OFFICE OF MILITARY GOVERNMENT FOR GERMANY (U.S,) 
OFFICE OF NAVAL ADVISOR 
Medical Section 
Room 124, EUCOM HDQTRS• 
APO 757 
FOREWORD TO THE TRANSLATION OF THE REPORT OF THE 
THIRD CONFERENCE OF THE MEDICAL CONSULTANTS TO 
THE GERMAN ARMED FORCES. 
In this report of the Third Conference of the Medical 
Consultants to the German Armed Forces we find a cross-section 
of the problems confronting them in the late spring of 194-3* 
At this time almost all of continental Europe was occupied and 
the war was still going along more or less satisfactorily in 
Russia and in North Africa, 
There was some concern over public health problems 
within the Army itself (tuberculosis) and within the occupied 
countries as regards typhus and other endemic and epidemic 
diseases. 
This portion of the translation project, when com- 
bined with the report of the Fourth Conference and the Classi- 
fication of Fitness, published previously, give a broad view 
of the changing aspect of the medical and manpower problems. 
It appears to be a reasonable assumption that the opinions ex- 
pressed are the best information available in Germany at that 
time concerning the particular subjects. 
HARRY J. ALVIS, 
Commander. Medical Corps, 
U. S9 Navy. INDEX FOR 
REPORT 
OF THE 
THIRD CONFERENCE OF SPECIAL MEDICAL CONSULTANTS 
FROM 24th TO 26th MAY 194.1 
AT THE MILITARY MEDICAL ACADEMY, BERLIN 
Translation prepared by; 
Office of Military Government for Germany (U* 3* ) 
Office of Naval Advisor 
Medical Section I 
TITLE 
PAGE 
The lectures could be printed only in an abbrevi- 
ated form or as short summaries. If the place of de- 
tailed publication is already fixed, this is given at 
the end of the respective article. 
Preface to the Report 2 
Speech of the Chief of the Armed Forces Medical Service 4 
I, Proceedings of the Consultants1 Committee on 
~0pht ha lino 1 ogV~ ° 
1* Primary treatment of injuries of the eyeball 
Stabsarzt (Captain, MC.) Prof* HANS KARL 
MUELLER 9 
2, Wounds in the eye due to magnetic particles 
and their treatment 
Oberstabsarzt (Major, MC,) Prof. DIETER 13 
3. Wounds in the eye caused by non-magnetic 
particles and their treatment 
Professor JESS 17 
4# Wounds in the eyelids and tear ducts 
Professor CLAUSEN 18 
5• Transportation of eye casualties 
Oberstabsarzt (Major, MC.) KAISER 18 
6# Wounds in the orbit 
Oberstabsarzt (Major, MC.) Prof. KYRIELEIS 20 
7. Papillary congestion caused by gunshot wounds 
of the brain 
Oberstabsarzt (Major, MC.) Prof. KYRIELEIS 22 
8. War blindness 
Stabsarzt (Captain, MC.) LEHNERS 25 
9. Fitness of eye casualties 
Generalarzt (Brig. General, MC.) KLEIBER 28 
10. About night blindness and other disturbances 
of the light perception __ 
Professor VOm HOPE 31 
11• Concerning night vision 
Marineoberstabsarzt (Lieut, Comdr., MC.) 
Dozent HEINSIUS 32 
12m Aggravation, simulation and hysteria 
Oberfeldarzt (Lt. Col., MC.) Prof. COLLIN 33 
13* “Trachoma” 
Stabsarzt (Captain, MC.) Prof, R0HR3CHNEIDER 35 II 
TITLE 
PAGE 
II* Proceedings of the Consultants1 Committee on 
"Surgery ' 37 
1. Heamputation and stump treatment 
Oberstabsarzt (Major, MC.) Prof. KREUZ 33 
2# Treatment by exercises and mobilization of 
the joints 
SS-Gruppenfuehrer (Lieut, General. Elite 
Guard) Prof. GEBHARDT and Standarx;enfuehrer 
(Lieut. Colonel) SCHULZE 40 
3. Marrow nailing of gunshot fractures of long 
tube bones at the front 
Oberarzt (1st Lieutenant, MC.) Prof. 
KUENTSCHER 42 
4. Marrow nailing of old fractures, threatening 
and existing pseudarthroses in the homeland 
Oberfeldarzt (Lt. Col., MC.) Prof. HAEBLER 43 
5. Special test of sulfonamide effects 
(SS-Gruppenfuehrer (Lt. General, Elite Guard) 
Prof. GEBHARDT and F. FISCHER 46 
6. Sulfonamide treatment of gunshot wounds 
Oberstarzt (Colonel, MC.) Prof. FREY 47 
7* Injuries caused by intrathecal administration 
of sulfonamides 
Stabsarzt (Captain, MC.) Dozent H.-R. MUELLER 48 
8* Sulfonamide treatment of infectious dermatoses 
SS-3turmbannfuehrer (Major, Elite Guard) 
Prof. VONKENNEL 49 
9* Injuries caused by sulfonamide treatment of 
gunshot wounds 
Oberstabsarzt (Major, MC.) Prof, RANDERATH 50 
10. Dosage of sulfonamide preparations to be ad- 
ministered 
Oberarzt (1st Lieut., MC.) Dozent SOBERING 51 
11# Pathologico-anatomical bases of chronic tissue 
damage in case of injuries due to cold 
Oberstabsarzt (Major, MC.) Prof* STAEMMLER 54 
12. Calling up for active service of men suffering 
from injuries due to cold 
Genaralarzt (Brig. General, MC.) Prof# 
GOHRBRANDT 57 
13* The diagnosis and treatment of pains due to 
gunshot injuries to nerves; along with 
directions 
Stabsarzt (Captain, MC.) Dozent ZUSLCH 59 III 
TITLE 
PAGE 
14. The operative treatment of peripheral nerve 
injuries due to gunshots 
Oberstarzt (Colonel, MC.) Prof. TOENNIS 61 
15. Limits of the therapeutic evaluation in the 
X-ray picture of peripheral nerve injuries 
shown by contrast methods 
Stabsarzt (Captain, MC.) BRUNNER 62 
16. Plastic operations in case of nerve paralysis 
SS-Gruppenfuehrer {Lt. Gen., Elite Guard) 
Prof. GEBHARDT and J. KOESTER 63 
III, Proceedings of the Consultants* Committee on 
Dermatology 64 
1. Judgement of fitness for active service of 
psoriatics 
Oberfeldarzt (Lt. Col., MC.) VOHWINKEL 65 
2. Experiences gained in the treatment of lues 
Oberstabsarzt (Major, MC.) Prof. 3CBREUS 67 
3* Experiences in the treatment of lues based on 
the new instructions, injuries caused by 
Salvarsan, deaths, etc. 
Oberfeldarzt (Lt. Col., MC.) Prof. GOTTRON 69 
4. Chemo-resistant gonorrhea 
Stabsarzt (Captain* MC.) Prof. FELKE 71 
5, Concerning the fitness for active service of 
men suffering from damage due to cold 
Oberfeldarzt (Lt. Col., MC.) Prof. E. HOFMANN 71 
IV. Proceedings of the Consultants1 Committee on 
Forensic Medicine 73 
Summary 74 
y. Proceedings of the Consultants* Committee on 
Otorhinolaryngology 76 
1. The treatment of gunshot wounds of the jaw and 
face by plate-wire method 
Professor PERWITZSCHKY 77 
2. Gunshot wounds in the larynx*, stenoses of the 
larynx and their treatment 
Stabsarzt (Captain, MC.) Prof. GHEIFEN3TEIN 79 
3* Surgery of grazing wounds of the ear and 
forehead 
Oberfeldarzt (Lt. Col., MC.) Prof. Dr. 
HUENERMANN 100 IV 
TITLE 
PAGE 
Vl» Proceedings of the Consultants1 Committee on 
'"Hygienee and tropical Hygiene ~ 10? 
1* Tolerance to a new combined vaccine against 
typhoid 
SS-Hauptsturmfuehrer (Captain, Elite Guard) 
DOETZE 108 
2# Tolerance to new typhoid, paratyphoid A and B 
vaccine 
SS-Sturmbannfuehrer (Major, Elite Guard) 
GROSS 109 
3. Experimental trial of a new typhoid vaccine 
Flottenarzt (Fleet Surgeon) Prof, HUGE 112 
4. Adsorbate vaccines against scarlet fever and 
diphtheria 
Stabsarzt (Captain, MC.) SCHMIDT-BURBACH 113 
5* Result of a trial with a variety of typhus 
vaccines against classical typhus 
SS-Sturmbannfuehrer (Major, Elite Guard) 
DING 123 
6, Results of a trial with a variety of typhus 
vaccines against North and West African forms 
of typhus 
Marinestabsarzt (Lieut., MC., Navy) 
Prof. HAUCK 124 
?• Immunization against yellow fever 
Stabsarzt (Captain, MC.) Prof. HAAGEN 128 
8. Urban yellow fever and jungle fever 
Stabsarzt (Captain, MC.) Prof. HOERING 128 
9* The treatment of diphtheria carriers 
Stabsarzt (Captain, MC*) HERTEL 130 
10. Ridding carriers of intestinal protozoa 
Oberstabsarzt (Major, MC.) Prof. HAUER 132 
11. The threat of malaria to the German population 
through returning soldiers 
Oberstarzt (Colonel, MC.) Prof. RODENWALDT 134 
12. Field latrines in subtropics and tropics 
Kriegsverwaltungsrat (Special Administrative 
Consultant) Dr. VICK 137 
13* Evaluation of the serological test for lues in 
regard to its diagnostic value with omission 
of Wassermann’s reaction 
Professor JAHNEL 143 V 
TITLE 
PAGE 
14. The standardization of cerebro-spinal fluid 
diagnosis in the hygienic laboratories 
Stabsarzt (Captain, MC.) SCHROEER 147 
VII« Proceedings of the Consultants1 Committee on 
Internal Medicine 151 
1* Possibilities of calling up men suffering from 
ulcer for active service 
Oberstabsarzt (Major, MC*) Prof* STEIN 152 
2* Possibilities of calling up men suffering from 
ulcer for military service 
Oberfeldarzt (Lt. Col., MC.) Prof* KATSCH 15? 
3* Postdysenteric intestinal diseases 
Oberstabsarzt (Major, MC.) Prof* STOERMER 16? 
4# Volhynia fever 
Oberstabsarzt (Major, MC*) Prof* SCHULTEN 172 
5* Concerning epidemiology and differential diag- 
nosis of the Volhynia fever 
Stabsarzt (Captain, HC.) Dozent K* SCHULZE 174 
i 
6* Concerning Rickettsias - Demonstration in the 
blood and in the Cerebrospinal fluid in case 
of Volhynia fever (V. F.) 
Stabsarzt (Captain, MC.) UNGER 180 
7* Experience with typhoid and paratyphoid 
Oberstabsarzt (Major, MC.) WESTPHAL 183 
8* Experience with typhoid and paratyphoid, par- 
ticularly their course in "immunized” in- 
dividuals 
Stabsarzt (Captain, MC.) Prof# SCHOENE 184 
9* Postdiphtheritic disorders! treatment, judge- 
ment of fitness for service, later possibil- 
ities of calling up for military service 
Oberstabsarzt (Major, MC#) Prof# SCHOEN 191 
10# Consequences of diphtheria, treatment9 and 
judgement of the fitness for military service 
Oberstarzt (Colonel, MC.) Prof# UHLENHRUCK 197 
Concerning the etiology of hepatitis epidemica 
Stabsarzt (Captain, MC.) Dozent DOHMEN 205 
i 4 
VIII. Proceedings of the Consultants1 Committee, on 
''Pathology ~ 214 
1. Legal status of soldiers having malignant tumors 
in view of the question of line of duty in- 
juries 
Oberstarzt (Colonel, MC.) Privy Councillor 
Professor BORST 215 VI 
TITLE 
PAGE 
2. Pathology.of injuries caused by Salvarsan 
Stabsarzt (Captain, MC.) PETERS 218 
3* Concerning pathology of injuries caused by 
inoculations 
Oberfeldarzt (Lt. Col., MC.) Prof, KLINGE 221 
4. Pathological anatomy of tularemia 
Oberstabsarzt (Major, MC.) Dr, SINGER 223 
5. Professor ROESSLE 228 
6. Pathological anatomy of the effects of de- 
tonations 
Doctor WERNER 228 
?• Physical bases of the effects of detonations 
Stabsarzt (Captain, MC.) DESAGA 228 
IX. Proceedings of the Consultants1 Committee on 
Pharmacology * 229 
1. Consequences of chemical warfare 
Oberstarzt (Colonel, MC.) Prof. FLURY 230 
2. Toxicology of explosives 
Professor HEUBNER 240 
3, On the toxicology of explosion- and combustion- 
gases 
Flottenarzt (Fleet Surgeon) PFLESSER 248 
4, Concerning the question of the use of potent 
drugs in the Armed Forces without control 
by the surgeon 
1st lecture: 
Oberstarzt (Colonel, MC.) Prof. W. WIRTH 250 
2nd lecture: 
Stabsarzt (Captain, MC.) Prof, ANTHONY 251 
3rd lecture: 
Marine-Stabsarzt (Lieut., MC., Navy) Prof, 
ORZECHOWSKI 252 
X. Proceedings of the Consultants1 Committee on 
Pharmacy and Food Chemistry ~ 254 
1, Medical equipment 
Oberfeldapotheker (Lt. Col., Pharm. Corps) 
Dr. FISCHER 255 
2. Chemical items of field medical equipment 
Oberstabsapotheker (Major, Pharm. Corps) 
Dr. MOUCKA 257 VII 
TITLE 
PAGE 
3# Pharmaceutical practice in the 6th Army 
Oberfeldapotheker (Lt. Col*, Pharm* Corps) 
Dr. PATZSCH 258 
4. Work and special duties of the corps pharmacist 
in the East 
Stabsapotheker (Captain, Pharm* Corps) 
Dr. KLEIN 259 
5. Reconstruction of the pharmaceutical chemistry 
and food chemistry industry in the East 
Oberstabsapotheker (Major, Pharm* Corps) 
Dr. von TREYDEN 260 
6* Food concentrates 
Oberstabsapotheker (Major, Pharm* Corns) 
Prof. Dr. UNGERER 260 
7* Special forensic and toxicological research 
Stabsapotheker (Captain, Pharm* Corps) 
Dr. MAYER 261 
8. Nutrition problems 
Oberfeldarzt (Lt. Col., MG.) Prof. Dr# Dr. 
LANG 261 
9* Food and chemical warfare agents 
Oberfeldapotheker (Lt. Col., Pharm. Corps) 
Dr. K. GEMEINHARDT 262 
XI. Proceedings of the Consultants1 Committee on 
Psychiatry 264 
1. Questions on the classification of psycho- 
neurological cases with respect to service 
incurred disability 
Oberstabsarzt (Major, MC.) CHRISTUKAT 265 
2. Consideration of the list of deficiencies with 
regard to some forensic-psychiatric questions 
Oberstabsarzt (Major, MC.) Prof. WUTH 265 
3* Hysteria and simulation, with special con- 
sideration of psychogenic factors added to 
organic injuries 
Stabsarzt (Captain, MC.) Prof. PANSE 266 
4. Encephalitis, myelitis, polyradiculitis, 
polyneuritis, poliomyelitis, inflammatory 
diseases of the central nervous system 
Geschwaderarzt (Colonel, MC., Airforce) 
Prof. PETTE 269 
5. The inflammatory diseases of the nervous system 
Kriegsarzt (War Surgeon) Prof. HALLERVORDEN 273 VIII 
TITLE 
PAGE 
6. Malarial therapy in the treatment of post- 
diphtheritic paralysis 
Oberfeldarzt (Lt. Col., MC*) FUCHS 276 
?• Late sequelae of commotio and contusio cerebri 
Oberfeldarzt (Lt. Col., MC.) Prof* BOSTHOEM 278 
XII. Proceedings of the Consultants1 Committee on 
Tuberculosis 282 
1. Treatment of pulmonary tuberculosis by occu- 
pational therapy 
Oberfeldarzt (Lt. Col., MC.) STEINMEYEH 283 
2. Investigations of pulmonary tuberculosis and 
other pulmonary diseases by tomographic X-ray 
pictures 
Geschwaderarzt (Lt, Col., MC., Airforce) 
Professor BACMEISTEH 287 
3. The organization of investigation by photo- 
fluoroscopy in the Armed Forces 
Oberstabsarzt (Major, MC.) GRASS 289 
4. Functional tests with patients suffering from 
pulmonary diseases in Armed Forces hospitals 
Stabsarzt (Captain, MC.) Professor ANTHONY 293 
5. Gymnastics for patients suffering from tuber- 
culosis 
Oberstabsarzt (Major, MC.) Prof. ULRICI 297 
6. Minor surgery with pulmonary tuberculosis in 
Armed Forces hospitals 
Oberstabsarzt (Major, MC.) RICKMANN 300 
7* Major surgery with pulmonary tuberculosis 
Oberarzt (1st Lieut., MC.) Dozent ADELBERGER 301 
8. Experience with the diagnosis and the treatment 
of extra-pulmonary tuberculosis in hospitals 
of the Armed Forces 
Oberstabsarzt (Major, MC.) KREMER 302 
Supplementary remarks to the report of the Second 
ConferencF of the East ’ " 303 
Concerning the tactical use of small hospital 
ships 
Marine-Stabsarzt (Lieut., MC., Navy) KUTSCHER 303 REPORT 
OF THE 
THIRD CONFERENCE OF SPECIAL MEDICAL CONSULTANTS 
FROM 24th TO'26th MAY 1943 
AT THE MILITARY MEDICAL ACADEMY. BERLIN 
Translation prepared by: 
Office of Military Government for Germany (U, S# ) 
Office of Naval Advisor 
Medical Section 2 
PREFACE TO THE REPORT 
The third conference of the medical consultants held 
from the 24th to 26th May 1943 at the Military Medical Academy 
in Berlin, brought together, as did the previous one in Novem- 
ber 1942, the leading medical officers, consulting physicians 
and specialists of all parts of the Armed Forces, the Waffeu- 
and the organizations and units commanded by the Armed Forces 
and affiliated with it. The scope of the meeting was enlarged 
by the participation of the otorhinolaryngologists and oculist,- 
Once again vital army medical questions were discussed 
with special consideration of the peculiar requirements of the 
various Armed Forces units. The important principles for the 
issuing of orders were established and by this means a scient- 
ific foundation has been created for future orders to all re- 
sponsible offices of the medical service. If above all, quest- 
ions of delayed and subsequent treatment were given first con- 
sideration during this conference, it was because of experience 
gained during 4 years of war, available for the physicians in 
general through scientific discussions. 
\ \ 
In the field of surgery special attention should be given 
to the discussion of the results of reamputation and stump 
treatment, mobilization of the joints and the return to duty 
of those disabled by effects of cold. The present experience 
with the use of sulfonamides for the treatment of wounds was 
summarized in a set of directions for their use compiled co- 
operatively by surgeons, pharmacologists and pathologists. 
The possibility of return to service and the treatment of 
ulcer and diphtheria patients, post-dysenteric gastro-intestinal 
disorders, as well as volhynia fever, which is important for 
the Eastern campaign, was discussed by the internists. 
The hygienists gave directions for the protective immuniz- 
ation for diphtheria and scarlet fever and reported among other 
things on the experiences made with tetravaccines important for 
a simplification of vaccinations against typhoid fever, para- 
typhus A and B, and cholera. 
The eye and ear specialists selected for the initial 
deliberations in their speciality those questions which most 
needed clarification. The eye specialists prepared general 
directions for the treatment of eye casualties with special 
consideration of injuries to the eye by foreign bodies and for 
the question of transportation. The ear specialists, among 
other things, prepared directions for the treatment of gun- 
shot wounds of the larynx. 
It is not possible to mention here all the various sub- 
jects discussed, all of which are of the same importance for 
army medicine. The following report affords ample evidence 
of the wide scope of the work done and the earnestness with 
which research work has been carried out in all branches of 
the Armed Forces medical services. The printing of this report had to be limited this time 
too. For this reason I ask everyone to make certain that the 
existing copies find as wide a distribution as possible, in 
order to bring the experiences stated therein to a general 
profitable usage. To each consulting physician, one copy of 
the report will be handed over for his personal use* 
/s/ Dr. HANDLOSEH 4 
Speech 
of- the Chief of the Armed Forces Medical Service. 
Gentlemenl 
The war time conferences of the consulting physicians, 
which should give the opportunity for scientific discussions 
of treatment and all urgent scientific questions resulting 
from the war and which should form the scientific bases for 
medical service directions, have become a permanent institut- 
ion. If one looks back at the meeting in January 1940 and 
the two conferences in May and December 1942, and views their 
results critically, it is possible even now to consider this 
venture as completely successful in every respect. The meet- 
ings beneficial to the welfare of our hard-fighting German 
soldiers, the wounded as well as the sick ones, and also for 
the benefit of the health service of the entire Armed Forces. 
In addition to this they also stimulated scientific research 
and increased the mental equipment of the German physicians 
serving in the Armed Forcesi 
Since the last time we came together at this place and 
in this circle for the second conference in December of last 
year, events of great military importance have overtakeh us. 
Fighting in the East has become so fierce again during this 
last winter that it required the utmost effort of all the 
forces at the.front and in the home country. Side by side 
with the fighting men stood our medical officers, non-dommis- 
sioned Officers and men of the medical corps in Stalingrad 
and Africa, to the last and they shared heroically in a sold- 
ierly bearing in the performance of their medical duties as 
in the fate of their troops. These comrades will always be 
sure of our gratitude and of the gratitude of the whole German 
nation* The medical service has been and will also be in 
future faced with important parts of the operations, regarding 
the situation of personnel and material which can be performed 
only by a centralized and well-planned direction. There are 
no more pressing special tasks and special problems than the 
improvement of this central supervision everywhere. This is 
the order of the hour and the future. 
For 'the first time in this circle we have with us today 
the two consultant groups of the otorhinolaryngologists and 
the oculists. There is no denying the importance of these 
special fields. The increasing ferocity of the war as well 
as the Ihrge number of wounded needing special treatment and 
care by these two branches immediately after combat and also 
during the after-treatment, makes' close cooperations with them 
absolutely necessary. 
i 
I welcome yoU all most cordially and at the saifie time 
I express the wish and request that you should put St our 
disposal again, during this meeting, your great practical 
and medical scientific experience acquired in time of peace 
and enlarged during the war, so that we may be able to de- 
cide the most urgent questions arid may further the solution 
of them. 5 
I especially welcome the General Commissioner of the 
Fuehrer for the medical and health service, General (MC.) 
Prof* Dr. BRANDT. He is the advocate of our interests with 
the Fuehrer. We wish him the best success for his tasks 
and his work and know that our common cause and our common 
aims are in the best hands with him. 
I also welcome the Reichs Commissioner of Health, State 
Secretary Dr. CONTI. Through his work in the civilian sect- 
or he is creating the basis for the preservation of the 
health of the home country and by this of the health of the 
rising generation fit for service under the flag. Many com- 
mon cares unite us, and we are endeavoring to overcome them 
by combined efforts. 
I would like to direct your attention to the fact that 
this third meeting was not arranged casually but that it 
was arranged after the leading advisors declared it to be 
important and necessary for the conduct of the war and was 
not to be postponed. The value of these meeting consists, 
as it always has, in affording a large number of specialists 
the opportunity to carry through joint negotiations and to 
decide on important policies. 
Let me give you a brief outline of the purpose of to- 
day's meeting. Let me give you first a survey of the prob- 
lems and aims of the last conference. At that time we had 
another winter in the East before us. It was necessary to 
arrive at a policy for the treatment of injuries by cold 
which had to be expected according to the special character 
of the Eastern climate. War experience teaches us that they 
may be lessened by appropriate and carefully introduced pre- 
ventive measures but can never be averted entirely. The 
surgery of war needs new directions for the treatment of the 
most important gunshot injuries. As in every field of medic- 
ine, here also, the methods and points of view are changing 
rapidly. Our aim is to advance the good things, for in the 
medical field war always has been the great teacher. Lectures 
have dealt with gunshot injuries of the abdomen, lungs and 
jaw; fractures by gunshots of the upper part of the thigh, 
injuries of the joints, transportation problems and in connect- 
ion with this the transportation bandages; shock and collapse 
as especially important for the winter campaign were also 
discussed. 
In collaboration with the hygienists, the consultants 
in internal medicine put on their program spotted fever and 
dysentery as the most threatening epidemics of the East, 
and in addition typhoid fever, against which our immunizat- 
ion procedure has given good protection. Furthermore, para- 
typhoid has been discussed. 
Besides these there have been discussions of wound 
diphtheria, diphtheria of the upper larynx and scarlet 
fever and finally, but not last, hepatitis epidemica and 
war nephritis. These last two diseases give us special 
problems to solve. They are also vital problems of the 
moment* It is the merit of Lt. Col. (MC.) Prof. GUTZEIT 
that he furthered Successfully research work in the field of the etiology of hepatitis epidemics. The hygienists have 
prepared directions, based on their special experiences, to 
which was added as an important document, the Atlas of Epi- 
demiology by ZEISS. A new series of charts of this atlas deals, 
among^other diseases, with paratyphoid A in Europe, with the 
distribution of the various mosquitos important for us, leish- 
maniasis, as well as leprosy in the South East. The next 
series of charts will deal with the Northern part of the Medi- 
terranean, Let me conclude with the enumeration of the special 
fields represented at the last meeting: you will find all the 
details in the report which you will receive through your office 
one of these days. 
We regret to announce this time too the death of comrades 
from the circle of the consulting specialists, gone from our 
midst since the last conference. On 22 December 1942 Lt. Col. 
(MC.) Airforce,Prof, Dr, MAGNUS died. Only shortly before he 
had attended our last meeting. 
On 19 December 1942 Oberstabsarzt (Major, MC.) Prof, Dr. 
WUELLENWEBER died, consulting internist for Wehrkreis (Army 
District) VI and on 10 May 1943 Oberstabsarzt (Major, MC.) 
Dr. GABE, consulting tuberculosis specialist for Wehrkreis 
(Army District) XII left us. Dr. GABE fell a victim to the 
disease, the fighting of which was the task of his life. Men 
of high merit in war and peace, who have all these years been 
valuable advisors to the medical service thus have left us. 
remember them as models of the most faithful performance 
of duty, together with those of many German medical officers 
of all ranks who during this war gave their lives in their 
profession for the liberty of the Reich, 
I ask you to rise from your seats in honor of these 
comrades. 
During the present meeting not only questions of pre- 
vent ion and first aid shall be the subject of discussions 
but also in the fields of surgery and restorative surgery. 
In the other fields late treatment will be discussed. For 
the present, questions of delayed treatment to be especially 
discussed, are: reamputation and stump treatment, mobilizat- 
ion of the joints, exercise treatment and sport for the 
wounded. 
During the last year a large scale use of sulfonamides 
against gas gangrene was carried through on all fronts. As 
was to be expected opinions about their general use and 
their value vary. I hope that during this meeting a further 
clarification of opinions may be reached by the discussion 
on sulfonamides. 
The ophthalmological specialists will deal with import- 
ant questions concerning injuries to the eyes. Prof. DIE- 
TER has developed a giant magnet for use in the field which 
is considered everywhere as a welcome advance. Protective 
glasses for protection against fragments have also been con- 
structed by him and a magnetic extraction device for the re- 
moval of splinters and bullets. You will have the opportunity 
to inspect these devices during this meeting. A special section has been devoted to vaccination serums 
in cooperation with different specialist branches. In the 
meantime protective immunization against diphtheria has been 
introduced. T*re have now to wait for the results. Our vac- 
cinatioii serums against typhoid, paratyphoid and spotted 
fever have been successful in every respect. Our aim must 
be to decrease the number of injections. Tests made in this 
connection with a tetravaccine, which besides typhoid and 
paratyphoid A and B shall also protect against cholera, have 
been successful. 
In discussing our working program I only choose a few 
points; others are not less important; when our directions 
will b© anounced on the 3rd day everyone will receive in- 
formation about them. 
I still want to say something about the general tasks 
of the consulting specialists. Their active service and 
their work have proven excellent. The longer the war lasts 
the more important the work of the consulting physicians 
becomes, especially as regards the education and training of 
our young physicians. Whenever and whereever it is possible 
medical training must be carried out and the advisors have 
to be the mental center of meddcal scientific teaching in all 
army districts and in the occupied zones as well as in the 
home country. 
I to thank you today, gentlemen, with all my 
heart for the faithful and hard work you are doing in these 
difficult times. We have to perform a medical mission and 
sustain a medical tradition. The work thus done for the 
Fuehrer and the nation can await the judgement of history 
without any presumption. The succes achieved during four 
long years of war speakes for itself when objectively and 
fairly judged. There never was nor will be any such phrases 
as "too much” among physicians and there shall now be no 
rest in the efforts for further perfection. 
Our third conference which I open herewith and to which 
I wish complete success, shall also be guided by these 
principles. 8 
I. 
PROCEEDINGS OF THE CONSULTANTS1 
COMMITTEE ON OPHTHALMOLOGY 
Translation prepared by; 
Office of Military Government for Germany (U. S* ) 
Office of Naval Advisor 
Medical Section 1*. Primary treatment of Injuries of the eyeball, 
StaMarzt (Captain. MG.) Prof, HANS KARL MUELLER 
Tho establishment of large eye departments in the field 
has proven excellent. The distribution of work among the 
ophthalmologists, the nurses and the medical corpsmen, as well 
as the use of devices for the examination of the eye and the 
surgical instruments, may be made in such a way that the care 
for the wounded, even for large numbers of them, may run 
smoothly. 
The fate of injured eyes depends largely on the follow- 
ing factors: 
1* Amount of damage to the eye caused by the injury; 
2. Size and density of the hemorrhage within the eye; 
3# Find and extent of the inflammation within the eye; 
4, Kind and nature of scar formation in the eye; 
5. Date of starting as well as suitable choice and 
execution of the treatment. 
In order to avoid secondary hemorrhage the putting at 
rest of the eyes (high-percentage atropin oi itment, long ban- 
daging of both eyes, bed rest with administration of sedatives 
(luminal) and analgesics, light diet) intravenous injections 
of Clauden, Calcium and Redoxon are necessary. The absorption 
of the hemorrhage may be furthered by potassium iodide, heat, 
diaphoresis, dionin, puncture of the anterior chamber and in- 
jections of saline. The infection of wounds can be fought 
with 25 per cent marfanil-prontalbin salve, pyrifer and by 
large doses of sulfonamides, as well as by atophanyl and 
cyclotropin. The wounded must not be moved too early. 
For the treatment of injuries to the lid, even when the 
wounds were soiled, early covering of the defects by curved 
plastics of IMRE or by the methods of BUROW and KNAPP, has 
been successful. 
Only if the purulent discharge into the wound area is 
to be expected from a sinus or the nasal cavity itself should 
early plastic closure not be used. In certain cases a cover- 
ing of injuries to the tunica conjunctiva after removal of an 
eye can be made successfully with conjunctiva tunica from 
corpses. 
If large parts of the cornea are missing, injuries to 
the cornea have a very bad prognosis. Corneal suture and 
conjunctiva tunica covering are often not able to prevent 
the loss of an eye. In these cases only the replacement of 
the lost tissue by cornea removed from corpses may improve 
the chances of a cure. A total keratoplasty was made four 
times. In two of these cases the eyes were in relatively 
good condition after 4 months. On several occasions the 
corneal defect was closed by partial keratoplasty and in some 
cases a closing of the wound was accomplished by this. iHjuries °f the cerium can be closed by operation, onlv 
V1® within the eye is clear regarding diagnostic 
ana therapeutic conditions# One must be sure, whether the 
Injury to the corium was caused by an intra-ocular particle, 
a shot through the eyeball, a ricochetting shot, a grazing 
shot, an injury^similar to a cut, or by a blunt force. One 
will always decide upon closing the corium wound only if one 
is convinced that by this, the danger of infection is les sened 
the density^of the aqueous tumor is restored quickly and scar 
formation will be influenced favorably. 
The success of corium suture depends largely on the 
surgical technique. The principle of the technique must be 
to expose the corium wound widely and to close it accurately, 
preserving as much as possible of the eyeball. This principle 
can only be realized with corium wounds of the rear bulbus 
section by bending back the lids to the sides, by canthotomy 
and incisions into the orbital rim. Before removing prolapsed 
parts of the Inside of the eyes it is favorable to use Glau- 
cosan in order to avoid renewed hemorrhages. One should also 
be sparing with the removal of prolapsed tissue in order to 
avoid unnecessary shrinking processes. If, however, the pro- 
lapsed tissue is already purulently infected it is better to 
remove too much than too little. One should not open up very 
large corium wounds to their whole extent, but should close 
them gradually to avoid a renewed prolapse of parts of the in- 
side of the eye. If possible one encloses the corium wound 
with a ring of diathermy coagulations to widen the scar in 
the choroid and in the retina. Well proven in this connection 
of electrolysis instruments of SZILY and MACHEMMEB, 
which is very handy and only requires an anode battery as a 
source of current. 
If the eyeball is shot through one should take care 
first of the wound where the bullet entered and afterwards 
of the one where it left. The size of the former and the • 
size of the particle in the X»ray picture, as well as the 
seriousness of the injury within the eye give indications 
concerning the necessity of operating the wound at the site 
of exit. One has to consider that the wound of exit is 
all’ays larger than the wound of entry. The corium suture 
for shots grazing the eyebal1 is -of greatest importance, be- 
cause these are often accompanied by large injuries of the 
corium, but without any serious injury to the inside of the 
eye. If it is a question of preserving the only remaining 
eye one will undertake a suture of the corium even with very 
large wounds. 
For the treatment of eye casualties by the non-specialist, 
attention should be paid to the directions given to the ad- 
vanced medical establishments in appendix 2 (H. Dv.) Army 
Manual 1 a on page 105 and 106. It is stated there with 
perfect justification that all serious and doubtful injuries 
to the eyes should be handed over to the specialist if possible 
within 12 hours at the latest. On many sections of the 
Eastern front, however, this cannot be achieved. It is there- 
fore proposed, if a large number of wounded are to be ex- 
pected, to employ groups of ophthalmologists, similar to 
those of surgeon groups, near the front, consisting of an 
ophthalmologist, a nurse and a medical corpsman. The equip- 
ment of this group should contain a specialist's case of instruments and the giant field magnet of DIETER, The best 
way of securing their services is through the army group 
from a medical institution which has at its disposal X-ray 
equipment and personnel to reinforce the ophthalmologist 
group* 
Experience £lso showed that frequently the operative 
treatment of the eyes by non-specialists does not improve 
the chances of a cure but rather diminishes them. It is 
therefore proposed to supplement the directions for treat- 
ment in this way that the non-specialist should generally 
abstain from surgical operations on the eye, if it is prob- 
able that the treatment' may be taken bver by a specialist 
within a period of 3 or 4 days. Until then the non-special- 
ist has to maintain the quiet position of the inner and outer 
eye muscles through binocular bandage and atropin ointment 
and duting the daily change of bandages to rub in disinfect- 
ing ointment as well as to administer large doses of sulfon- 
amides. 
The non-specialist should only carry out the surgical 
operations recommended in the directions for treatment if 
there is no chance of an eye specialist’s taking the treat- 
ment over within 3 or 4 days, when this is the case the 
operations have to be performed as soon as possible. Shatter- 
ed eyes should only be removed by the non-specialist if it 
is improbable that within the first 8 days after the injury 
an ophthalmologist can take over the treatment. 
Discussion: 
LOBECK: Army physicians should only bring the eyes to 
a resting position; no ointment should be applied if there 
are perforation injuries (layers of fat on the cornea make 
the examination more difficult; fat on the lids and in the 
conjunctiva increases the difficulties of an operation, oint- 
ment is not sterile). Early transfer to the eye department, 
even if the injury happened more than 48 hours before is 
urgently recommended. For after-treatment milk injections 
and albucid have been successful, 
DIETER: Warns earnestly against dabbling surgical 
operations. No doubt the advice of KLEIBER has been the 
only "correct attitude”, no trying to perform a surgical 
operation - to undertake an operation one has not mastered, 
cannot be condemned strongly enough. It is a crime committed 
against our wouhdedl 
REICHLING: In my opinion the operative care of injured 
eyes, including the restoration of the lids, in the orbital 
area, and anucleation, has to remain in the hands of the 
well-trained eye Burgeon exclusively and from the very be- 
ginning. This is advisable first, because for the decision 
to operate in cases presenting diagnostic problems only the 
eye surgeon is qualified to give an opinion based on strictly 
relevant findings; secondly, because perfect familiarity 
with the technique of eye operations is reouired. The cases 
in which- operators, well-trained in other fields, for instance 
surgeons,also master the necessary experience and technique for minor eye operations can naturally be only exceptional, 
for these, however, no positive instructions can be estab- 
lished. It is understood that through establishing directions, 
which forbid the care of injured eyes to non-specialists, in 
some cases damage may be caused even as great as the total 
loss of an eye by a delay of treatment. However, I do not 
believe that such damages as a whole, will even in the least 
equal the damage resulting from badly done operations by 
non-specialists. Everyone with experience knows of such ex- 
amples. Directions will not accomplish the purpose. Much 
more^profitable under certain circumstances will be a friend- 
ly discussion with surgeons of other special branches, espec- 
ially on the occasion of training courses. 
KAISER; The operative closing of cerium injuries is 
possible even days afterwards with good functional result. 
The corium wound is in some cases closed temporarily by the 
chemotic conjunctiva, which can prevent infection of the 
eyes for the time being. 
