work (dentists only).........................................28
(c)Wiring, fractures........................................................1
(d) Orthodontic bands for fractures....................................1
Operative surgery:
(a)Plastic methods on cadaver lectures and laboratory (surgeons only)...............24
(b)Bone and cartilage grafting on dogs (surgeons and dentists)......................12
(c)Blood transfusion.................................................................1
Anesthesia: (a)General anesthesia (ether)|.......................................................1
(b)Intratracheal anesthesia|
(c) Local anesthesia............................................................7
(d)Nitrous-oxide and oxygen..........................................................1
Postoperative care:
(a)Carrel-Dakin method, demonstration and clinic.....................................3
(b)Dental hemorrhage.................................................................1
Roentgenology:
(a)Symposiuns on dental Xray.........................................................3
(b)Location of foreign bodies with Xray..............................................1
Clinical demonstrations:
Surgical clinics.....................................................................2
Plastic operations on the face.......................................................2
Hospital clinics (to be announced).
Extraction of the teeth:
(a)Difficult extractions.......................................................1
(b)Clinical demonstrations.....................................................3
Special lectures:
Evacuation and transportation of the wounded.
Removal of inspirated bodies of a dental nature.

In addition to the facilities of the Evans Institute, lecture and demonstration rooms at the following institutions were at the disposal of the school: 27 Jefferson Medical College, Jefferson College Hospital, Medico-Chirurgical College, Medico-Chirurgical Hospital, Medical Laboratory Building, University of Pennsylvania, Philadelphia General Hospital, Pennsylvania Hospital, Temple University, and Hahnemann Hospital.

    The instructors for the school were those serving on the staffs of the school and the above institutions. 

    The first dental course, beginning November 5, 1917, was attended by 17 surgeons, 14 dentists, and 1 bacteriologist; the second course, beginning December 3, 1917, by 16 surgeons and 16 dentists; the third course, beginning February 11, 1918, by 10 surgeons and 19 dentists.26 Upon the completion of the course a report upon the ratings given each officer was forwarded the Surgeon General’s Office.26


537

NORTHWESTERN UNIVERSITY MEDICAL AND DENTAL SCHOOLS, CHICAGO, ILL.

    This school was started November 19, 1917, and two courses of four weeks each were given. The following is a synopsis of the instruction :28

SYNOPSIS OF COURSE
Hours
Work of plastic and oral surgery division...............................................1
Anatomy:
Lectures...............................................................................10
Dissections............................................................................30
Surgical anatomy and operative surgery:
Surgical anatomy of the mouth, face, and jaws; cadaver..................................4
Ligation of vessels of the neck, tracheotomy, pharyngotomy, ammkylosis of jaw, resection of upper and lower jaw; cadaver - 
Surgeons................................................................................8
Oral surgeons...........................................................................4
Plastic surgery of the mouth, cheeks, and jaws; cadaver.................................2
Plastic surgery of the nose; cadaver....................................................2
Plastics on skin and scars, suturing, transplantation of fat, etc.; cadaver........3
Bone and cartilage transplantation, nose and jaws...................................4
Infections and inflammations:
Focal infections........................................................................1
Local, of mouth and jaws. Chronic alveolar infections...................................2
Infections involving neck, salivary glands, maxillary sinus (adenitis, celluhitis,
glossitis)......2
Bacteriology of mouth and jaw infections, gas gangrene, tetanus, etc....................2
Treatment of acute infections of oral region; infections of maxillary sinus.............1
Syphillis in the Army, and its treatment................................................1
Gunshot injuries and infections:
Open wounds; injuries to trachea and larynx; physiological saline; Dakin-Carrel method,
tincture of iodine, etc................................2
Blood transfusion; its difficulties, technique of agglutination and hemohysis; laboratory
work on dogs by members of the class...................4
Blood tests in laboratory; blood transfusion............................4
Foreign bodies in pharynx, trachea, esophagus...........................4
Fractures and dislocations of jaws:
Treatment; prevention of deformities; lectures.....................3
Prosthetic restorations of nose and mouth parts....................2
Splint construction (oral surgeons only)..........................22
Demonstrations in connection with various clinics - anesthesia:
General anesthesia; ether, nitrous-oxide and oxygen, rectal, intratracheal.....2
Local..........................................................................1
Demonstrations in connection with surgical  clinics--Roentgenology:
Lectures; reports of war work..........................................2
Demonstrations in dental Roentgenology.................................1
Demonstrations of facial Roentgenology.................................1
Extraction of teeth - clinics..........................................2
Clinics:
Facial surgery........................................................20
Oral surgery...........................................................2
General surgery........................................................2
Special lectures on war experiences....................................4
Seminar...............................................................12

    Literature on plastic and oral surgery, published since the war began, including many translations of French and German articles, divided into eight groups as follows: 1. Muscle and fat transplants. 2. Fractures. 3. Bone transplants. 4. Nose. 5. Skin and face


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transplants. 6. Neck, larynx, salivary system, hemorrhage, nerve injuries. 7. Ankylosis, infection, injuries of cervical vertebra from the front. 8. Dental procedures.
    Total time scheduled for surgeons, 156 hours.
    Total time scheduled for oral surgeons, 159 hours.

    The first course ended December 15, 1917. Thirty-two officers reported for this class. The second course began March 1, and ended March 30, 1918.28

ARMY DENTAL SERVICE COURSE, NORTHWESTERN UNIVERSITY, CHICAGO, ILL.

    In addition to the courses in plastic and oral surgery, the Northwestern University gave a postgraduate course of instruction during the month of February, 1918, called the “Army Dental Service Course.”28 Nineteen men took this course, the majority of whom held commissions in the Dental Corps. The course was given at the same time as the regular postgraduate course, and certain of the lectures and clinics were given to the two classes together, while others were separate.
 
    The Army dental service course was planned with the object of giving to those who contemplated entering Army dental service, or who had already received commissions, a review of the field of Army oral surgery in order that they might be prepared to extend their work beyond that of routine Army dental service, as occasion might offer. The high percentage of injuries of the face and jaws called for a large number of men who were familiar with the surgery of those parts, and it was expected that a considerable number of dentists would eventually be placed in position as assistants to general surgeons in the care of these cases, the dentist making splints and prosthetic appliances for the restoration of lost parts. It was the purpose of this course to familiarize the dentist with this field so that he might be qualified to render the best possible service. The schedule for each course filled the hours from 8 a. m. to 5 p. m., and consisted, on the average, of two hours of lectures and six hours of clinics and demonstrations in the various departments each day. 

    The following schedule represents the course for dentists in splint making :28

COURSE IN SPLINT MAKING BY DENTISTS

    Friday, December 7, 1.30 to 4. p. m. - Draw and anneal German silver wire, 100 feet.
    Take impressions from Babbitt metal models of case of fracture of the lower jaw, in region of cuspid. Make casts, reconstruct and mount on occluding frame. Wax up for Heath vulcanite splint; invest, pack, and vulcanize.
    Monday, December 10, 1 to 4.30 p. rn. - Take impressions from Babbitt metal models of case of fracture in region of both cuspids. Make casts, reconstruct and mount on occluding frame. Wax up for posterior band splint; invest, pack, and vulcanize.

    Tuesday, December 11, 2 to 5 p. m. - Wire teeth of plaster models of upper and lower jaws (models to be supplied), using 30-gauge annealed German silver wire.
    Wire teeth of plaster model of upper jaw to a 16-gauge German silver arch bar; wire teeth of lower jaw in same manner, then wire lower arch bar to upper bar.
    Wednesday, December 12, 1 to 4.30 p. m. - Take impressions of upper model. Wax up model of splint with square brass tubing to the buccal of molar teeth on both sides. Invest, pack, and vulcanize. Then fit square brass rod into brass tubes and make wings to extend outside mouth to be supported by attachments to head cap.
    Thursday, December 13, 8 to 11 a. m.  - Take impressions from Babbitt metal models of case in which one half of the lower jaw is missing and mount on occluding frame with other half in proper relation to upper. Make German silver bands for two lower teeth with German silver flange attached on buccal side to hold lower jaw in proper relation to upper jaw.


539

    Thursday, December 13, 2.30 to 5 p. m. - Finishand polish the vulcanite splints made on Monday, Tuesday, and Wednesday.
    Friday, December 14, 8 to 12 a. m. - From Babbitt metal models of case in which anterior lower teeth and bone of chin have been lost take impressions of upper and separate impressions of the right and left lower teeth. Make casts and mount on occluding frame with lower teeth in proper relation to upper. Make German silver bands for two lower teeth on each side and connect with heavy arch to hold halves of lower jaw in proper place.

    The second course of instruction began on March 1 and ended March :30, 1918. The schedule was similar to that of the first course.

    The course was completed by 13 surgeons and 19 dentists. At the termination of the course the students were classified according to class standing, and reported to the Surgeon General as follows: Surgeons, class A, 6; class class B, 6; C, 1. Dentists, class A, 8; class B, 8; class C, 3.

    Affiliated institutions, the clinical material of which was available and used in the conduct of this course were: Wesley Hospital, St. Luke’s Hospital, Cook County Hospital, Presbyterian Hospital, Augustana Hospital, Frances Willard Hospital, and John Crerar Library.

