has not been prevalent for years. When such men mingle together,
there is great opportunity of infection if the chance offers and we
find, in the training camps abroad as in the states, that measles,
mumps and, to a less extent, scarlet fever, whooping couph and
chickenpox prevail. When these men have passed the period of
training and are ready to go into active service, they have, as a rule,
been protected by having had these diseases either before entering
camp or afterward, and there is comparatively little of such in-
fections at the front. Nevertheless, here and there small outbreaks
do occur which interfere considerably with the active service of the
troops. The diseases other than wound infections which are most
important in France and England are pneumonia and other repira-
tory diseases, meningitis, diphtheria, dysentery and, in the more
southern climates, malaria. The troops in France have, fortunately,
been protected from exposure to typhus fever and cholera and by
vaccination from typhoid fever.

The amount of tuberculosis among the troops at camp and the
troops at the front is disputed. In England, there is no increase
in the camps and there is certainly no great development of tuber-
culosis among the troops at the front. Among the French, it is
very difficult to decide on account of the lack of informatoin as to



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 57

the amount of tuberculosis among the civil population of France
and the fact that the men were called so suddenly to withstand the
German attack, that no proper physical examination could be made
of the troops. Examinations at the front have apparently revealed
a good deal of incipient tuberculosis and some advanced tubercu-
losis. Many of those sent home as incipient cases have after very
careful examinations made at the receiving hospitals been discharged
as not having the infection. Trench fever has been more interesting
than important.

Two diseases were prominent at the beginning of the war on
account of the infection of wounds through the dirt. These two,
tetanus and gas gangrene are, of course, not communicable under
ordinary conditions from person to person. The surgical care of
wounds has largely eliminated gas gangrene, and the use of anti-
toxin, the development of tetanus.

There was at first a great deal of typhoid fever and probably
also of paratyphoid fever. Happily vaccination has largely re-
duced these infections.

Malaria was of little importance. What did occur was mostly
relapses among those who had received their infections in Turkey
and Greece. In those countries malaria was frequent and severe.
The diseases which were being combatted with new r er methods were
meningitis, pneumonia, typhoid fever, paratyphoid fever, dysentery
and tetanus. The time at my disposal will be taken up in their
consideration.

CEREBROSPINAL MENINGITIS

Its Prevention and Treatment. This disease has been quite prev-
alent among the troops in the training camps in England and
Canada and somewhat so among the English and French troops in
France and the Australian and New Zealand troops in home camps
and on the transports.

Among the English troops alone, there were some 3000 cases
during 1915. The disease was somewdiat less prevalent in 1916
but was again serious in 1917. The civil population was only
slightly affected. Each year the greatest number of cases occurred
in February, March and April. The seriousness of the outbreak
developing in England in 1915 caused a very thorough investiga-
tion of the means of spread of the disease and the best methods of
prevention and cure. The outcome of the investigation has been
made public by the British Medical Research Committee and by



58 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

reports from individual workers such as Gordon, Eastwood, Tul-
lock, Griffith and Scott.

The information obtained corroborated the statements made by
Bolduan and Goodwin of the New York City Bacteriological Lab-
oratories in 1906 as to carriers and those of the Rockefeller Insti-
tute and the Health Department Laboratory as to the value of
serum and the different strains of meningococci. The work of
the English Research Commission has, however, taken up much
more thoroughly and probably successfully the treatment of car-
riers by the use of antiseptic sprays.

The general results of the English investigations are as follows :

Factors influencing the incidence of the disease. Whenever cases
developed among the troops bacterial examination of contact per-
sons revealed that there were many carriers for each case. As in
pneumonia, diphtheria, infantile paralysis and many other dis-
eases, so it is in cerebrospinal meningitis that only a few of those
who receive the infecting organism and in whom it gains a foot-
hold in the mucous membranes become truly invaded and ill. Those
persons who become carriers seem to be in almost no danger of
contracting the disease. The fact that a person carries the menin-
gococcus in his nasopharynx for a number of days without deeper
infection, almost proves immunity.