IVEN: During the winter 1941/42 several perforation in- 
juries with large iris prolapses, even as old as 14 days, were 
seen. The eyes were completely free from irritation. The 
prolapses were merely removed with the cautery close to the 
rim of the cornea without opening the anterior chamber. This 
procedure was arrived at as the result of experience made in 
a similar case, where by pulling forward the iris, opening 
of the anterior chamber and covering of the conjunctiva tunica 
the only remaining eye was lost through an infection from the 
surrounding area. During a period of observation of 14 days 
the eyes remained free from irritation through parenteral 
treatment. The removal of the anterior synechia was put off 
until a later period. 
HARMS; On principle one cannot prohibit a surgeon from 
operating on the eye, as unfavorable conditions may force him 
to do so. Fpr these exceptional cases one has to give him 
strict instructions. 
JESS; Warns against too great activity while trying to 
save injured eyes by extensive operations, of which, as known 
by general experience, one cannot expect that they will ever 
regain useful functions. The experience of the last war showed 
that very many of such skrinking eyes finally had to be removed* 
Nevertheless it seems only fair to point out the danger of 
sympathetic ophthalmia which may occur in such cases. 
HEINSIUS: 1. The experiences of H. K. MUELLER regarding 
treatment of lid injuries by early plastics are confirmed. 
The possibility of using THIERSCH*s graft is pointed out. 
Sulfonamide treatment is only effective as long as it is;con- 
tinued, because the sulfonamides are eliminated comparatively 
soon. 
2. As shown by experience many ophthalmologists lack 
sufficient surgical knowledge. It is therefore proposed if 
possible to designate the special branch departments of the 
field hospitals as surgical and non-surgical special depart- 
ments • 3. The value of the direction for troop physicians 
and medical personnel given by the Navy have proven useful 
in cases where an early transportation to the eye hospital 
is possible. Bandaging of both eyes and transport in a 
reclining position seem important. 
SCHMIDT: If no irritation exists the front medical 
units should abstain from the first care of perforation in- 
juries (operative) when the circumstances are unsuitable. 
As shown by my own experiences of the winter 1941/42 it is 
advisable to connect the opthalmological group with a central- 
ly situated collecting station for wounded men, as there is 
also the opportunity for observation of all cases of eye in- 
juries passing through before they are transported farther 
to the rear. 
KLEIBER; Fvcn simple eye operations, if urgent, may 
be made by a surgeon only if he is instructed accordingly. 
Especially in mobile warfare transportation is often so dif- 
ficult and extensive that the initial surgical care of the 
eyes cannot be the final one. As far as could be seen ex- 
perience with marfanil-ointment and marfanil powder was en- 
couraging. Bandaging of both eyes is important for the trans- 
port of men ■'-hose eyes have been injured, also it is advisable 
to change the bandaging during a transport lasting several 
days. 
DIETER; Plexiglas is well tolerated by the body and will 
heal in without reactions. Observations during September 
1939 stimulated the use of plexiglas for plastic replacement 
of the bony orbital rims, lately also foreclosing ofr the 
orbit "against the upper jaw cavity (periosteal sutures should 
be used for fixation of the inserted glass). 
days. 
2. Wounds in the eve due to magnetic particles and their 
treatment* 
Oberstabsarzt (Major* MC.) Prof* DIETER 
Starting from the fact that every injury to the eye eight 
cause loss of sight, the principle must be laid down; 
The sooner the treatment of the presumably injured eye 
is started, the more favorable are the prospects, and the 
sooner can the danger.be removed. 
The first treatment should be the final one if possible. 
The medical officer in the field cannot and need not 
ascertain the facts or even make a diagnosis. These tasks 
rest with the specialist only; he also is fully responsible 
for the measures to be taken. 
He can perform a proper examination only with the approp- 
riate instrumentarium. For this purpose there was developed 
a first-rate side illumination which will be exhibited in the 
form of a hand slit lamp of new design. Ophthalmoscopy is indispensable and can be performed 
in cases of recent in.iuries even better than in such of ad- 
vanced cloudiness of the refracting media (e.g. traumatic 
cataract. The value of the subjective methods of examinat- 
ion for a diagnosis of the v/hole case must not be under- 
estimated.) 
The X-ray picture (fluoroscbpy is not sufficient) is 
the most Important method for finding a foreign body in 
the eye or its vicinity after ascertaining by preliminary 
exam"*nation, whether a perforation of the eye exists. 
(Perforated, injured eyes containing foreign bodies 
inside or in the coats of the eyeball are more in danger than 
perforated, injured eyes containing no foreign bodies.) 
The earlier a foreign bodv can be removed the better. 
(In general, magnetic foreign bodies can be removed 
much more easily than non-magnetic material. Only an adroit- 
ly performed removal of the foreign body can preserve the 
eye and prevent all kinds of avoidable delayed damages.) 
This involves further diagnostic and therapeutic ob- 
ligations. 
The exact localization of a foreign body is the most 
urgent task. 
C0MBEBGfs method is recommended for exclusive applicat- 
ion as the best, the most reliable, and the most simple. 
Every special department should have as standard equip- 
ment two COMBERG bowls with accessories and the medical 
depots of the army should be able to furnish spare parts. 
(Supplementary methods for ascertaining the presence of 
invisible foreign bodies, like skeleton-free photos of the 
frontal section of the bulbus oculi, double photos of the 
moving eye and others, are used less in cases of war injuries 
than in peace times.) 
Stereo-X-ray pictures are especially important for the 
so frequently occurring scattering of particles and for dif- 
ferentiation of one or several particles in the eyeball. 
A distinction between magnetizable splinters and non- 
magnetizable ones is accomplished 
1. through a test by magnet, 
2. with aid of the sideroscope. 
The examination by the magnetic needle answers at the 
same time the question, whether the foreign body itself can 
be removed by an electromagnet. 
The great importance of these examination methods led 
to a new construction of highest sensitivity, the fields 
sideroscope, which will be demonstrated and proposed for 
adoption. The device is stable, transportable and can be 
employed at the front. A magnetic particle* exactly located and ascertained 
in the inside of the eye, must then be extracted without 
delay* (This is to be done for confirming the indication 
for an operation and for fixing the time for its performance.) 
The antibacteriological preparation of a presumably 
perforated, injured eye begins as a matter of principle with 
the first examination in order to make an operative treat- 
ment possible without loss of time* 
The chief supposition for operative measures is the 
availability of an electromagnet* Generally, a very power- 
ful giant magnet of highest efficiency is necessary* For 
that reason auxiliary giant magnets, some of which are quite 
efficient, were constructed during the first World War and 
also lately in the present one* 
The often expressed and generally acknowledged demand . 
led to another new construction which has been introduced 
as the field giant magnet* This device is independent of 
outside sources of current and other auxiliary installations 
(connection with electric battery). It is suspended in a 
way which permits the combination of a very powerful giant 
magnet with a hand magnet easy to handle and controllable 
power of traction so that injuries to the interior organs 
of the eye can be avoided. 
Cutting instruments of non-magnetizable material can 
now be produced; they will be exhibited. 
The extraction of magnetic foreign bodies from the 
frontal bulbus section is made in the usual manner. There 
are hardly any differences of opinion about the most gentle 
and therefore most suitable method. Extractions from the 
deepest layers of the corner producing the danger of a 
draining of the aqueous hum# of the eye, are carried out 
in miosis, as are many extractions from the anterior chamber 
and the frontal surface of tjie iris; otherwise when this 
is impractical in maximum mydriasis. 
We prefer the supine posture during the performance 
of a magnet operation. Thq field giant magnet, however, 
can be used with every oth# posture of the body. 
The extraction through the wound* under certain cir- 
cumstances, therefore diascleral by penetration of the corium, 
It absolutely indicated in cases of fresh injuries with a 
wound still open to some extent, in other words within 
about 8 days* The ciliary region must be treated with 
the utmost consideration, especially if it should be nec- 
essary under any circumstances to enlarge the perforation 
wound* 
The extra-ocular with the giant magnet, e.g. 
the drawing forward of the foreign body, particularly from 
the posterior section of the bulbus through the posterior 
chamber and pupil into the anterior chamber, and extraction 
from there, is In many cases of injuries by foreign bodies 
the most simple, the most gentle, and for that reason the 
method promising the best final results* Only if it is not p,osslble to remove the particle thus in a short time i.e. 
few days and after.repeated attempts, there may be 
a.j^ti^Ca^ion or even necessity for a diascleral removal 
of the foreign body. After previous exact localization, it 
by a tfieridianal incision, if possible 
without insertion of tne pole points into the vitreous body, 
or indirectly by making a meridianal or flap incision through 
t .e outer layers of the sclera using Mendoza sutures before the 
sclera is completely severed, and putting the magnet on the 
edges or the vound, or in cases of extreme urgency and after 
ail^other possibilities have been exhausted by entering the 
insiae of the eye nearest to the foreign body. This latter 
method is to be preferred if the particle can be kept under 
observation. 
.A newly designed hand-magnet is especially suited for many 
diascleral extractions, otherwise it is used for the extract- 
ions of particles lodged in the brain. To -prevent detachment 
of the retina, in all cases of diascleral extractions, dia- 
thermic scarification is to be performed though it is not 
a certain protection against the occurrence of this very 
serious later development. Other objections to a more fre- 
quent use of diascleral extractions are hemorrhages, loss or 
cloudiness of the vitreous body, even though the arteriae 
ciliares longae, the region of the vortex veins etc. are.pro- 
tected and the incision is placed more often between ora 
serrata and aeqiiator bulbi. 
Small particles may frequently remain in the depth of the 
orbit, while larger ones are to be extracted, best from the 
front, as soon as possible. KROENLEIN’s operation is rarely 
necessary. Secondary injuries are only avoided by early 
extractions. >♦ ■ h - 
■ . i 
Discussion: 
LOEHLEIN: Mr. DIETER deserves our special gratitude 
for the construction of the new field giant magnet, which 
is now available in large numbers and delivered to the eye 
departments of the field hospitals. Many eves will be saved 
through its use. DIETER’s eye protector, made of artificial 
glass, also seems to be very useful in the protection against 
splinters from mines. Regarding iron splinters, I would like 
to call the attention of eye physicians in field- and home 
hospitals to the fact that very often two and even three 
magnetic particles are located in the same eye which means 
that the hospital providing the later treatments, has the 
duty in every case of particles lodged in the eye, even if 
already one or two particles have been extracted, to ascert- 
ain by careful X-ray examination and repeated trials with 
the giant magnet, whether a particle still remains in the * 
eye. On the other hand, there are sometimes older cases in 
which iron particles are firmly embedded intraocularly and 
which have not yet caused siderosis and on which one would 
hesitate to make repeated attempts at extraction especially 
when the eye in question is the only one left and under 
certain circumstances, one may cause by 
tempts through destruction, e.g. destruction of the ciliarly 
body, than one gains by them. 17 
-k in.,, the eye caused by non-magnetic particle Pnd 
their treatment. 
Professor JESS 
Attempts to remove non-magnetic particles from the eye. 
i'hen infection has laready set ih, are dangerous and in case 
or obscured observation are frequently unsuccessful. In 
cases of this kind, one should be content with the care of 
the wound^and energetic general (sulfonamide) treatment and 
local antisepsis. In case of non-magnetic particles without 
infection of the eye, the composition of the particle should, 
ii possible, be ascertained. For this purpose anamnesis, 
negative sideroscope findings and magnet tests, the appearance 
of the and the kind and density of the X-ray shadow, 
microscopic and chemical examination of similar particles 
from the vicinity of the eye and the conjunctiva, and the re- 
action of the tissue upon these particles may be of help. 
The behavior of fragments composed of copper, brass and bronze, 
lead aluminum and its alloys, stones, vegetable and tissue 
matter, glass, china and organic materials, of gunpowder and 
chemicals will be discussed in every detail especially with 
regard to their tolercance. Auxiliary means, such as the 
telephone tweezers by WEVE, which have not found favor, the 
metal finder by COMBERG and the LEYDHECKER forceps which 
have not been sufficiently tested yet, as well as the X-ray 
screen method, which seems to be very complicated, will be 
shown in pictures. The great difficulty experienced in oper- 
ating on eyes with non-magnetic foreign bodies lodged in them 
justifies the demand that such cases should be sent only to 
specially equipped clinics which are in charge of highly 
skilled surgeons, and that in each case the chances of con- 
servative treatment are to be considered carefully. 
Discussion: 
KYRIELEIS: The good toleration of Plexiglass in cases 
of injuries to the ocular conjunctiva and even the bulbus 
itself is pointed out. Therefore no attempts at a removal 
of such particles should be made, especially with inadequate 
means. 
LOEHLEIN: We also have made the experience that many 
injuries caused by non-magnetic particles do heal in without 
complications. This applies especially to many alloys of 
copper which we dreaded largely for theoretical reasons. 
As the removal is frequently attended with a considerable 
amount of danger to the eye, we often tried to avoid it, 
particularly if the particle is healing in without reaction. 
As regards the method of my assistant TERTSCH, which con- 
sists in carrying out the extraction with simultaneous ob- 
servations in two X-ray screens, I employed it successfully 
in some cases; it is, however, not simple, because the 
operator, on account of the strength of the X-rays, is 
obliged to act quickly which is often at variance with the 
situation. ±jt Wounds in.the eyelids and tear duct*. 
Professor CLAUSEN 
The spsaker pointed out first the serious disfiguration 
injuries to the lids, the removal 
of i nich has to be made, not only for cosmetic reasons but 
because frequently the wearing of a prosthesis is made possible 
only by revision* or the visual power of a still intact eye- 
ball may thus be protected against impairment. 
The sneaker underlined furthermore the importance of 
a primary care of the wound which must aim at preserving 
damaged tissue and restoring displaced tissue to its original 
position* where it must be fastened with some appropriate 
approximation sutures, Thus one may succeed sometimes in 
avoiding later plastic bpefations If this is 
impossible* a subsequent disfigurement may, under certain cir- 
cumstances* be removed by simple plastic operations. 
Then there followed a discussion in detail of those 
plastic operations which have proved successful in the re- 
moval of traumatic lid coloboma* lid scars adhering to bones 
with extropion, and for a total replacement of lower and 
upper lid, in which connection free flap plastics and plastics 
with pedunculated skin flaps were especially mentioned. 
The replacement of the eyebrow arch by grafting on a 
pedunculated flap from the eyebrow of the other side is also 
briefly mentioned. 
Finally a possible restoration of the canaliculus, as 
also the importance of a complete removal of remnants of the 
lacrimal sac which sometimes may cause a very disagreeable 
suppuration, was mentioned. 
Discussion: 
DIETER: Injuries of the lid urgently require the most 
considerate restorative care/ Wire-plate sutures put fairly 
deep into sound parts (Ij- to 2 centimeters)' answered well* 
especially with adapted skin sutures put in between. Thus 
extensive plastics after operations are in most cases auite 
superfluous. (Demonstration)* 
5. Transportation of eve casualties• 
Oberstabsarzt (Major. MC.) KAISER 
On account of their close relation in connection with 
the subject of ’’transportation of eye casualties” questions 
of transportation in general and the organization of the 
medical eye branch in the army must be dealt with. The fate 
of the injured eye depends in the first Place upon a quickly 
performed operative closing of the wouhd, which is in this 
case of much greater importance than in case of injuries to 
any other organ. Therefore the operative treatment of the 
eye must begin with the least possible loss of time in a hospital near the front whose eye department is adequately 
equipped with instruments, including a giant magnet, and 
which is in charge of a specialist well experienced in surgery* 
ine treatment is to be accomplished best within the first 24 
i'he transport of eye casualties is also to be undertaken 
with tie aid of the medical air service. The physician in the 
liela ias to bring the injured eye into a quiet position by 
means of a bandage over both eyes, if possible, and to state 
the urgency of transport on the accompanying paper. The ad- 
vanced eye ward must be available to several divisions, it 
must be attached to an army field hospital and should be 
sufficiently large to take care of operated eye casualties 
on its premises until they are fit for transport. In case 
of being overcrowded with eye casualties the personnel can be 
reinforced by personnel reserves of the medical service of 
an army group or the army itself. 
During September 1942, out of 100 eye injuries at the 
eye ward in Warsaw, 36 arrived from the front in the base 
hospital without having been taken care of previously. The 
medical care of eye casualties at the front has improved. 
The uncared for eye injuries reached the eye ward in Warsaw 
on an average of 7*7 days, the cared for eye cases on an 
average of 16.6 days: for 1/3 to 1/4 of the cases wartime 
surgical operations were still necessary. Of these operat- 
ions, 56 consisted in the removal by surgery of those eyes 
which had become worse during the interval between the in- 
jury and the arrival at the base hospital. Eye casualties 
of April and May 1943 reached the first medical station for 
eye-injured on an average within 38 hours. Some of the eye 
wards of field hospitals are not yet sufficiently equipped 
with instruments. 
Eye operations, especially a removal of eyes by surgery, 
are not to be performed by non-specialists, a removal of both 
eyes should never be undertaken by a non-specialirt. 
If eye injuries occur simultaneously with injuries to 
other parts of the body, the care of the eye injury has ab- 
solute precedence over all other injuries provided that they 
do not endanger life immediately. For better supply of more 
complicated spectacle glasses, field optician shops are to be 
attached to the larger wards in the war area* Skilled op- 
ticians are to be drafted and assigned to the medical array 
service, they are the best aid of the army ophthalmologist. 
The introduction of a trasport paper is proposed which 
shall be used in a similar way as the accompanying paper of 
the wounded, for the purpose of distinguishing wounded and 
sick and secure special care for them during transportation, 
on the way from the field hospital to the base hospital. Im- 
portance of hospitals attached to the base hospital. The 
extensive work, with regard to medical care of the eyes, could 
only be accomplished by establishing a larger eye department 
equipped with good instruments, especially with the giant 
magnet and by employing several eye specialists. 62 per cent 
of the ward patients and 78.5 per cent of the ambulatory 
new patients of all 4 eye wards of reserve hospital Group B 
could be treated by the eye department in Warsaw alone. A largrr eye department permits a saving of personnel and 
material in the area behind the front as well as in the 
sector of a base hospital and in the homeland and also yields 
greater practical success. In spite of this, for purposes 
of transport, the possibility of ambulatory medical eye ex- 
amination in areas of larger troop concentrations must be 
taken into consideration. 
In order to master this wide field with its many sided 
tasks the eve physician is to be entrusted exclusively with 
the medical care of the eyes. 
Discussion: 
IVEN; The employment of eye physicians in war hospitals 
is very frequently ouite inadequate. As regards the employ- 
ment of additional physicians to meet an unusually large in- 
crease of casualties the necessity for establishing special 
departments for eyes, throat, nose and ears is sometimes not 
sufficiently understood, as the specialists are employed in 
some other capacity. Particular consideration has to be given 
to the necessary care in war hospitals which i s in most cases 
the first one by specialists, and not to questions of further 
transport. 
6. Wounds In the orbit. 
Oberstabsarzt (Major, MC.) Prof. KYRIELEIS 
Apart from the fact that the contents of the orbital 
cavity itself are very valuable, the importance of injuries 
of the orbital cavity is especially determined by the close 
local connections of the orbit with the accessory sinuses of 
the nose and the skull. Of the direct injuries to the orbital 
cavity the most important ones are those caused by small flat 
foreign bodies as well as injuries caused by stabs or by pen- 
etration of pointed objects. Both may, besides injuries of 
the bulbus, cause damage in the depth of the orbit Itself 
(tearing off muscles and nerves, hemorrhage etc.). Besides 
this, there is the danger of a primary infection of the con- 
tents of the orbital cavity through soiled foreign bodies. 
As a rule, small flat missiles and particles of missiles 
will destroy the eyeball itself or at least damage it more 
or less severely through contusion. If they penetrate farther 
through the orbital cavity there is the danger of accompanying 
injuries to the accessory sinuses, the cavity of the skull 
or of both. The opening of the accessory sinuses of the nose 
alone means danger of secondary infection of these never 
aseptic sinuses (orb?tal abscess and phlegmons). If accessory 
sinuses and the cavity of the skull are opened simultaneously, 
suppuration, developing in the orbita, may spread to the brain 
and its membranes* Thus an acute danger to life is created. Injuries due to penetration of pointed objects and stab 
wounds need not necessarily damage the eyeball itself# The 
bulbus, imbedded elastically in the fat and soft parts of the 
orbital cavity can evade to a certain degree the less sudden 
penetration of the point. The danger of a primary infection 
of the contents of the orbital cavity is considerably greater, 
as the penetrating foreign body (stabbing weapons, points of 
wood, or metal) is freouently not free from solid matter, as are 
practically the usually sterile, hot particles of shells or 
missiles of infantry weapons. The penetrating force of even 
comparatively blunt objects is often surprising. Under certain 
circumstances they may penetrate as far as the inside of the 
culvariura or the other orbital cavity. On the other hand change 
at the site of entrance may be surprisingly small, as the skin 
wounds and especially the wounds in the conjunctiva are able 
to close to a !»arge extent, owing to the elasticity of the 
tissue, and very often lead to an entirely wrong conception 
of the caliber of the penetrating foreign body. 
The orbital cavities may be affected indirectly by 
fractures of the skull bhse and thr facial parts of the skull, 
especially in cases of injuries by gunshots. 
If the line of fracture at the base affects the apex of 
the orbit, there is a possibility that in the course of several 
days, blood in the perimysium of the abducens may penetrate 
under the conjunctiva or through the loose orbital tissue in 
the subcutaneous connective tissue of the lids (late spectacle- 
shaped hematoma). If such a hematoma develops within a few 
hours after an injury to the skull by gunshot without showing 
any visible signs of force in the neighborhood of the eye it- 
self, this is practically a sign that the roof of the orbital 
cavity has been split to a large extent by the explosive effect 
of the shot, or by the counter shock (contrecoup). In this case 
it is almost certain that the ethmoid bone or the frontal sinus 
roof too has been broken and therefore an infection of the in- 
side of the skull from the accessory sinuses is threatening. 
Prompt action by the surgeon will be necessary in most cases 
to avoid complications endangering life. 
Fractures of the facial parts of the skull may lead to a 
breaking through of the orbital wall, especially of its bottom, 
from the outside, and as a result of this to a traumatic en- 
onhthalmos. If in such cases the eye itself is affected by 
the force, considerable shifting (luxation) of the bulbus may 
result, Hiich in some cases was even found in Its entirety, 
preserved in its shape, in the maxillary sinus during autopsy. 
As a rule, on account of the commonly associated seconders 
injuries, the treatment of injuries of the orbital cavity will 
have to be undertaken the assistance of a surgeon or by 
him alone. However, the eye physician will frequently play an 
important part as advisor, when it must be decided, whether an 
eye, hindering the rational care e.g. of an injury of the brawn, 
must be or whether it may be sacrificed as very_ 
probably being without value anyhow, on account of severe intra- 
ocular changes visible with the ophthalmoscope, or when there 
are sure signs of a tearing of the optic nerve. 
(Appeared in the "Archiv fuer Ophthalmologie” Volume 144 
(1941), 198 p. 23). jLc Papillary congestion caused by gunshot wounds of the brain• 
Oberstabsarzt (Major. MC.) Prof. KYRIELEIS 
Causes for increasing brain pressure in connection with 
injuries to the skull by gunshot are; hemorrhage, post-traum- 
atic edema, post-traumatic swelling of the brain, increased 
secretion of spinal fluid and impediments to the secretion of 
spinal fluid. 
i ’ 'hether an increase of brain pressure in the rear area 
of the eye, for one or several of these reasons, finds a vis- 
ible expression (congestion papilla, brain-pressure papilla) 
will depend essentially on the fact, whether the bone gap in 
the skull is open or blocked by bone fragments etc., as well 
as, whether the dura has been opened too or has remained in- 
tact. 
Papillary congestion is most likely to develop if a bone 
gap is blocked, the dura is intact, but also very frequently 
if the dura has been opened while the bone gap is blocked, 
only rarely will it happen with open bone gap and dura. 
The average degree of prominence will decrease in the same 
order. 
Hemorrhages, causing increasing brain pressure, appear 
as a rule immediately after an injury. Papillary congestion 
caused by them appearing within the first 24 to 36 hours, is 
an urgent indication for surgical treatment. 
During the first week post-traumatic edema and swelling 
of the brain do develop and later on decrease gradually. In- 
fectious influences do not play an important part during this 
time (aseptic brain pressure phase)# The pressure of the 
cerebro-spinal fluid, is increased by increased secretion and 
is counteracted by an unlimited spreading of the edema, but 
contributes, however, to the general increase of brain pressure. 
After the first week inflammatory influences become more im- 
portant, as causes of developing brain pressure. 
Congested papillas, appearing after the end of the first 
v-eek as a result of the stated symptoms, are no indications 
for an ©Deration, which at that time is only determined by 
general local findings. 
Remaining symptoms of congestion beyond the third week 
or reappearance of an already decreased papillary congestion 
are sure signs of a complication, in most cases of an abscess 
and will require renewed surgical treatment. 
(Has been published in the "Archiv fuer Ophthalmologie"). 
The preceding group of lectures in connection with re- 
marks made during the discussion suggested the following: Directions for the treatment and transport of eye 
casualties. 
An early expert care of the wound is of decisive import- 
ance for the fate of injured eyes* Their treatment is, on 
principle, to be undertaken by the ophthalmologist. For that 
reason, all wounded with eye injuries shall be transported as 
quickly and as carefully as possible to a well equipped eye 
department. 
In doing this, it is to be taken into consideration that 
a penetration of the eye injury is combined with injuries 
to other parts of the body, the injury to the eye takes ab- 
solute precedence with regard to operative care as long as there 
is no immediate endangering of life by other injuries. 
Prior to and during the transport a disinfectant atropin 
ointment (perhaps marfanil-prontalbin 25 per cent, atropin 3 
per cent) should be applied to the injured eye in order to se- 
cure a restful position of the inner and outer muscles of the 
eye and a bandage over both eyes should be made even in case 
of a one-sided injury. 
On the accompanying paper is to be stated explicitly: 
’’Eye injury. Quick, careful transport to the ophthalmologist.” 
Only if transportation conditions make it impossible to 
guarantee final expert treatment by a specialist within the 
first 3 days, does the temporary care remain in the hands of 
a non-specialist. To be considered is then the treatment of 
perforating injuries by of any existing prolapse, 
to be followed by a covering up of the conjunctiva of the 
wound to avoid a further loss of the contents of the eye and 
to prevent a secondary infection and besides, in case of in- 
juries to the lids the strictly conservative closure by suture 
of all preserved remnants of lid skin and the lid conjunctiva. 
Enucleation will be required, of him only rarely as there exists 
no sympathetic danger within 8 to 10 days. Only the specialist 
may decide about enucleation of an only remaining eye. 
Directions for the treatment of wounds hue to intraocular 
foreign bodies. 
A. Magnetic particles. 
Foreign bodies within the eye, determined by objective 
diagnosis and X-ray picture must be localized accurately 
(CROMBEHG method) and must then be extracted immediately if 
they are magneticles (magnet test); examination by sideitscope 
may be of additional value. 
The extraction is to be made with the field giant magnet; 
1. if possible through the wound, 
2* otherwise in frontal direction, from the anterior 
chamber after its opening by incision with a lancet, 3» diasclerally by meridianal incision only after re- 
newed localization and only if after repeated at- 
tempts, the Particle could not be drawn to the front; 
if necessary also by penetrating into the eye. 
These rules apply only to small particles (2 to 3 milli- 
meters) with smooth edges. 
If the anterior portion of the bulbus is not injured, 
larger fragments (more than 2 to 3 millimeters) are extracted 
diasclerally if possible, through the wound. If a widening 
of the round should be necessary, great care should be taken, 
as always, to avoid the ciliary region. 
Under certain conditions, smaller, older fragments very 
firmly healed in, are best left alone, especially if the 
operation would mean a more serious danger than siderosis 
(refer to physicians committee). 
In most cases small iron particles may remain in the 
orbita, larger ones are best extracted as soon as possible. 
The possible presence of several magnetic fragments has 
alwaj's to be kept in mind; Final control through X-ray pict- 
ure, also a final measure in the hospital at home. 
B, Non-magnetic single fragments. 
Single, non-magnetic fragments on the r. erf ace of the eye 
removed carefully after administering cocaine; the eye is 
covered with disinfecting ointment and baneaged. 
In case of numerous non-magnetic fragments spread over 
the eye (glass, sand, gunpowder etc,5 ths treatment consists 
in the beginning in rhe application of antiseptic ointment 
and bandage, later on open treatment. 
Non-magnetic fragments within the eye are only operated, 
on early by the ophthalmologist if they can be removed without 
difficulty from the anterior portion. If an infection has al- 
ready set in, a simultaneous drainage of the anterior chamber, 
covering of the conjunctiva, antiseptic local and general treat- 
ment is advisable. 
i 
Deeper lying non-magnetic fragments should for the time 
being remain in the eye, their removal should be left to the 
home hospital. In this case a diagnosis of the type of the 
splinter would have to be made followed by a decision, whether 
the operative removal of the fragment is to be tried in con- 
sideration of its type, its size and location, or whether it 
is justifiable to let the splinter remain in the eye. On ac- 
count of the difficulty of a decision and the difficulty of 
such an operation, injured men of this category should be 
transferred to certain hospitals adequately equipped. 
Regarding the transport, it is proposed to send a man 
injured in the eye along on the transport from a hospital to 
the base hospital with a transport paper, instead of an ac- 
companying paper attached to the patient’s hospital record; 
this transport paper is to giye personal data of the patient, 
the medical unit the patient is coming from, the kind of furthoi 
transport, the character of the eye injury, the necessary treat- 
ment during transport, and the destination of the transport. 25 
Besides these directions, the common experiences of 
the Present ophthalmologists from advanced hospitals led 
to the following proposal: 
Experiences on the Eastern front showed that, to the 
detriment of the patients, it is very often impossible, even 
with the best of intention, to transport them to the eye 
hospital quickly enough. This is the reason why every armjr 
physician should have at his disposal an emergency group of 
ophthalmologists (ophthalmologist with an assistant, two 
helpers, giant field magnet and set of operating instruments) 
which is attached to the field hospital department, and is 
employed in places with increased demand in connection with 
a field hospital equipped with X-ray apparatus. 
8* War blindness* 
Stabsarzt (Captain, MC.) LEHNERS 
Survey of the character of war blindness in its effects 
on body and soul. 
Survey of the causes of injuries and diseases leading 
to blindness, based on the experiences of 453 cases of the war 
blind collection hospital, Reserve Hospital # 132, in Berlin: 
A. Caused by enemy action: 
1. Pistol 0 - 0.0 96 
2. Carbine and M„G. bullets 74 - 16.2 06 
3. Shells of all kinds 160 « 35*1 96 
4. Mines of all kinds 108 = 24.0 9S 
5. Airplane bombs of all kinds 10 = 2.4 96 
6. Misc. (burial, uncertain causes) 3 = 0.7 96 
355 = 78.4 96 
B. Caused by accidents due to war; 
1. Accidental ignition of own ex- 
plosive charge and similar ac- 
cidents 24 
2. Careless handling of explosive 
charge and similar accidents 15 
3. Through crash (airplane, auto- 
mobile, etc.) 5 
4. Misc. (piece of wood, saw blade, 
hoof kick, nail, bolt) 6 
50 = 11.1 96 " 4C5» 89«5 °/6 „ „ . . 405 s 89.5 96 
C, Caused by diseases: 
1* Keratitis (in certain cases*late plastic 
operation 3 
2. Aphakia combined with: 
a. Amotio retina 2 
b. Iridocyclitis 1 
c. The same, with glaucoma 1 4 
3• Atrophy of the optic nerve: 
a. Methyl-alcohol poisoning 5 
b. Results of febrile illness 5 
c. Neuritis retrobulbaris 5 
d. Focal cephalitis 1 
e. Meningitis 4 
f. Prog, paralysis 1 
g. Leber’s optic atrophy 1 
h. operated brain tumor 4 
i* operated cerebellar abscess __1 _22 
■ 74.9 96 from all diseases 34 
4. Severe changes of the vitreous body 1 
5• Heredo-degeneration of the maculae 2 
, 37 = 8.1 % 
6• Sympathetic ophthalmia of the 2nd eye; 
through injury (lead missile)' 1 
after operation of cataract 1 
7. Simulation 1 
D. Caused by attempt at suicide 
~rtiil 8 August 1941J ” 10 2.4 9b 
(till 8 August 1941 = 150 new cases, 
applied to this 6.6 °/o) 
Fatal casess 
Late abscess in the brain 4 
Brain tumor 1 
(Editor's note: The figures given above Total 453 =10000 % 
are exactly as they appear in the printed ——0 
original.) 
Conclusions regarding protection of the eye. 
Survey of the remaining power of vision* Illustration to 
the plan not to hand over certain cases, until now considered 
as "practically blind" to the technical training for the blind 
in the future, but rather to train them somewhere in special 
practical courses with all optical auxiliary devices (telescope 
spectacles etc.) in order to reestablish them, if possible, in 
their former occupation or a similar one. 
Survey of additional damages inquiring training ftr another oc- 
cupation. Illustration of the possibilities of training for 
another occupation rendered difficult by additional body de- 
fects. Survey of the total of war blind of the present war, 
already employed: 
Mechanics and artisans 112 
Telephone operators or wireless operators 60 
Stenographers, clerks, candidates for civil 
service 58 
Industrial laborers 17 
Independent business men 12 
Manual work, for instance packer 10 
Masseurs 11 
University graduates, higher officials etc. 8 
Farmers 4 
Travelling salesmen 4 
General occupations with the Armed Forces, 
the the Labor Service 3 
Concert singers 2 
Interpreters 1 
Writers 1 
Business managers 1 
Total ~304 
Pointing out the special for timely instruction 
of the war blinded concerning their condition, before their 
transfer to the collecting hospitals, offer:.,. facilities for 
training, and a very cautious establish;': ig 1 a prognosis quo 
ad visum in the case of the practical!:/ tllr (danger of 
phthisis) to avoid mental reactions and in. the interest of a 
solid basis for the training, founded on the experiences at 
our disposal. 
Survey of the different ways of war blind training and 
the technical devices required for this. 
Discussion: 
SCHMIDT: The necessity of special training institutions 
for weak-sighted men is emphasized. For practical and psycho- 
logical reasons it is not advisable to mix them with the totally 
blind in a training institution for the blind. It is not suf- 
ficient to establish hospitals in which the weak-sighted are 
equipped with auxiliary optical devices-> There are not a few 
weak-sighted who cannot be assisted with auxiliary optical 
devices. They too must be made fit by special training for 
taking up again the occupation they learned« Younger weak- 
sighted men too are to be given the opportunity to take up a 
profession which demands only limited powers of vision. 
* LOEHLEIN; A number of eye hospitals in the homeland, 
nearly all of them university eye clinics, have lately been 
entrusted by the Army Medical Inspector with the special care 
of particularly weak-sighted members of the Army in order to 
separate them from the blind or practically blind, and to en- 
able them by practical testing of special optical devices 
(telescope glasses, magnifying glasses etc.) also, when needed, 
by adequate training to take up a profession for people with 
normal eye-sight. The overtiming majority of them are men 
who, although still able to go out into the streets., cannot 
read without special auxiliary optical devices. As far as the 
central power of vision may give a clue, the lowest limit would 
probably be around a power of vision of 1/50, the upper limit 
around 1/10# 9* Fitness of eye casualties. 
Together with directions for evaluation of the 
fitness of men whose eyes have been injured. 
_Generalarzt (Brig. General.. MC.) KLEIBER 
The^following directions are proposed for an evaluation 
of the fitness of men whose eyes have been injured: 
Conjunctiva: Synblepharon with chronic irritation, 
double vision and disturbances of movement, are fit for 
home garrison duty or civilian labor duties. 
Lacrimal ducts: Closures and fistulas without purulent 
discharge usually do not impair fitness for active service. 
For this reason classification as L 22 is too strict. 
Strabismus: Fitness for active service is not impaired 
by concomitant squinting; the squinting eye must, however, 
not be practically blind. In case of paralytic squinting 
constant double vision, demands the classification as for 
home garrison duty or labor duties. 
Cornea: In the case of inflammation of the cornea dis- 
position to relapse does not always exclude fitness for active 
service or front garrison service, this is, however, very 
often the case with herpes and keratitis dendritica. 
Practical blindness: This condition cannot be defined 
absolutely in figures. The stated degree of vision of 1/50 
has sometimes to be passed to nearly 1 -CLO. 
Iris: Healed over, non-relapsing iritid.es are to be 
judged according to the degree of vision remaining. 
Lens: In the case of stationary cloudiness of the lens, 
the fitness for service depends on the degree of vision; pro-, 
gressive cataracts of both eyes allow at the most, labor duties. 
Aphakia in one eye makes the man fit for active service if the 
injured eye with correction reaches at least 1/4 of normal 
vision and other eye is in good condition. 
Aphakia of both eyes - fit for home garrison duty or 
labor duties. If the only eye remaining is aphakic - fit 
for labor duties. Unfit for army service. 
Lens luxations - fit for labor duties. Horae garrison 
duty. 
Vitreous body: In case of cloudiness, findings and cause 
are to be considered, not only the degree of vision. Chronic 
disease of the ciliary region or recurring hemorrhages of the 
vitreous body make the patient fit for labor duties. - Unfit 
for army service. 
Choroid - Retina: Scars and old circumscribed spots do 
not impair the fitness for active service. Old detachment of 
the retina of both eyes after an injury, fit for labor duties, 
or home garrison duty. Garrison duty in individual cases if 
operated on with good permanent result, even garrison duty in 
the field (occupied territories). Optic nerve* With atrophies due to injuries the degree 
of vision and the range of vision are decisive, the'same ap- 
plies to amblyopias due to intoxication. One sided central 
scotoma after an affection of the accessory sinuses is — 
fit for active service. 