SCHOOLS OF ORTHOPEDIC SURGERY

    After the original personnel of the division of military orthopedic surgery of the Surgeon General’s Office was more or less automatically supplied and determined by the enrolling of the available trained orthopedic surgeons, it was quite apparent that this force must be considerably augmented as the demands upon its numbers increased. It was clear that the source of this supply must be found among the younger general surgeons and from a number of the many young practitioners who had already obtained acceptable training along surgical lines. In enrolling and recording the available orthopedic personnel the policy of the division was to depend entirely upon recommendations or personal applications for the first contact with the candidate. When such recommendation or application was received the person recommended or submitting the application was immediately reserved for orthopedic service. An effort was made to verify all statements concerning the experience and qualifications of the applicant and to decide as to his desirability and his adaptability. Those found desirable and available were transferred to this service. It was further evident that in addition to the elementary course in foot affections and care, splint work, and other orthopedic instruction, given at the Medical Officers’ Training Camps at Camp Greenleaf and Fort Riley, it would be necessary to give to some of the younger surgeons special instruction in the fundamental principles of orthopedic surgery, in order to train them as assistants in hospitals to serve under qualified orthopedic surgeons. It was finally decided that intensive training in the larger medical centers was necessary.30 In line with these views, early in September, 1917, arrangements were made with the postgraduate department of Harvard University and with the Post-Graduate Hospital, New York,32 to establish courses of instruction in these institutions, and a definite syllabus of this instruction was prepared. On October 15, 1917, arrangements were made for similar courses to be given in Philadelphia, Pa.31 Early in November a standardized course of instruction was determined upon,33 which was used in all schools. The facilities of the


540

Army Medical School, Washington, D. C., were offered for special orthopedic instruction, and property adjoining the Army Medical School was leased for this special purpose.34 About this time an orthopedic service was established at Walter Reed General Hospital, and the use of the wards and clinical material was offered in connection with the proposed course established officially through the approval of the Surgeon General.35 The first class under this arrangement entered upon the course on November 12, 1917. Other schools were established, following the same plan and schedule of instruction at the following places:  Oklahoma City, Okla.; Chicago, Ill.; and Los Angeles, Calif.30

    The teaching staff of these schools was composed of physicians, most of whom were not in the service.

HARVARD UNIVERSITY GRADUATE SCHOOL OF MEDICINE

     Courses of instruction in orthopedic surgery which were given at the Harvard Medical School and the large hospitals in Boston began in September, 1917,36 and continued until after the armistice, the last class beginning on November 1, 1918. 37 Several officers reported for the December class before it was decided to discontinue the regular courses, but arrangements were made to give them special instructions in orthopedic surgery.38
 
    The courses, as originally planned after the first trial course of four weeks, were intended to cover a period of six weeks,39 but were extended to eight weeks in the winter of 1917-18, and were reduced again to one month in the summer of 1918, when the demand for orthopedic surgeons became more urgent.41 

    The following instructions for the guidance of the students in their work in the schools, and in the rendering of reports, were issued by the Surgeon General, in April, 1918: 41

INSTRUCTIONS TO MEDICAL OFFICERS ATTENDING COURSES OF INSTRUCTION IN ORTHOPEDIC SURGERY AT HARVARD GRADUATE SCHOOL OF MEDICINE

    1. It is required that all necessary reports be promptly made out and forwarded through proper channels.
    2. It is expected that all officers in attendance in this course will be prompt in attendance, and a report will be required in case of lateness or of absence.
    3. A course being given in cooperation with a civilian institution, it is expected that the greatest possible care will be taken in relation to the laboratories, libraries, etc. This is particularly true as regards the anatomical department, where the observation of the following rules is imperative.
(a) Subjects must be kept covered when not in use, and steps taken to prevent drying.
(b)Subjects must be kept on blocks at all times to prevent maceration of dependent parts.
(c) Put scraps in the pail provided for that purpose.
(d)Greatest care must be used in handling frozen sections; these must not be dissected.
(e)Frozen sections must be returned to boxes in order after using.
(f) All material must be used with greatest care.
(g) Rooms must be kept clean and orderly at all times.
(h) The above rules will be strictly enforced.
    4. The course is under military supervision and the usual formalities will be observed.
    5. Inattention and lack of interest will be made a matter of record and forwarded to this office by those responsible for the instruction. Helpful suggestions regarding the conduct of the work will be appreciated and should be made subjects of communications which will be forwarded through the proper channels.

   *   *   *   *   *   *


541

    The following is an abstract from a general outline of instruction, suggested by the Surgeon General, for use as a guide to those conducting the courses at these special schools: 12

   *   *   *   *   *   *

    This course includes instruction in the fundamentals of orthopedic surgery, particularly as related to the military service, including review of the correlated anatomy, particularly of joints, muscles, and nerves, and a course on brace making and fitting. The following general outline of this course suggests the scope of the instruction for those who have had general surgical training, but no special orthopedic training.
    I. This course will be confined to work preparatory to assignment to reconstruction hospitals and will include:
(1) Operative surgery, plaster, shop, and gymnasium.
(2) Work in out-patient departments, and wards of large hospitals, supplemented by lectures bearing on reconstruction and plaster work.
(3) Materials used in reconstruction work and their application, touching on making, keeping, handling, and application of plaster bandages.
    a. Substratus of plaster, flannel, stockinet, and wadding.
b.Reinforcement of plaster casts with plaster, wood, wire, and iron.
c.Bracketing and making of removable dressings. Demonstrations of various methods of fixation; dressings allowing regular inspection of wounds.
    II. Regional application of dressings, splints, braces, etc., to the spine and each of the joints with special reference paid to positions of fixation and methods to be used in the field hospitals.
    III. Methods of mechanical control:
(1) Immobilization in recumbency and ambulatory.
(2) Compression, indications for -
    a. Stilting.
b.Traction, methods for recumbent and ambulatory.
c.Permanent dressings for treatment after operations of bones, joints, muscles, and tendons, with attention paid to position of fixation, in various conditions.
d. Removable dressings to permit manipulation, massage and inspection, heliotherapy, etc.
e.Apparatus specially made for, and the improvization of apparatus for complicated conditions, and the mechanics, of these forms of apparatus; special treatment of conditions and applications of apparatus and splints to the shoulder, elbow, wrist, hand, hip, knee, ankle, and foot.   f. Course in making removable dressings in plaster of Paris, cast splints improvised combinations of plaster, wire, steel rods, and wire gauze.
    IV. Braces: Typical orthopedic braces made of leather, celluloid, aluminum, and combinations thereof, adhesive plaster strappings, and the conditions met by these; wadding dressings for restraining motion causing pressure.
    V. Orthopedic operations:
(1) Osteotomies, bone sutures, grafts, etc.
(2) Joints, normal operations of joints such as excision and arthroplastry are not to be taught in this course on account of their extreme seriousness.
(3) Muscles and tendons; tenotomy, tendon transplantation and tendon implantations, with the conditions indicating their employment will be taken up and the suture of nerves with the subsequent treatment and the cases of this character will be gone into.
    VI. Manipulative Methods: Questions of forcible movements of joints to loosen adhesions and stretch shortened tissues will be taken imp and for the most part condemned, with emphasis on precautions. Mechanics of reducing malunited and unreduced fractures without apparatus touched upon.


542

    VII. Ward demonstrations which will have mostly to do with diagnosis and prognosis.
    VIII. Physical therapy which will touch upon hyperemia by various kinds of heat, and other methods of obtaining hyperemia, massage, passive movements, resisted movements, etc., with a course in therapeutic exercises, hydrotherapy, electrotherapy, and heliotherapy. Special attention will be given to the indications for, and application of electrotherapy and hydrotherapy.
    IX. Vocational reeducation: This course is planned with the idea of laying stress on kinds and percentages of disability, and ability on part of crippled men to perform certain occupations, and consideration of courses of instruction necessary for the reeducation of individuals disabled from military duty.
    X. Special anatomy in relation to reconstruction work in orthopedic surgery will be given attention in addition to stress to he laid on the principles of orthopedic surgery.
    XI. Principles and applications of hydro, and electro therapy; mechanical technique.

    Upon the completion of this course, the officers will be detailed to the medical officers' training camps, for training in military hospital administration in a course already provided by the Surgeon General. From these camps the officers will he assigned as attending orthopedic surgeons to various Army training camps, to the United States hospitals, or for the special training in military orthopedic surgery in England, after which the officers may be transferred to France.

   *   *    *    *    *    * 

    In addition to the intensive instruction in the fundamental principles of orthopedic surgery given at the above-mentioned institutions, some of the men who had attended the above courses, and others in small numbers, were given further instruction in orthopedic hospitals under orthopedic surgeons of experience, for the purpose of developing them for more specialized positions.30

SCHOOLS OF NEUROSURGERY

    On August 24, 1917, at a conference of the advisory board of the subsection of brain surgery, it was agreed that in order to carry out the Surgeon General’s plan of having this subsection represented in each base, cantonment, and evacuation hospital, approximately 250 surgeons would be required,43 and that in addition to these approximately 40 surgeons would be required for the proposed hospital for surgery of the head.43 It was proposed, therefore, to establish definite schools of instruction for the special training of skilled surgeons in this particular branch of surgery. A committee was appointed to select locations for the schools and to outline the courses of instruction. Philadelphia, New York, Chicago, and St. Louis were selected as locations for the schools.43

    The courses of instruction included anatomy and physiology of the nervous system, clinical studies, and a careful survey of the literature of brain surgery for the period of the war to date.43 The first course was begun in the University of Pennsylvania on September 17, 1917, and extended over a period of four weeks. At a meeting of prominent neurological surgeons in the Surgeon General’s Office, on October 5, 1917, it was recommended that the course of instruction be extended to three months for the following reasons 44

   (1) The small number of available trained neurological surgeons; (2) the present course of four weeks in progress at the University of Pennsylvania had aroused the interest of the neurological surgeons sufficiently to cause them to take further instruction in neurology; (3) the intensive training given in the first four weeks with emphasis upon neuroanatomy, phvsiology, and symptomatology of diseases of the nervous system furnishes an excellent foundation upon which to build a more thorough knowledge of neurology; (4) Surgeons classified in the division of brain surgery are not needed in Frace at this time, and it seems advisable to


543

have them continue in active service, furthering their knowledge of neurology. It is also recommended that these surgeons be assigned to military camps for the necessary military instruction; (5) to prepare a group of brain surgeons by October 1 for the proposed neurological schools in the war zone. It is further recommended that this clinical instruction be carried on under the direction of a member of the class who shall be designated as director and whose duty it shall be to assign, with the cooperation of this office, to the different neurological clinics of a given city, as many men as can be instructed. It is suggested that the hospitals for the care of chronic neurological diseases, neurological divisions of out-patients departments, large accident wards, etc., be considered the chief source of clinical material.  

    It is also recommended that large neurological laboratories be supplied with men capable of special training in this line, so that the division might have listed a number of surgeons capable of caring for neurological material in the laboratories.

   *   *    *    *    *    * 

    It is further recommended that this plan be instituted in Philadelphia at the completion of the present course at the University of Pennsylvania on October 13.
 