The abundance of carriers and of cases depends chiefly on the
virulence of the organism, the susceptibility of the population and
the atmospheric conditions. The season of the year is of the ut-
most importance. The importance of the susceptibility of a pop-
ulation which has not been subject to infection was clearly brought
out by the recent epidemic among the blacks in British South Africa
where the proportion attacked was much greater than ever occurs
among the white troops.

The carrier rate has been found to vary in different localities
and at different seasons of the year. This has been true in both
England and France. In parts of England where the disease is
endemic but not epidemic about two per cent, of the tested cases has
been the average amount infected. In some special classes of per-
sons, such as hospital out-patients, the amount has approached five
per cent.

In the recruits entering the British Army the percentage of car-
riers has been higher during the past winter than during the two
previous ones. This rise took place in December and in one garri-
son at the beginning of February fifty per cent, were found to be



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 59

carriers. With this increase in the number infected, an outbreak
of cases occurred. The Research Committee conclude that when the
carrier rate is low, the case rate is usually moderate. A rise in the
carrier rate is soon followed by an increase in the cases. This is
probably partly due to an increase in the virulence of the menin-
gococci.

Seasons. The influence of seasons has been already referred to.

The cases increased among the troops in England during Janu-
ary and February and subsided in April. The same general rise
and fall in cases has been noted in influenza, measles and mumps.
There was not noted any tendency for persons having these dis-
eases to suffer in any excess proportion to meningitis but the in-
creased coughing might have had an effect in spreading menin-
gococcic infection from carriers to non-infected persons.

The cold weather, besides affecting the mucous membranes, also
tends to bring the troops in closer contact in poorly ventilated rooms
and in parts of the rooms not well heated to allow a longer life
of the meningococci expelled into the air in the act of coughing and
talking.

The Virulence and Types of the Meningococci. This attribute,
except in so far as indicated by the severity of the cases, is very
hard to measure as no animal develops the disease naturally or
typically. The considerable immunity of most populations to the
common types adds a difficulty.

In England there were found to be in about ninety-seven per cent,
of the cases, but four strains of meningococci. These, like the
pneumococci, differed from each other in their immunological attri-
butes. The strain designated as number 2 was found to be dis-
tinctly less in virulence for animals than the others, but strains in
each type differed among themselves. The great majority of the
cases in England and France were due to the strains which were
designated as 1 and 2. Observations in this country agree pretty
closely with those in England.

Means for Checking the Spread. 1. The general conditions so
far as sufficient floor space and ventilation should be made good.

2. Prophylactic inoculations of killed cultures. Abroad in both
England and France, these have been given to only a small num-
ber of persons. Sophian of our own laboratories gave the inocu-
lation to several hundred persons in the Texas epidemic of 1912
with certainly no bad results. We have recently inoculated several
thousands of men in our home camps. These inoculations should



60 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

be thoroughly tested out. The doses should be of at least the same
amount as in typhoid inoculations. We have used for the three
doses, one, two and three billions. The reactions have not been
severe.

A serious difficulty is that the different strains as in the case of
pneumococci do not immunize efficiently against each other and that
type one, in rabbits at least, does not produce definite immunity
against even itself. The experimental injections should be made
partly with single types and partly with an equal mixture of all
types so that the completeness of protection given, in each case,
could be determined.

3. Identification and isolation of carriers.

The English and French have both tried to separate the carriers
from the uninfected troops and the results have been considered
good.

The English have used these methods of handling the carriers.

A. Where cerebrospinal meningitis has occurred frequently, all
the men in the unit or camp have been swabbed and the positive
cases removed. The general experience has been that when this
was done, the outbreak has stopped. The procedure requires a very
considerable laboratory force. Two trained laboratory men and
two trained assistants, if pushed, can, for a limited time, do 100
cases a day. All media, agglutinating sera and cleaning are sup-
plied from a central laboratory.