Glaucoma; Primary glaucoma is fit for home garrison 
duty or labor duty, while the one-sided secondary glaucoma 
allows home garrison duty only* 
Homonymous hemlanopslas; Are to be judged according to 
range and kind of trie remaining field of vision, fit for home 
garrison duty to unfit for army service* •. 
Anomalies of^refraction: Number B 25.1 demands a degree 
of vision of 1/2 if the correcting .glasses, do not exceed - 6.5 
or 4* 3 D. This request would also >be sufficient for greater 
anomalies of refraction of number B 25.2, for the degree of 
the faulty refraction is less important* A degree of vision 
of 1/10 and less is not fit for military assignment. 
According to the patients records in the archives for 
army medical science of the total number of wounded only 2.1 
per cent are men with injuries to the eyes. The reasons why 
this figure is so small compared to the 8-10 per cent of 
the first World War are that most of the wounds are due to 
mobile warfare. 
The statistical results are shown in the enclosed 
schedules. Because only finished cases were considered the 
judgements were final. They only refer-to Injuries to the 
eyes. other concomitant body injuries have not been taken 
into consideration. ‘ 
’ i -J .;;, . , ' 
The figures for total loss and blindness of both 
are probably too small, because the records of the blind are 
still in the hospitals for the blind, and, up to now. were 
only rarely handed over to the archives for army medical 
science. 
. < 
Discussion: ; . 
ROHRSCHNEIDER: Is of the opinion that many mistakes 
made in the evaluation of fitness for army service are re- 
sults of a too literal observance of the schedule of defects. 
He therefore proposes to modify the evaluation of defects 
of soldiers in conformity with the new points of view, in 
order to obtain a uniform evaluation of the fitness for army 
serene in the case pf soldiers with eye defects. 
OBERHOFF: In our army a modification of the opinion 
concerning fitness is only possible by the leading raeadical 
officer (as proposal by the medical officer in the field). 
The leading medical officer arrives at a decision after an 
examination by a specialist named by him. KRUSIUS: If possible full scope is to be given to the 
physician for individual non-schematic judgement. Illness 
or inferiority shall under no circumstances protect a man 
from performing some duty, but this duty shall be such as to 
secure the best possible performance and usd in each individual 
case# In accordance pith total war, however, this use is only 
limited by the "unfitness" rate (for the individual may serve 
in various branches of the Armed Forces, SS-police, Airforce, 
Navy and civilian Labor Service)• 
MUELLER: For the opinion "fit for front garrison duty” 
one has to consider that the man concerned will possibly have 
to do duty not behind the lines but,in the front line# 
HEINSIUS; 1. Confirms the experiences of faulty judge- 
ment'* In most cases the reason for it is insufficient con- 
sideration of the regulation? for examination and classification 
of recruits* 
2. As range finders the -wounded cannot be employed. 
For the examination of the range finders of the Navy, precise 
directions have already been drawn up which contain all re- 
gulations necessary# 
3* For squint-eyed recruits an operation is advisable';' => - 
to avoid military difficulties; har.dly any cases of doubled- 
vision have been observed* - ' •; . 
4. Relapsing diseases of the cornea require treatment 
in the same hospital, as a change of attending physicians is 
usually unfavorable zo the restoration of fitness for active 
service# 
COLLIN: Is of the opinion that patients suffering from 
glaucoma, whose disease is compensated, may be considered with- 
out hesitation as fit for home garrison duty if their power 
of vision and field of vision is sufficient. 
DIETER: In the case of hemianopsia of the right side the 
well-known complaints while reading may be eliminated sur- 
prisingly easily and quickly if the person concerned learns 
to read with the book turned around from the. right to the left 
and the lines from bottom to top. - ' Occasionally the well- 
founded judgement of a wounded,;man is, disregarded by the medical 
officer in the field. I know of several, cases, where wounded 
men, who were at least fjt forgarisenduty, were discharged 
by the medical officer in the field aslffi,t for civilian 
labor duties at the best*1. 
SCHMIDT: Tuberculous eyes have to be judged in each 
individual case# Especially are to be considered the length 
of time elapsed since the last transfer and the kind of oc- 
cupation since then. 10* About night blindness and other disturbances of the 
. light.perception. 
Professor VOM HOPE 
More than 2000 cases were observed. Apparatus: Engel- 
king adaptometer made by HARTUNG with adjustable intensity 
of current. The normal dark adaption, which was tested in a 
1000 persons who had no disturbance of night vision, fluctuates 
in proportion 1:5, Thus there are persons without disturbances 
having good, medium and below the average adaption. The latter 
are unfit for night-fighting and night-observation. The.dis- 
tribution curve of the normal adaption resembles a binomial 
curve. The average rate of frequency is a little below the 
calculated average rate. Only such persons may be rated as 
night blind or hemeralopes, whose final rate, after 30 minutes, 
is 1/15 or less of the average rate of frequency. Slighter 
reduction has to be considered as a weakness of light per- 
ception. In the majority of these cases there are simultaneous 
refraction anomalies of all kinds (not only myopia), as well 
as amblyopia, keratoconus and other symptoms of an 
inferior construction of the organ of vision, sometimes here- 
ditary. Simulation plays only an unimportant part. Only a 
small percentage of the cases shows signs of a lack of vitamin 
A. An exact anamnesis is necessary for their discovery. The 
vitamin A content of the whole blood and dark adaption show 
no parallelism. Besides the positive result of a diet supple- 
ment with Vogan (proprietary vitamin A preparation) carried on 
for about two weeks, only a rate below 50 is a sign of a lack 
of vitamin. Persons with good dark adaption will find an ac- 
quired reduction, even one to be rated inside the normal dis- 
persion much more disturbing than others with a constitutional 
weakness of light perception. Decrease to 1/3 and less of the 
average frequency rate should be classified as unfit for field 
service and night duty (weakness of light perception of a con- 
siderable degree). 
Discussion: 
OBERHOFF: I think it is dangerous to ask every man 
during the medical examination, as proposed by VOM HOFE, 
whether he secs badly in the twilight. As a matter of fact 
one should talk as little as possible with laymen about night 
blindness; • the expression "war hemeralopia” should especially 
be avoided, a term I am very sorry to say has cropned up 
again. 
MUELLER: Would it not be possible in the examinations 
of adaption to normalize the regulations for the conduct of 
examinations as regards current potential, light potential 
and light adaption. 
HEINSIUS: The vitamin A contents of the blood show, 
variations during the course of the day so that it is not 
possible to determine a lack of vitamin A by the blood serum. 
Reference is made to the research work of HAMBURGER and my- 
self about attempts to standardize and possibilities for 
comparison as well as the shortcomings of the adaptometers 
(see Klinisches Merkblatt fuer -Augenheilkunde, 1943). - It 
is impossible to compare several adaptometers. JESS: Points out that there always existed disturbances 
of adaption and field of vision in the case of test persons 
with distinctly decreased vitamin A contents of the blood 
caused by disease. Instead of the proposed term "weakness of 
light perception" it would perhaps be more practical to say 
"disturbance of night vision". 
VOM HOFE: The reason why I consider the term "weakness 
of light perception" as much more appropriate is because by 
this, it is made quaite clear that the adaption Is bad. In 
certain cases persons with absolutely normal adaption have dis- 
turbances of night vision too. 
11. Concerning night vision. 
Marineoberstabsarzt (Lieut, Comdr.. MC.) 
Dozent HEINSIUS 
During night fighting the soldier who recognizes the 
enemy first has the advantage# In the Navy aboard the sub- 
marines, patrol vessels and speed boats as commanders, look- 
out guards and bridge personnel, as well as aboard night 
fighter planes and bomber aircraft and at the optical apparatus 
of the anti-aircraft guns, soldiers with particularly good 
night vision are needed. For this reason, appropriate methods 
of selection were developed by the Germans as well as by the 
enemy. During night fighting one must be able to see with a 
light intensity below 9.5 x 10”3 (sunset or sunrise), or even 
below 6.3 x 10-6 (full moon). The examination of the trans- 
itional stage (cone vision and rod vision) is made with the 
nyctometer by COMBERG. The pure vision (rod vision), 
however, cannot be measured with this method. As it is 
especially important for night fightine the examination of 
it is either to be made with the NOWAK-WETTHAUER device or 
with luminous-color vision test by TSCHERMAK-SEYSENEGG and 
HEINSIUS. The examination with luminous color vision tests 
has been developed by myself as an auxiliary method and has 
proven useful for practical purposes. The firm of Sydor, 
Berlin, supplies this device as a nyctoscope. It furnishes 
a good dispersion of the night vision capacity rates found. 
The examinations have to be made regularly after 40 minutes 
of dark adaption. Especially important is the elimination 
of the central scotoma which requires a special training in 
parafoveal vision. For the training in this separation of 
attention and visual line, the mentioned luminous color 
vision tests have been proven useful. The lecturer1 s own 
examinations of the regional distribution of night vision 
capability of the retina are mentioned $ in the case of good 
night vision the best capacity is in a circular area of 
about 20 - 40° around the retina center. The observations 
by NOWAK. KOESTER, and FICK, v.KRIES and others, who obtained 
different values are to be interpreted as either due to indi- 
vidual peculiarity or as insufficient training connected with 
centripetal variations of vision. Local fatigue of the retina 
is eliminated by momentary observation of 3 seconds duration. 33 
Further influences on night vision already ascertained in 
1940 by my earlier examinations with the nyctometer can be 
confirmed again and are only mentioned briefly for this 
reason. It concerns individual variations which are dependent 
on the general physical condition of the individual in quest- 
ion. It is certain that here changes of the contrast funct- 
ion play an important part. 
In conclusion it is pointed out that naturally it is 
the duty of the medical officer in the field to inform the 
commanding officers of all possibilities of improving the 
dark adaption and the capability of night vision. Measures 
for the improvement of night vision are mentioned briefly. 
Discussion; 
KYRIELEIS; The most reliable method now for testing 
perception in the dark is the method of NOWAK, for an ex- 
amination, especially in the case of mass examinations, the 
instrument developed by the Auer company is the most reliable 
one. For training in vision in the dark the instrument by 
HEINSIUS seems useful. 
HEINSIUS: Unfortunately an examination with the apparatw' 
used by the Airforces serves only for testing sensitivity of 
differentiation* It remains to be seen, whether precise 
statements can be rflade of the capability of vision which 
tests contrast Vision and. resolving power in addition to 
light sensitivity; 
12* Aggravation, simulation and hysteria• 
Oberfeldarzt (Lt. Col.. MC.) Prof* COLLIN 
During the war an ophthalmologist freauently has the 
difficult task to decide whether the visual disturbance 
claimed by a draftee or member of the Armed Forces^is sim- 
ulated or of a hysterical nature. Such a decision involves 
extremely high responsibility on the part of the specialist, 
as the war regulations provide the death penalty for every 
one who tries "to evade military service by simulation. 
All our objective and subjective methbds of examination 
which have proven efficient for the detection of aggravation 
and simulation of visual disturbances aim at changing the 
methods of observation so as to way that 
the person examined cannot use his imagination iri following ,■ 
the course of the examination which results in contradictions 
with the optical and physiological rules. The leds the » 
person to be examihed knows about these rules upon which 
the test methods depend, the less complicated (and therefore 
harmless) the testing procedure appears and the less time 
the person to be examined has for reflection, the quicker 
will one succeed with the simulation tests. It requires, 
however, a great deal of experience for the specialist, patience shrewdness and knowledge of human nature, to prove 
that the person to be examined has in reality a greater 
acuity of vision than pretended and that the acuity of 
vision proven by figures means fitness for military service* 
In view of the serious consequences in a court martial 
of_a Simulation of visual disturbances”, the principal re- 
quirement is made that the diagnosis of a proven simulation 
may only be stated in writing by the examining specialist if 
no objectively justified aspect of disease exists, because 
of the pretended visual disturbance, and if the fitness for 
military service can be clearly proven according to the 
classification for fitness* In all difficult and doubtful 
cases, a clinical observation in the eye department of a 
reserve hospital located at the army district physician*s 
headquarters and a provisional opinion after consulting a 
second eye specialist as well as a neurologist is recommended, 
before the final opinion is given, so that a wrong diagnosis 
may be absolutely avoided, considering the grave decisions 
to be made. 
Discussion: 
ROHHSCHNEIDER: To avoid the serious court martial 
consequences of simulation, it is recommended to instruct 
the soldiers accordingly before the beginning of the ex- 
amination. 
HEINSIUS: The rank of the examiner often plays a part 
inasmuch as a Major (MG.) ”7ill get better examination results 
in a test of simulation than lower ranking officers of the 
medical corps. For detecting clumsy simulation the method 
of RIEKEN has been proven successful in Kiel, because mal- 
ingerers are mostly of the opinion that during the adaption 
test they have to state low rates in the dark too. These 
persons are easily convicted by the optokinetic nystagmus* 
DIETER; Soldiers suspected of simulation are admitted 
to the ward for "an observation” of 3 or 4 days and watched 
unobtrusively. The examination and final judgement is then 
not so difficult. 
JESS: Mentions a case of artificial conjunctivitis of 
a civilian pilot who had alleged constantly recurring serious 
irritation of the conjunctiva caused by dural (aluminum alloy) 
dust which he maintained by suitable measures. 
KAISER: Fcr detecting simulation of blindness in one 
eye the optokinetic nystagmus is of great importance too 
and may also be made by an improvised drum, for examination 
at different distances from the person to be examined* 
LOEHLEIN; The hope to clear up doubtful cases of 
suspected simulation with the aid of objective determination 
of the visual power by OHM*s nystagmus test can unfortunately 
not be realized at present, as the apparatus used by OHM 
and recommended by him is at present not available in working 
condition and has not yet been installed and tried out in 
other places. COLLIN: In his final remarks points out that in his 
experience stubborn malingerers are often not diverted from 
their purpose by being informed of the grave consequences 
of a court martial, but on the contrary in some cases even 
got their relatives to lodge a complaint with the superior 
authorities about their being suspected of simulation. 
13. "Trachoma". 
Stabsarzt (Captain. MC.) Prof. HOHRSCHNEIDER 
It is not to be supposed that trachoma may spread 
epidemically as a result of war activity in trachoma in- 
fected countries. The experiences made during the decade 
after Napoleon's campaign in Egypt of the spreading of con- 
tagious inflammation of the eyes, the so-called Egyptian 
inflammation of the eyes, nearly all over Europe, when 
the number of the blind in the different armies amounted 
to thousands, does not apply to the disease which we call 
trachoma today. The contagious inflammation of the eyes 
raging in the beginning of the last fcentury not trachoma 
but another disease. To avoid occasional infeotiori through 
contact of the troops with the civilian population infected 
with trachoma, instructions given regularly by the physicians 
in the field according to Army Manual No. 209/1 (instruction 
leaflet concerning trachoma) are sufficient. 
An important question is the evaluation of the military 
fitness of trachomatous men. It is to be expected that even 
now and in the future more than hitherto, trachomatous draftees 
vail have to be classified during preliminary examinations and 
more trachomatous soldiers will have to be treated on account 
of the inclusion of groups of the population in the German 
area which show in part a considerable percentage of tracho- 
matous persons, (e.g. people of German descent removed from 
the East). The following viewpoints have to be considered 
in judging trachomatous draftees: Draftees with trachoma 
healed or inactive for the time being cannot and do not need 
to be exempt from service, draftees in a stage of 
active infectious trachoma are also to be drafted for military 
service, but have to be sent immediately to a suitable hospital 
for treatment. A part of these vail have to be Judged as fit 
for active service after a treatment of 3 - 4 months, the rest 
will have to be Judged as unfit for service. By this com- 
pulsory treatment of trachoma, not only the interests of the 
Armed Forces are safeguarded, but at the same time the civil 
measures for fighting trachoma are effectively supported. 
Unfit for active service are only those men suffering from 
chronic infectious trachoma who are not amenable to treatment. 
Discussion: 
LOBECK; In the Northern part of the Eastern frort we 
found among 400 civilians 15 trachomatous ones, among 4000 
soldiers with eye diseases only 3* CLAUSEN; There is very little danger to our Armed 
Forces of being infected with trachoma by trachomatous 
civilians. Trachoma is only transmitted by direct in- 
filtration of infectious secretions into the conjunctival 
cul-de-sac. There is mentioned the case of Austrian soldiers 
during the first World War, when, through using of the same 
towel by ton or twelve soldiers, trachoma was, so to speak, 
inoculated. Sulfonamide preparations have the best effect 
in the case of a new case of trachoma. Older trachoma stages 
are almost absolutely uninfluenced by it. 
JESS; Mentions a number of cases in which somebody 
established a diagnosis of trachoma and prescribed sulfonamide 
treatment. An examination made afterwards, by a clinic in 
Leipzig, showed that these cases were completely free of 
trachoma none of them had, however, got the prescribed sul- 
fonamide treatment. The first erroneous diagnosis would 
therefore have led to a serious error about the success of 
the sulfonamide therapy. 
LOEHLEIN; As regards the treatment of trachoma with 
sulfonamides; As collective reporter of the experiments 
in the treatment of trachoma with sulfonamides made in many 
places simultaneously for more than a year, I should like 
to state; In general the conviction that the trachoma germ 
is finally killed in this way is not prevalent. In spite 
of this, it is a striking fact that the sublective and ob- 
jective manifestations of inflammations will usually decrease 
soon with this treatment. Thus it is possible by a com- 
bination of the mechanical and medicinal local treatments 
at present used to accomplish the latter much more carefully 
(by certainly many secondary injuries such as cicatriciVl 
entropion are decreased), and besides this to accomplish 
a clinical cure in about half of the time required until 
now. II. 
PROCEEDINGS OF THE CONSULTANTS 1 
COMMITTEE ON SURGERY 
Translation prepared by: 
Office of Military Government for Germany (U* S. ) 
Office of Naval Advisor 
Medical Section Minor and major surgery in the case of tuberculosis 
of the lungs 
(See Section XII, Articles 6-7) 
1* Reamputation and stump treatment. 
Together with: .Directions•* 
Oberstabsarzt (MajorT MC.) Prof. KREUZ 
1* Reamputation serves to obtain the best usefulness 
in the case of incompletely or imperfectly healed stumps or 
physiologically less valuable or technically useless stumps* 
2* Without exception a reamptitation is to be performed 
at a time when the stump is sound, except in the particular 
pathological area* 
3* The particular pathological area too must be free 
from inflammation and infection. Bone healing must be com- 
plete* Removal of sequestra and exostoses must have been 
performed previously. Open areas of the soft parts with 
fresh granulations are to be healed by transplanting epi- 
thelium before reamputation. 
4* A stump is ready for reamputation if it shows no 
signs of inflammation of its soft or bony parts* The wounded 
person must be in a good general state of health. 
5. The readiness for reamputation cannot be accelerated. 
The stump needs rest and time to become ready for final shaping. 
No premature exercise therapy, no premature operations should 
be done otherwise reinfections will result, 
6. For reamputation peacetime considerations regarding 
the employment of the stump determine the choice of the site 
for amputation. 
7* For functional employment a difference is made 
between stumps which require a prosthesis and stumps which 
do not require a prosthesis. All leg stumps absolutely re- 
quire a prosthesis (with exception of certain foot amputations). 
The majority of the hand stumps and the forearm stumps do not 
require a prosthesis. Only the upper arm stumps (of the arm 
between the shoulder and the elbow; require a prosthesis 
partly conditional, partly unconditional. 
8* In all arm stump reamputations the greatest con- 
servatism should prevail. Defects of the soft parts are to 
be covered plastically if possible. The chance given for 
the forming of SAUERBRUCH-channels to secure motion of the 
artificial hand must not be jeopardized. Nor is it per- 
missible to sacrifice parts of the hand and the arm which 
could be made into natural gripping organs in favor of an 
artificial arm. 9. Directions for reamputation of the leg (diagram)# 
We distinguish three zones: dispensable, indispensable. and 
inconvenient. 
In the dispensable zone a shortening of the stump 
length may be made to cover soft parts plastically. 
The sphere of activity for flap plastics is in the 
indispensable zone. Here no centimeter of bone may be sacri- 
ficed unless it is absolutely unavoidable. 
In the inconvenient zone the removal of the limb 
section in ouestion is demanded for good cooperation between 
stump and prosthesis for physiological or technical reasons# 
10. Amputations of hands and feet having become deformed 
in healing and functionally of inferior quality are only to be 
performed after joint examination by specialists. It is wrong 
to sacrifice a seriously damaged hand of limited function forth- 
with. Here an attempt at plastic restoration is advisable# 
Discussions 
SAUERBRIJCHs Speaks about the practical importance of 
the automatically movable hand and the mistakes of the operatic 
technique. 
HELLER: Recommends the epithelization of granulating 
places on the stump before reamputation is made. 
GULECKE refers briefly to the question, whether in the 
case of reamputations because of injuries to cold, tetanus 
antitoxin is to be injected once more. The transplanted skin 
flaps over stumps are numb for a long time and must not be sub- 
jected to strain. 
USADEL: Says that onesided circular incision is only ad- 
visable in the case of gas burns. 
HOCHE: Recommends the periarterial sympathectomy before 
reamputation in the case of injuries due to cold. 
SCHOENBAUER: Says that in 90 per cent of the cases re- 
amputations of the stump have to be made. He recommends the 
two phase amputation. 
LEHMANN: Recommends an early beginning of the extension 
of the soft part on the stump. 2. Treatment by exercises and mobilization of the .joint# 
Together with; Directions5 
3S-Gruppenfuehrer (Lieut# General. (Elite Guard)) 
Prof. GEBHARDT and 
Standartenfuehrer (Lieut# Colonel) SCHULZE 
1# The after-treatment must be a logical continuation 
of the operative and bandage treatment, consequently it must 
always' be controlled decisively from the surgical point of 
view# 
2# The possibilities of using the treatment by exer- 
cises can be subdivided into gymnastics of the patient, sup- 
ported by the measures stimulating the circulation, especially 
by massage, passive muscular exercise, sports suitable for 
wounded and occupational therapy# 
3# During the creative phase of active reconstruction, 
which is characterized clinically by healing in the narrower 
sense, by symptoms of inflammation and irritation, any mech- 
anical disturbance is injurious# 
4# The indications for treatment by exercise are de- 
termined: 
a# by the condition of the layers of tissue, 
the former wound area, - r 
b. by the conditions of the circulation of the 
blood, 
c# by the remainder of additional injuries 
(infections), 
d# by the intact state of the nerve system, 
e# by the possibilities of using the injured limb. 
5# In addition to the usual training methods only 
suitable detailed work will be successful (pulling, pressure, 
pushing gymnastics, passive motion treatment). 
6# It goes without saying that a modern exercise 
treatment cannot do without special apparatuses# 
7# In case of congestion, any irritation caused by 
exercise and any artificial arterial hyperaemies are to be 
rejected# 
8# Of the clinical pictures and hindrances in the 
case of limb injuries, contractures are the hardest to fight 
during the after-treatment. Contractures in the form of 
lingering inflammation are suitable for motion treatment, 
instead of this they need; a. sufficient rest (immobilization), 
b. (arterial) hyperaemia as a remedy, 
c. skillful massage, 
d. for extension, permanent pulleys (triangle 
with pulley, simple pendulum, permanent ex- 
pander, shaking apparatus, intermediate splints' 
9* The rules for the after-treatment of peripheral 
motor paralysis and paralysis caused by injuries to the limbs 
are; 
cu a practically useful regeneration of the motor 
nerve tract can only be secured with smoothly 
gliding joints and tend oils. A removal of the 
contracture must precede any treatment for ncrv 
trouble; 
b. spontaneous recuperation or a surgically pre- 
pared one is endangered by over-extension, 
overstraining; 
c. the recuperating nerve tissue is extremely 
sensitive against irritation and. requires short 
periods of intensive stimulations with long 
intervals of rest from irritation; 
d. shaking and traction exercises are to be com- 
bined vrith skillful massage; 
e. electrical examination and electrical gymnastic 
may sometimes be of decisive importance, though 
only if they are made by a thoroughly experience 
physician and are at least well regulated by hi 
10* Soldierly bearing must come first before sport for 
the wounded, just as during the clinical treatment. During 
the time of efficiency a man must strain every nerve so that 
he needs rest during each interval, therefore also when he is 
in hospital* 
11* A cautious moving of the limbs under anaesthesia 
may be attempted bnly exceptionally in case of the consequences 
of war injuries and only if X-raying shows that the articular 
space is free, consequently only in case of primary adhesion 
of the soft parts. 
12* Better and more conservative are (Jtiengel-bandages 
and intermediate splints. 
(Note; Quengel-bandages are moulded splints applied 
securely to a limb, so arranged with a hinge that the joint 
(elbow or knee) can be manipulated slightly without motion 
of the adjacent bones in the arms of the splint.) 
13. Remnants of ’’badly demolished joints’1 with extensile 
cartilage defects first of all require stiffening. If con- 
servative measures do not lead to synostosis early resection 
is indicated. 14. For the final conditions besides resection (painful 
primary adhesion of connective tissue which cannot be modified 
or bony ankylosis) joint plastic is to be considered. Subse- 
quently it requires a powerful muscle coat free of adhesionsf 
The injured person must be young, perfectly healthy for the 
future and there must be human and professional need for 
arthroplasty. 
Contraindications: Extensive adhesions in the area of 
the joints, deep immovable scars of the muscules, muscular de- 
fects, formations of callus hampering joint motion, paralyses. 
In case of infections with germs causing putrefaction, gas 
gangrene, gonorrhea, plastic operations are not advisable 
either. More important than schematic data (partial plastics 
and resection 1 year; total plastics 2 years after the in- 
fection has completely disappeared) is a long interval of 
freedom from local and general reaction. 
The joint must be free from pain when used, the muscle 
must grow, dystrophy must disappear by degrees. The best v/ay 
for the wounded person to acquire a self-critical attitude 
so as to desire stiffening or plastics is use of the limb 
every day. The partial plastic represents the minor operate* ■ 
It is practicable earlier and is more easiljr performed. I' 4 - 
applicable mainly in the connective tissue parts of the joint- 
Discussion: 
MALLWITZ: Gives particulars of the training of the 
attending personnel (gymnastic nurses) and about the differ- 
ence between nsports for the wounded" and "sports for the dis- 
abled". 
1. Marrow nailing of gunshot fractures of long tube.. bones 
at the front, 
Oberarzt (1st Lieutenant, MC.) Prof, KUENTSCHER 
Marrow nailing is a treatment of bone fractures in which 
the fractured parts are connected by a nail of stainless steel. 
The nail is of lamella shape and rests in the marrow cavity. 
The fixation is so tight that every other device, such as 
plaster of Paris bandage or extension bandage is superfluous 
and the injured limb may be moved immediately without re- 
striction. In the case of a fracture of the thigh, for in- 
stance, standing up and walking is possible without any 
apparatus after a few days. Only the nail, resting in the 
marrow cavity, replaces - as it were as an internal splint - 
the mechanical support, lost by the fracture. This has the 
immense advantage, that the damages resulting from the im- 
mobilization are avoided: such as muscular atrophy, stiffness 
of the joint, local and general impediments to the circulation. 
In the case of a closed new fracture the insertion of the nail 
is made under X-ray control through a skin incision of 2 - 3 
centimeters length at some distance from the place of fracture. 
After the healing of the fracture the nail is extracted. The experience of many hundreds of nailings showed 
that no essential damage of hopes and marrow appeared in 
spite of the size of the foreign body, and that, on the 
contrary there is an extremely strong formation of callus, 
because the circulation remains unhampered by the movement. 
Experienced accident surgeons only may use the method. 
It can also be used for complicated fractures, and in Jutecily suit- 
able fcr tie hooter tion of bjdly honied bone fractures, for pseu- 
darthroseer, spontaneous fractures etc. 
The question whether gunshot fractures too are to be 
"nailed" has not yet been decided. 
Discussion: 
ROSTOCK: Tells about the known results of the marrow 
nailing of gunshot fractures at the front. Of nine cases 
four died, the fate of another four is unknown, one is cured. 
4. Marrow nailing of old fractures, threatening and exist- 
ing pseudarthroses In the homeland• 
Oberfeldarzt (Lt. Col,. MC,) Profi HAEBLER 
1* The danger of infection with marrow nailing in- 
creases considerably by exposure of the fracture. While in 
the case of subcutaneous nailing only 1,5 per cent wound 
infections occurred, there were 5 among 45 cases of "open 
nailing" which is more than 10 per cent. Therefore in the 
case of old closed fractures, exposure must be avoided if 
possible. This is possible by a thorough mobilization be- 
fore the operation. By this one succeeded even after 10 - 
22 weeks in performing the nailing. without exposure of the 
fracture site. One fatal case warns against nailing in case 
of a bad general state of health. The mechanical disturbances 
known as causes of delayed healing have also to be considered 
during the nailing. Most important for the leg is an ad- 
ditional plaster of Paris bandage if the nail does not put 
the fracture at rest completely* If, after no 
accurate joining of the fracture ends, which is necessary for 
the insertion of the nail, can be secured, the nailing shall 
only be performed if more than six months have phssed since 
the injury occurred and if the position of the fragments in- 
dicates that the setting of the fracture will considerably 
hamper the use of the limb. This applies also if already 
existing callous masses closing up the marrow cavity make it 
clear that exposure is unavoidable, 
2, In osteotomy, on account of healing in a bad 
position, nailing is to be preferred to the other methods 
of joining the fracture ends. 
Besides the achieving of an absolute resting position 
it has the advantage that a far reaching resection of the 
bone and a removal of the periosteum is avoided. For re- 
lieving the hemorrhage, drainage is recommended. In the 
case of formerly infected fractures and gunshot fractures 
it is absolutely necessary. 3. Of 35 old gunshot and infected fractures or in 
case of pseudoarthrosis caused by such, 3 patients with 
fractures of the thigh died* Besides a minor fat embolism 
no cause of death could be ascertained in one case, in the 
second case the wounded patient was in a bad general state 
of health. With patients to whom an operation may prove 
dangerous, no nailing is to be performed# In the third 
case the omission of drainage resulted in a phlegmon and 
sepsis# All of the remaining 32 fractures showed bony 
healed, seven of them resulted in a local formation of 
sequestra, an occurrence which ordinarily cannot be avoided 
if the treatment is conservative# On the other hand, how- 
ever, an infection extending beyond the fracture cleft is 
avoidable# This has been observed four times, especially 
in those cases the wounds of which were healed,the longest 
time before# The cause Was either insufficient drainage 
or neglect to additional support for those fractures in 
which the nail did not give sufficient fixation# In the 
case of two delayed healings mechanical causes flocking 
fibula, existing defect) were responsible. 
4 severely suppurating fractures showed bony healing 
without any extension of the infection, however, a nailing 
of such cases is to be performed only if one does not succeed 
in fighting the infection effectively with conservative 
methods, regardlesr of the position. If It becomes necessary 
in any case to expose the fracture on account of an abscess 
or formation of sequestra the resting position guaranteed 
by simultaneous nailing is a great advantage in fighting 
the infection. A technically correct nailing, care for a 
good drainage in the wound by keeping it open and drainage 
in the right place and additional immobilization by a 
plaster of,Paris cast until the.danger of infection is over- 
come are absolute requirements for success. 
Discussion; 
KOESTLER: Marrow nailing is especially suitable for 
correction of a fracture combined with a deformity, with 
shortening of the limb and for fractures of trophically 
affected limbs. 
GOETZE; Points out the danger of infection and fat 
fSbpii§mfTieni8dcase refracturing method 
BOEHLEH; Reports on the result of two fractures of 
the thigh treated by him. At home he treated 50 old gun- 
shot fractures by marrow nailing. 
ORATOR: Reports on five cases observed by him. 
LEZIUS: Had bad experiences in Paris with the marrow 
nailing of fresh gunshot fractures. 
Directions for the marrow nailing of gunshot fractures 
of long tube bones at the front and at home. 
The method stated by KUENTSCHER was in the first place 
meant for the treatment of simple fractures and has been 
proven successful. The application of the method for war gunshot fractures 
too is tempting, as it saves extensive fixation bandages, 
especially for thigh fractures and upper arm fractures. 
Technically the method may be used at the fronttoo, after 
the wound has been prepared surgically in a careful manner. 
The performance of the operation under as "bloodless" con- 
ditions as possible is advisable. 
So far the experience with the marrow nailing of fresh 
gunshot fractures of long tube bones varies. A number of 
bad results have become known. 
A favorable course of healing has only been noticed in 
such cases, where good chances for attendance and long ob- 
servation by the operating doctor were guaranteed. 
It is proposed that three or four army surgeons should 
be commissioned to test the method and report on the indicat- 
ions and the results obtained. For the rest of the surgeons 
the prohibition of marrow nailing of gunshot fractures in 
the field will remain in force. 
The following directions are valid for hospitals behind 
the lines and at home: 
1. Simple fractures: 
With patients to whom an operation may prove 
dangerous because of their general condition no nailing 
is to be performed. 
If the fracture is older than 4-6 weeks and if 
its position of fixation is satisfactory one should 
desist from a nailing. In case of a delayed formation 
of callus it is only to be performed if it is to be ex- 
pected that open operation can be avoided. Before the 
performance of marrow nailing, however, a thorough 
mobilization for the leg, in certain cases a resection of 
the healed fibula, is to be made. 
If, after mobilization no accurate joining of the 
fracture ends, necessary fcr the nail, can be accomplished 
in the extension device, nailing is only to be performed 
if more than six months have passed since the injury oc- 
curred and if the position of the fracture makes one ex- 
pect a severe liinderance in the use of the limb* 
2. In osteotomy, on account of healing of the limb in 
a bad position or in case of a pseudarthrosis, nailing 
is to be preferred to the other methods of fixing the 
bones• 
Short drainage for relieving the accumulated blood 
is necessary. The nailing of fractures healed in a bad 
position and formerly infected or of pseudarthoses may be 
performed in the earliest case six months after the wounds 
have closed. 
Infected fractures and gunshot fractures: For patients to whom an operation may prove danger- 
ous on account of their general state of health, nailing 
should be out of question. 
In an otherwise good general state of health it 
may also be performed if the wounds have been healed 
only a short time or are still draining. Caution 
should, however, be observed. 
It is necessary to perform technically correct 
nailings, assure good drainage of the wound secretion 
by leaving the wound open and draining in the right 
place and additional immobilization by a plaster of 
Paris cast until the danger of infection is overcome. 
It is proposed to make the indication for nailing 
in the homeland depend exclusively on the decision of 
the consulting surgeon of the army district. 
5, Special test of sulfonamide effects• 
.SS-Gruppenfuehrer (Lt. General (Elite-Guard))_ 
Prof* GEBHABDT and F. FISCHER 
Conclusions: 
1* The development of a suppuration of the soft parts 
caused by bacteria cannot be avoided locally and internally 
even through immediate administration of sulfonamides. 
2* In the case of abscesses and phlegmons of the 
limbs, it could not be ascertained whether the course of 
inflammation by aerobic germs was influenced by sulfonamide. 
In case of the combined therapy of gas gangrene the impress- 
ion was obtained that there was a milder course under the 
effect of sulfonamide. 
3# Surgical measures are absolutely necessary for 
keeping the inflammation in check. 
Supplementary remarks: 
The dusting of wounds with sulfonamide powder may have 
an injurious effect if by this, the surgical principles are 
violated, e.g. if the powder base does not dissolve in the 
tissue fluid and obstructs the outflow of secretions by 
forming a crust. 
The wounds treated with sulfonamide powder show slightly 
less tendency to exudation. 
Working hypothesis: 
*" ———■— 
The inflammation in the mesodermal soft parts tends very 
early to a formation of necrosis. The center of the bacterial 
accumulation is the necrosis, the surroundings of which show 
thrombotic vessels. It is difficult of access for the chemo- 
therapeutical agents. 47 
Discussion; 
SCHHEUS; As far as I understood the test procedure of 
Mesa®. GEBHAHDT and FISCHER they do not allow any direct com- 
parison with the animal tests carried out by myself and 
others, because larger muscle Parts were eliminated by tying 
off vessels and could thus not be influenced by the perorally 
administered sulfonamides (cavity effect). The range of 
locally applied sulfonamides, especially the insoluble ones 
must not be overestimated, as the conditions of diffusion 
are insufficient in consequence of the low solubility. Here 
marfanil is to be considered particularly. The bad adherar.ee 
of gas gangrene infection which was emphasized by the speaker 
is completely identical with the observations in the animal 
test, ' ithout special local conditions (crushing of tissue, 
disturbances of circulation) infection cannot set in. These 
view points must be specially considered for the surgical 
treatment too, as, altogether the testing of sulfonamides 
for war-wound surgery should not be made from the viewpoint 
of antithesis but from that of synthesis. 
6. Sulfonamide treatment of gunshot rounds• 
Oberstarzt (Colonel. MC.) Prof. FREY 
Sulfonamide treatment of gunshot wounds can only be con- 
sidered as additional therapy. Under no circumstances must 
the thoroughness of the surgical wound treatment and the 
carefulness of putting the wound at rest be lessened by it. 
It neither tallies with the experiences of the test nor with 
those practices that in case of wounds which can be treated 
surgically only very late, say after one day, the subsequent 
sulfonamide therapy will influence the course of infection 
particularly. This is the reason, too, why the custom of 
dusting gunshot wounds, in case of a late change of dressing, 
as is usual today in many medical units is of hardly any 
value. In some branches of medicine, however, sulfonamides 
have yielded such surprising results, that abandoning their 
application for the treatment of gunshot wounds can hardly 
be justified. In order to get better results, it seems ad- 
visable to keep more to the experiences of animal tests. 