    These recommendations were approved by the chief of the section of surgery of the head on October 18, 1917, and schools were organized in the cities mentioned.44 Letters were sent to directors of all hospital units to nominate candidates for these courses. The directors were given to understand that the candidates would be returned to their units on completion of the course of instruction, or in case the units were ordered overseas prior to the completion of the course. The courses were later changed to cover a period of 10 weeks. 

    After the directors of the schools had been appointed, letters were written by the chief of the division of head surgery to the leading hospitals and universities of the cities in which the schools were located, requesting their cooperation and assistance in the operation of the schools.43 Letters were written to the commanding officers of military officers’ training camps, cantonments, base, evacuation, and post hospitals, asking for nominations to take the courses of instruction in these schools. The student body was made up of selections from those nominated from these organizations, together with nominees in civil life, commissioned in the Medical Reserve Corps and ordered direct to the schools.45 Adjutants were selected from the student body to assist the director in the preparation of returns, reports, etc.46 

    These neurosurgical schools were administered with the sole object of training medical officers to approach neurosurgical problems from the standpoint of the neurological surgeon, and to develop in them habits of neurological thought, so that they would be able to interpret symptoms and apply their knowledge to the neurosurgical problems which they were certain to encounter whether in a cantonment, base or evacuation hospital, or in a first-aid dressing station. For this purpose the neurological surgery of civil life was presented from both the neurological and the operative sides. To this was added much of traumatic surgery of the central and peripheral nervous system which was derived partly from the material in civil and partly from that in Army hospitals. The attempt was made to give the student officers sufficient training to make them able to recognize the nature of an injury to the nervous system, to determine the location of the injury and to decide upon the indications for or contraindications to operative treatment. The technique of operative treatment was considered in special surgical lectures and was demonstrated on the cadaver and on the living patient in the operating room, and special attention was paid


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to the latest principles of treatment of brain, spinal cord, and peripheral nerve injuries that were reported from the war zones. The courses were planned to give the officers, through lectures and clinical demonstrations, by the individual study of the anatomy, histology, and pathology of the nervous system on the cadaver and through the microscope, a thorough knowledge of the anatomy and physiology of the nervous system, followed by lectures, demonstrations, and individual clinical work in neurology, neurosurgery, and in the essentials of ophthalmology, otology, psychiatry, and Roentgenology with which the neurosurgeon should be acquainted. In all the teaching, this aim was kept constantly in the foreground. It was clearly recognized, also, that the actual practical training could be obtained only from experience and work at the front.

    It was not always possible to assign each group of officers to the school at the beginning of each session; at times the exigencies of the service made it necessary to assign officers to the school a number of weeks after a session had begun.47 The courses were so arranged, however, that officers who had come late continued their studies in the succeeding course, so that they obtained a complete training of 10 weeks, just as if they had been present from the beginning of a session. During the intervals between sessions there were operative clinics and clinical demonstrations in some of the schools, so that the time of the officers who were held over from one session to the next was fully occupied.
 
    Although subservient to the professional aims of the courses, the military duties and responsibilities of the officers were kept before them in most of the schools through regular systematic military drill and setting-up exercises and the explanation of the more familiar and usual official forms and regulations. 
 
    The school conducted at the University of Pennsylvania, as stated, was the first to be organized. The outline of the course of instruction given in this school is selected as typical of the work conducted in the other neurosurgical schools.

SCHOOL OF NEUROLOGICAL SURGERY, UNIVERSITY HOSPITAL, PHILADELPHIA, PA.

    This school was organized in compliance with instructions from the Surgeon General of the Army.43 The first course of instruction began on September 17, 1917, and terminated on October 22, 1917. The number of students taking the first course was 32. The second course began on October 23, 1917, and was completed December 29, 1917. It was composed of 27 students. The third course began on January 7, 1918, and was completed March 16, 1918, 25 in attendance.

COURSE OF TRAINING FOR NEUROLOGICAL SURGEONS, UNIVERSITY OF PENNSYLVANIA SCHOOL 48

    The instruction will be divided into three groups: (a) Didactic course; (b)laboratory course; (c)clinical course.

    They should comprise the following groups: (a) Anatomy; (b)physiology; (c)pathology; (d)operative surgery on the cadaver; (e) animal surgery; (f)clinical neurology; (g) operating room technique.
 
    It is estimated that by intensive work the course can be covered in four weeks, divided as follows: Morning ( 1½ hours)--anatomy, 15 lectures; physiology, 9 lectures; operative surgery, cadaver, 14 lectures; pathology, 6 lectures; animal surgery, 4 lectures. After-


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noon (1½hours)--clinical neurology, lantern slides, lectures, and assignments. (The remainder of the afternoon to be given up to presentation of cases in various hospitals.)

    The various courses will cover, in general, the following:
    (a) Anatomy: Scalp, skull, brain, with its various sections and the tracts in general. Subarachnoid space, circulation of the cerebrospinal fluid. The vertebral column. The cord with its segments and the plexuses and nerves. The circulation of the brain and cord.
    (b) Physiology: Contemplates the complete discussion of localization, reflexes, nerve degenerations, and stimulations, etc.
(c)Pathology: (1) gross, a consideration of hemorrhage, abscess formation in the brain with the presentation of material demonstrating and emphasizing localization; method of the preservation of material; cord and spinal column, presentations of fracture and dislocations of the discussion of concussion, contusions, hemorrhage, etc. (2) Miscroscopic studies of nerve injuries and nerve repair.
(d)Operative surgery on the cadaver: This course in a combined didactic and laboratory course, one-half hour to be given to discussion of technique and one hour to operations on the cadaver, covering the following: Scalp wounds, clean and infected; osteoplastic flaps and treatment of hemorrhage and fracture; technique of decompression, dual incisions; brain puncture; ventricular puncture; brain exploration; dural closure; scalp closure; hone transplant; fascial transplants; fungus, cerebri; foreign bodies; technique of lumbar puncture, technique of laminectomy.
(e)Animal surgery: Consisting of operations on the dog; of nerve suture, brain hemostasis, laminectomy.
(f)Clinical neurology: This course is carried on by the aid of neurologists, consisting of lectures, lantern slides discussions, demonstrations of patients, covering the following: Methods of examination and history writing, the spinal fluid localization of foreign bodies, neurologic and X ray.
    Diagnosis: Symptomatology and treatment, brain hemorrhage, concussion, fractures of the skull, abscess of the brain, meningitis, gunshot injuries of the brain and cord, fracture of the spine, cord injury, complete and incomplete nerve injury.
    In connection with this course use will be made of the material collected by Major Tarnowsky and Major Seelig who are working on collection of literature of the war.
    (g) Operating room technique and presentation of patients.

    This outline was followed during the first course of four weeks, but was elaborated for the succeeding courses, which were extended in duration and in work.
  
    The following method of classifying the students at the close of the course was employed: Group 1, those competent to operate, themselves, in neurological work. Group 2, those useful as assistants. Group 3, those suitable for assignment to courses of instruction in cantonment hospitals. Group 4, those not eligible for any of the above groups.

NEUROLOGICAL SCHOOL, PRESBYTERIAN HOSPITAL AND ALLIED INSTITUTIONS, CHICAGO, ILL.

    Two courses of instruction were given at this school. 44, 49 The first course began on November 1, 1917, and terminated on January 11, 1918.50 The number of students in the class was 27. On completion of the course the students were ordered to the following camps: Bowie, Beauregard, Doniphan, Hancock, Lee, Logan, MacArthur, Sevier, Shelby, Taylor, Fort Oglethorpe, and Fort Riley. From November 1 to November 23, inclusive, the course consisted of lectures and laboratory work given at the University of Chicago. From November 24, 1917, to January 11, 1918, inclusive, the work was chiefly clinical and was given at the Presbyterian Hospital, Cook County Hospital,


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and St. Luke’s Hospital. In addition to this, pathological demonstrations were made in the pathological laboratory; operative surgery on the cadaver was done in the anatomical laboratory of Rush Medical College, and postmortem examinations were held in the Cook County morgue. Once a week a seminar was held by the members of the class.

    The second course of instruction began on January 15, 1918, and was terminated on March 25, 1918.51 The instruction was similar to that given in the first course. Eleven students composed the second class, and upon the completion of the course they were ordered to the following camps: Bowie, Cody Custer, Grant, Lee, MacArthur, Pike, Sherman, and Travis.

NEUROSURGICAL SCHOOL, NEW YORK CITY

    This school, which was the largest of the neurosurgical schools, was organized at the Neurological Institute, New York City. The following hospitals and colleges in New York City cooperated in the organization of the school: 47 The Presbyterian Hospital; Roosevelt Hospital; New York Hospital; St. Luke’s Hospital; Mount Sinai Hospital; Bellevue and allied hospitals; Columbia University; College of Physicians and Surgeons, New York University; and Bellevue Hospital Medical School.

    Five courses were held as follows: First, December 3, 1917, to February 8, 1918; second, February 18, 1918, to April 26, 1918; third, May 6, 1918,. to July 13, 1918; fourth, July 29, 1918, to October 5, 1918; fifth, October 14 to December 21, 1918.52 The first class was composed of 25 students; the second, 30; the third, 19 new men and 7 who remained over from the previous class for further instruction; the fourth, 25; and the fifth, 19. 

    The method of classifying the students at the completion of the courses of instruction was as follows: Two groups were formed: (a) Those capable of doing independent neurosurgical work; (b)those fitted for assistants. Each group was again divided: A+ meaning first class and A- meaning not quite so good; B+ meaning those who, under a certain amount of guidance, might be able to do good independent work; B- representing men who were fitted to act only as assistants.

COURSE OF INSTRUCTION IN NEUROSURGERY IN THE SCHOOL OF NEUROLOGICAL, PLASTIC, AND ORAL SURGERY, ST. LOUIS, MO.

     One course of instruction in neurosurgery was given to a class of 36 students beginning November 3, 1917, and extending over a period of five weeks.29 This course was given by the same instructors and at the same time that the second course in oral and plastic surgery was given in this school (see Schools of Plastic and Oral Surgery, p. 531). The following is a synopsis of the course in neurosurgery:

THE OBJECTIVE

     I. To teach the correct interpretation of neuropathic symptoms: (a) As presented in shell shock; (b)in injuries to the brain and spinal cord; (c)in the early detection of cerebral hemorrhage and hemorrhage into the spinal cord; (d)the proper methods of eliciting reflexes and the differentiation of organic from functional nervous conditions; (e)the Barany tests as an aid in the localization of intracranial lesions; (f)the diagnostic value of the relation of intracranial pressure to general arterial pressure.