B. Swabbing of only those who have been in contact with the
cases. This is the method generally adopted by both the French
and English authorities for the troops, both in the training camps
and at the front.

The English consider, as a possible contact, everyone coming
within two yards of the diseased person for an appreciable time.
If the general carrier rate is low in a camp, this procedure will
probably be quite effective, but if high, much less so. It has been
found that a wise course is to swab a considerable number of non-
contacts from the same unit or camp and so judge the general
proportion of carriers among non-contacts as contrasted with con-
tacts.

It has been found that when repeated tests of ''non-contacts"
are carried out that an increase in carriers will be noticed in some
instances before any cases occur. By this means, an outbreak may
be forecasted and prevented.

C. The isolation and examination of both those in contact with



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 61

the cases and those in contact with positive contacts. The imme-
diate contacts are tested and those proving positive are considered
as foci to those who have been in contact with them. This method
is continued until no more carriers are discovered.

This method was carried out by the French in a large training
depot. The conclusion was that this method, while it did not wholly
stop all further cases, yet it did lessen greatly the number.

The Research Committee believe that, if in summer, a general
attempt to find the few chronic carriers could be made, that the
winter spread of the infection might be wholly or largely stopped.
This would mean a great deal of work from the bacteriological
squad — not only the culture must be made properly, but the culture
must be examined by trained observers.

Disinfection of Carriers. The difficulty of separating and iso-
lating carriers suggested attempts to free cases from infection by
douches, sprays and vapors. The majority of carriers soon free
themselves, but a considerable proportion remain injected for weeks
or months. A considerable proportion of these have pathological
anatomical conditions, such as enlarged tonsils and adenoids, which
are believed to favor the persistance of infection.

The longest duration of infection met with was 15
months.

Several different antiseptic solutions were used to make the spray.
The two which seemed the most effective were chloramine-T in
a one to two per cent, solution and zinc sulphate in a one per cent,
solution.

The spray was made by driving a steam jet across the tube con-
necting with the solution. It was found necessary to fill the cham-
bers with a dense cloud of very minute droplets as it was shown
that it was the droplets themselves and not any gases in the air
which produced the effect. One litre of solution per hour in a
room containing 1000 cubic feet gave about the right density. The
carrier remained in the room for ten to twenty minutes and inhaled
vigorously through the nostrils.

Chronic carriers at least were made to cleanse the nasal cavity
with salt solution before entering the chamber. An antiseptic
gargle such as a one per cent. chloramine-T or one per cent, per-
manganate of potash was considered of advantage.

The effect of the chloramine-T treatment is to produce an imme-
diate increase in the flow of secretion from the nasopharyngeal
mucosa. In some cases, the mucus which, before the treatment,



62 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

contained numerous living meningococci was found to be free on
leaving the chamber.

In the largest trial camp, 5,000 men were subjected daily to the
spray treatment. In these cases the one per cent, zinc sulphate was
used because it is less irritating than the chloramine.

The New Zealand and the Australian authorities used the spray
to free "carriers" going to England on the transports. The treat-
ment seemed not only to free carriers but to lessen the incidence of
mumps, measles and colds. It seemed to diminish the chance of
infections which take place through the mucous membranes of the
nasal cavities, mouth and pharynx. Fildes at the British Naval
Station at Portsmouth, after a very extensive test, came to the con-
clusion that no solution had much preference over another and that
the effect produced was not very great.

The French have not used the fine spray inhalation treatment.
The meningitis problem has been far less important in their army
and the rigorous use of cultures to separate the carriers has been
sufficient. They believe swabbing the nasopharynx with carbolized
oil is of advantage.

Dopter has tried the use of insufflations of dried antimeningitis
serum and thinks they may prove of value.

While it seems to me impossible that the serum would be effica-
cious, it is worth investigating as it is easy of application and per-
fectly harmless.