According to these a decidedly favorable effect on gunshot 
wounds is only to be expected, if sulfonamides are applied 
very early, that is even during the first few hours after 
the injury was incurred. If a wound can be covered reliably 
with powder in its entire extension, with the first three 
hours, and if the dusted tissue is still capable of reaction 
that is if the blood circulation is good, the outlook of 
success should be better. 
The local powder treatment is superior to peroral and 
parenteral therapy on account of the higher concentration of 
the sulfonamides attained at the seat of the infection. Graz- 
ing shots, tangential shots and wide gaping wounds are to be 
dusted with sulfonamide powder as soon as possible, therefore 
by the field surgeon. Deeper lying injuries, such as perforating shots and 
shots with the missile lodged in the affected part, have 
first of all to be thoroughly treated surgically at the main 
dressing station or at the nearest field hospital. Only after 
that is the dusting of the wound done and special care has 
to be taken that its deepest Dockets too, from which the 
serious infections are likely to set in, are dusted sufficient- 
ly. 
If the local dusting treatment is not sufficient (e.g. 
because the deeper layers could not be reached) or if it is 
not possible early enough, it is to be replaced or to be 
supplemented by intravenous or peroral doses of sulfonamides. 
They are applied prophylactically as well as therapeutically 
in the form of intensive therapy. According to the degree of 
the danger of infection, 6-10 grams are given for 3-4 days 
but under no circumstances irregular small doses which are in- 
sufficient to prevent inflammation, of no use and if given 
over a longer period may even have an injurious effect. 
In the case of wounds under suspicion of gas gangrene a 
daily dose of at least 100 cubic centimeters polyvalent gas 
gangrene serum should be given intravenously. 
In the case of abdominal wounds the application of 
Gibazol powder or of a liquid sulfonamide is to be recommended 
after a carefully performed operation. 
7. Injuries caused by intrathecsal administration of sul- 
fonamides ♦ 
Stabsarzt (Captain, MC.) Dozent H.-R. MUELLER 
No agreement yet exists in meningitis therany concerning 
the method of using sulfonamide (peroral, parenteral, intra- 
thecal). *vith intrathecal injection every remedy foreign 
to the tissue such as sulfonamides may cause an immediate 
injury to the central nerve system as a result of the missing 
buffer action of the cerebro-spinal fluid. 
Eubasin, so effective when administered perorally and 
parenterally is dangerous intrathecally on account of its 
alkalinity. We can add another case report t o the more than 
twenty serious injuries to the spinal cord mentioned in the 
literature. In the case of a meningitis patient a flaccid 
paralysis appearod with paralysis of the bladder developing 
In 48 hours after an intr...thocal injection of eubasin in a 
field hospital. 
Injuries are, however, seen also after the application 
of sulfonamides, generally considered as harmless intrathecally. 
Thus we observed in the case of suppurating meningitis after 
the administration of prontosil a temporary paralysis and 
weakness of the bladder and OBSHDISSE reported on two severe 
injuries to the spinal cord after ihtrathecal injections of 
albucid. An intrathecal administration of^sulfonamides cannot 
be advised because of these dangers, especially as it has been 
proven experimentally that immediately an ample resorption into the blood channel sets in and as a result of the sudden 
decrease of cerebro-spinal fluid concentration no diffusion 
worth mentioning can reach the real seat of the meningitis. 
Nor is it possible to secure any effective local therapy of 
meningitis from the cerebro-spinal fluid space because of 
collections of fibrin in the meninges and because of the 
seats of inflammation in the cerebral cortex. 
8. Sulfonamide treatment of infectious dermatoses. 
SS-Sturmbannfuehrer (Major (Elite GuardO). Prof, 
VONKENNEL 
Sulfonamide treatment of infectious dermatoses need not 
be restricted to the known parasitic ones but must also be 
regarded as the best first therapeutic measure for all second- 
er iJ.y infected ones. Until now we have only had disinfectants 
at our disposal; albumin precipitating ones such as carbolic 
acid or the hydrargyrum praecipitatum album; oxidizing ones 
to t hich also belongs chlorous toluolsulfonamide "chloramine", 
or dyes such as trypaflavine and methylene violet which be- 
sides a dye component contains a nitrogen element combined 
with a cuantivalence of five. By disinfection is meant a 
killing of the living cell by direct destruction of its 
structure. Disinfection is a catastrophe of the form, In 
the course of the functions of life it means an irreversible 
process and cannot consider any differentiation of the cells. 
For this reason an internal disinfection Us impossible, and 
even if it is applied locally irritation often sets in. By 
administering sulfonamides we practise chemotherapy. Chemo- 
therapy is a retardation of function. It aims at the function 
of the primitive germ cell without affecting the function of 
the differntiated organic cell. In accordance with this essent- 
ial difference between disinfection and chemotherapy, the surr- 
should disinfect the surroundings of the area of operation, t:- cm 
the itself locally and internally by chemotherapeutics, 
For the dermatologist too, the chemotherapy of infectious and 
infected dermatoses is a new departure. As the best form of 
local application an ointment of at least 10 per cent it to 
be recommended. The addition of Novocaine, tutocaine, or 
anaesthesia neutralizes the effect of the sulfonamides. 
The incorporation of a sulfonamide salt soluble in water 
has proven better than that of pure substance. Albucid and 
globucid form neutral sodium or triaethanolamin salts, eleudron, 
and pyrimal only alkaline sodium salts. For this reason only 
albucid and globucid are to be considered for incorporation in 
a form soluble in water, since we decline alkaline ointments, 
Eleudron and pyrimal must be incorporated in a firm substance. 
In order to avoid infection by production of spores the sub- 
stance must, just exactly like powder, be sterilized by means 
of heat. As a base vasaiine and lanolin or anhydricous lanolin 
may be used, 10 per cent globucid vaseline is to be recommended 
as the best remedy for all infectious dermatoses from impetigo 
contagiosa to the deep trychophytoses, for injuries due to cold, 
burns, ulcers, pemphigus, etc. In case of strongly oozing pro- 
cesses moist bandages with a 5 per cent solution of globucid can be made. For impetigo contagiosa, herpes zoster and 
especially for post-scaMtic treatment, the following shake 
mixture has proven effective: 
Globucid 
Talc, venet. 
Glycerin 
Aqua destillata ad 25.0 
As a therapeutic agent the powder is hardly of any im- 
portance, rather as a prophylactic if there is an inclination 
to intertriginous and interdigital eczema. Marfanil-prontalbin 
powder compounded of one part of marfanil and nine parts of 
sulfonilamide has no use for the dermatologist; neither can 
tibatin be used locally. Since a cure of infectious dermatoso; 
is also possible perorally, this may be combined with local 
treatment, for instance in case of cutaneous and subcutaneous 
processes such as furunculosis, abscesses, ecthyma, erysipelas, 
phlegmonosis, deep trichophytosis and is especially suitable 
for shortening the time of treatment. 
9. Injuries caused by sulfonamide treatment of gunshot wound, 
Oberstabsarzt (Major, MC.) Prof. RANDERATH 
The speaker discriminates between the following kinds of 
injuries caused by sulfonamides' 
1* Direct injuries which, according to the course of 
disease and the results of the post-mortem examination 
caused an injury to be regarded as due to a poisonous 
effect of the preparations used upon certain organs or 
tissues and 
2. indirect injuries which mislead one under the effect 
of therapeutic sulfonamide doses to assume a favorable 
course of the war-injury infection which somehow resulted 
in an injury for the wounded. 
In the area of the army known to the speaker in which 
systematic sulfonamide prophylaxis and therapy was practised 
direct injuries caused by sulfonamides were extremely rare. 
Fatal injuries to the liver or kidney were not observed. On 
the other hand the speaker noticed two cases of agranulocytosis, 
one of them after the administration of 45 grams of cibazol 
which was cured after the sulfonamide treatment was stopped. 
In this case the exitus resulted, after complete disappearance 
of the agranulocytotic blood picture, from a progressive 
wound infection after an injury by a shell fragment on the 
left buttock with an extraperitoneal injury to the rectum. 
Indirect injuries caused by sulfonamides are noticed 
more frequently. Their origin is to be traced back in the 
great majority of cases to a failure of the therapeutic effect 
of sulfonamides. The speaker mentions sbme examples• On the whole, injuries caused bv sulfonamides are so 
rare, that no contra-indication of the sulfonamide treatment 
of the gunshot wound infection can be derived from this. 
This final conclusion is to be made independent of the question 
of the effectiveness of sulfonamide prophylaxis and therapy 
of war-wound infections. 
10. Dosage of sulfonamide preparations to be administered 
Oberarzt (1st Lieut,« MC.) Dozent SOEHHING 
In consequence of the considerable differences of 
opinion among surgeons, no generally acceptable proposals 
for dosage of sulfonamide preparations may be deduced from 
clinical literature alone for the time being. For this 
reason, we are also obliged to use the results of theoretical 
research for this purpose. By animal test as well as by 
tests on cultures the growth inhibiting effect of sulfonamide 
derives is securely established. 
The work of recent years has shown more and more that 
penetration of the entire vector organism is less important 
than achieving the highest possible concentration in the 
area of infection. However, in order to Prevent the blood 
itself from becoming infected, even today one cannot forego 
obtaining and maintaining the highest possible blood levels 
of sulfonamides. 
As far as the question of dosage is concerned the most 
important results of animal tests and culture tests are men- 
tioned briefly. It is shown that the inhibiting substance* 
known since it was described by WOOD, and which also appears 
in the wound secreta makes the demand still more urgent that 
the highest possible concentration be obtained in the area 
of infection. 
There are two ways of meeting this demand: 
a. local application, 
b. using the blood to distribute the medicine. 
To a.: Practice has shown that in order to achieve 
sufficient concentration it is absolutely necessary to have 
clean conditions in the wound. Consequently this form of 
sulfonamide application must be performed exclusively by a 
surgeon and not by a physician in the field. It is necessary 
during every change of dressing to repeat the application in 
order to maintain effective concentration - which also depends 
on the solubility of the substances - as long as possible. It 
should be carried out as early as possible as then the pro- 
portion: concentration of the medicine to the number of germs 
is favorable. To b, Oral therapy and injection therapy deliver only 
part of the dose administered to the area of infection. In 
these methods of administration, however, the toxic effect 
has to be considered more than in local application. There- 
fore the physician in the field has to start it. The tech- 
nical possibilities are commented upon briefly. 
The following dosage routine * based on the available 
possibilities - is recommended: 
1, Three days after the injury 7*0 grams eleudron, 
cibazol or globucid, distributed during the day are 
given by mouth or as an injection, whereby a sufficient 
blood level is created and maintained, 
2, During the first surgical wound treatment and 
during each change of dressing the wound is dusted 
thoroughly with a suitable wound powder - Marfanil- 
Prontalbin, cibazol, globucid - according to stock 
available. It is very hard to establish maximal doses 
for this, as at the front, resorptive or local injuries 
were hardly ever observed, 
3, Repetition of the oral dose, or of the injection, 
is only necessary if definite symptoms of a generalized 
infection appear. It has then to be carried through 
energetically and with decreasing doses until the dis- 
appearance of fever. Occasional doses are of no thera- 
peutic value. 
Discussion: 
SAUERBRUCH; Mentions the chemotherapeutic experiences 
during World War I# He does not mean to reject the sulfonamides 
but would like them to be judged with greater reservation and 
criticism. 
SCHOERCHER: Considers the effect of tincture of iodine, 
rivanol or phenol-camphor as better, 
BOEHLER: In the Vienna hospital for accidents formerly 
3.7 per cent of disturbed wound healing occurred, since the 
use of sulfonamides 7 per cent, 
HEUBNER: Catalytic products originate in the organism 
as a part of the effect of the sulfonamides. 
USADEL: There is no denying that the sulfonamides have 
a therapeutic effect, 
KRUEGER: Exact surgical treatment of the wound is de- 
cisive, but so is early prophylactic use of sulfonamides. 
SCHOENBAUER: Sulfonamides are especially valuable in 
case of inflammations of the urinary system and in meningitis, 
SCHULEMANN: The effect of sulfonamides does not depend 
on the species but on the milieu. Directions for the application of sulfonamides« 
Tests (GEBHARDT-FISCHER) had the following results: 
The development of a suppuration of the soft part caused 
by common pus producing germs cannot be avoided even by 
immediate internal and external application of sulfonamide 
preparations. No influence by sulfonamides on the course 
of inflammatory disease of anaerobic germs could be ascer- 
tained. In case of combined gas gangrene therapy the im- 
pression of a. milder course under the effect of sulfonamides 
prevailed. 
Injuries caused by sulfonamides (RANDEHATH) are com- 
paratively rareo In a direct form they appear as injuries 
to the liver, even acute yellow liver atrophy, as injuries 
to the kidneys and as agranulocytosis. For this reason the 
white and red blood picture should be controlled as far as 
this is possible under front-line conditions. Lowering of 
body temperature caused by attacks on the central regulation 
center may be considered as indirect injury which often makes 
it impossible to draw any final conclusions from the course 
of the fever curves concerning the course of wound infection. 
Moreover an occasional progressive deep lying wound infection 
may result from the local powder treatment. No direct damage 
of tissue has been noticed in the regions of the effective- 
ness of the preparations. 
In the treatment of meningitis intrathecal application 
of sulfonamides (MUELLER) is to be rejected too, as~ it may 
lead to serious disturbances in the area of the spinal cord 
and to paralyses. 
It has been pointed out in the clinical review that the 
optimistic voices have been decreasing while the critical 
ones have increased. The troubles mainly seen by the clinical 
specialist are lack of appetite and vomiting as well as in- 
creasing fatigue. 
Early application in the wound area is essential for 
the effect. Enteric or parenteral administration of sul- 
fonamide preparations cannot prevent the setting in of wound 
infection, but the course can be influenced favorably. 
Thus we get thefollowing rules for practice: 
Any superficial wound, such as grazing shots, tangential 
shots, widegaping wounds in the soft parts are to be dusted 
as early as possible with sulfonamide powder. Dusting is 
of no use if the depth of the wound cannot be reached. To 
dust small wounds at the spots where the bullet entered and 
left the body is ineffective. Dusting of the skin is sense- 
less and may produce eczema. In case of deeper wounds the 
quickest and most thorough surgical wound treatment has to 
be performed. In addition to this the wound may be dusted 
with sulfonamide powder which must reach even the deepest 
recesses. Powder treatment of granulating wounds is not in- 
dicated. If during the first few hours no possibility of 
powder treatment exists or if this does not seem sufficient 
it is to be replaced or completed by peroral administration 54 
of sulfonamides. Intravenous injection cannot always be 
carried out under field conditions. According to the danger 
infection to the wound large doses are to be used for a 
short period, that is 6 - 10 grams of sulfonamide during 3 - 4 
days (the total not to exceed 50 grams). Small doses are 
usually ineffectual and therefore without influence on the 
course of infection and if they are given for too long a 
time they may have a harmful effect. Suitable preparations 
are preferably eleudron, cibazol and globucid. If possible 
the medication is to be prescribed by the field physician. 
In the case of wounds in danger of gas bacillus infection 
- and this applies to all large and deep muscle wounds - gas 
gangrene serum should be given besides the local and oral use 
of sulfonamideo In the case of second operations, e.g. re- 
section of the ribs, for empyema of the pleura, for secondary 
sutures and later amputations, the new operative wound can 
be dusted sufficiently with sulfonamide powder after control 
of the bleeding-. 
Under no circumstances must the thoroughness of the 
surgical wound treatment be less because of the additional 
use of sulfonamides. 
For gunshot wounds of the abdomen as well sulfonamides 
may be used in the form of a powder (approx, one tablespoon) 
or an emulsion placed in the abdominal cavity. 
11. Pathologiqp~anatomlcal bases of chronic tissue damage 
in case of injuries due to cold. 
Oberstabsarzt (MajorT MC.) Prof* STAEMMLER 
I# Changes in vessels, 
a. In the demarcation area there often are endangiitic 
processes which 1. take place through spreading of inflammation 
from the adventitia to the intima and 2. spread primarily from 
the intima by the infiltration of plasma. 
Striking "honeycombed endophlebitis" with xanthomatous 
fatty granulations in the veins are observed. 
The disproportion between the age of the Vessel changes 
and the time passed since the exposure to cold leads one to 
suppose that vessel changes may continue to develop for a 
long time after the exposure ceases. 
b* Following exposure to cold, endangiitis of the large 
vascular trunks, apart from the damaged area may be present 
continuously or discontinuously, which corresponds to the 
circumstances of juvenile gangrene and may be the origin of 
the same. II, Changes in nerves. 
Very frequently part of the changes in the nerves occur 
in a very severe form. Extensive disintegration of the medul- 
lary sheaths, in most cases also of the cylinder of the axis, 
with formation of fat globules and fatty granular cells, often 
extending far beyond the actual area of the injury duo to cold. 
Parallel with this there is often a very severe peri- 
neuritis and endoneuritis which in its intensity does not 
run parallel with the nerve disintegration but apparently 
depends on it. 
Nerve disintegration is considered as due to anoxemia, 
IIOWner tissues. 
Atrophy of the epidermis with hyperkeratosis. Lesions 
are seen in the elastic fibers of the cutis. Vacuolar trans- 
formation of the sudoriparious glands is seen. 
Severe, often focal, atrophy of the muscles (outside 
the necrotic area proper) with atrophic proliferation of 
the nuclei. 
Atrophy of the bones, also outside uhe demarcated area 
proper, most likely of the SUDECK's kind of atrophy. 
Discussion: 
OSTEHTAG: From the collecting area of the homeland I 
only know such cases as were shown by STAEMMLER, which partly 
had died intercurrently or of which I received amputation 
specimens or reamputation specimens. This material is not 
clear enough to solve our problems. Important for late in- 
juries, which may extend over years and decades, are the few 
observations which concern soldiers of the first World War 
(chiefly of the first few months of 1917) and the patients 
with injuries due to cold who have died intercurrently. 
Changes in vessels, lesions of nerves, injuries to muscles 
and damage to bones exist side by side. In the case of in- 
juries to the muscles one must differentiate between such as 
are cause by direct effects of cold and such as must be con- 
sidered as depending on the nerves. Such muscle degenerations, 
depending on the nerves, often influence only small areas and 
make themselves apuarent as irregular degenerations of the 
fibers. Contrary to motor losses which are rarely observed 
we could demonstrate degenerations even to the retrograde de- 
generation seen in the anterior horn cells. Partly, the 
nerve decay is caused by a primary effect of cold, partly 
through disturbances of the nourishment of the tissue due to 
the edematous infiltration, partly through changes of the 
vessel. 
The most important factors in late results of injuries 
due to cold are the incompletely cured i.e, incompletely 
restored vessels and the disturbance of the autonomous nervous 
system. If a vessel is completely closed by scars and a new 
circulation from collateral vessels is formed tho danger of extensive late injuries is far less than in case of preserved 
vessels flith damaged walls* In case of such an incompletely 
recovered vessel, located in the periphery, spasms may be 
started by all kinds of irritations, especially of cold, and 
which involve the entire vascular trunk. They are to be sup- 
pressed if the part previously injured by cold e.g. the big 
toe, is anaesthesized. Their occurrence can be stopped by 
local application of vasodilating drugs. 
The second danger is infection We know that parts once 
injured by cold are especially subject to infections. The 
entire endothelial takes part in the reaction to in- 
fections » It leads to spasms and to er.darterial changes in 
the pathological vessels. The latter may be quite extensive 
within a short elms* Already, four months after the injury 
due to cold 'in the injured extremity only, endangiitic pro- 
cesses are also \.r bo found* 
It is generally known that the healthy animal reacts 
even on repeated injury by cold with a restoration of the 
vascular system. I know that the cold injuries in the high 
mountains occurred especially easily in association with in- 
fection or after use of medicaments (e.g. pyramid on). 
SIEGMUND; The procurement of suitable test material is 
very difficult. Keener interest of the attending physicians 
in the scientific necessities would be desirable and cannot 
be enjoined on them very well. The most interesting thing 
in the examination of late cases is the irregular spreading 
of the changes in the vessels, bones and muscles, as well as, 
though less distinct, the changes in the nerves which are due 
to a degeneration. These processes are often intermittent 
too* Besides older changes, new ones are also seen which in 
my opinion are also the result of disturbances of the blood 
circulation and changes of tonus in vessels. They are con- 
nected with effects on the vegetative nerves, to the afferent 
as well as to the efferent fibers and periadventitial reticula. 
SCHOPPER; Reports on late vessel injuries due to cold 
associated with spotted fever which occurred in the form of 
endangiitis obliterans which causes later gangrene in the ex- 
tremities, though no clinical symptoms were to be noticed 
before the onset of spotted fever. 
STAEMMLER: Comment on the reports of OSTERTAC and SIEG- 
MUND s The nerve changes which I have noticed spread centrally 
beyond the organic changes in the vessels. Endarteriitis ver- 
rucosa is frequently seen. In my material nerve changes are 
not interrupted (as contrasted with changes in vessels and 
bones). In injuries due to cold the infection factor plays 
a certain part though it is no conditio sine qua non. 
SIEGMUBD: Searching for anatomically demonstrable changes 
by staining of neurofibrils seems to oe to offer good prospects 
for the sympathetic ganglia as well. The undemonstrated associ- 
ation of infections and other secondary changes, which leads 
to delayed disturbances of circulation and nutrition, sometimes 
acts by ways of the vegetative nerve system. The injuries to 
the nerves are not so much a result of a direct effect of the 
cold as disturbances of the blood circulation caused by the cold, 
as can be shown by experiments. The changes in bones will be 
treated in detail in a treatise which is in the course of pre- 
paration* 12». Calling up for active service of men suffering from 
injuries due to cold. 
Generalarzt (Brig. General, MC.) Prof. GOHRBRAEDT 
It is comparatively easy to find delayed injuries after 
exposure to cold. Deficient blood circulation of the skin, 
lowered skin temperatures, disturbances of sensitivity and 
local changes in the skin and profuse perspiration 
will indicate late injuries after a previous damage by cold. 
In doubtful cases, complicated methods of examination (oscillo- 
metry, arteriography etc.) must be used to determine the form 
and severity of the late injury. 
The number of men suffering from injuries due to cold 
can only be calculated correctly if those soldiers are con- 
sidered also who had previously suffered from frost-bite and 
were called up for active service again without any demon- 
strable morbid changes. Soldiers with changes in the vessels, 
which resemble the picture of late injuries, must not be 
counted among those injured by cold if they did not suffer 
any important injury clearly due to cold. Besides these, 
those whose late injuries are due to faulty amputation stumps, 
must not be reckoned among those suffering from injuries due 
to cold. 
The question of how far men suffering from cold injuries 
may be called up for active service again is answered as fol- 
lows: If after injuries due to cold certain morbid changes 
can still be observed, these soldiers will be called up for 
active service according to their physical limitations, either 
not at all or only in a limited capacity. Above all one has to 
take care that they will not suffer from a new damage due to 
cold again. 
In the case of soldiers who have suffered from injuries 
due to cold and seem to show no pathological symptoms, the 
decision concerning their full or limited active service de- 
pends on whether or not they belong to the group of those havin 
been injured by cold. All soldiers with disturbances of their 
vegetative nervous system, the so-called vegetatively stigmatLzeo 
especially the vagotonic ones, are to be considered as especi- 
ally endangered by cold. After having suffered from injury due 
to cold once, the hazard by cold not only persists but is even 
increased. This is the reason why men endangered by cold 
should be employed only in a limited capacity, e.g. only on 
those frontsvhere no special cold temperatures are to be ex- 
pected. 
Most of the soldiers who suffered no permanent damage 
after injury by cold andare not especially endangered by 
cold will become fit for active service again. Unfortunately 
the period for observation of the two last winter campaigns 
is not yet sufficient to prove this statement positively. Wc 
know that late injuries by cold may still crop up even years 
later. Therefore it seems appropriate for these soldiers also 
to not expose them to a renewed injury by cold. This is, how- 
ever, only a precautionary measure. Directions for re-calling for active service those 
soldiers who have suffered damage from cold• 
Pathologico-anatomical bases: 
The principal changes with injuries due to cold which 
are no longer recent are found in the blood vessels and the 
nerves. The vessels show changes in the demarcation area 
which are to be classed among the group of endarteritis and 
endophlebitis. It cannot be said with absolute certainty to 
what extent they are a result of exposure to cold, a result 
of subsequent infection, or of the inflammatory demarcation 
of the injured tissue. 
It is important that following injury due to cold en- 
dangiitic processes may develop far beyond the demarcation 
area which are maybe either continuous or discontinuous with the 
changes in the vessels in the demarcation area, e.g. in the 
vena femoralis. Thus after an injury due to cold the parts 
affected by the cold, in many cases a very extensive process 
of decay is to be found, which reaches far beyond the serious- 
ly injured area. It consists in a disintegration of the 
medullary sheaths combined with the formation of products 
of disintegration, of neutral fatty composure and of cells 
of fat granules with destruction of the axis-cylinder and 
at least a relative increase of SCHWANN*s cells. The pro- 
cess is often combined with perineuritis and. endoneuritis. 
The disease is considered as a result of anoxemia and could 
also be created experimentally. It seems to have a good 
prognosis and may heal up with absolute functional restor- 
ation. 
Besides the diseases of the blood vessels and nerves 
those of the muscles (necrosis and atrophy), of the skin 
(atrophy, hyperkeratosis, dystrophia,of the nails) and the 
bones are of less importance. They are to be considered 
throughout as results of disturbances of the circulation. 
Clinical part: 
Men actually suffering from cold injuries with manifest 
morbid changes, no matter whether a special danger by cold 
can be proven or not, will not be fit for active service or 
at least only for limited employment according to the de- 
gree of the injuries, and must not be exposed any more to 
a renewed hazard due to cold. They are to be employed ac- 
cordingly. 
Those men, who suffered damage due to cold but no 
longer show any morbid changes, are particularly predis- 
posed to cold damage, above all the so-called vegetatively 
stigmatized group, and they can only be employed in a lim- 
ited way, e.g. in districts where no danger of damage from 
cold is to be expected. After an injury due to cold the 
danger of cold injuries which existed previously not only 
remains but will even be increased. If such a danger of injury by cold by predisposition 
does not exist, and if no morbid changes can be proven, full 
fitness for active service is to be assumed. As, however, 
late injuries may still appear years later; the present 
period of observation, however, is too short to allow a 
final diagnosis, it is advisable to employ, when possible, 
those men not in danger of injury due to cold but without 
manifest symptoms of disease, according to the injuries 
suffered only as fit for limited e.g. not to 
expose them again to the danger of cold injuries. 
\ 
According to the observations and experiences up to 
now one must reject as incorrect the View that every one 
who has been exposed to or has suffered damage due to cold, 
is particularly liable to get a permanent injury and is 
therefore only fit for limited employment. If in spite of 
this a fitness for United employment is assumed this is 
only a matter of precaution. 
13* The diagnosis and treatment of pains due to gunshot 
injuries to nerves, along with directions• 
Stabsarzt (Captain, MC.) Dozent ZU5LCH 
For therapeutic reasons it is necessary to subdivide 
gunshot injuries of the pain of gunshot injuries to nerves 
according to the quality of pain* Three groups of pain 
(mixed forms also are seen) are to be distinguished according 
to quality, duration and "Trigger-mechanism". 
1. Group of "prickling pain" (pain paresthesias) with 
"tickling-prickling sensations" as in the case of a "numb 
foot" or as if masses of ants were walking on the skin, with- 
out interruption. Besides these, pinching-pressing 
"lightning" pains which are only temporary. Location in the 
nervous system. Onset within a few hours or days after the 
injury and may last for weeks and months. Slowly decreasing. 
Intensification with change of weather, alleviation by di- 
version of the mind. Severe sleeplessness. 
Treatment: 
(Symptomatic) Relaxation position of the nerves. Avoid- 
ing of mechanical irritation of the wound through^massage 
or medico-mechanical treatment! Strong susceptibility to 
cold even in summer - gloves! Analgesics less effective, 
caution against morphine on account of habit formation. 
During the first weeks, large doses of vitamin seem es- 
pecially effective (30 - 40 cubic centimeters/ in 20 in- 
jections). With vaccineurin-treatment (12 injections in 
o weeks) success has been noticed too. Operations on nerves 
ineffective. 
2. Group of the "burning" pains of causalgia* Typically 
appears as in the case of medianus and ischiatico-tibialis 
nerves and corresponding multiple injuries. Location in the peripheral parts of the limbs, principally on the volaf 
sides. Begins a few hours or days after the injury, lasts 
for months and years, starts and increases by startling and 
irritating impressions of the organs of senses eye, ear, 
touch. Onset of pains in the hypersensitive dry skin of 
the involved limb, in the opposite side or in the entire 
body. Caution against the diagnosis "hysteria or simulation”i 
Treatment: 
Symptomatic relief through relaxed position of the 
nerves, effect of moist coolness upon the involved ex- 
tremity or the opposite extremity, mental diversion. Avoid- 
ing any effect of heat (sweat box, heat pad). Specific 
treatment by alternating baths (1 minute cold, 3 minutes 
hot for 30 minutes, 2-3 times daily) of the injured ex- 
tremities or opposite extremities. With insulin cures (20 
injections of 20 - 50 units with 3 hours effect within three 
weeks; caution against hypoglycemia, trained personnel nec- 
essary). 
In severe cases and failure of conservative treatment 
first of all a novocain blockade at the place of injury is 
to be considered. If it is effective, an operation on the 
nerves is advisable. If this treatment fails, a temporary 
blockade of the sympaticus or its permanent disconnection 
by alcohol injection or operation is to be considered, 
3» Group of "cutting, darting" permanent pains of 
severe intensity through compression of the nerves with aneurysm 
g&aWtfc-G1 or strong formation of scars. Corresponding 
surgical measures. In contrast to the usual indication in 
case of intervention with the nerves, early operation be- 
fore expiration of the first 6 months. 
Discussion: 
CORDEL: Neuritides in nerves injured by gunshots 
are recognized by pressure pain above the place of injury 
up to the area of the plexus. 61 
14» The operative treatment of peripheral nerve injuries 
due to gunshots. 
Oberstarzt (Colonel, MC.) Prof, TOENNIS 
Directions: 
The following time limits, which were arrived at by 
observation of the spontaneous restitution of aseptioally 
healed nerve gunshot injuries, form a basis for the in- 
dication to operate as well as for the determination of 
the moment favorable for the operation. 
Location of Injury 
Space i 
of Time 
Average Onset 
of Recovery. 
A. 
Plexus brachialis, 
at any height of 
the plexus. 
i 
- 
10 
months 
10 
months 
B. 
N. radialis 
in the upper arm, 
1 
— 
6 
months 
6 
months 
in the forearm. 
2i 
— 
4 
months 
3 
months 
c. 
N, medianus 
in the upper arm, 
3 
— 
7 
months 
7 
months 
in the forearm. 
1* 
— 
3 
months 
3 
months 
D, 
N, ulnaris 
in the upper arm, 
Ur 
— 
6 
months 
6 
months 
in the forearm. 
1 
■* 
4 
months 
4 
months 
E. 
N. ischiaticus 
gluteal area, 
i 
- 
12 
months 
12 
months 
upper third of 
thigh, 
2i 
- 
12 
months 
10 
months 
middle third of 
thigh, 
H 
- 
8 
months 
8 
months 
loYrer third of 
thigh, 
i 
— 
6t 
months 
6 
months 
knee area, 
H 
- 
5 
months 
5 
months 
leg area* 
it 
— 
5t 
months 
4 
months 
If, until the average time of onset of recovery of 
a nerve, no symptoms of a returning motor function have 
appeared, an immediate operation should be performed. If 
before this moment motor functions reappear, there is no 
reason for an operation if a steady improvement is observed. 
If, however, a delay in the beginning of the function of the 
individual muscles takes place, and that without any other 
traceable cause, such as neuritis and intercurrent diseases, 
the place of injury in the nerve should be laid open* A 
positive failure for the HOFMANN tapping test shows a certain 
probability of the onset of motor restitution* Failures in nerve suture are a result of bad adaption 
of the nerve ends, partly or complete bursting of the suture 
by increased tension as a result of involuntary brusque 
movements during the period of after-treatment. This is the 
reason why after operation the limbs must be put in a rest- 
ing position by means of a plaster of Paris cast, in case of 
stronger tension on the nerve for at least 6 weeks. After 
this the extreme position of joints is relinquished step by 
step but continuously held firmly in the new position by a* 
splint which keeps it in a qui&t position. After 8-10 
weeks one may begin with cautious passive movements. For 
injured nerves in the leg a bed rest for 32 to 4 months is 
necessary. The rest of the treatment corresponds to that 
adopted before the operation. 
The degree of success depends on the careful carrying 
out of the after-treatment. 
15, Limits of the therapeutic evaluation in the X-ray- 
picture of peripheral nerve injuries shown 
by contrast methods, 
Stabsarzt (Captain, MO.) BRUNNER 
The showing of injured peripheral nerves in the X-ray 
picture is recommended: 
1. In all cases where, in connection with first 
operative care, a disturbance in the healing of the 
nerve cables may be assumed after 3-4 months b}' non- 
appearance of the HOFMANN tapping phenomenon. In this 
way reappearing failures of healing are recognized with 
absolute certainty and taken care of by secondary oper- 
ation without much loss of time, 
2. In cases where, before the first operative care, 
the site of the nerve injuries cannot be determined 
through the clinical picture with its numerous scars, 
the X-ray picture with many metal fragments,the neuro- 
logical test (thigh-ischiadicus, upper arm-ulnaris- 
medianus-radialis) will permit the accurate determinat- 
ion of the site of interruption so that the operation 
field may be restricted and an indiscriminate extensive 
exposure of the nerves can be avoided. 
The use of Vasoselectan yields much better results than 
Torotrast. It is resorbed in a short time (14 days to 3 
weeks) secreted chiefly through the kidney. If necessary 
one may begin with the operative care of the injured nerve, 
eliminating any irritation by a foreign soon after its 
use. 16# Plastic operations in case of nerve paralysis• 
SS-Gruppenfuehrer (Lt# Gen,, Elite-Guard) 
Prof. GEBHARDT and J. KOESTER 
The following recommendations are made for a success- 
ful performance of a plastic operation for treatment of 
nerve paralyses: 
1# Creating a passive support of the joint by extended 
tenodesis« 
2. Active strengthening by conservative transplant 
ation of muscles, 
3# Supporting silk-rein plastics which supply addit- 
ional strength from the still operating chain of links, 
4. Strengthening by muscular neurotization: Attention 
must be paid to; 
a# Creation of broad areas of contact; 
b. Control of hemorrhages by transferring anatomic- 
ally limited muscle parts, avoiding surfaces of in- 
cision in the muscle tissues which are in danger of 
hemorrhage and later formation of obstructions by 
scars; 
c* Removal of the muscle fasciae in contact with 
paralysed and non-paralysed muscles, as they too 
hinder the growing across of nerves; 
d. Decrease of irritation by foreign body within 
the area of contact by avoiding supporting sutures 
between the two muscles; 
e. Bony, or periosteal anchoring of the donor, 
which through this besides becoming a neurotiseur 
also becomes an active support. III. 
PROCEEDINGS OF THE CONSULTANTS1 
COMMITTEE ON DERMATOLOGY 
Translation prepared by: 
Office of Military Government for Germany (U. 3. ) 
Office of Naval Advisor 
Medical Section Treatment of infectious dermatoses with sulfonamides 
(See Section II, Article 8) 
Calling up for active service of men who have suffered 
from injuries due to cold 
(See Section II, Article 127^ 
Pathological anatomy of injuries due to Salvarsan 
(See Section VIII, Article 27 
Pathology of injuries due to Immunizations 
(See Section VIII, Article 3) 
1« Judgement of fitness for active service of psoriatics• 
Oberfeldarzt (Lt. Colonel. MC.) VOHWINKEL 
Well-known specialists maintain the point of view that 
no^psoriatics should be in the Army. If, however, no psori- 
atics were drafted into the ICO 000 man Army because suffic- 
ient thoroughly healthy young men were available, it goes 
without saying that this had to be changed with the intro- 
duction of universal (compulsory) military service# Psori- 
asis frequently appears for the first time during the 
period of puberty and early manhood, men are more often af- 
fected by it than women. Often it is tho strong 
young men who are affected, who are in othor respects com- 
pletely fit for military service. 
One must not forget either that a skin-disease very 
often changes its aspect through a change of environment. 
Psoriasis certainly is a disease whose origin and cure are 
influenced by climatic factors, above all by light and air. 
ROLLIER once called attention to the fact that psoriatics 
are free from symptoms as long as they expose themselves 
freely to the sun and by this acquire a dark-pigmented skin. 
We also know that ultraviolet light rays are a good remedy 
for psoriasis. In hardly any civilian occupation will light 
and air produce such an abundant effect, especially during the 
summer months as is the case in the Labor Service and Army. 
This may have the result that symptoms of the disease show 
a different form with some soldiers. 
A number of newly enlisted soldiers attacked by psori- 
asis who were transferred immediately to my department were 
kept under observation by myself for about one year# It 
proved that the majority had no or only unimportant recurrenc- 
es or easy to cope with by the physician in the field. Quite 
exceptionally soldiers in their first year of service had 
to be confined to a hospital a second time for 2-3 weeks 
to be treated for a relapse t£ psoriasis. 