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    II. Head surgery: (a) The proper care of fractures of the skull and spinal column; (b)the advantages of early relief of pressure in hemorrhage into the brain and cord; (c)the dangers of permanent destruction of the nervous elements of the brain and cord incident to edema and hemorrhage; (d)the demonstration of operations designed to relieve pressure; namely, trephining, decompression, and laminectomy; (e)the care of the dura and the prevention of meningeal infection.

COURSE

     Neuropathology (10 hours): (a) Lectures and demonstrations (4 hours), showing pathological brains and several specimens showing the effects of accidental injuries. Brain abscess, hydrocephalus internal and external, and brain tumors were considered in detail, with a full elucidation of the underlying principles of stimulation of the respiration by the intravenous use of hydrocyanic acid. (b)Autopsies (6 hours).

    Anatomy of the nervous system (10 hours): Course covered a complete and detailed dissection of the brain and spinal cord tracts.
 
    Physiology of the nervous system (12 hours): (a) Lectures and demonstrations upon the dog with the necessary instruments of precision, showing the relation of intracranial pressure to the general arterial pressure and the blood supply to the vital centers of the brain and accounting for some of the phenomena which accompany fractures of the skull and injuries to the brain and spinal cord. (b)Detailed description of the motor and sensory pathways of the spinal cord and internal structure of the brain. 

    Clinical neurology (78 hours): (a) Lectures, dispensary work, and ward walks (18 hours), going over brain and cord lesions, demonstrating reflexes, and tracing the motor and sensory paths. (b)Examination and diagnosis of new cases in the dispensary (16 hours). (c)A full discussion of the post-traumatic neuroses, and the differential points between Jacksonian and idiopathic epilepsy. (d)Operative clinics, showing the technic of operations, namely, trephining, resection of the Gasserian ganglion, three laminectomies, one after injury, suture of the ulnar nerve, lumbar and ventricular puncture in hydrocephalus, tumor of the pituitary, subsellar and suboccipital decompression, the use of acacia and sodium bicarbonate in the treatment of shock, and the arrest of hemorrhage by the use of bone wax and fresh muscle (44 hours). (e)Demonstration of craniocerebral topography on the monkey. (f)Student officers performed in the laboratory--trephining, decompression and osteoplastic decompression on the cadaver, and decompression and laminectomy on the dog. 

    Eye and ear (14 hours): (a) Demonstration of all the various methods employed in testing hearing. (b)The Bárány tests of the vestibular apparatus in relation to the diagnosis of intracranial lesions discussed fully in lectures and in dispensary. A thorough exposition of the clinical significance of the eye-pull, past pointing with both arms and trunk, and of spontaneous and induced vertigo, together with the technic of application of the tests was given. Class divided into sections to insure individual instruction in the technique of the work (7 hours). (c)Examination of the eye by direct and indirect ophthalmoscopy, with particular stress laid on the recognition of incipient choked disk, differential diagnosis between choked disc and optic neuritis, optic atrophy, and other pathologic eye grounds. Variations in intraocular tension from disease or injury were fully disussed (7 hours).

    The seminar (14 hours): All references pertaining to this course in French, German, and English, taken from the list issued by the Surgeon General’s Office, read, briefed, and reported upon at seminar. Also the book, War Surgery of the Nervous System, was divided into sections and reported by the student officers at the seminar.

    Résumé: This intensive course deals with the all important subject of fractures of the skull and spinal column and the brain and cord lesions incidental to the same. As the writers on these subjects, who are working in the war zones, give many conflicting views and have set down certain facts which are really modifications of former principles of surgery, such modifications being due to circumstances incidental to warfare, it has been necessary in this course to reconcile divergent opinions expressed and to accentuate the accepted teaching on the following mooted points: (1) The indications and contraindications for the removal of fragments of bone, missiles, and other foreign substance from the brain. (2) The indications and contraindications for immediate surgical interference, the question of early closure of wounds not contaminated, and the prevention of sepsis. (3) The contraindications for drainage of brain


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tissue, the correct method of drainage where the indications are absolute for same, and the prevention of hernia cerebri. (4) The indications for sufficiently prolonged care at the evacuation hospital and the extreme contraindications for moving of head cases. (5) The indications and contraindications for lumbar puncture in head injuries.

SCHOOLS OF MILITARY ROENTGENOLOGY

     At the time the United States entered the World War, little preparation had been made for the use of the X ray in the Army under war-time conditions, and the number of qualified Roentgenologists available for service in the Army was inadequate for the contemplated needs.53 The American Roentgen Ray Society had realized these facts for some time previous to the declaration of war, and a committee on preparedness had been appointed by the society for the purpose of studying the problem and outlining the action to be taken in case the United States was drawn into the war. Through the activities of this committee a list of the practicing Roentgenologists in the United States was compiled and considerable correspondence and propaganda were carried on for the purpose of interesting Roentgenologists, in civil practice throughout the country, in the military service. A canvass of the United States revealed the fact there were in the United States at the beginning of hostilities less than 300 trained Roentgenologists, and of really expert men probably not more than 100. It was recognized, therefore, that the problem must be solved by the institution of training having a scope broad enough to produce the necessary number of Roentgenologists sufficiently trained to do military Roentgenology, and of inducing medical men in sufficient numbers to enter the service with a view to their training as military Roentgenologists.

    Soon after the United States entered the war the Surgeon General assigned a specialist in Roentgenology to his office and placed him in charge of all X-ray activities of the office.54 In order to meet the problems mentioned above, this officer, in cooperation with the committee on preparedness of the American Roentgen Ray Society, immediately took under consideration and completed arrangements for the establishment of a central school of Roentgenology at Cornell University Medical College, New York City, with sections in Boston Mass.; Philadelphia, Pa.; Baltimore, Md.; Richmond, Va.; Pittsburgh, Pa.; Chicago, Ill.; Kansas City, Mo.; and Los Angeles, Calif.55 These schools were placed under the direct control of the War Department and the trained Roentgenologists in charge of them were commissioned in the Officers’ Reserve Corps.56 Student officers in groups of 10 were assigned to the various schools. Upon the completion of the courses of instruction those destined for foreign service were ordered to New York for final examination and further instruction before any were ordered overseas, and others were ordered to camps and hospitals in the United States.

    The curriculum decided upon was tentative, it being realized that it was impossible to attempt to provide Roentgenologists with broad training and extensive clinical experience in any reasonable length of time. It was decided, therefore, to concentrate the teaching upon the essentials, both physical and medical, so that the students would be well grounded in the physics of radiant energy; familiar with the apparatus for the production thereof and its troubles and the remedies to be applied; skilled and well trained in the essential methods


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of localization of foreign bodies in the human anatomy, and the methods for transferring such information to the surgeon; and having as much experience as it was possible to obtain in the short time allotted in the diagnosis of fractures, dislocations, and human pathology other than surgical. It was further decided that the exigencies of the situation would not permit of a longer period of instruction than three months, to be followed by a short post-graduate course in the school at New York, to be devoted to a review of localization methods and machine instruction.57

    The course of instruction, which was both didactic and practical, embraced the following subjects: 57 (1) Roentgen physic; (2) practical working knowledge of all types of X-ray apparatus, including wiring of machines, trouble finding, and charting transformers; (3) principles and use of both gas and Coolidge X-ray tubes; (4) use of the fluoroscope; (5) construction and outfitting of a dark room as well as developing and other necessary dark-room technique; (6) plate making, including both exposure time and position of patient for various types of examination; (7) Roentgen anatomy; (8) interpretation of plates, including the normal, variation from the normal, and pathological conditions; (9) systematic record keeping, including marking of plates, recording interpretation of same, as well as the method of imparting this information in a short, concise, intelligent manner to the surgeon; (10) localization of foreign bodies by all approved methods; (11) handling of patients in a rapid, efficient manner.

    Instruction began in June, 1917, and by September 1, all the schools were in operation.57 These schools continued in operation until the early part of the year 1918, the last school, with the exception of the one in New York, closing March 1, 1918. The number of officers given instruction in these schools, with the exception of the New York school, averaged between 25 and 30.58 
     
    The main object of the school, during the latter part of its existence, was the completion of the preliminary training given at the schools at Fort Riley and Camp Greenleaf.57 

    The following is a summary of the personnel who received instruction at the New York school:59
Officers of the Medical Corps (regular course)................................244
Officers of the Medical Corps (2 weeks course).................................58
Officers of the Sanitary Corps.................................................23
Enlisted men, Medical Department...............................................75
Officers of the United States Navy and Public Health Service...................11
Supplementary course of instruction to Roentgenologists of experience..........11
  Total.........................................................................422

SCHOOL OF MILITARY ROENTGENOLOGY, CORNELL UNIVERSITY MEDICAL COLLEGE, NEW YORK CITY

    This school was opened June 9, 1917.59 In June, 1918, it was partially dismantled, much of the apparatus being sent to the Medical Officers’ Training Camp, Camp Greenleaf, for use in its school of military Roentgenology. The teaching force, likewise, was greatly depleted, its members being ordered to overseas service, or to Camp Greenleaf, to assist in the conduct of that school


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of military Roentgenology.6 It continued, however, to carry on instruction in methods of localization, and to provide clinical experience in the various New York hospitals for men awaiting orders at the port of embarkation.6 In the fall of 1918, when a great shortage of Roentgenologists suddenly arose, due to the unexpected call for an increased number of hospitals for overseas service, the capacity of the New York school was augmented for the purpose of assisting in meeting this emergency.60 The school was finally closed January
21, 1919.61

    Quarters for the school were tendered gratuitously by Cornell University Medical College; 59the transformers, Roentgenoscopes, tubes, stands, and other apparatus were supplied, without cost to the Government, by the manufacturers; 57 the facilities of the Edward N. Gibbs Memorial X-ray Laboratory, University and Bellevue Medical College, were placed at the command of the Surgeon General for use in connection with the school,59 and clinical facilities were offered by the various hospitals of the city.57