It is apparent that while much has been done to lessen the spread
of meningitis the results are only partially satisfactory and further
investigations are necessary.

Treatment. The English and French authorities, like ourselves,
consider serum treatment is of great value. An important point has
been brought out that any serum, to be efficient, must be potent
against the types of meningococci occurring in the cases under treat-
ment. During the first year of the war, much of the serum used
was of little strength and unequal in its potency for the different
types. The results with this serum were very disappointing.

The Rockefeller Institute and the New York City Health Depart-
ment have always made certain that the horses were treated with
balanced cultures of the different types of meningococci and that
every lot of serum was tested for its potency.

The United States Public Health Service has just ruled that no
serum should be sent out from American producers until the Gov-
ernment has assured itself of the serum's potency.



THE AM URIC. IN CONGRESS ON INTERNAL MEDICINE 63

Cultures from a number of the European cases have been brought
over to make sure that those obtained by us at an earlier time fully
cover the present strains.

Immunisation against Typhoid Fever. The greatest accomplish-
ment in the prevention of disease during the war is unquestionably
the limitation of typhoid and paratyphoid fevers through vaccina-
tion. The military and civil authorities in all countries are in accord
as to this.

The results in the French Army are most striking.

At the beginning of the war, less than half of the troops had
been vaccinated against typhoid fever and none against paratyphoid
fever. During the winter and spring of 1915 typhoid vaccination
was pushed, but it was only in the fall that the paratyphoid vaccines
were commenced.

The typhoid and paratyphoid developments were as follows :

During the fall of 1914 and the early winter of 1915, there were
many days in which 500 to 700 cases developed and several thou-
sand deaths occurred each month. With improved conditions and
the general use of typhoid vaccines, the incidence gradually im-
proved so that less than 100 were reported. With the hot weather
the cases increased somewhat, so that for a few days, as many as
500 occurred, but bacterial examinations revealed that there were
mostly paratyphoid fever. Before the summer of 1916, the troops
had all been vaccinated against both the typhoid and paratyphoid
A and B bacilli. The sanitary conditions were also better. The
combined result of the vaccination and the better care was that, at
the worst periods, less than one per cent, of the cases developed as
compared to 1914 and less than ten per cent, of the summer of
1915. The 1917 results were even better.

The English from the start vaccinated all their troops against
typhoid fever and after the first year against the paratyphoid fevers.
The sanitation has always been good. The combined effect has
been to make typhoid and paratyphoid fever cases very infrequent.

Dysentery. The bacillary and amebic types of dysentery have
been moderately prevalent in both the French and English armies.

The amebic infection of the English troops in France occurred
from men transferred from Turkey, and of the French troops
through the addition of men from North Africa.

The amebic form occurred during all seasons of the year, while
the bacillary form occurred only in hot weather. At some portion
of the front the Shiga infection was most important, at others, due



64 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

to the other strains. A number of persons suffered simultaneously
from both infections.

Prevention. There is no specific treatment to prevent infection
in dysentery. The ordinary precautions used against intestinal in-
fections are employed as thoroughly as possible. The vaccines so
far prepared from the various strains of dysentery bacilli have been
too toxic to be much employed. The use of specific serum and
bacillus mixture — sensitized vaccine — is still in experimental stage.

There have been no vaccines developed which are effective in
developing immunity against infections due to the ameba.

Treatment by Serum of Bacillary Infection. The polyvalent
serum from horses which have been injected with various types of
bacilli is used in the treatment of severe cases in doses of forty to
100 c. c. It is as a rule administered subcutaneously every twelve
or twenty-four hours for usually three or four times. The earlier
it is given the better. When one type of bacilli is found to be the
sole cause of the local epidemic, a serum especially potent for this
type is employed if it is possible to obtain it.