There are of course severe and very severe cases of 
psoriasis, stfiich do not permit military service. Among 
these are,especially psoriasis arthropathica, quite ex- 
tensive forms of psoriasis which often relapse as shown by 
their history, and cases of psoriasis inversa which are 
often particularly malignant and may lead to secondary erythroderraias. These diseases must be classified by the 
examining physician from the beginning according to L 3? 
or U 35 or U 62. As for the remaining cases it would be 
wrong to deprive young men with lighter forms of psoriasis 
of the education and training by the Army, especially as 
Psoriatics are often particularly strong men in other re* - 
spects in excellent condition of health. In many cases one 
bven has the impression that military service is only of 
advantage to this skin disease* 
If one has worked in large hospitals during this war 
or inspected dermatology departments it could generally not 
be noticed, certainly not in France, that psoriatics with 
lighter symptoms were hospitalized for any considerable time. 
As a rule the lighter cases were always sent 
back for treatment to the troop physician. On the other 
hand the severe cases were treated on the wards - there is 
no other possibility. In my department in Paris, 241 psori- 
atics with severe skin-disease were treated in one year. 
The average period of treatment was 30 days. These figures 
indicate that without exception, severe cases were treated. 
My inquiries with physicians who manage large dermatology 
departments in the West showed that of recent date hospitali- 
zation requests from the field physicians were made accord- 
ing to regulations. In spite of this it will happen now and 
then that patients are admitted whose treatment could have 
been taken over by the field physician, or whose symptoms 
are of such minor importance that they will need no therapy 
at all. This should be avoided, as at present every man is 
needed by the Army. It is an important task of the field 
physician to do everything, in order to maintain the fit- 
ness for military service of his men and thus the Army*s 
readiness for action. During the inspection of defense posts 
and advanced bases in my section of service I often examined 
the state of health and the general hygienic conditions of 
the soldiers. Thereby it could be observed that naturally 
there is always a number of cases of psoriatics in which 
neither the patient nor the physician pay any attention to 
the symptoms of the disease, because they are not very ex- 
tensive, On the other hand also such cases were noticed 
which after all showed fairly severe changes of the skin 
and should not have been left untreated for aesthetic reasons 
on account of the close living conditions of soldiers. In 
these cases it must be decided whether the troop physician 
should not undertake treatment with prescriptions which do 
not molest the patient or which do not damage the laundry 
to any extent. In some cases this may be quite possible, 
even maintaining the fitness for active service of the 
patient, 
I was informed of two striking cases; Both of them 
were men from 28 to 32 years of age. For years they have 
been known at a university clinic for diseases of the skin 
as particularly severe psoriatics, resisting any therapy, 
but, in spite of this they were drafted. Both were workers 
from the armament industry and both had to be discharged 
from military service after about 4 months, after staying 
in hospitals nearly the entire time. The severe aggravation in the beginning of their service with the Army was cer- 
tainly to be traced back in both cases to the fact that 
they could not care for their skin regularly with baths 
and ointments. They had been in a position to do this 
during their civilian life and had been able to perform 
their job. Thus, however, they were of no use either to 
the Army or to the armament industry. Perhaps it would 
be advisable with psoriatics, if no lighter forms are in- 
volved, to take expert opinion about them at the clinic 
or hospital where they are known. The judgement of such 
institutions which has to be given most conscientiously 
and to the best of their knowledge, might in such cases 
be considered more when they are drafted. 
The classification chart gives instructions under 
number 3 how skin diseases are to be judged. No doubt 
can exist after the before-mentioned that all columns of 
this number are applicable for the treatment of psoriasis, 
according to the seriousness of the disease and its ten- 
dency to relapses9 According to column 6 "chronic and con- 
tagious skin diseases of such forms that they provoke 
. loathing" belong to the class "unfit for service"• The 
two before-mentioned cases are such. Psoriatics of this 
type are absolutely unfit for active service. 
Directions: 
Light cases of psoriasis either need no treatment at 
all. or they should be treated by the field physician. 
By this, fitness for active service is maintained. 
Medium and severe cases are to be sent to a hospital, 
because it is only there that the installations for ap- 
propriate therapy to obtain a quick restoration of the 
patient’s fitness for active service are available# 
The most severe cases such as psoriasis arthropathica, 
psoriasis inversa and most extensive cases which show" a 
history of frequent recurrences are usually unfit for ser- 
vice. They have to be classified as L 3 or U 3 or U 62. 
At the first military medical examination inquiries at 
hospitals in which psoriatics were often treated are^of 
value in some cases before the first medical evaluation 
is given. 
2. Experiences gained in the treatment of lues* 
Together with directions: 
Oberstabsarzt (Manor. MC.) Prof* SCHREUS 
The new instructions for the treatment of lues were 
the chief subject under discussion. On the whole they 
correspond v/ith the experiences as well as with the measures 
demanded by active conditions, as far as they demand a de- 
parture from peace time routine. The following points were fully discussed: 
1* The course of treatment for a cure generally de- 
mands no departure from peace time routine. No change in 
usual practice should be made. In cases of strong con- 
stitution and normal organic conditions 0.6 grams of Neo- 
salvarsan or Natriumsalvarsan may be injected twice a week 
or every 5th day. It is, however, to be pointed out that 
a decreased dose to be graded individually, must be pre«* 
scribed by the physician, if the general physical condition 
of the patient or the findings in single organs indicate 
this. In decreasing the doses and the resultant weakening 
of the effects of the cure it must be considered that an 
inadequate treatment may have serious consequences for the 
patient. Under no circumstances is it allowed, for reasons 
of energetic lues treatment, to expose the public to a 
dangerous risk caused by war as by intensive but inadequate 
treatment the danger of contagious recurrences and a spread- 
ing of the disease may result. 
2. From these points of view the increase of inter- 
vals between the single injections has to be judged too, 
which is in Itself indicated with every appearance of in- 
tolerance. The total lengthening of the cure thus caused, 
which generally is not in the interest of the Army, must be 
considered too. 
3. Techniques The dissolving of Salvarsan is to be 
performed with the greatest care and separately for each 
single injection. The tendency of Salvarsan to oxidize 
and the resultant increase of toxicity must be considered. 
The cleanliness of the containers and the syringes for dis- 
solving the Salvarsan, especially that residues from pre- 
vious injections are not present, must be watched over con- 
stantly, When an injection is made it must always be con- 
sidered that a different medicament is injected. Pharmaco- 
logists consider it as dangerous to use less than about 7 
cubic centimeters sterile aqua (twice distilled) 
solving Salvarsan. It is not advisable to use additional 
substances in the dissolving medium (glucose, calcium com- 
pounds, cebion). If one wants to administer such substances 
they should be given separately from Salvarsan. The injection 
has to be made slowly (at least 1 minute). Paravenous in- 
jections have to be absolutely avoided. The injections are 
to be made with the patient in a reclining position. 
4. General points of view: A careful questioning 
and examination of the patient is necessary before the 
beginning of the treatment and during the treatment before 
every Injection. The latter examination is to be made with 
stripped upper part of the body. One must especially watch 
for exanthema and purpura. The mucous membranes of the 
mouth and throat are to be examined too. One always should 
inquire how the patient tolerated the last injection, es- 
pecially whether fever or chills were noticed. Before every 
injection the urine has to be examined for albumen, if the 
diagnosis is positive for sediment and once a week for 
urobilin. In case of the slightest suspicious symptoms a 
specialist's advice must be asked for before a continuation 
of the treatment, in order that, according to circumstances, 
more detailed examinations (blood-picture) may be made. In areas with accumulated appearance of hepatitis epidemica 
special attention is to be paid to the function of the 
liver, 
5, As regards the total number of courses it is re- 
commended to give 2 "safety” courses after disappearance 
of the clinical symptoms. If the seroreactions do not be- 
come negative it is generally to be recommended that a 
specialists advice be requested about the amount of the 
dose to be given. 
6, Cases in which Salvarsan cannot be used, because 
the patient cannot stand it, are to be treated in the same 
way. 
7* If it may be supposed in consideration of the 
clinical findings, the treatment history and the spinal 
fluid test, that the patient received an adequate treat- 
ment, it may generally be assumed after 2 years at the 
earliest following careful observation that the disease is 
cured and permission for marriage can be given. in 
exceptional cases and after consulting a specialist should 
this period be shortened, 
8, The further application of complement fixation 
reactions is also desirable. On account of the difficult 
decision concerning the amount of treatment and the evaluat- 
ion of the cure, one cannot eliminate their use. It is 
therefore proposed, apart from the present existing regulat- 
ions concerning the use of sero reactions, to make it poss- 
ible for the WASSERMANN examination of the serum to be per- 
formed, at least if requested. 
3» Experiences in the treatment of lues based on the 
new instructions« injuries caused by Salvarsan, 
deaths, etc. 
Oberfeldarzt (Lt. Colonel, MC,) Prof# GOTTRON 
There are two reasons why lues treatment is discussed 
anew, the one is, because lues itself is increasing and the 
other, because of an increase of the often fatal injuries 
caused by Salvarsan, Fatal cases due to drug and therapeutic 
action during a stage of disease like lues I and II are 
always alarming. The importance of injuries caused by Sal- 
varsan as regards their frequency is evident in comparison 
with the fatal cases during narcosis, after chloroform which 
appear in 1:2500, while fatal cases due to Salvarsan in one 
field hospital were observed 1:100 in another as 1:730, of 
the treated lues patients. However, in the dermatology 
clinic of Breslau University only one fatal case among 1400 
treated lues patients was observed during the last years. 
Salvarsan dermatitis, acute yellow liver atrophy, agranulo- 
cytosis and panmy©16phtisis as well as purpura cerebri are 
the diseases with fatal result. At present the proportion 
of these diseases is quite different from that during the period after the first World War* During that time fatal 
cases of Salvarsan dermatitis were predominant while at 
present it is purpura cerebri, agranulocytosis and panmyeloph- 
tisis* This becomes understandable by the fact that physic- 
ians learned to avoid severe Salvarsan dermatitis and to 
treat an early case, and also to diagnose and estimate cor- 
rectly the warning symptoms of the development of a Salvarsan 
dermatitis with exception of paravenous infiltrations which 
are found in 42 per cent of the Salvarsan dermatitis patients. 
The possibility of the appearance of liver injury is also 
taken into consideration by physicians more than before, so 
that for this reason injuries to the liver with fatal result 
caused by Salvarsan treatment have become more rare# This 
is surprising, since injuries to the parenchymal liver due 
to many infections and not least of all by hepatitis epi- 
demica, are rather frequent and thus the danger of an in- 
jury to the liver during the Salvarsan treatment is increased. 
On the other hand it is to be considered that the food con- 
ditions in the Armed Forces are more favorable than during 
the first World War and the inflation period 5 therefore the 
more serious effects are avoided. Injuries to the blood- 
building apparatus and the purpura cerebri are the predom- 
inant symptoms. The first of these may be limited by ob- 
servation of the skin for hemorrhages before eabh injection 
of Salvarsan and by examination of the blood-picture to be 
made afterwards. If the blood picture is not examined be- 
fore every injection, which is not practical, hardly any 
warning symptoms of agranulocytosis will bo detected. Pur- 
pura cerebri may be limited by treating hemorrhagic 
ary exanthmata adequately with bismuth, before the application 
of Salvarsan, and by considering that the Salvarsan itself 
widens the stream tract, slows down the stream, and so pro- 
duces those conditions of circulation on which purpura cerebri 
depends. This progress gradually results first in a brain 
edema and only afterwards in a purpura which, however, some- 
times does not fully develop. Previous infectious diseases 
developing into the above-mentioned conditions of the cir- 
culation should cause one to be cautious in the use of Sal- 
varsan. From all this it may be seen that it is not lues 
which is to be treated but the lues patient, and that greater 
consideration should be given to the individual treatment 
of the lues patient. Lues I and II are not fatal, but 
seldom the patient dies from the treatment of them. Injuries 
caused by bismuth which are fatal only in exceptional cases 
are mentioned. For the undesirable occurrences in connection 
with lues treatment, technique is more responsible than the 
remedy. 4* Chemo-resistant gonorrheas. 
Stabsarzt (Captaih. MC.) Prof. FELKE 
As a superficial infectious disease, gonorrhea, on 
account of its accessibility, permits an excellent obser- 
vation of the processes of chemotherapy. Of the relations 
between the three factors, organism, germ and sulfonamide, 
those between germ and sulfonamide are always considered 
as more measurable, in corroboration of tho work of FELKE. 
According to this the majority of chemo-therapcutic failures 
shows gonorrhea strains which are resistant to sulfonamides 
in the culture as well. These organisms retain their 
characteristics in corpore and in vitro when transplanted 
to new culture mediums and partners (confirmed by HAGERMANN, 
VONKENNEL, KIMMIG)• 
Thus the danger exists that the susceptible strains 
disappear more and more, while the resistant ones increase 
in percentage. Consistent with this is that in the East 
the gonorrhea treatment has fewer chemotherapeutic failures 
than in the West where general chemotherapy has been applied 
already for some years. This clinical observation urgently 
needs experimental study by tests of the strains. 
It must be demanded that in the treatment sulfonamides 
should be used in doses as strong as possible and that the 
greatest attention should be paid to the cure of female 
sources of infection. 
If chemo-therapy fails the best effect seems to be 
obtained by fever therapy beginning from the 4th week of 
infection with 40 per cent Olobintin or Pyrifcr and then 
in combination with an intensive additional sulfonamide 
course* Besides this the classical but mild local treat- 
ment is necessary. 
5, Concerning the fitness for active service of men 
suffering from damage due to cold. 
Oberfelderzt (Lt» Colonel, MC.) Prof* E. HOFMANN 
During the second Russian winter the troops were living 
under different conditions than during the first Russian 
winter owing to the change of humidity during the day and 
cold during the night. 
Medical care must provide against this. The complaints 
remaining after injuries due to cold are only partly based 
on objective findingsJ Capillary dysfunction, sweaty feet, 
sclerosis* The conditions of blood circulation of the in- 
jured extremity may bo worse than normal for weeks and months* 
Consideration is to be given to the possibility of late 
injuries) and under certain circumstances attention is to 
be paid to SUDEK's bone atrophy. It goes without saying that 
such persons must be treated particularly careful during 
their later service. Tho care for the reemployment of men suffering from 
cold damages must be left principally to the replacement 
unit. 
Information and detailed instructions by the field 
commanders and the field physicians are always urgently 
needed even before the beginning of the dangerous season. 
The soldier/ must know how injuries due to cold arc 
caused. He must find understanding for his needs with the 
non-commissioned officers, clothing, boots and shoes must 
be handed out according to the needs, sufficient socks for 
changing, boots should be large enough so that two pairs 
of socks can be put on. 
Special attention is to be paid, however, again and 
again to the treatment in due time of sweaty feet not only 
in consideration of the perspiring of tho foot in summer, 
but as prophylaxis against new injuries due to cold during 
the winter* 
At the replacement unit medical evaluation is necessary 
to determine whether the soldier is still fit to do infantry 
service or whether he has to be transferred to another arm 
of service. It would be harmful, however, if at the replace- 
ment unit or at the front field unit tor much would be said 
of men suffering from injuries due to cole, and if a soldier 
became aware of a possibility to over avail!.-', to tho disease 
he experienced. While one can notice that the soldier in 
tho front line in action is inclined to underestimate be- 
ginning cold injuries, one can observe later on that he 
frequently emphasises his complaints. 
Here tho correct psychological care for the soldier 
is necessary at the replacement unit. 
If all precautionary measures are taken it is obviously 
not necessary to withdraw the majority of the men suffering 
from slight frost-bite from the service at the Eastern front. 
It is necessary to carry out all the necessary hygienic 
measures for those suffering from frost-bite, as well as 
for the new-comer on all sectors of the front:. IV. 
PROCEEDINGS OF THE CONSULTANTS' 
COM M ITTEE ON FOR ENSIC MEDICINE 
Translation prepared by: 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section (Summary) 
In the Army the consultants on forensic medicine have 
not yet been fully organized. Thus for the present it was 
less important during the conference to speak about results 
and to frame directives. It seems more advisable to check 
the instructions given in the service regulations for the 
consultant forensic physicians and the manual on the evalu- 
ation of self-mutilation with the experiences made so far, 
which was used as a basis of discussion at the previous con- 
ference# 
In this sense the reports of the two first forensic 
medical consulting physicians active in the operation sector 
Oberstabsarzt (Major, MG.) Prof. MUELLER and Stabsarzt 
(Captain, MG.) Prof. BUHTZ on their experiences were fully 
discussed# It proved that the employment of forensic physic- 
ians was warmly welcomed notably by the army administration 
of justice, but also by the medical corps, and especially 
by the pathologists who have been particularly overworked 
until now# The demarcation of activity, especially against 
that of the pathologists, has been successful. The field 
physician and the troops must still become more used to con- 
sulting the forensic physicians. In the future this will be 
favored in a desirable way by the order of the Army Surgeon- 
General of 7 May 1943 to the effect that forensic autopsies 
are to be made only by consultant forensic physicians or 
pathologists. 
Among the results of the previous employment of forensic 
medical specialists rhe well-known examinations by BUHTZ in 
the forest of Katyn must be particularly mentioned. These 
are especially binding for us scientifically in order of the 
echo they found in the homeland as well as in foreign countries 
and especially by the collaboration with forensic physicians 
of friendly and neutral countries. 
For a further planning of action the atffiitoor of 
individuals required for filling the existing positions had 
to be named from the circle of forensic physicians with 
the cooperation of the president of the German Society 
for Forensic Medicine and Criminal Affairs. In this great 
difficulties had to be overcome, because the needs of aca- 
demic work and of experts, activity in the civilian sector 
had to be considered in each individual case. 
As regards single special fields Oberstabsarzt (Major, 
MG.) MUELLER dealt with the microscopic diagnosis of short 
range gunshots. He far surpassed the old inadequate ex- 
amination of excised preparations for powder ingredients 
with a new method, that is the microscopic examination of 
thin strips of epidermis from smoke suspicious areas. The 
method is introduced as an additional examination medium 
besides other optical methods and besides microchemjcal 
methods. 
In a lecture on self-mutilation with chemical means, 
PLANNING mentions that some new observations of self-mutil- 
ation by injection of petroleum and by application of var- 
ious stimulants to the skin have been reported. Prof. SCHMIDT, Danzig, was able to contribute the experience 
that petroleum in the tissue could not only be proven by 
distillation when newly applied but also in ulcers which 
were some weeks old. 
The lectures of HALLERMANN linked the problems of 
the consultants’ group with the theme proper of the con- 
ference: The right to support in case of sudden death. 
HALLERMANN based his lecture on the well-known classi- 
fication of cases of sudden death into; 
A* such as are explained principally by an undetected 
primary disease; 
B. such ones in which the probable causes of death 
are factors of constitution and disposition and 
C. cases for which the cause of death is not as- 
certained even by autopsy by a specialist. 
In cases of sudden death the following view-points 
were underlined by him as important directions for clari- 
fying the questions of the causes and the acknowledgement 
of an injury receivsd in service* 
For the A- cases causality is to be aiswered in the 
affirmative, if fundamental conditions on the pecul- 
iarity of army service contributed esseno ally to and 
caused the fatal result of the primary iisease. A con- 
nection is re co denied, if death would have resulted by 
progress of one primary disease by Divine dispensation and 
if only conaioin.; irrelevant to the law, variable and 
accidental, were responsible for death in the given period. 
For B-cssas lie external or internal accidental causes 
are often responsible for death.. Causalty is to be re- 
cognized if a fundamental accidental cause or a temporary 
disposition is to be •/raced back to army influence. 
In C-cases often the imperfection of our knowledge 
has to be considered in favor of uhe person entitled to 
support* In case of sudden death anatomically uncertain 
injuries received in service are to be recognized if the 
possibility of a harmful effect of army service influences 
is not precluded by clear signs. 
Special attention is called to the fact that a judging 
of the degree of causal influence is to be determined ac- 
cording to the conditions of the individual case and not 
by its effect on a thoroughly healthy person. V. 
PROCEEDINGS OF THE CONSULTANTS * 
COMMITTEE ON 
OTORHINOLAHY N G 0 L 0 G Y 
Translation prepared by: 
Office of Military Government for Germany (U. S. ) 
Office of Naval Advisor 
Medical Section Effects of sulfonamides; 
CSee Section II, Articles 5 - 10) 
Late results after commotio and contusio cerebri. 
XSee Section XI, Article 7) 
1» The treatment of gunshot wounds of the .jaw and face 
by plate-wire method. 
Professor PERWITZSCHKY 
Opinions still differ about an appropriate treatment 
of injuries to the face. On the whole the following three 
principal groups may be distinguished; 
1* The conservative method of treatment, in which 
the wounds are first made to heal with supporting bandages. 
Later on the remaining defects are covered with plastic 
operation. 2. The wounds are stitched after trimming of 
the wound edges. 3* Each wound is sutured in the stage 
of granulation (early suture, GANZER). 
In the beginning of the Eastern campaign I first 
adopted the method mentioned first in my department of jaw 
surgery and facial surgery. As a routine method it did 
not satisfy me, especially in those cases in which the 
mouth cavity was opened up. Until the time T hen plastics 
could be made sometimes months passed - owing to jaw cor- 
rections - which meant torture for the patient. The saliva 
flowing through the defect in the mouth was distressing for 
the wounded men, it moistened the bandages and soiled the 
laundry and uniforms. Consumption of food was hampered and 
was disgusting, speed was disturbed and hard to uhderstand. 
Although plastics made Jater yielded satisfactory cosmetic 
results, the functional results, however, left much to be 
desired. For this reason I tried to close the wounds in 
the stage of granulation. Silk and catgut proved unsuitable 
as suture material, since the sutures were cut through too 
easily and suppurations of the puncture-channel set in. For 
this reason I used the wire introduced for plastic operations 
already in surgery by MIKULICZ and inserted plates which 
allowed strong tightening and did not cut through# While 
in the beginning I only selected cases which seemed suitable 
to me on the strength of my experiences gathered in the 
meantime* I undertook to stitch all wounds in the face with- 
out regard to their condition and size. Possessing now 
experiences of 250 unselected cases and considering the 
satisfactory results, I demand that all wounds be closed 
promptly by the plate-wire method, because in no single 
case I obliged to remove the suture on account of a beginning 
infection. 
Now, as it turned out later, this method of wound treat- 
ment was adopted already during World War I by GANZER who 
called it "early suture". The technique is very simple: Only badly soiled 
Founds are rinsed out with a solution of camomile, and 
occasionally necrotic shreds are cautiously removed* 
Bone particles are only removed if they are loosely 
lodged in the tissue and are no longer connected with 
the tissue® Considering the remarkable capacity of re- 
generation of the lower jaw-bone any unnecessary removal 
of bone parts might hamper spontaneous consolidation by 
damaging the periosteal bone® I employ the so-called 
matress-suture with aluminum-bronze wire 0*5 millimeters 
thick and put RANDOLF-plates at the places of suture, in 
order to prevent a cutting through® A dry bandage is 
used. If later on the sutures became loose decreas- 
ing swelling of the tissue, the wire suture is tightened. 
The wires are only removed when the wound is healed se- 
curely and thoroughly. 
The success with early suture is invariably satis- 
factory without regard to the time passed since the in- 
jury was incurred. The advantages over the conservative 
method of treatment are especially striking. Early 
suture shortens the length of treatment considerably, 
produces an early endurable condition for the wounded man 
and saves him the other plastic operations necessary for 
covering up the defect. 
A large number of gentlemen who have visited my de- 
partment for jaw surgery and facial surgery had an opport- 
unity to convince themselves that in addition to the good 
cosmetic results, the functional results T,ere excellent 
as well, because the defect is closed up bv local tissue 
by the early suture while in case of secondary plastics 
- apart from the size of the operation or operations - 
the plastic flap has a considerable disadvantage which is 
especially apparent functionally. 
(Showing of diapositives). 
In a few cases which were sent to my department al- 
ready in a cicatrized stage I freshened up the edges of 
the defect with the sharp currette, if there was suffic- 
ient material for covering up and applied the plate-wire 
suture. 
Moreover, I use wire suture as tension sutures, as 
probably all plastic surgeons do, in order to isolate the 
tension of the wounds closed by approximation sutures 
away from these suturest. especially if this tension makes 
one apprehend that a cutting through of the stitches may 
result by active muscle movements. For plastics of the 
nose a form for the transplant may also be obtained by 
applying wire plates. 
Recently WASMUND described wire suture as a counter- 
sunk suture in order to avoid the scars of the puncture 
channel which occasionally appear in connection with the 
plate-wire method. Discussion: 
GREIFENSTEIN - Koenigsberg: The combination of 
sutures for facial wounds should be used more frequently 
in every stage though with more selection - than is done 
at present* It is not advisable, e*g. in the case of 
deeply located necroses whose removal often takes a long 
time* 
The mucous membrane of opened up accessory sinuses, 
which is more or less changed by inflammation, must always 
be removed too after creating a wide connection to the nose, 
if one suspects fracture of the rear bony wall* 
HAMMER - Berlins It is pointed out that the opinion 
advocated again and again even before this war in writing 
and verbally by facial surgeons and jaw surgeons, espec*- 
ially by Prof* AXHAUSEN that operative wound treatment 
for newly injured men of our district is the method of 
choice. The time limit of first aid may be extended in 
suitable cases to the 8th or 9th day. According to our 
experience no active measures are advisable in the stage 
of granulation. It is recommended to bring the gaping 
wound margins closer together by means of adhesive tape, 
to treat the wound carefully and to watch for complicat- 
ions. Adhesive tape was quite sufficient for bringing 
the wound margins together. For this purpose we did not 
need wire suture. For later treatment one must discrimin- 
ate between scar plastics and defect plastics. In any case 
we do not regard freshening up of the wound margins by 
scraping off with the sharp currette as suitable, since by 
this the required splitting of the wound layers cannot be 
obtained, the functional and cosmetical disturbance of the 
scars cannot be removed, and the accurate surface of in- 
cision, necessary to obtain cosmetically satisfactory scars, 
cannot be achieved. As material for sutures in plastic 
operations we need wire suture to relieve the tension and 
limit it to the cases in which it is required. For exact 
adaption of the wound margins in plastic operations in the 
facial area thin silk suture seems more appropriate than 
the RANDOLF-wire 0.5 millimeters 'chick which is used by the 
speaker. 
2. Gunshot wounds in t1 e larynxstenoses of the larynx 
and their tree .men t.> 
Stabsarzt (Captain, MG.) Prof. GREIFENSTEIN 
This description of gunshot wounds in the_ larynx and 
their most frequent and most serious result, difficulty of 
breathing due to stenosis of the air passage, is based on 
the experiences of the special department of a general 
hospital in the home territory with approximately 100 
such cases. 80 
During the first few weeks of the Eastern campaign 
a considerable number of fresh larynx injuries, one or two 
days old, were conveyed to us for treatment by air trans- 
port , so that we may define our attitude regarding the 
question of the most appropriate early treatment, not only 
epicritically, but from out own practical experience too. 
Everywhere practical clinical and therapeutic points of 
view should be predominant, while the discussion of several 
theoretical questions, as well as the statistical evaluation 
of our observation material and the results of treatment 
must be left to be dealt with later on. Renouncing any 
claim to completeness, my chief aims are 1. to survey of 
gunshot injuries in the larynx, their consequences and the 
valid principles of treatment, 2. to underline observations 
differing from the experiences of the World War I, 3* to 
emphasize known facts which are often disregarded and 4. to 
make diagnostic and therapeutic suggestions which I could 
not find at all in the literature on the subject. Compared 
to other organic injuries or even with injuries to the ex- 
tremities, gunshot injuries in the larynx are rare incidents- 
Without doubt they have to be considered as serious injuries 
to which a large number of wounded succumbs right on the 
battle field either by suffocation or bleeding to death and 
especially by aspiration of blood. In spite of the existence 
of numerous statistics it is difficult to obtain a clear con- 
cept of the fate of men wounded in the throat or larynx be- 
cause of the variety of the material on which the findings 
were based. In the present era of air transport there is 
certainly no justification anymore for the concept stated 
more than once in literature of World War I that only prog- 
nosticate favorable gunshots in the larynx, reach the base 
hospitals. 
Every larynx or trachea injury must be considered as 
part of a more or less serious throat injury. The crowding 
of the most important organs in the narrow space of the 
throat makes it clear that an injury to the larynx is some- 
times of less importance than the accompanying injuries to 
the vessels, the oesophagus, the cervical vertebrae and the 
spine* Under field conditions the accompanying injuries 
mentioned are therefore the most important, because they 
urgently require treatment. It is only later on, often 
only in the special departments of war hospitals and base 
hospitals, that the question of kind and size of a gunshot 
injury to the larynx becomes of greater interest* The ex- 
ceptional position of a gunshot injury to the^larynx is 
based upon the fact that it is not really an injury to an 
organ which has to be dealt with, but one of a complicated 
articulated mechanism which may have serious results for 
breathing and speaking. The importance of more serious in- 
juries to the larynx is especially clear if one consideres 
them with HOFFMEISTEH as a special kind of complicated 
fracture, the healing of which is often aggravated by the 
appearance of an infection. For weeks the^treatment of 
serious injuries to the larynx is accompanied by the danger 
of perichondritis and other complications resulting from 
them. The close anatomical and functional relations to the 
oesophagus later on causes the danger of aspiration, which 
is especially great during the first few days if internal 
hemorrhages set in, but later on too, as long as a cannula must be worn. Finally, even after the anatomical healing 
of the injuries to the larynx serious changes of form and 
disturbances of function remain in a not inconsiderable 
percentage of the cases, which require after-treatment for 
months and even years, in order to restore free breathing 
and a useable voice* Unfortunately in some cases this aim 
cannot be achieved so that the injured men remain permanent- 
wearers of cannulas. 
In some cases the recognition of an injury to the 
larynx is very easy, in other cases, however, it may be- 
come very difficult and without specialists* devices im- 
possible. It is certain at the first glance if the in- 
jured cartilage frame or the opened up lumen can be ob- 
served in the wound. .Although the other classical symptoms 
of an injury to the larynx such as dyspnoea, vocal dis- 
turbances, difficulties, of swallowing, coughing up of light- 
red blood, as well as emphysema vary and are only rarely 
completely absent, they cannot be considered as positive 
proof. Even if several symptoms appear together they re- 
main ambiguous and may be caused in the same way by an in- 
jury to the pharynx or the esophagus, by indirect partici- 
pation of the larynx by haematomata and edema, by vagus- 
recurrent nerve paralysis or by an injury to the pleural- 
apex of the lung (emphysema). A positive hemoptysis proves 
an injury to the mucous membrane and increased danger^of 
infection by this, though not positively the perforating 
character of the gunshot* These fundamental statements 
make it clear that in many cases of injuries to the lower 
part of the throat it is impossible to make an accurate 
diagnosis of the location of the injury with the medical 
units at the front and accordingly the treatment there 
must be and may be a more symptomatic one, chiefly con- 
cerned with relief cf dyspnoea and control of hemorrhage. 
The extensive information which nay V gained by laryngo- 
scopic and X-ray examinations justify the demand that the 
patient should be conveyed to a specialist1s department as 
quickly as possible, an opinion which, 1 am glad to find, 
is also stated plainly by FRANZ in his manual of war sur- 
gery. It is certain that the most convenient way of trans- 
port is by air, which at the beginning of the Eastern cam- 
paign brought a large number.of men injured in the throat 
or larynx to us for treatment even on the day after* they 
wore injured. No serious objections are to be raised 
against the transporting of the tracheotomized patieht, 
provided that they are in good general condition of health 
and if there are no other serious injuries* Moreover, the 
accompanying personnel must be able to clean the inner tube 
of the cannula with reliability. As far as the condition 
of the injured man allows it, it is advisable to begin on 
the day on which the tracheotomy was performed to make him 
familiar with the manipulations for a removal and cleaning 
of the inner tube of his cannula. 
Contradictory to the statements in the text boo&s, 
the previous history of throat or larynx con- 
tains only very rarely any statements about unconsciousness 
or severe shock. Sometimes immediately after the injury 
was suffered surprisingly heavy and prolonged physical ex- 
ertion was accomplished. It is out of the question that, as is stated in a well-known handbook, the wounded man in 
case of gunshots in the soft parts of the throat nearly 
always collapses and becomes unconscious (STAHL), 
It is of the greatest importance for the first clin- 
ical diagnosis of a gunshot injury to the throat to de- 
termine the direction of the shot channel. Even less than 
in other areas of the body, this falls together in the 
throat with the line connecting the spot where the bullet 
entered and the spot where it left, or where the bullet is 
lodged in the affected part. During the return from the 
"injured position" to the "normal position" (KILLIAN) in 
which we examine the injured man a change of the course 
of the shot channel takes place too by a lateral shifting 
(WILDEGANS) of the organs of the throat and soft parts to- 
wards each other. The thorough examinations into this 
question made by KILLIAN during World War I cleared up 
mapy unaccountable cases easily and convincingly: cases 
which on the one hand, according to the position of the 
spot where the bullet entered and that were it left, should 
haVe been combined with injuries of the deeper organs of 
the throat, but where this was not so; on the other hand 
apparently harmless superficial gunshots passing right 
through in which attention was attracted only to serious 
deeper injuries by the appearance of complications* One 
always has to realize this uncertainty in the diagnosis 
of every gunshot wound in the throat, and in cases of 
doubt should try to meet it with renewed examination of 
the wound and operative tracing of the gunshot channel or 
at least with the most careful observation. 
In spite of this restriction as to the value of the 
supposed direction of the gun-hot for the diagnosis of in- 
juries to the organs of the throat, the experience gained 
by observation of material, comprising approximately 100 
cases, tought ua that in most cases fundamental conclusions 
may be drawn from the external picture of the injury not 
only with regard to injuries to the organ, but also as re- 
gards the kind of injuries to the larynx. This recognition 
is more the important, as the decisive first clinical diag- 
nosis usually has to be made by a non-specialist, I there- 
fore based 6n it the following classification^of gunshot 
injuries to the larynx. Numerous classifications of this 
kind have been made in part more from a pathologico-anatom- 
ical point of flew, in part more from a therapeutic point 
of view. They all have their justification, their advan- 
tages and disadvantages* The best-known scheme is^the one 
drawn up by KILLIAN, which is based on the respective level 
of the injured part of the larynx, with the characteristic 
associated symptoms. In practice, however, it became 
evident that in case of fresh and even in case of older 
injuries to the throat or larynx such a distinction could 
not always be made either with outside observation or with 
the aid of laryngoscopic and X-ray examination* Shell part- 
icles and other rough missiles among which deformed infantry 
missiles also are to be reckoned, often cause damage which 
affects several areas of KILLIAN’s classification* In ac- 
cordance with the objection of v. MEHRER, KILLIAN extended 
his original scheme in this consideration. Ifi figures, however, this latter type of cases is at present even more 
frequent than during World War I, so that the value of this 
classification based on the level of the injury is impatp-ed. 
Moreover, injuries perforating the larynx in a diagonal 
direction downward or vice versa, as well as the lengthwise 
ones cannot be placed in the classification of KILLIAN. 
Without doubt KILLIAN has the merit of having made, for 
the first time, a laryngologically founded classification 
of gunshot injuries to the larynx, considering the peculiar- 
ities of the larynx which is also the basis for my own 
classification in its essential points* 
A classification of gunshots in the larynx made by 
HAERTEL, besides making a detailed division of the various 
gunshots, considers especially the perforating and non- 
perforating or destructive character of the gunshot. 
The following classification of gunshot injuries to 
the larynx and the trachea is proposed: 1. Paralaryngeal 
shots* 2. Injuries at the entrance to the larynx. 3* 
Direct frontal shots. 4. Direct posterior shots. 5, 
Sagittal shots. 6. Longitudinal shots. 7. Destructive 
shots. 8. Tracheal shots. 9. Shots with the missile 
lodging in the larynx. 
For specialist purposes we usually complete this 
short diagnosis in telegram style, taking into consider- 
ation as far as it is known and ascertainable, the accurate 
diractiori of the gunshot, the kind of missile, the special 
characteristics of the laryngeal area concerned, a gunshot 
with the missile lodging in the larynx, and possible com- 
plications. To justify this subdivision a short list is 
to be made of the pecularities of the origin, the external 
picture of the symptoms, the other injuries of each indi- 
vidual group, the anatomical and functional consequences 
of the injury as well as the possible complications. 
1. Paralaryngeal gunshots-. Gunshots in closest1: 
neighborhood to' the larynx may lead one to suppose a direct 
injury to the larynx in case of a certain position of the 
spot where the bullet entered or left the larynx. In this 
the result of the mirror examination is, besides exact 
location of the course of the shot channel of decisive 
importance. If no signs of a direct injury are to be 
found though an indirect affection of the inner larynx in 
the various forms: hemorrhage, edema, paralysis of the 
vocal cords, under certain circumstances also tears in 
the mucous membrane. In case of gunshots passing though, 
as well as of shots with the missile lodged in the larynx, 
the larynx may be affected in this form. Gunshots in the 
throat which show a strong effect of contusion may lead 
to extensive bleeding of the skin and mucous membrane. 
Larger hematomas in the area frequently extend as far as 
the region of the piriform sinus. Even injuries by shots 
more distant from the larynx may cause symptoms of injuries 
to the larynx by an increasing spreading of submucous hem- 
orrhages, by infection and by inflammatory swellings. As 
"purely traumatic reactions of the.mucous ftfptoane arc 
concerned, which are particularly active near the entrance 
* * . . -1 . . >■ to the Iprynx, they usually decrease considerably after a 
few days# The voice is often affected; severe dyspnoea, 
making tracheotomy necessary, is, however, very rare. 