SCHOOLS OF UROLOGY AND DERMATOLOGY

    The number of men with adequate training in urological surgery, venereal diseases, dermatology, and syphilis was found to be insufficient for meeting the needs in base hospitals and the large camps. It was decided, therefore, to create opportunities for the younger men who might elect to do so to receive post graduate instruction in these subjects. To this end, schools for medical officers were established, in the autumn of 1917, in New York, at Columbia University, in conjunction with Vanderbilt Clinic; in Boston, at Harvard Medical School, in conjunction with Massachusetts General Hospital and Peter Bent Brigham Hospital; in St. Louis, Mo., at Washington University Medical School, with clinics at St. Louis City Hospital, Barnes Hospital, and Barnard Skin and Cancer Hospital.62 These schools were discontinued in the spring of 1918, all instruction in urology and dermatology being concentrated at the Medical Officers’ Training Camp, Camp Greenleaf, Fort Oglethorpe, Ga.63
  
    The courses were intended to cover a period of four weeks, and this applied to the first, but the second and third courses were extended to cover a period of six weeks each.64 

    Approximately 85 officers were detailed to take the courses.65

    The following syllabus of instruction of the course given at the Boston school, from February 1 to March 15, 1918, represents the scope of the instruction given the other schools:66

SYLLABUS - INTENSIVE COURSE IN DERMATOLOGY, SYPHILIS, AND GENITOURINARY DISEASES

A. DERMATOLOGY

(Monday, Wednesday, Friday, 9 to 12 a. m., Massachusetts General Hospital)

    I. Lectures (11 hours): (1) The principles of dermatology; their practical application to diagnosis and treatment (anatomy, pathology, etiology, physiology).
    (2) Common diseases - inflammations (eczema, urticaria, dermatitis, d. calorica, d. venenata, d. arteficialis (malingering).
    (3) Common diseases due to bacteria (impetigo, furunculosis, erysipelas, tuberculosis. anthrax).
    (4) Common diseases due to parasites (pediculosis, scabies, ringworm of groins, straw itch).


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   (5) Common diseases  - infectious, contagious (the exanthemata).
    (6) Diseases of the foot - affecting efficiency (hyperidrosis, clavus, callositas, verruca, pernio, erythromelalgia, and allied conditions causing pain).
(7)Systematic conditions and external manifestations (fatigue, toxemia, vasomotor disturbances, the kidneys, the digestive tract, disturbed metabolism).

     II. Laboratory lectures and demonstrations (10 hours): (1) Pathological methods; pathological diagnosis (pathologist to Massachusetts General Hospital; 6 hours). The technique of obtaining,,preserving, mounting, and staining; the microscope and its use; relationship of clinical signs and symptoms to the pathologic; illustrations by demonstrations and by the exhibition of slides.
    (2) Skin test methods (2 hours).
    (3) How to use the pharmacopoeia (2 hours). Exhibition of drugs and forms of external applications; demonstration of the value of the percentage column; emergency pharmacy, how to use what is at hand; practical pharmaceutical hints.
    (4) The clinical use of the laboratory in daily practice. (In connection with the daily exercises in clinical work.)

    III. Clinical lectures (16 hours): (1) On the topic of the lectures in I and II (5 hours).
    (2) On the exanthemata - at Boston Hospital for Contagious Diseases (33 ½ hours).
    (3) The relation of disease of the skin to systemic conditions (1 hour).
    (4) The organization and conduct of a skin clinic (one-half hour).
    (5) Organization, equipment, and conduct of a skin hospital (one-half hour).
    (6) Nursing in diseases of the skin (1 hour).
    (7) Dermatologic therapy - various (2 hours). (Light therapy; heliotherapy; hydrotherapy; radium; refrigeration; instruments.)
    (8) Ward visits.

    IV. Clinical work (15 hours): (1) In the out-patient department. History taking; notes and note making; methods of examination; diagnosis, laboratory work in the outpatient department; treatment of patients; the use of instruments and apparatus in treatment; practice as executive assistant; case study; research.
    (2) In the ward. Observation of disease progress; studies in diet; in metabolism; case examinations; intensive study of assigned cases; preparation of case reports; records and record keeping; cytology, stool examinations; routine of the ward medical officer; experience in nursing; methods of application of treatment, dressings.
    (3) In the daily use of notebooks. Records of each day’s work and experiences; of each day’s problems and questions; of suggestions received; of all matters of interest encountered; to be kept and to be used in directing home studies and in connection with all class exercises

    V. Class exercises (5 hours): (1) Conferences. For the presentation by the student to the class of prepared case reports and for the demonstration of the cases reported.
    (2) Colloquia. Held at intervals, for the purpose of a general review of the course work, for the reading of notes taken, for the presentation of problems and for the asking of questions, for the purpose of a general, informal discussion of everything in which students and instructors may have opportunity to get closer together.
    The plan of this course contemplates the acquisition of the greatest possible clinical experience by the student.
    It is intended that the instructor shall lay a sure foundation by his lectures but shall otherwise interfere as little as possible.
    Under the instructor’s supervision, the student will perform all clinical and laboratory work himself, in every exercise, whenever possible.
    That no problem may remain unsolved and that the inaccuracies of memory may not interfere, the student is expected to enter the facts in his notebook at the time and, later, to present them at the class exercises.
    A series of colloquia has been provided for to which the student may bring his problems and questions for informal discussion.


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    `These informal class meetings are expected to do much in smoothing the way for the student, in promoting interest and zeal and in bringing student and instructor to more intimate understanding.
    The outcome depends uponthe freedom with which the student utilizes the invitation and opportunity.

B. SYPHILIS

(Tuesday, Thursday, Saturday, 9 a. in. to 12 m.; Massachusetts General Hospita.l)

    I.Lectures; clinics (26 hours): (1) Syphilis (6 hours).
    (2) Eye syphilis (3 hours). Lecture; clinic.
    (3) one syphilis; exhibition of museum specimens (1 hour).
    (4) X-ray diagnosis (X-ray department, Massachusetts General Hospital; 5 hours). Demonstration of methods; of diagnosis; clinics.
    (5) Syphilis in surgery (1 hour).
    (6) Syphilis of the throat (3 hours). Clinical lecture and demonstration of cases.
    (7) Syphilis of the ear (3 hours). Clinical lecture and demonstration of cases.
    (8) Visceral syphilis (1 hour).
    (9) Syphilis of the spinal cavity (3 hours). Lecture and demonstration of spinal puncture and injection.
    II. Laboratory exercises (6 hours): (1) The microscope in diagnosis (4 hours). (cm) Dark-field microscopy; (b) staining of spirochaeta; (c) detection.
    (2) The Wassermann test (Pathological laboratory of Massachusetts General Hospital; 2 hours.
    III. Clinical exercises (16 hours): (1) Clinics (5 hours).
    (2) Therapeutic clinic (3 hours).
    (3) Salvarsan administration (5 hours).
    (4) Diagnosis (3 hours).

     All lectures on syphilis and on special topics will be fully illustrated by cases and clinics.

    The students will be afforded every opportunity for studying disease manifestations, for diagnosis and treatment, for the laboratory detection of the spirochaetae and for the studying the Wassermann test by means of clinics and clinical work and by means of special laboratory exercises.

C. GENITOURINARY DISEASES

    I. Lectures (30 hours): (1) Methods of examination; urinalysis.
    (2) Ureteral instruments; asepsis and use.
    (3) Cystoscops; construction and use; urethral catheterization.
    (4) Physiology of kidney; methods of estimating renal function; their importance and limitations.
    (5) Acute gonorrhea.
    (6) Chronic gonorrhea, prostatitis; vesiculitis.
    (7) Treatment of gonorrhea.
    (8) Stricture of urethra (2 hours).
    (9) The prostate.
    (10) Prostatism (2 hours).
    (11) Renal infections (3 hours).
    (12) Calculi, renal and ureteral; pyelography.
    (13) Tuberculosis of bladder.
    (14) Tuberculosis of genital tract.
    (15) The kidney: Tumors, hydronephrosis, cysts.
    (16) The kidney: Malformations; injuries; idiopathic hematuria.
    (17) The bladder: Tumors, diverticulae, malformations, wounds; result of spinal cord lesions.
    (18) The scrotum and testes: Anomalies, inflammation, hydrocele, spermatocele, henatocele, tumors; vas and cord; vesicles.
    (19) Penis: Malformations, tumors, phimosis, paraphimosis.
    (20) Pain in genitourinary tract: Varieties and significance.


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    (21) Hematuria and pyuria.
    (22) Major operations (4 hours).
    II. Clinics (46 hours): (1) Out-patients’ department; clinics (32 hours).
    (2) Operative clinics (12 hours).
    (3) Diagnosis and treatment - ward visit (2 hours).
    III. Laboratory exercises (12 hours): (1) Test for urea in the blood; the phenolsulphonephthalein test (2 hours).
    (2) Demonstration: The tubercle bacillus (2 hours).
    (3) Methods of pyelography - X-ray department (2 hours).
    (4) Bacteriology of the gonococcus (2 hours).
    (5) Demonstration of gross and microscopic anatomy of the genitourinary system (4 hours).
    IV. Class exercises (10 hours): (1) Weekly class meeting: Review of the work of the week, submission of notes and case reports, general colloquium, quiz (10 hours).

    Throughout the course it was intended that the student should examine and treat the patients, under the supervision of the instructor; that he should assist at major operations, when possible; that he should become familiar with the use of the cystoscope, with the methods of diagnosis preceding operation, and with the laboratory diagnosis of venereal disease.

    The lectures were fully illustrated by lantern slides and by pathological specimens from the laboratory of the hospital and from the Warren Museum of the Harvard Medical School.