B. Amebic Infection. Treatment of Carriers. The usual treat-
ment with emetine hydrochloride was found to fail, in more than
half of the cases, to rid them of the infection. Lately, emetin bis-
muth iodide has been substituted by the English with better results.
The drug is given by the mouth in doses of three to four grains for
each of twelve consecutive days. In order to prevent nausea and
vomiting, the emetin may be given in pills coated so as to pass the
stomach unaltered. Diarrhea and vomiting are thus less apt to
occur. Jepps and Meakens report ten out of eleven cases were
cured after twelve daily doses.

Pneumonia. Lobar and broncho-pneumonia due to exposure or
as complication of measles and other infections are common both in
the camps and in the fighting area. Lobar pneumonia had been
epidemic among the Singalese in their camps in Southern France.

Borrel showed me the clinical results of the treatment of many of
the cases with serum. In many cases, the temperature fell shortly
after its use. The dose was fifty to 100 c. c. and usually repeated
once or twice. It was given subcutaneously. He had also vac-
cinated all the men in two large camps. In one camp, the cases
became milder and less frequent about ten days after the second
inoculation. In the other camp, the course of the epidemic was
unchanged. The strain of pneumococci used came from a case in
the first camp and it is possible that the type of pneumococci in



THE AMERICAN CONGRESS ON INTERNAL MEDICINE 65

the second camp are different. The results in South Africa are
certainly very encouraging and I certainly feel that we should test
out the value in our camps so that we may soon have additional
knowledge.

Tetanus. During the early period of the war considerable tetanus
appeared among English wounded and still more among the French.
Injections of 500 units were first made compulsory in all infected
wounds and then in all wounds. The close of 500 units was repeated
at the end of several days in all infected cases and again when
thought necessary.

Less than one in 1000 now develop tetanus in the English and
French Armies, and these rare cases are usually those who re-
ceived no antitoxin. The serum in the developed cases in France
is mostly given subcutaneously or intravenously because of fear
of anaphylactic shock if given intraspinally in cases who had pre-
viously had an immunizing dose of antitoxin. The British advocate
the intraspinal method.

Trench Fever. This is a form of relapsing fever occurring espe-
cially among the English troops in Flanders. The fever is accom-
panied by headache and pains in the lower limbs. The blood con-
tains infectious organisms which do not pass the stone filter. Micro-
scopical examination reveals no microorganisms. It may be con-
veyed by insects.



SOME PROBLEMS OF CARDIOVASCULAR DISEASE

By EDWARD E. CORNWALL

Brooklyn, New York

The central pump and its tubal connections, including the kidney
filters, may be subjected to extraordinary wear and tear, and the
pathological and functional manifestations of this wear and tear,
though variously distributed in locality and time, may be brought
into one focus and looked at as a whole ; and this whole we call
cardiovascular disease. The essential unity of cardiovascular dis-
ease is found in the etiology and interrelationships of its different
manifestations; and these make it possible to consider it as a clini-
cal entity and to treat it as such. It is not synonymous with arterio-
sclerosis, or chronic nephritis, or chronic myocarditis, although



66 THE AMERICAN CONGRESS ON INTERNAL MEDICINE

those are the three principal pathological foci around which its
manifestations cluster, so to speak.

Of the many problems presented by this disease, only two will
be discussed here, viz., its prophylaxis and the treatment of the
high blood pressure which is often found associated with it.

The prophylaxis of cardiovascular disease is one of the large
things in preventive medicine, and one which deserves more atten-
tion than it has generally received. This disease occupies relatively
as large a place in the morbidity of the latter half of life as do dis-
eases of bacterial origin in the first half. Its prevention or post-
ponement means much in prolongation of life and usefulness and
well as saving of misery. The loss to the world from the shorten-
ing of the period of useful human activity caused by the premature
development of this widespread disease is difficult to estimate, but
it looms large enough to make its prophylaxis a medical thing of
the first magnitude.

This prophylaxis must take into account the etiological factors.
Among those factors heredity stands out prominently. The quality
of the material of which the cardiovascular apparatus is made dif-
fers widely in different individuals, and this quality is inheritable.