Naturally grazing gunshots and the rare contour gunshots 
have to be reckoned among this group of gunshot injuries. 
The transition to injuries of the larynx proper are the 
ricochet bullets which often leave the cartilage still un- 
injured on the other hand, while they cause extensive 
tearing of the mucous membrane inside the larynx. 
2» Gunshots at the entrance to the larynx• Bess/n<rs* 
of their peculiarities this group*of gunshof injuries was 
already defined by earlier authors. In most cases gunshots 
passing right through in a transverse dn action are con- 
cerned in which the hypopharynx is always injured as well- 
Accordingly the difficulty of swallowing is clinically pre- 
dominant so that often the diagnosis implies an injury to 
the esophagus, especially if neither the voice nor breathir :- 
are affected. Injuries and defects of the epiglottis arc 
frequent, fractures of the hyoid bone by gunshot are also 
not seldom. The strong disturbance of the swallowing 
mechanism resulting therefrom gives rise to the great 
danger of aspiration and aspiration pneumonia. However, 
after they are healed fractures of the hyoid bone and 
epiglottis defects behind surprisingly little dif- 
ficulty in swallowingo 
3* Direct frontal gunshots. Under this designation 
shall be included frontal”tangential gunshots in the larynx, 
connected with an injury to the cartilage and frontal^gun- 
shots passing through -:he mucous membrane as perforating 
injuries. Both kinds of injuries differ with regard to the 
danger of a perichondritis which is naturally greater in 
the case of gunshots passing on through. It seems to me 
that the important point is that no severe associated in- 
juries are to be expected, considering the superficial 
direction of the gunshot channel, and this justifies in- 
cluding them in one group. The opened larynx lumen is often 
completely exposed on account ol the thin soft parts cover- 
ing it and this encourages the insertion of a cannula at 
the place of injury. A secondary injury of a shoulder is 
also frequently seen with frontal gunshot injuries of the 
throat. After healing, frontal gunshots leave a narrow 
scar formation which may lead to diaphragmatic adhesions 
of the labium vocale, especially at the level of the vocal 
cords. 
4. Direct posterior gunshots. They are to be dis- 
tinguished from group 3 because of the possibility of 
severe attendant injuries, especially to the throat vessels, 
the vagus and the plexus. The more to the rear they occur, 
the greater is the danger of injuring the esophagus too by 
which, occasionally, an esophago-laryngeal^fistula may bo 
formed. If the cricoid and arytenoid cartilages are af-_ 
fectcd too, great danger of perichondritis threatens by in- 
fection of the hypopharynx. For this reason KILLIAN dis- 
tinguished a special group of posterior subglottic gunshot 
injuries. Not less than 50 per cent of his cases were com- 
plicated by perichondritis. Permanent complications are 
particularly serious; often median fixation of the vocal 
cords through ankylosis of the arytenoid joints with dys- 
pnoea, while the voice is preserved. Anatomically midway, so to speak, between groups 3 
and 4 are frontal gunshots smooth projectiles passing 
through the thyroid cartilage, characterized by holes of 
caliber size where the bullet entered and left on both 
sides of the neck* Such gunshots passing through not 
seldom progress almost without symptoms if it so happens 
tnat neither vocal cords nor false vocal cords are damaged. 
5. Sagittal gunshots. Frequently in this case shots 
with the missile lodged in the larynx arc concerned, which, 
after penetrating the larynx and the esophagus are stopped 
by the vertebral column. In a pure form, taking their c n- 
exactly on bhe sagittal plane they must be considered c.j 
rare, since in case of great dynamic lorce of the bullet 
they are usually fatal, probably owing to injuries to the 
spine* Shots with the missile lodged in the vertebrae and 
prevertebral shots with the missile lodged in the throat 
have usually entered in a diagonal direction and thereby 
frequently cause injuries to the hypopharynx-esophagus and 
frequently do not affect the larynxc 
6. Longitudinal gunshots. Longitudinal gunshot 
injuries to the throat and larynx according to the reports 
during World War I appear as typical injuries to soldiers 
hit while in a firing position. We have not been able to 
observe such a cause of origin ourselves. On the other hand, 
however, longitudinal gunshots in the throat occurred b$r 
gun fire from an airplane. A number of observations was 
collected in the literature of the first World War in which 
the missile entered the head, penetrated the throat long- 
itudinally and cane to rest in the chest or abdominal 
cavity, tnus penetrating a large area of the body in an 
axial direction. It was very often observed that the 
bullet had entered at the lower jaw and in the further 
course of the missile cause a fracture of the hyoid bone, 
injury to the front edge of the thyroid cartilage and 
tracheal injuries. By this the anterior mediastinum is 
more or less opened up. The possibility of intrathoracic 
or even abdominal gunshot wounds vrith the missile lodged 
in the body must be considered too. If the missile does 
not enter the thorax the prognosis of these injuries may 
be described as comparatively favorable, severe as they may 
appear at first sight, because they appear as longitudinal- 
tangential gunshots in the larynx without extensive des- 
truction or defects of the cartilage frame and the dangers 
to be feared arise more from infection of the opened up 
mediastinum, than from the pure tracheal injuries. With 
regard to the larynx the prognosis is more serious in 
the case of longitudinal gunshots which take an oblique 
and deeper course, e.g. such as enter at the floor of the 
mouth. 
7. Destructive gunshots» In this^group we have 
destructive gunshots causing rough complicated fractures, 
as well as the shooting away of large parts of the laryn- 
geal cartilage frame. Besides the seriousness^of the in- 
juries they are caused jointly by larger, particularly 
multiple rough missiles. Men injured by destructive gun- 
shots show a high primary mortality by suffocation. In 
cases where large parts of the laryngeal cartilage has been shot off, aspiration is particularly dreaded. As by tho 
shooting off of parts of the larynx a ,?ide opening up of 
the air passages takes place we find the cannula nearly 
always lodged in the wound, 
8# Tracheal gunshots. They are found frequently as 
attentant injuries of longitudinal shots and destructive 
shots in the larynx. In cases of isolated tracheal in- 
juries the appearance of extensive emphysema is almost the 
rule. It may, however, be caused by an injury to the pleura 
and the appex of the lung. The dangers of tracheal gunshots 
are due to the possibility of infection of the anterior 
mediastinum, which, however, do not seem to be,so great as 
one should expect theoretically. Among 9 cases treated by 
ourselves we had to register a disastrous result only ohcec 
The insertion of the cannula into the gunshot wound is 
sometimes not to be avoided if the tracheal injury is loc- 
ated deeply. With every tracheal injury a close search is 
to be made for a gunshot in the thorax with the missile 
lodged in the body, 
9• Gunshots with the missile lodged in the body. 
The intralaryngeal location of gunshots with the missile 
lodged in the body is often unrecognized. Among gunshots 
with the missile lodged in the body are those in which the 
missile is lodged in the wall where it was stopped by the 
cartilage frame and those in which the missile is found in 
the mucous membrane on the side where the bullet entered or 
on the opposite side. Thus in contrast to gun-shots with 
the missile lodged in the mucous membrane, gunshots in the 
wall with the missile lodging in the body are non-perforating 
injuries* In the majority of gunshots with the missile 
lodged in the mucous membrane observed by us the missile 
was found in the false vocal cord or in the sinus piriformis. 
Sometimes they may project right into the larynx lumen and 
may even be observed laryngoscopically# In the category 
of gunshots with the missile lodging in the body belong 
also those gunshots penetrating to the inside of hollow 
organs or internal gunshot wounds passing through from 
which material may be aspirated, coughed up or swallowed. 
Among 12 observations of my own on intra-laryngeal gunshots 
with the missile lodged in the body tracheotomy was re- 
quired only 4 times, surprisingly not even in the case of 
an infantry missile passing freely through the subglottic 
area which lodged there nearly without any symptoms for 
16 days. In cases of gunshots with the missile lodging in 
an organ so sensitive against mechanical and infections 
Injuries as is the larynx, a wide indication for removal 
of tho missile, possibly by eMoscopy, seems advisable. 
The most important measure for a first treatment of men 
injured in the larynx is the relief of any dyspnoea by 
tracheotomy. Besides this it serves also for prevention 
of aspiration, especially in the case of internal hemorrhage. , 
if a larynx tamponade can be made from the tracheotomy wouru.-. 
and a tamponade of the throat from the mouth if the source 
of bleeding should be located there, A tamponade through 
the gunshot channel should be attempted only in case of 
life endangering hemorrhage and a gaping wound. With very rare exceptions the demand for broad diag- 
nostic indications for prophylactic tracheotomy with gun- 
shots in the throat or larynx, which proved successful 
during World War I, seems to have found general recognition 
at present* Thus among 95 men injured in the larynx and 
trachea there are 59 on whom a tracheotomy had been pre- 
formed mostly of whom were sent to us with cannula inserted 
while the minority of them had to be tracheotomized sooner 
or later* This large number of tracheotomized patients as 
compared with the report of KILLIAN, who during World War I 
had hnly 31 tracheotomized men out of 87 injuries to the 
larynx, is to be accounted for easily by the fact that a 
large number of seriously injured, e*g. with wide exposure 
of the air passages and esophagus caused by bomb particles, 
came to us for treatment, thanks to modern treatment facil- 
ities* Already during World War I HAERTEL had pointed out 
that one must not draw the deceptive conclusion from KILLj 
report that 65 per cent of larynx injuries take a good cove 
He is, however, of opinion based on his findings and estii. 
ations that at least 70 per cent, but probably an even la. 
percentage of injuries to the larynx must be tracheotomized 
at the front on account of dyspnoea. 
i 
Agreeing in principle with WIETING, GOLEKE and others 
we always consider prophylactic tracheotomy under field 
conditions as indicated in the following casess 
1* In cases of beginning dyspnoea* In cases 
of marked or continuous hemorrhage from the air passages 
or the pharyngeal area. 3- In of increasing skin 
emphysema. 4. In cases of strong swelling in the neigh- 
borhood of the air passages resulting from hematoma or 
from wound infection. 5. In cases of intralaryngeal 
shots with the missile lodged in the larynx and larger 
shots of the same kind in the immediate neighborhood of 
the air passages in which the missile cannot be removed 
Immediately. 
That injuries of this nature may take a favorable 
course even without preventive tracheotomy cannot lessen 
the justification of the fundamental requirement. Es- 
pecially in cases when the time for transport cannot be 
fixed definitely, ahd when adequate supervision is lacking 
it is advisable to tracheotomize too often rather than not 
often enough. 
In no fewer than 12 cases of gunshots in the larynx- 
trachea the cannula had been inserted at the place of in- 
jury sometimes after extending the gunshot channel. The 
conditions of the wound with direct frontal gunshots and 
shots shooting away parts of the larynx, sometimes with 
longitudinal gunshots too, positively invite one to do so. 
A general warning against such a procedure is certainly 
justified, because it may cause obvious complications and 
may favor the development of stenosis. Even when the 
cannula remained for some time no disadvantageous results 
were noticed in our cases. As a method of emergency end 
for guaranteeing the transport to a place with suitable possibilities for treatment we would not reject it on 
principle. MAHSCHIK too approves of this procedure as a 
makeshift. In any case it is gafer and more appropriate 
than to not insert a cannula at all, relying on it that 
breathing through the gunshot channel will be sufficient 
for the moment, which may, however, be obstructed at any 
time by blood and secreta. It is hardly necessary to em- 
phasize the fact that in such cases a typical tracheotomy 
is to be made as soon as possible. This applies also to 
2 cases of cricothyreotomy or intercricothyreotomy which 
were registered in the patients1 records as tracheotomy. 
In the text books of war surgery we find again and 
again the exhortation to remove the cannula as early as 
possible, which is supported, if at all, by pointing 
out the difficulty of decannulation later on. In cases 
of simultaneous injuries to the hypopharynx and the floor 
of the mouth such a generalization of early decannulation 
is especially warned against in view of the possibility 
of late hemorrhages. With perforating injuries to the 
larynx this danger of hemorrhages is not so serious a warn- 
ing, however, it is still quite as justified, on account 
of the possibility of infection of the gunshot channel with 
a subsequent perichondritis, which always means a serious 
complication. Especially with injuries of the subglottic 
area in which,after decannulation, considerable•increase 
of pressure occurs during coughing and speaking, one should 
wait for a firm healing of the wound in the mucous membrane. 
An accurate laryngoscopic examination should always precede 
the removal of the cannula. In some cases we were obliged 
to use tracheotomy on account of perichondritis which cer- 
tainly was connected temporally and causally with premature 
decannulation. Contrary to general opinion the duration of 
time the cannula is in place plays only a minor part when 
a suitable cannula and good care are used. Even when the 
cannula remained for weeks and months I cannot remember 
having ever experienced any great difficulty of decannula- 
tion with adults. I am, however, frequently obliged to 
make corrections with injured men sent to me for treatment 
already tracheotomized: to widen the tracheotomy wound or 
to insert another cannula, especially to exchange unsuitable 
fenestrated cahnulas. If possible a high tracheotomy reach- 
ing to the cricoid cartilage is replaced by a lower one. 
Occasionally I heard of field surgeons who in deliberate 
opposition to the other rules of war surgery practise prim- 
ary suture for injuries to the throat and larynx after ex- 
cision of the wound in the soft parts, probably starting 
from the consideration that the trachea must be restored 
by air means. Without the possibility of a real air tight 
and secreta-tight closing up of the larynx-trachea wall, 
in other words, if only the wound in the soft parts of the 
trachea wall is covered up, this procedure must be consider- 
ed as positively dangerous, no matter whether there is a 
tracheotomy or not. The formation of emphysema, spread into 
the mediastinum, infection of the cartilage wound of^the 
mucous membrane (perichondritis) and its neighborhood 
(phlegmon and mediastinitis) may and must be the consequence. In exceptional cases a primary suture of laryngo- 
tracheal injuries may be permitted an experienced physician, 
provided a long period of observation is exercised# The 
omission would probably cause great dangers, thus e#g# in 
the case of a complete or nearly complete severance of the 
trachea or in the case of extensive lacerations of the in- 
jured cartilaginous larynx frame. In case of an injury to 
the thyroid cartilage too, in the form of a laryngofissure, 
one might expect advantages by a primary wound treatment 
and suture# I see, however, no sufficient reason to per- 
form this under certain conditions, as recommended by 
HAEKTEL on smaller and more harmless injuries tooi In 
theory one can agree with HAERTEL under certain)conditions; 
but in practice the possibility of making a perfect suture 
of the mucous membrane within the larynx might prove im- 
possible. In particular the possible gain of time in con- 
valescence should hardly be a temptation, considering the 
conditions in the field and the risk of an infection of the 
perivisceral connective tissue# 
Quite another thing, however, is the question of 
active surgical treatment of injuries by gunshot of the 
larynx, in order to avoid stenosis through the formation 
of and shifted cartilage fragments# If one considers 
how long and difficult the treatment of chronic laryngeal 
stenosis is by either conservative or surgical methods, one 
would be inclined to favor a primary laryngotomy with suture 
of the mucous membrane, repositioning of the fragments and 
subsequent dilation treatments -in order to avoid the de- 
velopment of stenosis from the very beginning# In my opinio1 
difficulties in decision are created by unfavorable wartime 
conditions rather than by fundamental differences of opinion. 
If a violent hemorrhage of the larynx sets in, or a bullet 
is lodged intra-laryngeally, one would not hesitate to per- 
form an early operation which usually would mean a splitting 
of the larynx. On the other hand it might in many cas*s bo 
very difficult under front line conditions and by the pre- 
sence of a marked primary traumatic reaction of the mucous 
membrane, to get a clear picture of the kind and extent of 
the injury to the larynx. This is often only^possible in 
the special wards of a reserve-hospital containing all the 
necessary paraphenalia, that is at a time when a formation 
of scars has already taken place so that one cannot replace 
the dislocated fragments. 6n the one hand, if on looking at 
unexpected serious scarlike changes associated with a late 
laryngeal fissure one thinks of how suitable and timely an 
early operation would have been, it is on the^other hand 
necessary for surgeon and patient to have patience, if the 
early operation is no longer possible. I h/ve seen again 
and again that not only edema but also swelling, which I 
first believed to be permanent changes, has improved con- 
siderably after weteks or months. Also with a seemingly 
rigidly fixed arytenoid joint, which even when touched with 
a probe impressed one as being ankylosed, later on gains a 
certain mobility so that a decannulation was still possible. 90 
The decision, whether an earlv operation is advisable 
or not, depends to a large extent on the possibility of de- 
termining in time and with sufficient certainty the con- 
sequences of injuries to the mucous membrane and the larynx 
frame, which may result in a permanent and serious difficulty 
of breathing. We have the conviction, that the period of 
treatment of mucous membrane and cartilage-injuries can be 
shortened by an early operation, without reducing the certai 
ty of success. 
Traumatic suppurative perichondritis is always a very 
serious, regrettable and not too rare complication, en- 
dangering the healing process and the results of treatment 
of bullet injuries to the larynx. This complication may 
follow even small injuries to the cartilage, seemingly harm 
less in the beginning. This makes necessary a tracheotomy 
even with injuries in the later stages of treatment* We 
were not able to confirm either with regard to incidence or 
ratio of localization with our patients the statement of 
KILLIAN that perichondritis occurs especially in cases of 
injuries to the upper part of the larynx in about 28 per cen 
of the cases as against 9 per cent of injuries to the lower 
parts* It is noteworthy in clinical respects that even seriov 
suppuration and purulent discharging forms of perichondritis 
frequently show only a slight increase in temperature and 
in spite of marked edematous swelling of the mucous membrane 
create only surprisingly slight difficulties in swallowing. 
The concept of the necessity of surgical treatment for sup- 
purating perichondritis of the thypoid and annular cartilages 
and also the drainage of internal or external abscesses of 
perichondritic origin has been generally accepted. It is 
based on the research work and successes of HINDSBSRG. Sup- 
purating perichondritis without surgical treatment used to 
mean a complication endangering life, e.g* suffocation, 
aspiration-pneumonia, spread by gravity into the mediastinum, 
general sepsis. We have had, with timely intervention, no 
death among our patients. The disastrous significance of 
any perichondritis combined with bullet injuries of the 
larynx consists first of all in prolongation of the disease 
for weeks and months, in the formation of excess granulation 
tissue of perichondritic origin, causing stenosis, by the 
constriction of the subglottic cavity, especially with peri- 
chondritis of the annular cartilage and not least of all in 
a median fixation of the labium vocale by scars or ankylosis 
of the arytenoid joints. The seat of the perichondritis or 
of the abscess must always be opened, diseased cartilage, 
granulations and sequestra must be removed subperichondrally 
with the sharp currette, in which case frequently one or 
even both lamellae of the thyroid cartilage will be destroyed 
by this procedure. The annular cartilage lamella must bs 
exposed widely by a median incision of the mucous membrane. 
In one case the operation of a subsiding perichondritis after 
laryngofissure disclosed a big sequestrum caused by the 
breaking through of a suppurating perichondritis of the 
annular cartilage in both directions. Even though a sup- 
porting frame of bone may develop from the remaining peri- 
chondrium, one may often see in X-ray pictures extensive 
calcifications almost regularly which develop into permanent 
stenosis following serious cases of perichondritis. Cases of slow healing perichondritis, not suppurating, usually 
confined to circumscribed thyroid-cartilage areas, have 
sometimes been observed as late complications. They all 
underwent involution by conservative treatment and usually 
resulted only in slight hardening of the cartilage (plastic 
perichondritis). In one case of a loss of the epiglottis 
caused by a gunshot wound a perichondritis of the stump 
appeared several weeks after decannulation which necessitated 
a secondary tracheotomy. 
In establishing the indications for removing bullets 
lodged inside the larynx or in the throat we usually go far 
beyond the general surgical principles. We were brought to 
that decision by the following experiences and consideration.'., 
the danger of infection with lodged missiles, which have 
passed through the trachea or esophagus, is a particularly 
great one. Moreover it is impossible to keep the surrounding 
tissues in a fixed position, so that a reactivation and ex- 
tension of an otherwise mild infection results more frequent 
than in any other part of the body. Lastly, the already hea. 
injuries of the mucous membrane may produce ai new infection 
of the track of the missile even after a long lapse of time, 
an event which an angina or a catarrh of the upper respirator;, 
passages seems occasionally to favor. Missiles lodged either 
in the throat or larynx have proved to be especially in dange- 
of infections during the winter months of the war by carrying 
along with them particles of cloth from collars of uniforms, 
overcoats, headprotectors, a circumstance which has to be 
taken into account if an operation for a lodged missile is 
indicated. Lastly when a missile is lodged in the mucous 
membrane of the larynx, one has also to consider the possibil- 
ity of a spontaneous ejection into the lumen with its aspir- 
ation. 
An absolute location of the lodged missile is possible 
in every case with the help of all means for diagnosis, par- 
ticularly by direct examination of the larynx and by X-ray 
methods. X-ray pictures in two planes are often not suf- 
ficient to give even approximately as good an idea of the 
location of the splinter, as does a skillful fluoroscopic 
examination. It also makes it easier to decide the best 
way of getting at the missile, to locate the area of the 
skin nearest to it, and to ascertain its movement by feeling 
and_moving the soft parts during the act of swallowing. 
X-ray pictures taken one above the other and A-PX pictures 
of tne larynx after insertion of the film into the hypo- 
pharynx are usually just as useless for the location of 
missiles lodged in the larynx, as the high frequency metal 
searcher, which was often considered necessary for the 
operation for their removal. One should never operate re- 
lying merely on X-ray pictures ¥/hich may have been taken 
some time before, because a shifting of the bullet may have 
occurred in the meantime, or it may have been spit out or 
swallowed or aspirated. To avoid such mistakes, a fluroscopic 
examination must be made immediately before the operation, 
which should never be omitted. Among 12 bullets lodged 
intralaryngeally there were 2 cases which had been operated 
on externally in vain several times (opening up of the 
oesophagus and laryngofissure) though the splinters were so^situated that after an exact location their removal was 
quite easy and could be performed in a very short time. 
In 2 cases bullets lodged in a suitable position were re- 
moved successfully be fenestration of the thyroid cartilage, 
in one case by a subhyoid pharyngotomy, We have so far 
managed to avoid laryngofissure which represents the typical 
access-operation and which also makes it possible to sur- 
vey in detail the extent of the injuries and their conse- 
quences, including the treatment of hemorrhage by following 
the track of the missile. The indication for removal of 
bullets by endoscope has to be limited to the visible, or 
at least clearly detected, bullets lodged immediately under- 
neath the mucous membrane of the pharynx, the larynx and the* 
trachea, provided that there is no danger of violent hemorr- 
hage and that the foreign body can be grasped with the right 
instruments without danger of aspiration# 
When missiles lodged in the sinus piriformis.after hav* 
pierced the lumen of the trachea or oesophagus and which are 
tirafe situated on the opposite side of the spot from where tu 
bullet entered, are exposed from the outside, they easily 
slide babk into the lumen through the short canal of the 
missile in the mucous membrane which has usually been en- 
larged by infection. Aspiration must be avoided by careful 
creation of a wide access, suitable posture (elevated pelvis, 
FREUDENBERG*s position) circumstances permitting, also throng 
preventive tracheotomy and tamponade. If there are limited 
space conditions, the employment of nose-speculae instead of 
blunt hooks is imperative in order to keep apart the edges 
of the wounds. Blunt hooks have proved to be superior to 
all ingeniously constructed grasping forceps for the removal 
of foreign matter such as in case of dislocating splinters 
from „their beds. 
The treatment of remaining permanent effects on the 
larynx and trachea after injuries to them, e,g. stenoses and 
impediments in speech, requires a very experienced physician, 
and physician and patient alike have to show much patience. 
The aim is very simple to describe: restoration of a suf- 
ficiently wide air passage and a normal voice. Owing to the 
rarity of injuries to the larynx in peace time, only a few 
specialists possess enough experience with the numerous 
and various conservative and surgical methods to be able 
estimate their advantages and drawbacks or their applicability 
in each sipgle case immediately. The adaption of the method 
of treatment to the individual case, when there is no other 
injury, is as important as with stenoses of the larynx and 
has to be based upon an exact knowledge of the consequences 
of the injuries in anatomical and functional respects. It 
is, under these circumstances, a logical demand, that the 
injured man must remain under the care of one physician 
during the entire period of treatment. The best possible 
treatment results will be obtained, if all these cases are 
sent to a special hospital, a procedure which already has 
proved its value in the first World War under KILLIAN, Each stenosis of the larynx due to an injury by gunshot 
rnich may have taken place weeks or oven months before, re- 
quires first the determination of whether the required state 
of quiescence has set in, and if the process of healing makes 
good progress* There are no objections to beginning treat- 
ment by either surgical or conservative method if no in- 
flammatory reactions of the mucous membrane, swellings or 
edema are recognized* The choice of treatment depends en- 
tirely upon the type? character and extent of the stenosis. 
By functional investigation it must be ascertained if the 
air can pass freely during temporary closing of the tracheo- 
tomy wound and thus one gets a good idea of the actual degj c 
of the narrowing. Edges and folds of scars which protrude 
now on one side and then on the other side like wings on a 
stage, sometimes have the appearance of severe stenosis, 
because they prevent an unobstructed view into the trachea. 
To ascertain whether the air can pass tolerably is import- 
ant since one is inclined from the beginning to create an 
additional widening of the trachea by conseravtive methods, 
even though stenoses of slight to medium degree do permit 
unhampered breathing. But in cases of actual severe stenosc 
the surgical method will frequently be the only appropriate 
procedure. In only a comparatively few cases will it be 
possible to decide immediately on the best method of treat- 
ment after an examination by the laryngeal mirror. Usually 
all the diagnostic means will bo needed to form a clear idea 
of the character of the stenosis. The direct methods of 
examination, including those directed bade, ards from the 
tracheotomy opening, thorough X-ray examination including 
fluoroscopy and lateral views at various levels and also 
a presentation in relief of the mucous membrane by means 
of contrast must be employed for this purpose. The most 
frequently encountered traumatic stenoses appearing singly 
or combined are: 
1. Circumscribed fold-cord- or diaphragm-like scars 
of the mucous membrane, 
2. Coalescence of the vocal- or the false cords at 
the anterior commissure, 
3. Extensive changes of the wall due to callous 
padding of the scars, healed but deformed fractures 
and perichondritic growth of cartilage, 
4. Median fixation of the vocal cords by ankylosis 
of the arytenoid cartilage, usually due to 
annular cartilage perichondritis or to contraction 
of the scars on the posterior wall. 
If one considers in addition, that frequently flat 
scars instead of cartilaginous defects such as at the 
margin of the thyroid cartilage lead not infrequently to 
a flattening out of the entire lumen, one gets an idea of 
the variety of types of stenoses. In contrast to the older reactionless stenoses is 
the group of fresh constrictions which are much more dif- 
ficult to evaluate and along with which one can recognize 
extensive laryngeal edema and swelling of the mucous mem- 
brane. Here it is important to decide if these findings 
are the results of long lasting perichondritis or simply 
the effects of disturbances of circulation due to scar 
formation whether an active treatment can be undertaken, 
or whether it is better to wait for some time. The most 
propitious time for the use of conservative dilating pro- 
cedures is when the inflammation has disappeared entirely, 
while the formation of scars has not yet reached its final 
stage. In these dases we usually try to ascertain first 
whether the local findings undergo a change through active 
hyperemia, light therapy and Injections of calcium. If 
involution takes place or conditions remain entirely un- 
changed. one may start slowly with gentle dilating measures 
of short; duration. Any reaction of temperature, as well 
as local or general reactions, requires a temporary inter- 
ruption of the treatment, and in cases of a strong reactiv- 
ation of inflammatory processes, when circumstances permit 
a change of treatment. 
If one cannot ascertain the nature of the stenosis, 
ot if swellings or scars obstruct the view into the deeper 
recesses, an exploratory opening of the larynx is to be 
taken into consideration. Thus, many strange laryngoscopic 
findings, difficult to explain otherwise, arc explained 
in a surprising manner locating a center of granulations, 
a sequestrum, or mucous polyps, or a fistula unnoticed be- 
fore. For the treatment of stenoses of a permanent nature, 
due to an injury to the larynx by a missile, we have at 
our disposal the bloodless treatment by dilatation and the 
surgical procedure, both of which aim at restoring a suf- 
ficient width of the trachea. For treatment with bougie, 
first of all, the milder cases of the pure scar stenosis 
are to be considered. Space-creating plastic operations 
rarely have the desired effect. On has rather to endeavour 
to preserve the width of the trachea and to prevent a re- 
newed contraction of scars and to avoid a new formation of 
stenoses. This dilatation-procedure following operative 
intervention is therefore above all a purely passive measure© 
It is important to differentiate between this method and 
the proper dilatation procedure, the real^stretching of 
stenoses, in order to avoid misunderstandings. The em- 
ployment of the same instrumentatrlum for both purposes 
gives support to such a linguistic and inherent inaccuracy. 
The purposes aimed at both procedures are as different as, 
to use a comparison, the reduction of a fracture from the 
fixation of a fracture by plaster cast. How much the 
borderline between proper dilatation treatment and operative 
procedure is confused can best be explained by assertions 
from BRUEGGEMANN, that excision of scar is frequent- 
ly necessary before an insertion of sounds and that before 
insertions of sounds the stenosis should be widened by 
using a dilator. The great number of instruments and methods for dilat- 
ation procedures, as also for surgical procedures, will not 
and cannot be described here in all details. For treatment 
of the^above mentioned types of tiaumatic stenosis, the 
following procedure is chosen quite frequently; 
i 
The circumscribed scar formations under 1# (above) are 
well suited for proper dilatation treatment, which according 
to location, may be undertaken either through-the mouth 
or with sounds retrogressively from the tracheotomy-opening. 
Among the various forms of sounds BRUEGGEMANN1s cannula sound 
is probably the one most useful and most frequently uded. 
Endolaryngeal intervention, incisions and excisions of the 
scars in addition to the dilatation treatment may be necessai 
or might at least be useful for shortening the period of 
treatment* The scar deformities of the vocal cords of group 
2 due to injuries by frontal shots are frequently acdonpantec 
by serious impediment of the voice. Their firm condition 
requires, as a rule, a division or excision by surgery with 
the use of the endoscope or from the outside. Owing to the 
well-known inclination to renewed formation of scars and to 
prevent renewed coalescence, a preservation of the width 
gained by preventive dilatation by insertion of discs is re- 
quired. Caustic or cold caustic severing subject and ob- 
servation of cases which rere treated unsuccessfully in this 
manner in some other hospital. 
Changes of the walls of lesser degree, as described 
in group 3 may be subjected to dilatation treatment with 
promise of success. On extensive severe scar-stenosis, es- 
pecially if a cartilaginous growth of perichondritic nature 
develops, such as is frequently observed after serious in- 
jury by gunshot, we have immediately undertaken the submucous 
excision of the tissue from which a stenosis is developing 
with the formation of a laryngostomy, which we carefully 
covered with hairless skin from the supraclavicular pits 
as advised by KILLIAN. The lobes, which are based at the 
lower borders of the laryngostomy on both sides, are raised 
and carefully united to the mucous membrane of the larynx. 
Defects of the mucous membrane may be replaced during this 
process by pulling the lobes more or less strongly into the 
lumen of the larynx. The mucous membrane, lining the formerly 
narrow lumen, is usually not large enough to cover the widened 
trachea. The incised portion of the thyroid cartilage will 
also be covered by this procedure so that necroses at the 
edge of the cartilage can be avoided. The skin of the thrbat 
which is easy to move at the place from which the flaps were 
taken can almost always be united successfully by primary 
suture. Particular care has to be taken in sewing the edge 
of the skin at the upper borders of the laryngostomy as 
otherwise both sides might grow together by the presence 
of granulations and thus cause a gradual narrowing down of 
the laryngostomy which will obstruct a free view towards the 
entrance of the larynx and increase the difficulties for 
preserving the width obtained for the lumen of the larynx. 
In the majority of cases we have used rubber tubes for pre- 
ventive dilatation, as recommended by KNICK, which proved 
very serviceable if employed in surgery on^laryngeal stenoses 
in pre-war times. We have never observed irritations of such serious nature that we had to interrupt the treatment, even 
if it lasted for months. Tamponades, following plastic 
operations, have always proven excellent, if hard cylindrical 
tampons were covered with Epithen ointment, I consider 
this method the most gentle one for after-treatment, but 
unfortunately the most troublesome one, as the tampons 
have to be changed daily or at least every other day and 
must be observed continually for the proper position. 
If the use of a rigid bougie was required, for instance 
for the purpose of spreading the thyroid cartilage-lamellae, 
it was always chosen according to the actual condition of t 
wound. VOGEL has lately used individually formed bougie 
made of STENT*s mass, to which he ascribes certain advant* 
if compared with BRUEGGEMANN*s sound, I already pointed 
out in the final words of my lecture in Breslau, that I 
do not consider STENT*s mass the ideal material for sounds, 
because it easily disintegrates, possesses a certain rough- 
ness of surface which leads to irritation of the mucous 
membrane and my break comparatively easily. Dentists have 
made sounds of rubber for us which satisfy all requirements 
for comfort and do not break easily. Occasionally casts 
of dental material (BAYER) were made of the lumen of the 
larynx, which permitted free breathing through the upper 
passages. 
If the lumen of the larynx should prove to be of 
sufficient width after a lengthy, preventive dilatation 
treatment, the laryngostomy is closed by plastic operation 
and the cannula is removed later on. In cases of median 
fixation of the vocal cords through ankylosis of the 
arytenoid joints, frequently mistaken as double paresis 
posticus, the decannulation in general results in a weaken- 
ing of the voice. The most varied kinds of excisions of the 
vocal cords (KILLIAN), shifting of the vocal cords (VOGEL), 
mope or lees extensive sacrifice of the arytenoid 
cartilage, even a "submucous exenteration of the larynx" 
(SERCER;, have been recommended and executed with variable 
success. In these cases also there is the necessity for 
an after-treatment with tampons or dilatating instruments. 
The success of all these complicated treatments, which re- 
quire much time often depend less on the employment of 
certain methods and rather on mastering and executing them 
carefully* When I reported in 1936 on laryngeal and tracheal 
stenoses which are encountered very rarely and also men- 
tioned their surgical treatments, I pointed out, that not 
every time does one achieve success with just one special 
procedure, frequently praised as the simple one, but 
that during the treatment of a particular case various 
changes of the plan of treatment-are often required. On 
account of the long duration of the treatment, a critical 
comparison of the diverse methods used with out patients 
cannot be undertaken as yet. 
The necessity and the success of voice-treatment by 
physicians after injuries to the larynx and after-treatment 
of stenoses must be pointed out explicitly. If an injured person has to wear a cannula permanently 
after injury to the larynx by a missile, even though the 
voice is normal, I consider the conditions justifying an 
award of the Silver medal have been fulfilled* The same 
proposal is made for injured persons whose breathing is 
hampered by stenoses and whose speech is impeded in a 
manner which will not allow them to take a job which re- 
quires fairly heavy work or a profession in which they have 
to use their 'voice. The above named injuries seem to me 
at least as grave as the loss or the permanent uselessness 
of a hand, a foot or an eye. 
Literature: (Copy from the printed text as it appears 
there.) 
1. HARMER, L; Narbenverengerungen des Kehlkopfes. In 
Denker-Kahler: Handb. d. Hals-Nasen-Ohren- 
heilk. Bd. 3. 1037. 
2. HAERTEL, F; Die Kriegsschussverletzungen des Halses. 
Erg. Chirurg. Bd. 11. 4?1. (1919). 
3. HINDSBERG: Perichondritis und Chondritis der Kehlkopf- 
knorpel. In Denker-Kahler: Handb. d. Hals- 
Nasen-Ohrenheilk. Bd. 3. 378. 
4. KILLIAN, G: Die Kriegsverletzungen des Kehlkopfes und 
der Luftroehre. In v. Schjerning: Pland- 
buch der aerztl. Erfahrungen im vreltkriege. 
Bd. 6. 242. 
5. MARSCHIK, H; Verletzungen des Kehlkopfes, der Luftroehre 
und der Bronchien. In Denker-Kahler: Hand- 
buch d. Hals-Nasen-Ohrenheilk. Bd. 3* 540. 
(Bhese imblicatlonf give detailed informations about 
the older literature.) 
6. BRUEGGEMANN, At 
Ueber seltene Kehlkopfverletzungen. Verh. 
b. Vereinig. suedwestd. Hals-Nasen-Ohren- 
aerzte, 19. Vers. Muenchen 1933- 
7* GREIFENSTEIN, A: 
Seltene Larynx- und Trachealstenosen nebst 
Bemerkungen zu ihrer chirurgischen BePiand- 
lung. Hals- usw. Arzt I. 27. 101. (1936). 
8. IWANOW: Ueber die Behandlung der Kehlkopfstenosen. 
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9. KNICK, A: Die Behandlung von Narben-stenosen des Kehl- 
kopfes und der Luftroehre. Z. Hals- usw. 
Heilk. 10. 307. 1924. 
10. MARSCHICK, HsZur Behandlung der Larynxstenosen. M. Ohren- 
heilk. 70. 1010. (1936). 11* MAYER, 0: Ein Beitrag zur Behandlung der Stenosen de,f 
Larynx und der Trachea. M, Ohrenheilk. 
66. (1933). 
12* SERCER, A: Zur operativen Theraple chronischer Kehl- 
kopfstenosen. M. Ohrenhellk. 70. 1009. 
(1936). 
13* UFFENORDE, Ws Zur Behandlung der Larynx-Tracheastenosen. 
Schwere Narbenstenose und•Verbrennung in 
Kehlkopf und unteren Luftwegen. Z. Ohrer- 
heilk. 14. (1926). 