SCHOOLS OF NEUROPSYCH1ATRY

    The opening of the large number of camps almost simultaneously, in the summer of 1917, created such a great demand for neuropsychiatrists that it was hardly possible to send them to military officers’ training camps for preliminary military training. A few were ordered to these camps and in addition a few officers who were taking the regular course of training at the camp were accepted for neuropsychiatric service; and some neuropsychiatrists acquired their military knowledge by the actual performance of duty. These methods of training were obviously inadequate, and it was found desirable to provide additional professional instruction. This instruction was generally furnished by the directors of special medical institutions at the following institutions: Michigan Psychopathic Hospital, Ann Arbor, Mich.; Boston State Hospital; Neurological Institute, New York City; Philadelphia General Hospital; Phipps Psychiatric Clinic, Baltimore, Md.; Government Hospital for the Insane, Washington, D. C.; Manhattan State Hospital, New York City.67 The directors in question, who were given the title of military director, were generally the superintendents of the institutions who had been commissioned in the Army, or who were serving under contract. The military directors secured the collaboration of many other professionally prominent and representative teachers, each within his respective vicinity.67
 
    The student officers ordered to these schools were on duty status and between two and three hundred were given this instruction.67 Reports were made to the Surgeon General by the directors, on the progress of the work, qualifications, etc., of the students, and from these reports it appeared that about 20 per cent of the student officers could be considered as qualified in this specialty at the close of the courses. The most promising students proved to be those


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who had been in active work for about 10 years rather than the recent graduates, or older men.

    The courses were outlined and scheduled for six weeks in duration, although in some cases it was necessary to interrupt the instruction where the services of the student officers were urgently needed for actual military duty, while in some instances students were kept at the schools for longer periods.67 Even when courses were not actually in progress, there were usually some students left on special detail to profit by the usual clinical routine of the institutions concerned. In this manner the officers had exceptional opportunities to perfect. themselves in their specialties, and the Surgeon General had the advantage of obtaining information as to an individual officer’s professional and personal qualifications before he was assigned to military duties. The course of study included lectures, clinics, demonstrations, and laboratory work. The fields covered were psychiatry, psychology, personality problems, serology, neurology, neuropathology, with collateral instruction in otology and ophthalmology.

COURSE IN NEUROLOGY AND PSYCHIATRY, POST-GRADUATE SCHOOL OF NEUROLOGY, PHILADELPHIA, PA.

    In planning the courses in neurology arid psychiatry the Philadelphia School considered the amount of time which the exigencies of the service would allow to be devoted to the subject, and the rosters and schedules were prepared accordingly.68 While it was realized that the instruction given in neurology should be, and was, largely clinical, it was deemed essential to give some didactic and semididactic instruction in neuroanatomy, neurophysiology, and neurological medicine. The outlines were planned, therefore, to include a limited amount of this work. Physiology of the nervous system, especially as concerns cerebral, spinal, and peripheral localization, received particular attention, and an effort was made to follow closely the anatomico-physiological teaching by the presentation of clinical cases illustrating the subjects taught. Organic neurology was taught by systematic demonstration of organic symptomatology, illustrated by cases which were made to cover a wide range. The Philadelphia General Hospital provided many cases of tabes and other forms of sclerosis, syringomyelia, organic hemiplegia and other organic nervous diseases, which were demonstrated. The differentiation of such conditions as hemorrhage, thrombosis, and embolism and their separation from focal lesions like tumors and abscesses were amply illustrated. Moving-picture demonstrations were sometimes used. Instruction in syphilis of the nervous system and epilepsy were emphasized. The morphological recognition of disordered glandular functions were taught through a study of both neighborhood and glandular svmtomatology. Pathology of the cerebrospinal fluid and neurohistology were thoroughly gone into. Electrodiagnosis and electrotherapeutics were covered, including a description of the various forms of electrical apparatus. Reactions of degeneration were elucidated and illustrated, and the diagnostic differences shown by cerebral, spinal and peripheral lesions were exhibited by a study of cases of hemiplegia, monoplegia, meningomyelitis, poliomyelitis, and nerve injury. Close attention was given to those phases of ophthalmology which are associated with neurological work. Instruction in neurootology included, among other phases, detailed instruction in the Barány tests.


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      The plan for the course of instruction in psychiatry was based on suggestions contained in Medical Department Circular No. 22, Office of the Surgeon General, Washington, D. C., dated August 1, 1917. h However, the instruction given was not confined to those suggestions, and full advantage was taken of the very large and varied amount of clinical material available.

COURSES IN NEUROPSYCHIATRY, STATE PSYCHOPATHIC HOSPITAL, ANN ARBOR, MICH.

     The course of instruction in iieuropsychiiatry at the State psychopathic hospital of the University of Michigan was attended by 77 officers of the Medical Corps.69 The first officer reported on July 23, 1917. The course was in charge of the director of the State psychopathic hospital, who was employed as a contract surgeon in the Army. The instruction was organized so as to give the officers as practical an experience as possible and stress was laid upon the relation of the various subjects to problems of military medicine. It included instruction in: Psychiatry; neuropathology; neurology; ophthalmology; otology.
  
    The following abstract of the courses given at the State psychopathic hospital, Ann Arbor, Mich., gives an idea of the scope of the work covered in these schools.69

PSYCHIATRY

    Psychiatric instruction was given at the Pyschopathic Hospital and the following subjects were covered: 69

    1. General survey of the problems of mental disorders in their military relations (2 hours).
    2. Discussion of the organization for neuropsychiatric work; of the schemes and methods for diagnosis and recording of data (2 hours).
    3. General psychopathology; didactic lectures, with clinical demonstration (10 hours).
    4. The functional mental disorders of the present war; survey of the experiences published in the German, French, and British literature (4 hours).
    5. Shell shock and the psychoneuroses (2 hours).
    6. Psychoneuroses; neurasthenia; anxiety neuroses; hysteria; compulsion neuroses; didactic lecture and clinical demonstrations (4 hours).
    7. Manic-depressive insanity; didactic lecture and clinical demonstrations (2 hours).
    8. Dementia praecox; didactic lecture and clinical demonstrations (4 hours).
    9. Syphilitic mental disorders; didactic lecture, clinical and anatomical demonstrations (4 hours).
    10. Epileptic mental disorders; didactic lecture and clinical demonstrations (2 hours).
    11. Psychopathic personalities; didactic lecture and clinical demonstrations (4 hours).
    12. States of mental defectiveness (2 hours).
    13. Feeble-mindedness and mental subnormalities; didactic lecture and clinical and anatomical demonstrations (2 hours).
    14. Psychometric tests; didactic lecture and practical work in making examinations of defectives and delinquents (6 hours).
    15. Mental disorders of organic brain diseases; arteriosclerotic mental disorders; mental disorders with tumors of the brain and brain injury; didactic lecture and clinical demonstrations (2 hours).
    16. Serological diagnostic demonstrations; technique and interpretation (2 hours).
    17. Attendance at the psychiatric clinic in the medical school at the university (1½ hours each week).
    18. Practical work in study of cases and preparation of histories on the wards of the hospital.

h See Vol. I, p. 940.


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NEUROPATHOLOGY

   A systematic course in the pathological anatomy of mental and nervous disorders was given. This course covered 14 periods of two hours each. The subjects covered in this course were as follows:69

    1. Embryological development of the central nervous system. Surface topography of the brain.
    2. Study of gross fiber arrangements and ganglia of the brain.
    3. Histology of the nerve cell; nerve fiber; neuroglia and cortical architecture.
    4. Histology of the spinal cord.
    5. Neuronic arrangements of the nervous system. Fiber paths.
    6. Localization of nervous function; correlation of structure and function; diaschisis; theoretical consideration of aphasia and apraxia.
    7. General pathology of the nervous system; malformations; diseases of the membranes of the nervous system; pathological changes in nerve cells; pathological changes in nerve fibers; secondary degeneration.
    8. Inflammation, repair, and reactive processes in the nervous system.
    9. Syphilis of the nervous system; gummatous formations; meningitis; vascular lesions; histological process of general paralysis.
    10. Circulatory disorders of the nervous system; arteriosclerosis; hemorrhage; softening.
    11. Tumors of the nervous system.
    12. Pathology of the spinal cord; myelitis; poliomeylitis; progressive muscular atrophy; amyotrophic lateral sclerosis.
    13. Tabes; Friedreich’s ataxia.
    14. Pernicious anemia; multiple sclerosis; syringomyelia; hydromyelia; peripheral neuritis.

    Exercises 1, 2, 5, and 6 were carried on with brain dissections and demonstrations.69 Exercises 3, 4, 6 to 14 were carried on with studies of microscopic preparations.

NEUROLOGY

    The instruction in neurology was given in the neurologic wards of the hospital of the University of Michigan. The course was divided into three parts:

    a. A lecture course designed to cover the course systematically.
    b. Clinical demonstrations in which the officer was assigned to a case and allowed one hour to examine, his examination and conclusion being criticized by the instructor before the whole section, and free discussion was encouraged.
    c. A series of formal clinics in neurology, the same as given to the senior medical students in the University of Michigan, with special emphasis on the military aspects of the cases under discussion.

OUTLINE OF LECTURE COURSE

    Methods of history taking and filling out of forms used in the neuropsychiatric service of the United States Army.

    Technique of neurologic examination; demonstration; routine methods for rapid examinations of men for neurologic conditions (as abstracted from memorandum of instruction issued to examiners in neurology and psychiatry relative to preparation of statistical data, dated September 13, 1917).

    Aphasia; hemiplegia; bulbar syndrome; Jackson’s syndrome; epilepsy--idiopathic and Jacksonian; optic atrophy; Paraplegia.
    Brain injuries--localization; brain abscess; brain tumor; hydrocephalus.
    Cerebral arteriosclerosis; cerebral embohism, thrombosis, and hemorrhage; bulbar palsy; syphilis of the nervous system.


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    Spinal cord injuries - localization; myelitis--tranverse and traumatic; poliomyelitis; spinal cord abscess; spinal cord tumor; syringomyelia; lateral and combined sclerosis; tabes dorsalis; pachymeningitis; herpes zoster.
    Neuralgia; neuritis--diptheritic, alcoholic, and nonalcoholic; injuries to nerves; facial palsy.
    Meningitis - cerebrospinal, tuberculous, and other forms.
    Endocrinopthies - adrenal, thyroid, pituitary, and ductless glands; Basedow’s disease; vagotonia; myasthenia gravis; paralysis agitans.
    Lumbago; sciatica; pes planus; migraine; chorea, tics; chronic progressive tremor; eye disease; ear disease; Menière’s disease.
    Progressive muscular atrophy (other hereditary diseases of the nervous system, unlisted).
    Psychoneuroses - neurasthenia, hysteria, psychasthenia, and other forms.
    Traumatic neurosis - effects on the nervous system of traumatism that does not produce demonstrable organic change.
    General treatment principles - psychotherapy, rest, massage, intraspinal therapy, etc.