14. VOGEL, K: Ueber die chirurgische Behandlung traumr~ 
tischer Kehlkopfstenosen. Z. Hals- usw. 
Heilk. Im Druck. 
15* WALDAPFEL, R: Die roentgenologische Darstellung der Keh'1 
kopfstenosen. M. Ohrenheilk* 70. 1007. 
(1936). 
Discussion; 
VOGEL: The employment of sounds made of protective 
materials is reported as a substitute for BRUEGGEMANN1s 
cannulas, which are difficult to obtain in wartime, for the 
after-treatment of surgically treated scarred stenoses of 
the larynx. As an advantage, the possibility to give the 
sound any size or form$ to control the area of the larynx 
during the after-treatment constantly and to combine this 
sound with any cannula of hormal width, is emphasized. 
After the complete healing over of the inside of the larynx, 
a plastic closure of the laryngostomy should be undertaken, 
which has been kept open up to that time. In cases of con- 
traction of the vocal cords in a median position by a scar 
in the posterior wall, shifting of the vocal cords is ad- 
vised: laryngofissure, severance of the vocal cords and 
the laryngeal pouch cords (false vocal cords) from the In- 
sertion at the arytenoid cartilage, excision of scars, cover- 
ing by a THIERSCH graft, fixation of the graft and vocal 
cords by insertion of a STENT1s sound in such a position 
that it will secure sufficient width of the glottis. After 
the healing over of the wound at the roar wall, closure of 
the laryngofissure should take place spontaneously. STENTfs 
mass must be softened and moulded over the spirit flame when 
in a dry condition, not in hot water, otherwise it will 
get brittle. 
SEIFERTH: Missiles lodged in the wall of the larynx 
can be removed as a rule by fenestration. Once only I was 
obliged to perform a laryngofissure. - Retained smooth 
missiles in the walls of the larynx and the trachea may sli'o 
down during an operation from the outside just as easily as 
during a removal by endoscopy. The choice of the method^to be 
employed depends entirely on the position of the projectile 
and the possibility of locating it. As a sure indication for 
performing a tracheotomy I especially mention the developing 
of threatening development of emphysema. .BRDEGGEMANN: We see again and again that even ex- 
tensive injuries to the larynx do heal up finally with 
remarkably good function* Therefore I object to deform- 
ing operations on fresh injuries of the larynx* One 
should not remove particles of cartilage that are needed 
later on* For the preservation of cartilage the cannula 
sound should be used more frequently in severe injuries to 
the larynx accompanied by destruction of cartilage* I have 
already used this method successfully in the first World 
War* Unfortunately, the cannula sound is not bo be ob* 
tained any more. I am often asked for it but cannot spare 
one* Perhaps some official action can recommend the pro- 
duction of cannula sounds. 
HUENERMANN: Experiences of GREIPETTSTSIN with his 
own patients and his report on cases prove, that 
the treatment of injuries to the larynx by bullets re- 
quires certain qualifications which only physicians with 
special clinical experiences in rhinolaryngology can poss- 
ibly possess. There is always a certain risk in cases of 
injuries of the larynx that patients who are not sent to 
a specialist will not be appropriately treated, In one 
case of nasopharyngeal fibroma, who had been in a large 
ward for patients with diseases of the ear, without special- 
ist treatment for 442 days, proves that the establishment 
of wards for men with serious laryngeal injuries is nec- 
essary* 
BARTH: In cases having indications for a tracheo- 
tomy an early transfer and good transporation must also 
be kept under consideration* The decannulation should 
not be undertaken at all by the medical establishment 
at the front and should take place only when the injured 
person can remain under appropriate long lasting observ- 
ation by specialists. It is wrong, when the tracheotomy 
is performed at the main dressing station, the cannula remov'd 
2 days later and then the injured man is taken to a field 
hospital, as I have observed once. In an emergency one 
may insert a cannula into the track of the missile itself, 
but this should not be the rule. One has to be warned 
against undertaking excisions of wounds, removal of broken 
off parts of the cartilage and more or less extensive 
sutures at the most advanced medical establishments. As 
a rule, one has to consider the nossible sudden removal 
of the wounded and one never knows how soon they will again 
be under the care of specialists. Besides there is the 
possibility of removing, without need, precious material, 
necessary for later plastic operations* 
PERWITZSCHKY: It is sometimes surprising how well, 
even in functional respects, laryngeal wounds heal under- 
neath suitable dressings. For that reason one has to 
warn against too active intervention. 
ZANGE: With gunshot injuries of the pharynx and the 
esophagus in the neck, combined with serious difficulties 
in the swallowing process, neither the tracheotomy nor the 
closing off of the larynx from the tracheotomy gives suf- 
ficient protection against aspiration pneumonia* In these 
cases, SOEREN's laryngeal drainage is the most certain 
prophylactic measure. MUENDNICH: The enthusiasm of surgeons at the medical 
establishments at the front for performing tracheotomies 
is very great. With paralaryngeal and paratracheal gun- 
shot wounds a tracheotomy is frequently made without an 
obvious reason. Usually there is a sufficiently long 
waiting period at hand so that there is no need for im- 
mediate intervention. The danger of a tracheotomy placed 
too high with an injury to the annular cartilage is not 
well enough known among the surgeons. It should be es- 
pecially pointed out in the directives. 
GREIFENSTEIN; Emphysema has of course been con- 
sidered as an indication for a prophylactic tracheotomy 
in the directives. STENT’s mass is a very poorly suited 
material for the production of individually formed sounds, 
whereas synthetic rubber on the other hand has given proof 
of its suitability already in the manufacture of dental 
prostheses. The seat of perichondritic fistulas or ab- 
scesses in the cartilage must always be exposed widely 
and be cleaned out radically. A careful long lasting 
drainage has to follow in order to prevent a new inflamm- 
ation. 
3, Surgery of grazing wounds of the ear and forehead• 
Oberfeldarzt (Lt. Col-,. MC.) Prof. Dr. HUENERHANN 
Through well chosen examples the necessity of con- 
sideration by the ear, nose and throat specialists of 
gunshot injuries which involve the ear and adjacent cavities 
is pointed out. In addition the necessity for an examin- 
ation by an ear specialist of all gunshot wounds of the 
head, as well as injuries caused by blunt objects, is 
noted. The reason for the consultation with ear, nose 
and throat specialist is that only he is in apposition 
recognize possible injuries to the ear and adjacent cavities 
of the nose with his special examination^methods. Careful 
X-ray examinations of the skull and special X-ray pictures 
are necessary too. These are very difficult to get, be- 
cause the technique of it is not yet well mastered. Doubt- 
less one should strive for improvement! conditions will 
improve somewhat by introduction of the helpful implement 
mentioned by BERGERHOFF, which will constitute a valuable 
addition to the field X-ray outfit.v The small'costs of these 
implements will be paid for in a short time through the 
saving of films. 
With gunshot wounds of the ear and accessory sinuses 
there always exists the danger of simultaneous brain dura 
injury and therefore the danger of meningitis. In all these 
cases one is not concerned alone with the care of the brain 
injury, but in addition the mastoid cells and the accessory 
sinuses, which have been opened up by the shot, have to be 
cleaned out’. Especially good care has to be taken to ob- 
tain the be«t possible drainage. Another great danger ex- 
ists with these wounds through the fact that they tend to 
deceptive healing and under the tissue scar remaining bone- 
fragments and parts of injured mucous membrane frequently 
continue in a latent inflamed condition, which can lead 
through an incidental catarrhal infection of the nose sudden- 
ly to the worst complications. In a similar way one must point out the necessity 
of being alert for dammed up infection in the mastoid 
cells and the frontal sinus, especially when they are 
closed by damaged bones. The X-ray picture gives inform- 
ation about this condition, because a cloudiness can be 
recognized within the limits of the plugged sinuses. 
Even many months after such an injury a latent inflamm- 
ation might develop, as happened in one case, where sub- 
sequently brain abscesses and suppuration of the cerebral 
dura occurred. In order to avoid these late complications 
a cleaning out of the closed-up sinuses is necessary. The 
best^and most certain ventilation of the frontal sinus is 
possible through insertion of a little rubber cap, which 
has to stay there for 6 weeks, according to the method of 
SEIFFERT. 
The earlier gunshot injuries of the ear and accessory 
sinuses are presented to the specialist, and the earlier 
they are treated by him, the better will the danger of 
fatal late complications be avoided. 
The special field of surgery of the ear and accessory 
sinuses has to make use of the experience in war surgery and 
has to adopt the elementary principles of general surgery 
and to enlarge the experience upon them. Much clinical 
experience is necessary in order to master the very diffi- 
cult problems presented by injuries of this kind. For that 
reason it is recommended, that in addition to establishing 
a large number of ordinary special wards, that in larger 
sections an extra division should be fitted out for the 
seriously wounded and to assign to it the most complicated- 
cases^ 
Discussion: 
PEEWITZSCHKY: A similar instrument for arrangement 
of positions suitable for the taking of X-ray pictures 
of the skull has been mentioned already by BRUENING and 
has proved to its usefulness. During late operations for 
the purpose of closing up a persistent fistula in the 
frontal sinus, special precaution must be observed as 
scars which have closed bone gaps might be torn out quite 
easily, and in this way meningitis might be more possible. 
GHEIFENSTEIN: A negative X-ray picture does not 
exclude the presence of extensive depression-fractures 
when there are grazing and tangential gunshot injuries 
of the mastoid* On the other hand a haziness of the cell- 
system in newer injuries may be occasioned only by traum- 
atic edema of the mucous membrane and by hemorrhage in 
the cells. The clinical findings are the deciding factors 
for the necessity of operation. 
SEIFERTS: The prospects of successful treatment of 
frontal basal brain injuries are good, when adjacent sinuses 
are cleaned out thoroughly. Meningitic processes, which 
have been fed by the adjacent sinuses, healed up in a shott 
time when remnants of the sinus were cleaned out during a 
later operation. A mastoidectomy must be performed in all- 
cases when injuries of the mastoid occur. If the antrum 
(mastoid) is not opened up an otitis will develop and a 
later dperation will always be necessary in this case. Directions from donsultants1 committee on ear, nose 
and throat, ' 
The group of specialists on ear, nose and throat has 
been admitted for the first time to the meetings of the 
consultaht physicians. According to peacetime experiences 
diseases of the ear, nose and throat comprise about 30 per 
cent of all the cases of illness, . In the statistical sick 
reports of the Army this percentage is not reached, because 
many cases in our field disappear into other columns. 
A great part of the injuries in our speciality are 
life endangering but may be overlooked easily because of 
the small external wounds. 
It is not possible for our special group to formulate 
directives on all pressing questions in our entire branch 
during the first participation at the conference# We there- 
fore had to limit ourselves to a few important themes. 
I• Gunshot injuries of the larynx, laryngeal stenose *. 
and their treatment# 
#Every injury of the larynx and/of the trachea must be 
considered a potentially serious throat injury# The first 
consideration has to be the evaluation of all accompanying 
injuries of vessels and esophagus which might have to take 
precedence in the treatment. 
The recognition of a laryngeal injury is simple if in- 
jured cartilage structure or the exposed lumen can be ob- 
served in the wound. All other symptoms such as difficult 
breathing, voice impediment, difficulty in swallowing, 
coughing out of light red blood and emphysemas are ambiguous 
and do not prove anything with certainty. All these symptoms 
appear likewise in injuries of the food passages with in- 
direct participation of the larynx through haematoma, edema, 
paralysis of the recurrent nerve or with injuries to the 
pleura apex and peak of the lungs. 
The following classification of important, reliable 
clues gives guidance to the non-specialist, especially about 
first evaluation and the urgency of a speedy transfer; 
1# Paralaryngeal shots# 
With the involvement of the inner larynx through 
hemorrhage, edema, tearing of the mucous membrane and re- 
current nerve paralysis. Frequently voice impediments. 
Occasionally dyspnoea. Laryngeal mirror examination is 
important# Usually prompt improvement of symptoms# 
2. Injuries of the entrance of the larynx• 
Usually from frontal shots. Hypopharynx always injured 
too, therefore is frequently diagnosed as an injury of the 
esophagus. 3* Anterior frontal shots (midline). 
(Tangential and perforating shots)* 
General: Absence of serious injuries to the sur- 
roundings* Insertion of cannula frequently uossible in 
wound itself. 
4• Posterior frontal shots (lateral to the mid 11 n 
Accompanied by injuries of vessels of the throat, and 
the nerves of the vagus-plexus. The more dangerous the 
farther back (esophagus) and the higher up the track of the 
missile runs (injuries of annular and arytenoid cartilage 
with infections from hypopharynx and danger of perichondrit:* a 
5• Sagittal shots• 
Appears rarely in pure form. Usually missiles are 
stopped by vertebral column after passing through the larynx 
and esophagus. In every case of a missile lodged in the 
throat para-vertebrally and in the vertebra (mostly diagonal 
shots) one also has to watch out for injuries to the esophrf—. 
and the larynx. 
6. Longitudinal shots. 
Entrance of missile frequently at lower jaw, in face, 
sometimes in the cavity of the mouth* Injury of hyoid bone, 
larynx structure, possibly involvement of trachea, opening 
up of the anterior mediastinum, missile lodged in the thorax. 
In regard to the larynx the prognosis is more serious slant- 
ing and deep penetrating longitudinal shots* 
7• Destructive shots* 
Mostly through large and multiple missiles, which cause 
large, complicated fractures (high primary mortality) with 
wide opening of the respiratory passages. In this case a 
cannula usually may be placed in the wide open larynx. 
8* Trachea shots. 
E*g. also as attendant injury of longitudinal and 
destructive shots of the larynx. In isolated cases of 
tracheal injuries emphysema frequently occurs* On should 
watch out for injuries of the pleura and esophagus. Danger 
of anterior mediastinitis in every injury to the trachea. 
Insertion of cannula in wound, sometimes located very low. 
Search for lodged missile (iirthorax). 
9. Penetrating shots (lodged missiles). 
Missiles lodged in walls stopped by cartilage and 
lodged missiles in mucous membrane at the entrance or on 
the opposite side. In addition shots which penetrated to 
the inside which might be aspirated, coughed out or be 
sxvallowed. The intra-laryngeal location of a penetrating 
missile will often not be recognized* Generally, eventual 
removal by endoscope is the correct indication. The treatment of injuries of throat and larynx must 
and should be only preventive and symptomatic in medical 
units at the front sufficient to alleviate difficult breath- 
ing and hemorrhage* Even if there exists only questionable 
injury to the food passages (trouble in swallowing, em- 
physema, salivation), on account of the danger of phlegmon 
of the throat and mediastinitis an attempt to clean up the 
situation by revision of the wound and a following up of the 
shot canal should be made. A speedy transfer to a special 
ward is unquestionably desirable. 
The request for specific indications concerning pro- 
phylactic tracheotomy, a procedure which has proved its 
value already in World War I, has been emphasized uncon- 
ditionally by experience in the present war. Under field 
conditions the indication for preventive tracheotomy is 
given by; 1. onset of dyspnoea, 2. profuse or persistant 
hemorrhage from the air passage or' the larynx pharynx, 
3* increased emphysema under the skin, 4. large swelling 
of the tissue surrounding the airways due to hematomas or 
wound infection, 5. intralaryngeally lodged missiles and 
larger missiles lodged in the immediate neighborhood of the 
air passages which cannot be removed immediately. 
Especially, if the time of transfer is uncertain and 
transportation is without sufficient supervision then one 
may perform a tracheotomy rather once too often than once too 
seldom. 
A tracheotomy should be located below the wound, if 
possible outside of injured soft parts. Insert the cannula 
in the entrance or exit wound only as an emergency solution, 
although it cannot be avoided in some cases of tracheal in- 
juries. The tracheotomy should be performed in the correct 
manner as soon as possible. 
Besides creating a certain passage for breathing a 
tracheotomy serves also for the prevention of aspiration, 
especially in cases of hemorrhage in so far as a laryngeal 
tamponade may be made from the tracheotomy wound outward 
and a tamponade of the esophagus can be undertaken from the 
mouth outward and the source of bleeding then located. A 
tamponade through the shot-canal should be undertaken only 
in cases of serious hemorrhage and a wide open wound. A 
drainage of the larynx is necessary.with longer lasting 
impediments of swallowing and should be performed according 
to SOEHENSEN. 
Decannulation may be undertaken only when firm healing 
of the wound of the mucous membrane and cartilage can be 
depended on (otherwise there is danger of perichondritis) 
and when the laryngoscopic examination has^demonstrated a 
free lumen of the larynx and (especially with injuries of 
the hypopharynx) the danger of bleeding, including late 
bleeding by erosion, have been eliminated* If a tracheotomy 
has been performed correctly and faultlessly then 
of time the cannula has been in the wound plays an unim- 
portant role as a cause of a difficult decannulation. A 
cannula should not be removed by field medical units a short 
time before transfer. 105 
A primary suture of laryngeal and tracheal gunshot 
wounds is taken into consideration by the expert only when 
omission of it would result in greater danger and more 
serious consequences (e.g. with extensive tearing of the 
trachea or much exposure of injured cartilage structure). 
The otherwise very frequently useful and advantageous early 
operation, laryngotomy with the care of the mucous membrane, 
cartilage and dilatation treatments, will remain the ex- 
ception under field conditions, because it cannot safely 
be decided whether the consequences of the injuries will 
lead^to a permanent serious stenosis. Serious injuries to 
cartilage with profuse hemorrhage or larger missiles lodgfd 
intra-laryngeally would be the most frequent indication for 
an early operation. 
The residual permanent damage following laryngo-tracheaJ 
injuries such as stenosis, voice impediments, requires the 
planning of a highly individualized treatment which must be 
followed faithfully and which should take place always in the' 
same ward, if possible In special wards. Emphatic attention 
must be directed toward the necessity and the success of the 
treatment of the voice, after many injuries of the larynx 
and following treatment of stenosis. 
II* The care of injuries to ear, nose and associated 
injuries? 
1. According to our experience most of the cases 
of meningitis following gunshot injuries of the head arise 
in the ear and nasal accessory sinuses. 
> 
2. The results of treatment of head injuries can 
be improved on considerably if during the primary care not 
only the brain dura wound is attended to, but also that the 
adjacent accessory nasal sinuses and the air cells of the 
ear are carefully cleaned up. 
3. Consultation by surgically trained ear, nose and 
throat specialists for the diagnosis and treatment of these 
wounds is necessary, as well as concerning all injuries t.e 
the upper jaw and face and. admission of such wounded to the 
ear, nose and throat wards in medical establishments farther 
back to the rear should be used. 
4. Judgement of injuries to the ear and accessory 
nasal sinuses depends to a large degree upon faultless 
X-ray views of the skull, if possible stereo-pictures. 
The average technique in the field of roentgenography 
leaves much to be desired. It must be improved upon. 
The adjustable apparatus mentioned by BERGERHOFF (Deut- 
scher Militaerarzt, 1942, Heft 4) gives considerable help 
in the focusing process. Its rapid introduction, which_ 
is already planned, should be made possible* Besides thus, 
the technical assistants have to be instructed about correct 
focusing etc. 
5. The condition of the eardrum and ear canal or 
the ability to hear of itself does not justify a deduction 
concerning the involvement of the ear but rather the X-ray 
findings and the clinical symptoms convince the otologist 
about the kind of the injury. 6, In most cases operative treatment is necessary 
as soon as the mastoid cells and the middle ear have been 
opened up. Ear injuries incline to deceptive healings, 
in which the wounds of soft parts grow scars, while the 
bone wound continues in a latent inflammed condition out of 
which it easily develops into a late meningitis, if the 
site of injury is not cleaned out. 
AlSo with frontal sinuses and ethmoid bone injuries 
a cleaning out of the diseased bone and mucous membrane 
parts and the creation of good drainage is necessary. 
7. In order to facilitate the execution of the many 
difficult tasks, produced by this kind of complicated in- 
juries, the establishment of special wards for the seriously 
injured (with each Army? Medical Department or Army District) 
will be recommended, which will have to be fitted out ex- 
ceptionally well with good instruments and able personnel. 
All complicated or doubtful cases are to be transferred to 
them. The smaller wards (with peacetime sicknesses) and 
the dispensaries should be left in the care of those physic- 
ians who do not practise surgery in peacetime. VI. 
PROCEEDINGS OF THE CONSULTANTS1 
COMMITTEE ON HYGIENE 
AND TROPICAL HYGIENE 
Translation prepared by: 
Office of Military Government for Germany (U. S* ) 
Office of Naval Advisor 
Medical Section Typhoid and paratyphoid experiences. 
(See Section VII, Article 7) 
Problems of encephalitis, etc. 
(See Section XI, Article 4) 
A• Combined and adsorbate-immunization serums • 
1« Tolerance to a new combined vaccine against typhoid, 
paratyphoid and cholera, 
SS-Hauptstnrmfuehrer (Captain, Elite Guard) DOETZE" 
Previous attempts for simultaneous protective immuniz- 
ation with a combined serum against several infectious agents 
have been successful several times, first by CASTELLANI and 
later by RAMON. There was little incentive for developing 
a simultaneous active immunization against several infectious 
agents in Germany because of the high standard of hygienic 
conditions, apart from the fact, that the doctrine of com- 
petition of the antigens has retarded the employment of com- 
bined immunization material. Conclusive proof regarding in- 
fluence on immunity through the administration of different 
immunizing agents has not yet been produced, so that the 
concept of competition of the antigens cannot be used to 
minimize the results of practical experience with combined 
agents. The limit in employment of combined agents may not 
be found in the competition of the antigens but in the too 
violent reactions caused by the administration of increased 
quantities of antigens. 
The testing of tolerance to combined agents for that 
reason appears to be of foremost and decisive importance 
concerning its use. The testing can only be of value when 
done on human beings. We have therefore tried out, on a 
number of persons, the toleration to a new tetravaccine 
against typhoid, paratyphoid A and B and against cholera. 
The vaccine was placed at our disposal by the Behring Werke, 
Marburg (Op. 194 212, active until the lo December 1945). 
The vaccine was clear, slightly opalescent without coarse 
particles and contained, according to information furnished 
by the producer: 
in 1 cc. s 500 millions of typhoid bacilli 
250 millions of paratyphoid bacilli A 
250 millions of paratyphoid bacilli B 
2 billions cholera-vibrions. 
Injections with this vaccine were performed at inter- 
vals of 7 days and were given alternately under the skin 
of the right and left chest between the nipple and the 
collarbone in doses of 0.5, 1.0 + 1.0 cubic centimeters. 
Altogether 250 healthy, well nourished men doing heavy 
work were vaccinated. 
The tolerance to the vaccine was 
to the local and general reactions and for details follow 
up examinations of the vaccinated men took place on the 
1, 3, 5, 7, 13 and 20th day after vaccination. Examinations showed narked local reactions in only 
about 50 per cent of the men following the 2nd and 3rd 
injection* There was no essential difference between 
the 2nd and 3rd injection* The local reactions generally 
lasted about three days and rarely longer than five days* 
Reactions occurred most frequently on the first day* The 
reactions conformed throughout with those observed with 
vaccination using TAB (Triple typhoid-paratyphoid) vaccine* 
No special inconveniences were observed with general re- 
actions* No increase in temperature took place* The 
capability for work was not impaired in a single case* 
In summary it can be stated on the bases of observation 
on 250 men, that the tolerance to the tetravaccine against 
typhoid, paratyphoid A and B and cholera (producer Behring- 
Werke) is in no way different from the tolerance to TAB, 
used up to now, and that there is no objection to its em- 
ployment on a greater scale. 
2* Tolerance to new typhoid, paratyphoid A and B vaccine• 
SS-Sturmbannfuehrer (Edjor. Elite Guard) GROSS 
On the basis of observations on 1000 men the tolerance 
to a new endogen adsorbed vaccine against typhoid, para- 
typhoid A and B produced by the Behring Vcrke was studied. 
The vaccine had been produced through a special procedure 
bringing into solution typhoid and paratyphoid A and B 
bacilli. The resulting endogen had been adsorbed by 
aluminim hydroxide* The final endogen concentration in 
1 cubic centimeter was equal to an amount of endogen ob- 
tained from 
500 millions typhoid bacilli 
250 millions paratyphoid A bacilli 
and 250 millions paratyphoid B bacilli* 
The content of aluminum hydroxide in this vaccine amounted 
to 10 per cent. 
The vaccine v/as Injected underneath the skin of the 
chest, strictly subcutaneously at intervals days in a 
strength of 0.5 cubic centimeter at the first injection and 
1*0 cubic centimeter at the second and third injections* 
The 1000 men selected for the vaccinations had an 
average age of 25 years and were in moderately well 
nourished condition. 
200 vaccinated men (group l) were under daily medical 
observation. Reactions of the second group of 800 men 
(group 2) were observed every second day* The figures 
appearing in this report are based on results of evaluations 
of the first group, to which we might add that the results 
xvere about the same in both groups* In estimation of reactions a differentiation was made 
between general and local reactions. 
Fever was slightly more frequent than other symptoms 
of a general reaction. Repeated measurements of temperatures 
gave the following picture; 
Injection: 
Io 
II 
in 
Subfcbrilo temperatures 
(above 37.5°C.) 
3.0 96 
4.5 $6 
5.0 96 
Temperatures above 38° C. 
5.5 96 
15*0 7o 
2.0 96 
Elevated temperature was found mainly during the first two 
days. 
Other appearances of general reactions wore observed 
only individually as the following records show: 
Injection; 
I 
II 
III 
Exhaustion 
1.0 
% 
2.0 
96 
0.5 
9 
Headache 
8,5 
% 
11.0 
56 
9.0 
96 
Chills 
3.0 
% 
11.0 
% 
9.0 
9 
Pain in limbs 
1.5 
9b 
1.0 
56 
2.0 
9 
Pain at site of injection 
2.5 
°A 
2.5 
% 
6.0 
% 
In evaluation of the local reactions following injection 
two phases could be made out: the acute inflammatory stave 
from the 1st to the 4th day and from the 5th day to the stage 
of depot resorption. The first phase was marked, with the 
exception of reactionless cases, by a reddening of the skin 
around the site of injection as early as 3 ‘to 4 hours after 
immunization. This reddening showed small infiltrates and 
also a certain tenderness to pressure (50 percent) particular- 
ly after the second and third injections. According to 
frequency and size we could observe 4 different groups of 
reactions, namely reddenings with an average diameter of 
2x2 cm., 4x4 era., 7x7 cm. and larger. 
After the first injection the reactions with an average 
diameter of 2x2 and 4x4 cm. were seen in about equal numbers. 
Only an infinitisimal part of the reactions had a diameter 
of 7x7 cm. after the first injection. Reaction sizes of 
4x4 and 7x7 cm. were more prevalent with the second inject- 
ion in contrast to the smaller reactions with the first in- 
jection. The third injection produces about an equal dis- 
tribution of all sizes of reactions. 
The numerical proportions of all observed reactions 
of all sizes on the second day after injection were: 
I injection II injection III injection 
69.0 % 91.0 % 74.0 S6 The phase of local accumulation (depot resorption) 
was recognized by the fact that reactionless infiltration 
developed of 1x1, 2x2 and 3x3 on. in size from the sixth 
day after the injection which persisted up to 8 weeks and 
did not cause any inconvenience to the immunized men# 
Infiltrated areas with a diameter of 1x1 cm. and 2x2 cm. 
were observed in that order of frequency. Larger infil- 
trations were less frequent. 
The observation showed, that the number of cases of 
infiltrations increased from injection to injection and 
reached the highest point with 79 per cent of all vaccin- 
ated persons 4 weeks after the third injection. In a 
small number of \zases reactionless infiltrated cords de- 
veloped which extended from the site of injection toward 
the armpit. Also small sterile abscesses, which were re- 
absorbed in a short time were seen. Reactionless swelling 
of the lymph glands, up to the size of a bean were also 
observed in the corresponding armpit. 
The differential blood count showed an insignificant 
deviation from the normal. 
Within the group of 200 men the O-agglutination. ac- 
cording to GRUBER-WIDAL, showed a certain rise of titer 
in a small number of cases against typhoid as well as 
against paratyphoid. The highest titer of ls200 was 
reached in the 7th and 8th week after the 1st Injection 
(8 per cent and 8.5 perceeht respectively) • 
Absence from work on account of the immunization 
was small and coincided with the day of injection and 
the three days following with few exceptions. 
There were unable to work of 
group I 
group I and II 
(200 men) 
(1000 men) 
1st injection 
2.0 % 
1*5 % 
2nd injection 
7.0 9b 
1.8 96 
3rd injection 
2.5 9b 
0.8 96 
It can be stated in summary that the typhoid, para- 
typhoid A and B adsorbed vaccines of the Behring Werke 
with the Op. No. 284 212 as used in these experiments, is 
certainly tolerated well in every way when used with the 
dosage employed here. At the present, nothing can be said 
concerning the protection given by this vaccine in case of 
exposure to these diseases. 3» Experimental trial of a new typhoid vaccine. 
Flottenarzt (Fleet Surgeon) Prof, HUGE 
Efforts to produce more potent typhoid vaccines than 
the ones existing and trying to get along with just one 
injection have been studied for a long time, GRASSET es- 
pecially has occupied himself with these problems and by 
all appearances produced a very effective vaccine. His 
procedure was to open up the typhoid bacilli through a 
repeated freezing and thawing process, leave the emulsion 
alone for several days at about 37° C. and then centrifuge 
it, after which the remaining liquid was treated with Forma- 
lin in order to attenuate any toxic substances. According 
to his reports, quite a number of persons have been vaccin- 
ated with one injection of this vaccine v/ith rather good 
results which were at least equal, if not superior, to those 
of the threefold injection with the customary vaccine. 
Others have later simplified the production of the vaccine 
omitted the addition of Formol and claim, nevertheless, 
to have had just as good immunization results* 
With existing work as a foundation, I have occupied 
myself for the last 12 years with this problem with the aim 
in mind to prodmce an adsorbable vaccine that would avoid 
reactions produced by Formalin. For the destruction of the 
typhoid bacilli I have employed, just like GRASSET, a re- 
peated freezing and thawing process (freezing at minus 80° C., 
thawing at 56° C.) and then putting the emulsion into the 
incubator. Further experiences showed, however, that the 
freezing and thawing process was not necessary at all in 
order to destroy the typhoid bacilli and that it was suf- 
ficient to let it stay at about 37° C. The dregs at the 
bottom were centrifuged off and the remaining liquid cut 
with aluminum hydroxide, fhe vaccines produced in this 
manner were concentrated and for injections had to be 
diluted in a ratio of 1 to 10. In experimental trials 
on animals with the present vaccine, titers for 0 and H 
up to 1:50 000 have been produced. The vaccine was satis- 
factory and did not produce any local irritations. Trial 
immunizations on human beings resulted in the same picture. 
On the basis of work done with Vi-Antigen I prodeeddd 
later to use a whole series of typhoid strains for the pro- 
duction of the vaccine. I have highly virulent cultures, 
which were freshly isolated from large epidemics, which have 
been passed through the mouse and then used for the pro- 
duction of vaccine, I have not been able to find remarkable 
difference in the several groups. Finally, I used only a 
single strain and one Vi-culture. The latter culture I 
employed for the reason that one finds in it the most im- 
portant factor for immunization. On the basis for a long 
series of experiments, regrettably interrupted by external 
circumstances, I have adopted the following working pro- 
cedures 
. The emulsion is centrifuged, the sediment is removed 
and diluted with distilled water, put into the incubator 
and left there for some time. The first liquid is treated 
with aluminum hydroxide, the residue washed out and pre- 
served as a concentrate in Phenol-NaCl. Concurrently with this, Vi-dialysate is produced from a good Vi-culture in 
the customary manner. 20 per cent of this dialysate is 
added to the vaccine. Experiments on rats, undertaken 
according to the system of SIBLING although with only one 
injection resulted in the rats surviving a dose 40 times 
the minimal lethal dose 16.5 f, d.l.m. The rats were 
killed later and were examined bacteriologically for 
possible viable bacilli. On only a few cases among the 
surviving rats could the presence of typhoid bacilli in 
the spleen be proved but never in the intestines or blood. 
Of course, the infection was performed with a heterogenous 
culture* Only the shortage of animals prevented me from 
experimenting on a larger scale. 
In order to make use of all the available mass of 
bacilli dialysates have been produced even out of the 
residues of the bacilli treated with distilled water. 
They also showed the property of agglutination* On the 
other hand it has also been tried to obtain antibodies, 
if possible, from the Remains of the dialysates of the 
Vi-culture. 
In the course of examination it was determined, that 
in the production of vaccine one has to watch out not only 
for the composition of the single strain of bacilli, but 
that the relative weight of the component parts also plays 
an 'important role. It is therefore necessary to weigh the 
bacilli and to make up a corresponding combination according- 
ly. The behavior of the residual nitrogen and the composite 
protein gives a reliable clue to go by. 
At the present time I have advanced so far that only 
an evaluation of the results of experiments on animals is 
necessary. After that, no obstacles are presented against 
experiments on human beings. 
4. Adsorbate vaccines against scarlet fever a.nd diphtheria■. 
Stabsarxt (Captalnr MC^LSCHMIDT-BIBBACH 
In consideration of the many evidences of good re- 
sults with adsorbate vaccine for diphtheria this consultant 
advises its employment on adults in the campaign against 
diphtheria. For adults up to 30 years two doses of 0.2 
cubic centimeter each at an interval of 4 weeks are re- 
commended. 
Vaccines made of streptococci, according to GAERTT- 
3GHEWSKY and those made from native toxins according to 
DICK may be considered obsolete today. After ANDO and 
collaborators have determined through analysis of the 
culture filtrates of haemolytic streptococci that the 
specific erythrogenic exotoxin can be separated from the 
non-specific, allergically active nucleoprotein, then the 
question is raised, whether only the pure erythrogenic 
scarlet fever toxin obtained through alcohol:precipitation 
should be used for the DICK reaction as well as for the production of the vaccine. Adsorption of this toxin by 
aluminum hydroxide will yield a vaccine producing an ef- 
fective protection with 2 to 3 injections with well toler- 
ated reactions. This consultant wishes to emphasize, that 
the appearance of strong reactions always has to be con- 
sidered as a symptom of high grade susceptibility toward 
scarlet fever. In these cases the same dose should be 
injected again and hot the next higher one. The pro- 
tective vaccination against diphtheria and scarlet fever 
can also be combined through the employment of adsorbate 
vaccines. In order to do this, two vaccinations with the 
double vaccines must be performed at an interval of 4 weeks. 
An analysis of the reactions should be made in order 
to determine, whether the reactions observed on the indi- 
vidual patient were caused by the portion of the vaccine 
against diphtheria or by that portion against scarlet fever 
in order to be able to draw final practical conclusions 
about continuing the vaccination. 
Discussion on the lectures about combined and ad- 
sorbate vaccines. 
SCHREIBER: Of utmost importance in this discussion is 
the question if it will be possible to introduce to the 
Armed Forces the vaccines against typhoid, paratyphoid A 
and B and cholera, examined by MRUGOWSKI, Tolerance to 
this vaccine is hardly different from that to the vaccine 
TAB. It is not yet determined, how the agglutination titers 
will behave after vaccination against typhoid, paratyphoid 
and cholera. Taking favorable results for granted, one can, 
for obvious reasons, not draw final conclusions about the 
usefulness of a vaccine from the increase of agglutination 
titers alone but can consider the behavior of the titers 
only as a hint, - then I would have no objection against 
the unconditional introduction of this vaccine in order to 
save our soldiers one injection, namely the vaccination 
against cholera with reference to the initial and also the 
booster vaccination. I beg you, when drawing up directives 
on the future scheme of vaccinations, to keep in mind, that 
in this fourth year of the war it is of really^no little 
importance whether there are more or less vaccinations 
than heretofore. 
ROSE (to DOETZER): The results of these examinations 
affirm the correctness of the system in use by the Tropical 
Branch of the Robert Koch Institute for the last 6 years, 
that is to inject simultaneously with the normal dose of 
vaccine against typhoid and paratyphoid, in the same 
hypodermic syringe with 2 billions of cholera vibrions. 
All vaccinations had been well tolerated. No increase of 
reactions above those observed with vaccinations against 
typhoid and paratyphoid alone took place# On the other 
hand, the commercially available combined vaccine, con- 
taining only 500 millions cholera vibrions in 1 cubic centi- 
meter must be rejected, as this small number of vibrions 
seems to be insufficient to produce immunity against cholera. 
It is suggested that we refrain from of the name 
Tetra-vaccine in the Armed Forces for this vaccine but 
rather to name it in such a way that even the troop physician inexperienced in immunizations can unmistakenly recognize 
it for what it is* In other words, tb speak of a vaccine 
against typhoid, paratyphoid A and B and cholera* It is 
advised, that the place on the body for injection also 
be studied in future examinations of this kind about toler- 
ance to certain vaccines. As a rule for the German Armed 
Forces protective vaccinations against typhoid and cholera 
have to be administered under the skin of the chest, as 
contrasted to spotted fever which is given under the skin 
over the deltoid muscle. The latter spot for vaccination 
is generally preferred in foreign countries. The opinions, 
on which site the local reactions are of greater incon- 
venience to the vaccinated persons, are divergent. A 
decision on this question, through careful comparison, 
is urgently desired. The location should be determined, 
on which site the acute inflammatory reaction and the 
longer lasting permanent infiltration of the adsorbate 
vaccines would be the least inconvenient. 