   *   *   *   *   *   *

     There were approximately 640 cases in the Neurological Clinic during the period of the course, all of which were available for study by the medical officers taking the instruction.69

OPHTHALMOLOGY

      The following subjects covered, with the aid of drawings, specimens, and anatomical models: 69

 A
    1. A review of the anatomy of the eye as an optical instrument.
    2. Physiology of the accommodation and physiologic optics.
    3. Anatomy and nerve supply and physiology of the eye muscles, with binocular vision amid fusion and including the deep origin, relation and course of the third, fourth, and sixth nerves.
    4. Muscular anomalies such as manifest and latent spastic strabismus, including heterophoria.
    5. Diplopia and extraocular paralysis and nystagmus.
    6. Nerve supply and physiology of the pupillary reflexes, including miosis, mydriasis, hippus and Argle-Robertson pupil.
    7. Anatony and physiology of the retina, optic nerve, chiasm, primary visual ganglia, optic tracts, and cortical visual centers.
    8. Mechanism of production of choked disk and significance.

B
    1. Diagnosis of optic neurosis and malingering.
    2. The eye manifestations of wounds of the motor and sensory nerve of the eye and of the optic nerve, tracts, radiations, and centers.
    3. Visual fields and hemiopia.
    4. Eye symptoms produced by intracranial lesions, with particular reference to trauma.
    5. Eye symptoms of brain tumor, meningitis, multiple sclerosis, myelitis, locomotor ataxia, superior polioencephalitis, general paralysis, exophthalmic goiter including the various signs associated with exophthalmic goiter, chorea, migraine, and herpes zoster of the eye.

OPHTHALMOSCOPY

    1. Direct and indirect methods, including examination of the ocular media with the ophthalmoscope.
    2. Ophthalmoscopic appearance of the fundus and the diagnosis of syphilitic, albuminuric, diabetic, leukemic lesions of the fundus and other lesions of the fundus dependent upon general diseases.


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    3. Differential diagnosis of ocular lesions of the ehoroid, retina, and the optic nerve, with especial reference to their differentiation from those lesions associated with general diseases.
    4. Ophthalmoscopic appearance and diagnosis of glaucoma.

    Throughout the whole course from one-third to one-half of the time was devoted to the study of cases with the ophthalmoscope, with demonstration of the ophthalmic changes peculiar to ocular and general diseases with especial reference to their practical differentiation. 69

OTOLOGY

    A course of lectures and demonstrations of disorders of the ear in their neurological relations was given, the following subjects being covered:69

    1. Functional examination of the internal ear; disorders of the cochlear portion of the eighth nerve; vestibular nystagmus.
    2. Tests for detecting simulation of deafness.
    3. Diseases of the internal ear; Menière's disease; arteriosclerosis of the internal ear; injuries to the internal ear; syphilis of the internal ear; hysterical deafness; occupational deafness.

    In general it may be stated that the plan as followed worked out quite satisfactorily. The chief difficulty was the marked difference in preparation and experiences of the men for taking such a course as given. Some had had no neurological or psychiatric experience and had little interest in the field. Others had had a limited experience as physicians in hospitals for the insane. In many instances this occurred in their early medical work, and since then their chief interests had been the general practice of medicine. A relatively small number had had a somewhat better than average experience in neurology or psychiatry.

    As the time during the day that might have been utilized in work was fully occupied by the various courses of instruction, the matter of military training while attending the course was left largely to the interest and wishes of the majority in a group.69 Some groups showed a certain amount of interest in this matter, and systematic courses of drill were carried on under supervision of officers attached to the Reserve Officers’ Training Corps of the university. The problem of maintaining a military attitude on the part of the men was difficult. There was a marked difference on this among different groups. When there were several in the group who had been previously in training camps there was some effort on the part of the group to carry out a military behavior. In general it must be said that there was little effort at this institution toward maintaining more than the usual relations between teacher and pupil.

    The enlisted personnel for nervous and mental cases was made up, as far as it was possible to obtain them, from attendants who had previous experience in State hospitals. They were assigned to neurology and psychiatry duty direct, in some cases by orders, when already enlisted, and in others they were inducted into the service and were sent first, as far as possible, to a training camp where they were given military training and later assigned to permanent psychiatric duty. This special class of experienced men was by no means sufficiently numerous to meet the demand, and was supplemented by men from the Medical Department at large. As few of these had previous special training, they were sent, when possible, for instruction to St. Elizabeths Hospital, Washington, D. C. 


559

    The nurses were also obtained in large part from the training schools of State hospitals, and these women nurses became members of the Army Nurse Corps. Special women assistants, termed psychiatric aides, were taken into the Army after a course of training at Smith and other colleges.

REFERENCES

    (1) Letter from the Surgeon General of the Army, to the commanding officer, base hospital, Camp Jackson, S. C. (through the division surgeon), May 14, 1918. Subject: Course of instruction in pneumonia. First indorsement, office of the commanding
officer, base hospital, Camp Jackson, S. C., to the Surgeon General of the Army, May 17, 1918. History of base hospital, Camp .Jackson, S. C., June, 1918. On file, Historical Division, S. G. O.
    (2) Letter from the Surgeon General to the Chief of Staff, February 8, 1918. Subject: Lease of New Haven Hospital, New Haven, Conn., for tuberculosis. On file, Record Room, S. G. O., 601 (New Haven, Conn.) F.
    (3) Memorandum for Acting Chief of Staff, to Assistant Secretary of War, February 11, 1918. Subject: Lease of New Haven hospital for tuberculosis hospital. Approved, February 12, 1918. Telegram from George B. Lummer, New Haven, Conn., to the Surgeon General, February 26, 1918: “Lease signed for hospital to-day.” On file, Record Room, S. G. O., 601 (New Haven, Conn.) (F).
    (4) Letter from the commanding officer to the Surgeon General, September 9, 1919. Subject: Final report (U. S. Army General Hospital No. 16, New Haven, Conn.). On file, Record Room, S. G. O., 314.7 (G. H. No. 16) (K).
    (5) First indorsement from War Department, A. G. O., to the Surgeon General, March 21, 1918. Subject: Designation of hospitals. On file, Record Room, S. G. O.,  323.7 (General Hospitals) (K).
    (6) War Diary, from commanding officer, U. S. Army General Hospital No. 16, New Haven, Conn., to the Surgeon General, January 15, 1919. On file, Historical Division, S. G. O.
    (7) Administrative History of the Cardiovascular Section of the Division of Internal Medicine, Surgeon General’s Office, by Col. Lewis A. Connor, M. C., August 29, 1919. On file, Record Room, S. G. O., 024-10 (Cardiovascular).
    (8) Outline of curriculum for a course in physical diagnosis of the cardiovascular system and of heart disease. On file, Record Room, S. G. O., 702 (Cardiovascular).
    (9) Letter from Capt. Bernard Smith, U. S. Army General Hospital No. 9, Lakewood, N. J., to Col. Lewis A. Connor, Surgeon General’s Office, December 21, 1918. Subject: Program of exercises and outline of history taking, U. S. Army General Hospital No. 9. On file, Record Room, S. G. O., 353.5-1 (Cardiovascular).
    (10) Report of the activities of the Medical Department, U. S. Army, port of embarkation, Hoboken, N.J., for the fiscal year ending June 30, 1919. On file, Historical Division, S. G. O. Also: Annual Report of the Surgeon General, U. S. Army, 1918, 330.
    (11) Report of the activities of the division of general surgery, Surgeon General’s Office, from April, 1917, to July, 1919. On file, Historical Division, S. G. O.
    (12) Memorandum for the Surgeon General from Col. William H. Moncrief, M. C., chief of the division of general surgery, Surgeon General’s Office, October 5, 1917. On file, Record Room, S. G. O., 353.1 (Fracture Courses General).
    (13) Correspondence on file in the Record Room, S. G. O., 353 (Surgery).
    (14) Letter from the Surgeon General, U. S. Army, to the director of class in war surgery and fractures, February 4, 1918. Subject: Material of instruction in surgery. 0n file, Record Room, S. G. O., 353 (Surgery).
    (15) Syllabus of instruction in standard methods for treating fractures. On file, Record Room, S. G. O., 353.1 (Fracture Courses General).
    (16) Memorandum for Colonel Sullivan (chief of division of general surgery, Surgeon General’s Office), from H. I. Wilson, captain, S. C., U. S. Army, November 11, 1918. Subject: Personnel carried by the division of general surgery. Copy on file, Historical Division, S. G. O.


560

    (17) Letter from Col. R. P. Sullivan, M. R. C., to Dr. Edward S. Judd, Rochester, Minn., December 8, 1917. Subject: Instruction at Mayo Clinic. On file, Record Room, S. G. O., 353 (Training General).
    (18) Letter from Surgeon General, U. S. Army, February 27, 1919, to the military director, Mayo Clinic, Rochester. Subject: March 1st class of instruction. On file, Record Room, S. G. O., 210.6 (Detail for March, Mayo Clinic). Also: Letter from the Surgeon General, U. S. Army, to Maj. Edward S. Judd, Mayo Clinic, Rochester, Minn., February 17, 1919. Subject: Medical property. On file, Record Room, S. G. O. 440 (Medical Property, Mayo Clinic, Rochester, Minn.) F.
   (19) Outline of course of instruction, Officers’ School of General Surgery, Mayo Clinic, Rochester, Minn., January 7 to February 3, 1918. On file, Historical Division, S. G. O.
    (20) Letter from Dr. E. S. Judd to Col. F. W. Weed, M. C., September 8, 1924. Subject: Classes at Mayo Clinic, Rochester, Minn. On file, Historical Division, S. G. O.
    (21) Outline of course of instruction, Officers’ School of General Surgery, Mayo Clinic, Rochester, Minn., December 9, 1918, to January 18, 1919. On file, Historical Division, S. G. O.
   (22) Correspondence from the Surgeon General of the Army to Dr. E. S. Judd, Rochester, Minn. Subject: Course of instruction given in the Mayo Clinic. On file, Record Room, S. G. O., 220.6 (Details for Instruction, Rochester, Minn.).
   (23) Correspondence re schools of oral and plastic surgery. On file, Record Room, S. G. O., 700.3   (Oral and Plastic Surgery) and S. G. O. 730 (Oral and Plastic Surgery) and S.G. O. 024 (Oral Surgery). Also: Report of the activities of the subsection plastic
and oral surgery, section of surgery of the head, division of surgery, Surgeon General ‘s Office. On file, Record Room, S. G. O., .024 (Sub-Section of Plastic and Oral Surgery).
  (24) Annual Report of the Surgeon General, 1918, 366.
   (25) Annual Report of the Surgeon General, 1919, Vol. II, 1100.
   (26) Correspondence. Subject: Oral units. On file, Record Room, S. G. O., 322.3 (Plastic and Oral Surgical Units).
   (27) Schedule of instruction and synopsis of course of instruction in Officers’ School of Plastic and Oral Surgery established by order of the Surgeon General of the Army in the city of Philadelphia, Pa. On file, Historical Division, S. G. O.
  (28) Officers’ School of Plastic and Oral Surgery, Northwestern University, Medical and Dental Schools. On file, Historical Division, S. G. O.
   (29) Report of the course of neurological, plastic, and oral surgery, Officers’ School of Neurological, Plastic, and Oral Surgery, St. Louis, Mo. On file, Historical Division, S. G. O.
   (30) Yearly report, division of orthopedic surgery, from David Silver, assistant director, to the Surgeon General of the Army, July 15, 1918. On file, Historical Division, S. G. O.
  (31) Report on division of military orthopedic surgery, November 11, 1917. On file, Record Room, S. G. O. 730 (Orthopedics) and reports and correspondence on the subject of orthopedic instruction. On file, Record Room, S. G. O. 353 (Orthopedics).
  (32) Correspondence on instruction in orthopedics. On file, Record Room, S. G. O., 353 (New York City, N. Y.) (F); 353 (Orthopedics, General); 730 (Orthopedics).
  (33) Schedule of orthopedic instruction. On file, Record Room, S. G. O. 730 (Orthopedics).
  (34) Letter from Brig. Gen. Wm. H. Arthur, commandant, Army Medical School, to Surgeon General of the Army, November 3, 1917. Subject: Outlining course for twenty-second session, orthopedic instruction. On file, Record Room, S. G. O. 730 (Orthopedics).
  (35) Correspondence. On file, Record Room, S. G. O., 353 (Walter Reed General Hospital) (K); 353 (Orthopedics, General); 730 (Orthopedics).
  (36) Letter from Surgeon General of the U. S. Army to A. S. Begg, captain M. C., September 21, 1917. Subject: Assignment of stations. On file, Record Room, S. G. O., 353 (Orthopedic School, Boston).


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  (37) Letter from Surgeon General of U. S. Army to A. S. Begg, captain, M. C., October 29, 1917. Subject: Officers ordered for course of instruction. 0mm file, Record Room, S. G. O., 210.6 (Orthopedic School, Boston).
  (38) Letter from Surgeon General of the Army to R. W. Lovett, major, M. C., November 23, 1918. Subject: Orthopedic officers to report December 2, 1918. On file, Record Room, S. G. O., 353 (Orthopedic School, Boston).
  (39) Report of third meeting of Orthopedic Advisory Council, dated November 21, 1917. On file, Record Room, S. G. O., 730 (Orthopedics).
  (40) Letter from the Surgeon General of U. S. Army to the director of orthopedic instruction, Harvard Medical School, July 22, 1918. Subject: Orthopedic instruction. On file, Record Room, S. G. O., 353 (Orthopedic School, Boston).
  (41) Circular letter from Surgeon General’s Office to officers attending course of instruction in orthopedic surgery at Harvard Graduate School of Medicine, April 29, 1918. On file, Record Room, S. G. O., 353 (Orthopedics).
  (42) Mimeograph outline of instructions, undated, issued by the orthopedic division, S. G. O. On file Record Room, S. G. O., 730 (Orthopedic).
  (43) Report of the activities of the subsection of brain surgery of the section of surgery of the head, Surgeon General’s Office. On file, Record Room, S. G. O., 730 (Neurosurgery).
  (44) Memorandum for Lieut. T. C. Lyster, October 9, 1917, from Capt. Charles Bagley. Subject: Memorandum for extension of the course in neurological instruction. On file, Record Room, S. G. O., 353-1 (New York City) (F).
  (45) Letter from Charles Bagley, Jr., major, M. R. C., to Dr. Charles A.. Eslberg, May, 3, 1918. Subject: Detail for instruction in neurological school. On file, Record Room, S. G. O., 210.6.
  (46) Letter from Charles H. Frazier, M. R. C., to Capt. H. H. Kerr, December 17, 1917. Subject: Successor to Major McCoy as adjutant. On file, Record Room, S. G. O., 201 (Joyce, Thos. M.).
  (47) Correspondence. On file, Record Room, S. G. O., 353 (Neurosurgery, Philadelphia, New York, Chicago, and St. Louis) (F); 730 (Neurosurgery).
  (48) Course of training for neurological surgeons, University of Pennsylvania School. Contained in: Memorandum for Lieutenant Colonel Lyster, from Charles Bagley, Jr., captain, M. R. C., division of brain surgery, October 8, 1917. On file, Record Room, S. G. O., 730 (Neurosurgery).
  (49) Correspondence on the subject of neurosurgery and neurology. On file, Record Room, S. G. O., 352, Chicago, Ill. (F) and S. G. O., 730 (Neurology - Chicago, Ill.) (F).
  (50) Report of subjects presented and practical work done in neurological school, Presbyterian Hospital, Chicago, Ill., November 1, 1917, to January 11, 1918. On file, Historical Division, S. G. O.
  (51) Report of second neurological school, Presbyterian Hospital, Chicago, Ill., January 14 to March 25, 1918. On file, Record Room, S. G. O., 730 (Neurology - Chicago, Ill.) (F).
  (52) Weekly schedules of the Neurosurgical School of New York. On file, Record Room. S. G. O., 353 (Neurosurgery, N. Y. City) (F).
  (53) Christie, Arthur C.: Preparation for X-ray work in the war. New York Medical Journal, 1918, cvii, 172. Also: Wheatley, Frank, Jr.: Roentgenology in the American Army. The Boston Medical and Surgical Journal, Boston, Mass., clxxviii, No. 22, 727.
  (54) Special Order No. 14 W. D., May 17, 1917, par. 49. (Detailing Maj. A. C. Christie, M. R. C., to the Surgeon Generals Office.)
  (55) Letter from Maj. A. C. Christie, M. R. C., to the Surgeon General, May 24, 1917. Subject: Organization of School of Roentgenology. On file, Record Room, S. G. O., 156, 755 (Old Files).
  (56) Letter from Maj. A. C. Christie, M. R. C., to Maj. Alfred L. Gray, M. C., November 28, 1917. Subject: Closing of schools of Roentgenology. On file, Finance and Supply Division, S. G. O. 231/18 (Gray, Alfred L.)


562

  (57) Johnston, Maj. George C.: A report on the development of the X-ray service, U. S. Army. On file, Historical Section, S. G. O.
  (58) Individual reports of schools of Roentgenology. On file, Historical Division, S. G. O.
  (59) Letter from Maj. Leon T. LeWald, M. C., to Surgeon General, January 21, 1919. Subject: Closing of School of Military Roentgenology. On file, Record Room, S. G. O., 352-1 (Roentgenology).
  (60) Weekly report of chief of division of Roentgenology to the Surgeon General, September 20, 1918. On file, Weekly Report File, Record Room, S. G. O. (Roentgenology).
  (61) Weekly report from section of Roentgenology, division of surgery, to the Surgeon General, February 21, 1919. On file, Record Room, S. G. O., Weekly Report File (Roentgenology).
  (62) Correspondence. On file, Record Room, S. G. O., 156, 772 (Old Files) and 188, 331 (Old Files). Report of the section of genitourinary, venereal, and skin diseases for the period ending December 31, 1917. On file, Record Room, S. G. O., 730 (Urology).
  (63) Correspondence. On file, Record Room, S. G. O., 352.4 (School of Urology, Camp Greenleaf) (C); 353 (Camp Greenleaf) (C).
  (64) Letter from the Surgeon General, December 18, 1917, to . J. Bentley Squier, 49 East Forty-ninth Street, New York, N. Y. Subject: Intensive course in urology and dermatology. On file, Record Room, S. G. O., 353 (Urology).
  (65) Correspondence on instruction in urologic surgery. On file, Record Room, S. G. 0., 210.6-1, Detail for Instruction (New York City, Boston, Mass., and St. Louis, Mo.) (F); 353 (Urology) (New York City, Boston, Mass., and St. Louis, Mo.) (F).
  (66) Syllabus and schedule of instruction of a course of intensive instruction in dermatology, syphilis, and genitourinary diseases, given at the Massachusetts General Hospital and the Peter Bent Brighani Hospital, Boston, Mass., from February 1, 1918, to March 15, 1918. On file, Record Room, S. G. O., 353 (Boston, Mass.) (F).
  (67) Semiannual report, division of neurology and psychiatry, January 2, 1918. On file, Record Room, S. G. O., Weekly Report File. Correspondence. On file, Record Room, S. G. O., 353 (Training Neuropsychiatrists) (Boston, Mass., New York City,
N. Y., Philadelphia, Pa., Baltimore, Md., Washington, D. C., An Arbor, Mich., Talmage, Calif.) (F).
  (68) Mills, Charles K.: The Neurologic and Psychiatric Teaching of Medical Officers, with some Discussion of the Course Given in the Philadelphia Post-Graduate School of Neurology. Transactions of the American Neurological Association, Fifty-fourth Annual Meeting, Atlantic City, N. J., May 9-10, 1918.
  (69) Course of instruction in neuropsychiatry for medical officers of the U. S. Army, conducted at the State psychopathic hospital, Ann Arbor, Mich. On file, Record Room, S. G. O., 353 (Ann Arbor, Mich.) (F).