(To HUGE): The immunization with a single injection, 
if possible without any reactions, is an old desire of all 
hygienists and especially of all persons about to be vac- 
cinated. Whether it ever can be realized with employment 
of non-viable agents or with toxins derived from them, must 
be doubtedsaccording to all present knowledge. We know, 
that the kind and mass of antigen alone are not of decisive 
importance for the degree of possible protection. Of 
greater significance are the repeated stimulation and the 
interval of time between the injections. The interval of 
7 days, customary in the German Armed Forces, is at the 
same time in no case the best choice from the point of view 
of immunizationj but it has been forced on us out of pract- 
ical considerations as in most cases a longer period of 
time would lead to an incomplete execution of the vaccinatic . 
(To SCHMIDT-BURBACH); Through the pressing into the 
service of the airforce helpers of extreme youth there 
have come under the hygienic care of the Armed Forces, age 
groups which we, with the exception of the Preparatory 
Military Schools, never had to consider before, neither 
in the Armed Forces nor in the State Labor Service (Reichs- 
arbeitsdienst). In regard to the increased hazard to these 
groups through scarlet fever and diphtheria, the Medical 
Inspector of the Airforce ordered the general protective 
vaccination against those two infections. The vaccination 
with the combined vaccine against diphtheria and scarlet 
fever will be divided into 5 Injections which are to be 
given at intervals of 14 days each. Nothing can be 
ported yet concerning the epidemiological results^of this 
measure, as it has been in progress too short a time. 
However, it is worth mentioning, that several medical 
stations had to report such severe reactions that they 
discontinued, on their own initiative, the completion of 
the ordered vaccination. Of course, these severe react- 
ions have not been observed in generalj so that we have 
to keep in mind the possibilities of mistakes in dosage. 
At any rate, these observations admonish one to be cautious 
in further proceedings. We object especially to recommending 
for the Armed Forces at the present time, the simultaneous 
vaccination against scarlet fever and diphtheria in a single njection, I- is desirable to collect a greater amount 
oi experience, with less sensitive age groups in the 
civilian sector before one continues in this manner with 
the Armed Forces* Of course, particularly careful super- 
vision of single experiments is to be desired. The pre- 
judice against the protective vaccination against diph- 
theria for adults is based not only on experience made by 
immunizing nursing personnel but also of similar observa- 
tions made in immunizing student teachers* In addition to 
that there is the fact, that in spite of stronger reactions 
experienced by adults, the immunity conferred through vac- 
cination against diphtheria appears to be smaller with adu?J 
than with the more youthful groups* T suggest adopting 
the principle, that generally for protective vaccinations 
in the Armed Forces and when various strengths of vaccines 
have to be injected, at each vaccination date, that these 
Various doses, exactly as in protective vaccinations against 
choleic and diphtheria, be issued in different volume rath/ r 
than in doses of different concentrations. Different volu,r 
will eliminate the danger of confusion of concentrates, 
which happens in practice again and again although in 
theory it seams so^easily avoidable. If there were in us 
only a single vaccine of standardized concentration its 
supply and availability would be facilitated. To the 
question of General (MC.) Professor oCHREIBEK, in regard 
to the position taken towards passive immunization through 
serum, it has to be reported, that in the Airforce the 
passive immunization with heterogeneous scrums against 
diphtheria and scarlet fever has been forbidden in prin- 
ciple. The motive of this prohibition is the consideration, 
that the passive immunization has apparently a well merited 
place only in pediatries. Under military conditions the 
exposure can seldom be removed within the short period of 
protection obtained by the use of the serum and on the 
other hhhd the susceptibility of those age groups which do 
interest us is considerably less than in childhood. Further 
more, experience has taught us that those reactions appear- 
ing after employment of prophylactic serums, invalide more 
of the troops than the sickness itself. Serious serum sick- 
ness, yes, even cases of death, have been the consequences 
of the employment of prophylactic serums. Finally, there 
has to be taken into consideration, that in wartimes an 
unnecessary sensitization of the soldier against serum 
has to be avoided, as the possibility of an injury at any 
time has to be taken into account, which in turn would 
necessitate an injection of tetanus serum. It would be 
desirable if other parts of the Armed Forces would follow 
the example set by the Airforce. 
CLAUBERG: Efforts to simplify vaccination methods 
through the combination of the antigen and adsorption of 
the same on aluminum hydroxide, in order to obtain vaccine 
depots in the tissue with a delayed resorption process, arc 
to be welcomed. At any rate, all the new kinds of com- 
bined vaccines have to be examined immuno-biologically for 
immunization and supported by experience. Advance inform- 
ation never could be given regarding the possible mutual 
benefits on the one hand or the possible hindrance oi the 
effectiveness of a certain vaccine. Expectations of success from the so much desired single injection should not be 
raised too high. In my own investigations (in collaboration 
with SARTORIUS) the vaccines proposed for single injections 
among them Sublimate, Lipo and Endo-Anatoxin-Precipitation 
vaccines, came off second best almost always when compared 
with bacilli suspensions of the related kind employed under 
similar conditions and which are in general use at the present 
time. One will hardly ever get along without the repeated 
immunization stimulating doses. In my latest examinations 
concerning protective vaccination against diphtheria in 
adults, the use of a minimal dose of vaccine i.e. 0.1 cubic 
centimeter adsorbate has proved to be sufficient. The re- 
actions fortunately were small and the success of vaccination 
extraordinarily good. In regard to older persons, perhaps 
with those above 35 years, one should get along without the 
protective vaccination against diphtheria altogether. If 
epidemic conditions should force upon us a different attitude 
then 0.1 cubic centimeter anatoxin will suffice for these 
age groups. The basic immunity against diphtheria present 
in the adults of our population as an expression of latent 
permeation of the infection can itself be stimulated with t1u 
smallest dose of antigen, as the negative results of the 
Schick-test convincingly prove through the simple expedient 
of its repetition. For that purpose the above mentioned 
dose of unadsorbed toxoid is sufficient which, by the way, 
will be more speedily resorbed and therefore promises a 
speedier success. Because of the serious reactions observed 
in cases of immunization with the combined vaccine against 
scarlet fever and diphtheria a re-examination of the gener' '!;r 
rough, empirically stipulated dose should take place. Es- 
pecially the lately used quantities of antigen seem to bo 
rather high and not without objection. One will have to 
keep in that antigen doses and antigen effect do not 
stand in proportional dependency to each other but rather 
follow the binominal function, i.e. one never succeeds in 
obtaining more than the optimal effect through increased 
doses of antigen. For that reason it is necessary to de- 
termine that dose which finally must be chosen anyway, and 
which would not need to be exceeded in order to bring about 
the desired effect. 
HORNUNG: Three things seem to me to be of importance: 
1. Dose: It should not be greater than is absolutely 
necessary. 
2. Location: I prefer a vaccination into the chest 
to a vaccination into the upper arm, because the 
latter is more in motion. . 
3. Interval: 8 days are too short a time as examinat- 
ions in Marburg have shown. The organism has to 
have time to build up antibodies. The importance 
of longer intervals are also shown by experiences 
of the French with the injection de rappel, the 
so-called "recall” injection. 
necessary. WAGNER: Combined vaccinations against diphtheria and 
scarlet fever had been executed in a submarine training- 
division in such a way, that between the injections of the 
protective vaccine against diphtheria occurring at a 4 
week interval a vaccination against scarlet fever was in- 
serted, so that a 14 day interval between the single vac- 
cinations could be maintained. Owing to a careful choice 
of dose, there was no increase in vaccination reactions to 
be observed. The suddeh decrease of incidence of both sic1 - 
nesses in the above mentioned naval unit speaks for the 
success of this procedure. 
RODENWALDTs With regard to this question, I beg of 
you to take into consideration the experiences of the Dutch 
with vaccinations with tetra-vaccines of the Mecca pilgrims. 
For the last 15 years the pilgrims have been vaccinated 
with tetra-vaccine and the resulting experiences have been 
splendid. 
KROEGER: Since October 1942 all new entries in the 
State Labor Service (Reichsarbeitsdienst) have been vaccin- 
ated against diphtheria and scarlet fever right from the 
start, exclusively with adsorbate vaccine. No statement 
can be made at present about the results of these vaccinat- 
ions and their epidemiological effects as the necessary 
particulars are only collected just now. In reference to 
tolerance to the vaccine, which seems to be of interest 
to all of you the following can be said however; The ex- 
ceptions against vaccinations for scarlet fever taken by 
UHLENHUT and the scruples mentioned by ROSE against the 
employment of combined vaccines because of their severe 
secondary symptoms in contrast to the ones experienced with 
the vaccination against diphtheria, alone or rather with 
the divided protective vaccination against diphtheria and 
against scarlet fever cannot be concurred with. If UHLEN- 
HUT recommends the limitation to the well tried protective 
vaccination against diphtheria and its safely controllable 
secondary effects, then we have ascertained in thousands of 
cases of simultaneous vaccination against diphtheria and 
scarlet fever, that, if there have been incidents at all, 
they have occurred in connection with the vaccination against 
diphtheria and not with that against scarlet fever. During 
the past half year of winter we have tried out the com- 
bined vaccines against diphtheria and scarlet fever in 
several thousand vaccinations in two labor districts (Arbeitj> 
gauen). Since differences in the degree of tolerance, in 
comparison with the divided vaccinations had not been noted 
in the reports, the order was given, that with the beginning 
of April of this year, all fresh draft groups have to be 
vaccinated with the combined vaccine. Up to now no reports 
have been received from other districts in regard to es- 
pecially striking symptoms during the progress of vaccinat- 
ions, 
UHLENHUT: I surely may assume, that the vaccinations 
with tetra-vaccine against typhoid, paratyphoid A and B 
and gholera were performed on soldiers who had not been 
vaccinated before, I would be interested to hear something 
more definite about the results of the Vidal-Reaction *dth regard to the effects of the single components of the 
vaccine on it. With reference to the combined vaccination 
against diphtheria and scarlet fever, the statements by 
ROSE about more serious reactions seem to be noteworthy, 
' e certainly do possess a very excellent vaccine against 
diphtheria and also a well tolerated and effective vaccine 
against scarlet fever, I would like to recommend especially 
the vaccine by FARAGO, At any rate, it must be avoided 
under any circumstances that a less easily tolerated 
combined vaccine should bring into discredit the well tried 
vaccine against diphtheria. I do doubt, that there is an 
urgent necessity for a combined vaccine against diphtheria 
and scarlet fever, nevertheless, it is my opinion that the 
experiments, within the State Labor Service should be con- 
tinued. 
Directions for immunization against typhoid, para- 
typhoid A and B and cholera. 
The combined vaccination with TAB vaccine has proved 
its value. It gives protection simultaneously against 
typhoid, paratyphoid A and B. It has been proved that it 
is possible to add to that vaccine the vaccine against 
cholera without changing in the least its degree of toler- 
ability, The effectiveness of the single components is 
not reduced by it. 
Each vaccination has to be performed flawlessly. It 
is to be considered as a suigical operation. For each can- 
didate about to be vaccinated, a sterile needle has to be 
used. Used needles have to be boiled. A sufficient number 
of the right kind of needles should be available in advance. 
The injection has to be given strictly subcutaneously 
between the nipple and clavicle. The spot for injection 
has to be disinfected first. With intramuscular injection 
more serious reactions have to be expected. The intervals 
between the single injections are 7 days. These periods 
of time must not be shortened. It is better to aim at a 
lengthening of these periods in order to give^the body more 
time to produce immune bodies. The immunization of new 
draftees therefore has to commence immediately. 
Each complaint about the tolerance to the new vaccine 
or about affected health condition due to vaccination has 
to be investigated personally by the troop physician and 
the results are to be forwarded through the usual official 
channels. 
By the 1st of March the troop physician has to in- 
spect all records of the soldiers and to ascertain, whether 
all prescribed vaccinations have been received and to ad- 
minister later on those which are missing# Directions for the simultaneous employment of typhoid, 
paratyphoid A and B, and cholera vaccine, 
!• In consideration of the many necessary protective 
immunizations a reduction of the number of individual 
injections is desirable, 
2. This aim is to be accomplished through the use 
of combined vaccines. 
3« For this purpose a well tolerated combination 
vaccine against typhoid, paratyphoid A and By and 
cholera is being produced (TAB Choi.) 
4. Its dosage and administration is in accordance 
with the previous customary procedure i.e. injections 
of 0.5, 1,0 and 1.0 cubic centimeters at intervals 
of 7 days. 
A re-vaccination of 1.0 cubic centimeter is to b* 
performed 6 months later in the months of March and 
September• 
5. In case of outbreak of cholera, the pure cholera 
vaccine and not the combined one is to be employed, 
because it contains more agents and therefore promises 
a better effect, 
B• Directions for protective vaccinations agains 
diphtheria and scarlet fever• 
I# General. 
The protective vaccinationswith adsbrbate vaccine have 
particularly reil shown thsir value in. the fight against diph- 
theria .and scarlet fever. Their use is recommended therefor 
to the Armed Forces, in epidemics as well as for protective 
vaccinations. 
During the performance of the protective vaccination 
against diphtheria and scarlet fever, certain special pre- 
cautionary measures have to be observed concerning the 
dosage and especially the technical performance of the 
vaccination. (Refer to III later). 
Immunity is attained only a certain time after vac- 
cination. 
A full effect of the protective immunization is to bo 
expected only 2-3 weeks after the 2nd injection. 
Inasmuch as the adsorbate vaccine against diphtheria 
does not contain animal protein, it may be^employed un- 
reservedly even after previous serum administration. Details of the protective vaccination against diphtheri 
The observance of the prescribed interval of at least 
4 weeks between the two necessary injections is important 
(see II). as the resorption of the depot of the first in- 
jection is finished only after about 3 weeks and only with 
the beginning of the 4th week is the most propitious time 
for a good immunizihgoeffect of the second injection. 
There are no objections against vaccinations during 
an epidemic of diphtheria# The intervals of time between 
the injections are not to be reduced in spite of cases 
of this sickness appearing. 
In cases of severe reactions after the 1st diphtheria 
injection the 2nd may be omitted. 
After a recently recovered diphtheria sickness no 
protective diphtheria immunization is necessary. There are 
no objections against the injection of other vaccinations 
between the 1st and the 2nd diphtheria injections, e.g. 
protective vaccinations against typhoid. 
A simultaneous vaccination against diphtheria and 
smallpox must be avoided. 
Details of the protective vaccination against jjcsy?Jj2t 
fever. 
With regard to the protective vaccination against 
scarlet fever, the observance of the indicated intervals 
of time is also imperative, but, in contrast to the pro- 
tective vaccination against diphtheria, the intervals of 
time are not be lengthened under any circumstances. 
A vaccination during an epidemic of scarlet fever^is 
also possible. The protective vaccination is not required 
after overcoming an attack of scarlet fever itself. 
Concerning vaccinated persons with more serious re- 
actions after the 1st injection, the second injection is 
to be performed with the same dose as the 1st injection 
(see under dosage). 
% 
It is possible that scarlatinous exanthemas may 
appear in a few cases following the protective vaccination 
against scarlet fever. They are a sign of a particularly 
susceptible individual towards scarlet fever. For that 
reason a re-vaccination of these candidates is unquestion- 
ably necessary. 
II. Dosage. 
a. Protective vaccination against diphtheria. 
Vaccines: Diphtheria Toxoid Asid or ALFT of the 
Behring Werke, 
Doses Young people up to 21 years receive 0.2 cc, 
twice of either vaccine. * Adults over 21 years receive 0*1 cubic centimeter 
twice with an interval of at least 4 weeks between the in- 
jections. Adults over 28 years of age in general do not 
have to be vaccineated with the exception of Medical Officers 
and Medical Personnel. 
b• Protective vaccination against scarlet ftvcr. 
Vaccines 2 "Scarlatox Asid" or "Adsorbate vaccine" 
against scarlet fever, of the Behring Werke. 
Dose; "Scarlatox Asid" given 2 6r 3 times, each time 
1 cubic centimeter of concentrations I, II and possibly III 
at intervals of 2 weeks. 
"Adsorbate Scarlet Fever vaccine" from the Behring 
Werkes 3 times, 1 cc. each time, with an interval of 2 
weeks between the injections. 
III. Vaccination technique. 
In order to avoid undesired reactions and injury due 
to immunizations the following particulars are to be ob- 
served when administering immunizations. 
1. The presently used vaccines against scarlet fever 
and diphtheria are depot vaccines which, for slowing 
the resorption process, hare been adsorbed by aluminum 
hydroxide. Therefore everything that might lead to a 
speed-up of this resorption process has to be avoided, 
e.g. a dilution of the vaccine with physiological 
sodium chloride solution by which too large masses 
of antigen suddenly pass into the body which in turn 
would be strengthened but would have to react without 
a simultaneous increase of the production of anti- 
bodies. 
2. It must be observed strictly that the vaccine is 
deposited underneath the skin (below the raised skin- 
fold) and sufficiently distant from the point of in- 
jection. In this manner a backflow of the vaccine 
along the Injection canal will be prevented, which 
might produce more serious reactions and the growth 
of sterile abscesses. Intra-muscular Injection re- 
sults also in an undesired speeding up of resorption 
with its already mentioned subsequent symptoms. 
3. Caution has to be observed, especially in mass 
immunizations, to strictly adhere to the correct 
dosage, as for instance, a slight^increase from the 
prescribed dosage of vaccine in diphtheria immunizations 
may lead to quite serious reactions. 
4. Hypodermic syringes and needles have to be steril- 
ized by boiling; rinsing with or soaking in^alcohol 
or any other chemical disinfectant solution is not 
sufficient. 5. As for the immunizing biological effects of the 
inoculation itself, the part of the body chosen for in- 
jection (upper am5 chest, aMcninnl) 1 s of no significance 
6. Empty vaccine bottles are not to be used for any 
other purposes. 
B• Vaccinations against typhus. 
5_» Result of a trial with a variety of typhus vaccines 
against classical typhus. 
SS~Sturmbannfuehrer (Major, Elite Guard), DING 
Among the vaccines for active protective immunization 
against typhus, obtained from non-viable agents and in use 
by the German Army and the German civilian administration 
in general, only that vaccine produced from the intestines 
of lice has proved its usefulness in experiments on human 
beings. 
In order to test the tolerance and the protective effects 
of vaccines obtained from egg membranes, lungs of rabbits and 
dogs, equal sized groups of male persons, who up to that 
time had never been in contact with tyuhus, were put under 
observation. Euqal sized groups of people, sick with typhus, 
but who had bot been vaccinated for protection were also 
observed. 
The following vaccines were tried: 
1. Vaccines derived from the intestines of lice, 
according to FEIGL; 
2. Vaccines derived from egg membranes, according to 
GILDEMEISTER, HAAGEN; 
3. Two vaccines of different strengths from the Behring- 
Werke. produced according to the revised method of OTTO 
and WOHLRAB. These vaccines are not employed today any 
more | 
4. Vaccines produced from the lungs of rabbits, ac- 
cording to the method of DURAND-GIROUD; 
5. Vaccines produced according to the system of COM- 
BIESCO and collaborators from the lungs of dogs. 
The tolerance to all of these vaccines was satisfactory. 
No hindrance for performing the usual work was observed. The 
fever was reduced through the protective immunization, the 
duration of the fever was shortened by about a week when com- 
pared with the duration experienced by non-Immunized persons. 
The immunization with vaccines by WEIGL, GILDEMEISTER and 
GIROUD, produced from pure Rickettsia prowazeki strains, showed particularly favorable results* This immunization 
prevents death in the majority of cases* It does not seem 
to reduce, however, the frequency of this disease* 
The protective vaccination was of no influence on the 
reduced blood pressure, although it lessened considerably 
the participation of the central nervous system in the im- 
munized groups in contrast to the non-immunized persons. 
The exanthem did not become hemorrhagic with the im- 
munized group ahd it disappeared on the average one week 
earlier than in the non-immunized comparison groups. 
6. Results of a trial with a variety of typhus vaccines 
against North and. West African forms'of'typhus".' 
Marinestabsarzt (Lieut* MC*. Navy) Prof* NAUCK 
Apart from the "classical typhus" transferred by liec, 
there exist in North Africa two other forms of typhus, trans- 
mitted through fleas, "rat-typhus" and the exanthematous 
"tick typhus". 
The dominant form of typhus in North Africa does not 
cause epidemics of such proportions as experienced in 
Eastern Europe. It is less a question of serious local 
outbreaks and rather one of having the appearance of a 
more general spread among the people which, under favorable 
conditions, produced a considerable increase in the number 
of sick persons. Since 1937/38 an increase in the number 
of sick persons in Morocco, Algiers and Tunis has been ob- 
served. At the end of 1941 and at the beginning of 1942 
another rise in figures of considerable proportion occurred. 
Immunization experiments with live vaccine, on a large 
scale, were undertaken in Morocco and Tunis during the last 
pre-war years, especially with employment of less virulent 
murine strains, whose pathogenicity had been further re- 
duced through a special procedure (attenuation by cattle 
bile and mixing with egg yolk or olive oil). For practical 
use only the new methods of BLANC (with bile treated virus 
of fleas) and the method of LAIGRE-DURAND (mouse brain) come 
in question which, in comparison to former methods, possess 
only minor hazards. In spite of this live vaccine cannot 
be recommended for our combat troops in Africa, as the ef- 
fects of it in practice have not been ascertained yet with 
a sufficient degree of certainty. 
For the production of non-vital vaccines the use of 
North African strains is suggested, as non-vital vaccines 
possess a comparatively limited immunizing ability and because 
the quantity of vaccine, produced according to the method of 
WEIGL and employed successfully in the production of vaccines 
in Abyssinia, is not sufficient to fill greater demands. The 
preparation of vaccines from the primary egg-membrane of 
fertilized hen eggs is to be advised. It seems possible that the form of classical typhus which prevails in North 
Africa is more closely related to murine tyohus than to the 
typhus prevalent in Eastern Europe. It might be worth in- 
vestigating if murine strains, which have the advantage of 
being easier to culture, could be used in the Processing of 
vaccines for North Africa. With that possibility in mind, 
there would be given at the same time an increased protection 
against sporadic outbreaks of rat typhus* In how far a pro 
tection against exanthematic tick fever would be accomplished 
also cannot be decided as yet, because practical experience 
in this regard is still missing* 
Discussion about typhus vaccines. 
ROSE: More impressive than the numerically expressible 
effects of typhus immunization on the progress of the disease 
are the personal observations at the bedside and the much 
more favorable general condition of the vaccinated patients. 
The most important result of the examination is the observ- 
ation that an equivalent degree of immunity cannot be obtained 
through vaccination, as is produced through a natural infect- 
ion* The influence of the vaccination o£ the progress of the 
disease, especially the prevention of a fatal outcome, is a 
potential gain and represents an improvement which we could 
hardly expect from a vaccine obtained from non-vital agents. 
After the uniformity of results of typhus vaccination has 
been determined for vaccines produced by various methods, 
it is our obligation to concentrate our efforts upon those 
vaccines which, with the least expenditure of men and materia' 
possess comparatively the highest volume production, in order 
close the gap which still exists today in covering our re- 
quirements. The observations made by EYER, that a toxin 
could not be proved in experiments with lice rickettsias on 
animals, are of themselves no arguments against the employment 
of vaccine obtained from lice intestines. But the also de- 
monstrable presence of toxin in vaccines derived from egg 
yolks is not to be considered valid. On the other hand, 
clinical observations of vaccinated persons show, that the 
different vaccines are all equivalent in regard to their 
toxicity and in the production of more severe reactions and 
the protective effects achieved. Undue importance should not 
be placed on certain types of Rickettsia prowazeki. One 
should not forget in this consideration that even if vac- 
cination is carried out with a different type of Rickettsia, 
Rickettsia murina for example? a cross immunization against 
Rickettsia prowazeki of practical importance may be obtained. 
With regard to the naming of the various typhus vaccines in 
the directives for use in the Army, it is recommended that 
the names of the different producers be omitted and only 
names describing the material be used: vaccine from lice 
intestine, egg yolks, mouse lungs, etc. etc* It has to be 
pointed out also, that the louse vaccine, frequently credited 
ic WEIGL, goes back originally to DA ROCHA-LIMA* WEIGL1s 
work is rather in the field of further technical developments 
and the practical employment of the vaccine. EYERj 1* Those vaccines, processed according to 
presently recognized methods, are all useful, inasfar as the 
producers use the necessary care during their production, 
2# Different cultures of Rickettsia prowazeki differ 
among themselves* Therefore it is advised, just as tith 
other vaccines, to employ, if possible, numerous Rickettsias 
originating from different localities* Besides polyvalent 
vaccines, special purpose monovalent vaccines have to be 
produced from currently active epidemic cultures, e.g, for 
North Africa, employment of cultures of the strain "Tunis 
Rickettsia1', which from all appearances may be considered 
a type between Rickettsia prowazeki and Rickettsia mooseri. 
3* Even though typhus vaccines should be rich in 
RickettSias, one should not have the idea that there is no 
limit to this requirement, because there are optimal con- 
centrations above which an increase will not produce greater 
effects# With regard to louse intestine vaccines, this 
optimum remains between 50 and 100 intestines of lice# 
4# The vaccination performed at three separate date:-, 
produces better results than the single vaccination. The 
interval of time between the single vaccinations should be 
at least 8 days, the concentration of each dose should be 
increased and not equal every Apart from this, trial- 
experiments with vaccinated, and, later on, artificially in- 
fected human beings show very strikingly the high value of 
the vaccinations performed at three different dates. 
5, Experiences with vaccines from louse intestine 
of German origin prove conclusively, up to the present 
there have been more than 1 million vaccinations, that the 
rate of mortality among the vaccinated persons could be 
reduced to 1/3 of the rate occurring among the non-vaccinated 
6, The assumption by HAAGEN, Strassburg, that the 
protective effects of FI, (flea?) vaccine seem to be anti- 
toxic in nature has to be accepted. This cannot be deduced, 
however, from the results of an examination bjr GILDEMEISTER 
and HAAGEN about the degree of toxicity ascertained during 
the production of the vaccine from egg membranes, as Rickett- 
sias from louse intestines are not toxic to mice and still 
they immunize very well, 
RUGE: According to reports made by medical authors 
of the Navy, the vaccine, which is produced there, docs not 
prevent with certainty the contracting of an infection. 
The progress of the disease, however, runs a lighter course. 
No fatalities have occurred up to the present time. The 
vaccine is very well tolerated. 
RODENWALDT: Only one question for Professor NATICK: 
I may be mistaken, but I seem to remember, that^the effects 
of vaccinations, performed by the French on natives in North 
Africa, have been much better than those experienced on 
Europeans, What is the explanation? SCHREIBER: We have been informed through the lecture 
by DING, which of the presently used typhus vaccines are of 
approximately equivalent value* They are those which we 
have employed for a long time already. It is of importance 
at the present time, that we make up our minds, which of the 
equivalent vaccines can be massproduced the most easily. In 
the coming winter, we will be in need of great quantities 
of vaccine, and the more wo have, the better it is. I beg 
of you when composing the directives, to keep that in mind 
and to give preference to that vaccine which can be produc'd 
most easily in great quantities. In my opinion it will be 
the vaccine derived from mouse lung. 
UHLENHUT: Has the effect of the convalescent serum 
undergone a critical examination as regards its healing 
and protective power during experiments on human beings 
which apparently have not produced fundamentally different 
results? It would be interesting to know the effects of 
the convalescent serums in a combined trial (serum vaccin- 
ation). If one could produce live vaccine, avirulent to 
human beings, as in the system employed for the production of 
vaccine against yellow fever and smallpox, then the pro- 
tective effects might be materially improved as experinece 
indicates that live vaccines are more effective than non- 
vital ones. At the present time, it seems we are able only 
to prevent death. This kind of experiment is necessary. 
For the time being we have to hold on to non-vital vaccines. 
Directions on typhus immunizations. 
1. The following vaccines, when expertly produced, 
are useful and equally good in application for protect- 
ive immunization against typhus: 
a. vaccines from the intestines of lice, 
b. vaccines from egg membranes, 
c. vaccines from the lungs of mice, 
d. vaccines from the lungs of rabbits. 
All of these ’arc good,'provided that they are produced 
from different, if possible currently epidemic strains 
of Rickettsia prowazeki. 
2. Every institute, ordered to produce typhus vaccines, 
has to investigate, which production system will yield 
the best results in regard to quantity. 
3. Apart from the yield of any system, the actual 
local conditions for obtaining culture substrata and 
animals for experiments and the supply of food for 
the animals are of decisive influence in the choice 
of any manufacturing plan. 4* It is desired, In cases of initial immunization 
against typhus, that the up to the present decreed 
interval of 8 days between the first and second and 
the second and third injection be lengthened to 10 
to 14 days, provided that the time element is available. 
Immunization agaihst yellow fever, 
Stabsarzt (Captainf MC.) Prof. HAAGEN 
The different methods of protective immunization against 
yellow fever will be discussed and reports will be given 
about our own experiences with the scarification vaccination 
performed according to the system of PELTIER and collaborator-' 
8, Urban yellow fever and .jungle fever* 
Stabsarzt (Captain. MC.) Prof* HOERING 
Both of these diseases are identical in clinical and 
bacteriological respects' and differ only in epidemiological 
considerations. yellow fever was a disease con- 
fined exclusively to monkeys living in jungles; and which 
might have been carried back into human surroundings by 
human beings who had been infected themselves in the jungle 
(vector: Jungle mosquito) and from where it had been trans- 
ferred still further by Aedes aegypti. In epidemic districts 
of Africa, yellow fever is a children’s disease which frequent- 
ly is not recognized clinically as yellow fever and in this 
wjay continues to exist on a permanent basis. Heal jungle 
fever without Aedes aegypti has never been proved in Africa 
but its existence has to be taken for granted as yellow 
fever is a natural monkey disease also in Africa* The prose 4 
situation, with regard to yellow fever in Africa, is .in- 
fluenced by the great epidemic of 1940 in the Sudan (Ruba 
Mountain) as well as by the fact that the U.S* Armed Fences 
found themselves under obligation to perform 
vaccinations on their troops on a large scale which fact 
has been ascertained from reports of about 25 585 cases of 
yellow fever (with 62 fatalities) among U.S* soldiers through 
post-vaccinal icterus simplex. 
Biscussion about yellow fever. 
ZSCHUCKE: Why has the use of a combined vaccination 
with performance of the protective vaccination against 
smallpox, as recommended by French authors, been refused. 
This is supposed to: 
a* increase the protective effects against jrellow 
fever, according to the French, 
b* save one vaccination because, on account of in- 
creased danger of infection through smallpox, each 
soldier is mandatorily vaccinated before his tran- 
fer to Africa as a protection against smallpox 
anyway. Answer: 
a. The supposed increase of protective effects against 
yellow fever have not been verified in our own ex- 
periments, 
b. Since every soldier is vaccinated against smallpox 
on entering the German Army, a later re-vaccinat:* c i 
is superfluous* 
EYEH: Correctly produced vaccines against yellow fever 
can be kept potent for 2 years when they are stored at plus 
4 degrees Celsius. In working with a neutotropic mouse brain 
virus the danger that a foreign virus causing jaundice might 
be introduced is smaller than by employment of weaker culture 
of Soper (D 17) in combination with human serums, which methoc 
seems to be preferred by the Americans. 
HOERING: Answering ZEISS: The possibility of import- 
ation of epidemics to Southern Europe exists today just as 
well as it existed during the last century because Aedes 
aegypti is to be found over all Southern Europe (also there 
is the possibility of importation through airtraffic). 
With reference to the remarks by HAAGENs With regard to 
cases of jaundice occurring after yellow fever vaccination, 
examinations of corresponding cases, undertaken before the 
war, have proved this assumption an impossibility for the 
reason that many of the vaccinated persons sick with jaundice 
(always after a long incubation) had acquired even at the 
beginning of their jaundice high titers of protective agents 
against yellow fever in their blood. 
With regard to the question from EYEH: The vaccine, employed 
by the Americans, appears to have been the vaccine 17 D de- 
rived from egg cultures and produced by the Rockefeller 
Institute. On account of these experiences, all serums have 
been omitted with the result that every occurrence of jaundice 
was stopped immediately in every case. The identity of these 
vaccination cases with our own cases of hepatitis epidemica 
is questionable, however. Against this assumption is the 
fact that no contact infections oritinating from any of these 
25 585 cases in the U.S. Armed Forces could be observed. 
Directions for prophylactic vaccination against yellow 
fever. 
1. In connection with the prosecution of the war in 
yellow fever infested Africa i.e. coastal cities as 
well as the interior and virgin jungle, the German troops 
are to be considered as exposed to the danger of yellow 
fever. 
2. Since the same virus is the cause of all the so- 
called different types of yellow fever and since it also 
produces the same clinical picture of the disease itself, 
immunization against yellow fever fulfills its purpose 
to protect qgainst any infection of yellow fever type. 3* The method of choice for the German Armed Forces 
is the percutaneous vaccination with cerebral mouse v:‘rns 
in the customary manner employed against smallpox, Theie 
are no objections against a simultaneous vaccination 
against smallpox, 
4. The vaccination should be performed before transfer 
into yellow fever infested zones tc?.kes place, if c 
already in Germany. 
D. Venereal diseases. 
As a part of the proceedings of the Consultants1s Com- 
mittee on Hygiene a discussion took place with participation 
of dermatologists, about the campaign against venereal disease 
Reports were given by Flottenarzt (Fleet Surgeon) GRUHSKE and 
Oberstarzt (Colonel, MC) Prof. LOEHE, which resulted in the 
establishment of certain directives. Their inclusion in this 
report is not necessary. They will appear in the form of 
directives. 
E. Other questions pertaining to our particular 
branch. 
9. The treatment of diphtheria carriers. 
Stabsarzt (Captain. MC.) HERTEL 
The significant position of diphtheria carriers with 
regard to diphtheria epidemics is sufficiently well proven. 
The treatment of the diphtheria carrier is necessary because 
the active protective vaccination can never produce full ef- 
fects on account of its manner of injection and its 
effectiveness in general, whereas the treatment of diphtheria 
carriers can be considered as a nreventive attack on the out- 
break of the disease at its veritable source. 
All attempts of treatments undertaken up to the present 
are to be considered as futile. Locally acting chemotherapy 
as well as non-specific irritation therapy (X-rays, ultra- 
violet rays, protoplasma activation) and specific, active 
mediums (lysates, vaccines) biological procedures^(bacterial 
antagonism) and operative methods are unreliable in the at- 
tempts to remove the germs. Results of our own experiments 
have verified these opinions. All in all 90? diphtheria 
carriers have been treated. A certain new remedy, different 
in composition and producing different effects, attains 
success in only 84 per cent of the treated cases. This per- 
mits the assumption that every method of treatment, which is 
based solely on effects produced by preparations, will fail. 
Observations of untreated diphtheria carriers points out the 
causal connection of pathological changes of the upper re*- 
spiratory passages and the persistence of the bacillus. 131 
Through the means of smear examination, rhinoscony, X-rav 
examination and the ascertainment of type* disease con- 
ditions of all kinds in various degrees of severity in the 
upper respiratory passages, pharynx and accessor}?- sinuses vdln 
be found in every case of saprophytic bacilli. These con- 
ditions render the treatment rfiore difficult* In two cases 
specific suppurations in the maxillary sinus could be de- 
tected. Through employment of the previously mentioned ex- 
tract derived from plant matter as a medium of disinfection 
a method of treatment can be developed which is elastic in 
its application,-depending on the findings in pathological 
and anatomical findings in the upper respiratory passages 
and^therefore has to be adjusted strictly according to the 
individual case. It combines local* rhinological treatment, 
locally applied disinfection by mediums of the most diverse 
variety and variable, operative procedures, (rinsing and 
disinfection of cavities, tonsillectomy). The most stubborn 
cases among diphtheria carriers were successfully cleared 
up in this manner. Later examination of 83 diphtheria 
carriers after their discharge proved only in one case, wlr? r 
had been considered negative4 the continued presence of 
diphtheria bacilli. 
Special directives for the treatment of diphtheria 
carriers are not required. For the clearing up of these 
carriers, in as far as it seems warranted, the taking into 
consideration 6nd the removal of any possible changes of 
pathological and anatomical nature in the upper respiratory 
including the accessory sinuses, is necessary. 
Concerning chemotherapy, the employment of the Lacuprins, 
at present under investigation in several army hospitals, 
is to be recommended in which case the nasal treatment, 
besides tampons covered with ointment, has to consist of 
rinsings of the nose with a watery solution (1 to 15) and 
purposeful spraying of the channels in the nose in order to 
be useful. 
Discussions 
UHLENHUT; The most exact examinations of HERTEL are 
of extreme importance especially since all previous attempts 
at clearing up diphtheria carriers have not led to any 
positive results. I have occupied myself repeatedly with 
this problem. Because killing the bacteria in the crypts 
of the tonsils and in the upper respiratory passages by 
disinfecting mediums applied externally seemed to be of 
extreme difficulty, we have developed, right at the spot, 
iodine in a nascent state by gargling potassium iodide 
and an acid HpOP solution but also without success (MUENCH- 
MEYER). The use of Ozone was also futile. 
Lately, trials with antiformin solutions have been 
undertaken in a reserve hospital ih Freiburg. At my sug- 
gestion, in cases of wound-diphtheria, compresses with a 
2 per cent solution were made through which (under bacterio- 
logical control) favorable results were obtained in several 
cases. Antiformin possesses, as is known,_a dissolving 
effect on bacteria and neutralizes the toxin. Besides, it 
stimulates the granulation process in the wound, in a partic- 
ularly good manner (C. f. Bakt. XLII Berichte Flin. Wo. 
1908, 29)* Failures, however, rill occur because of the 
difficulty of the problem. RUEHL; A hint concerning the necessity for a differc 
lation of types* The entire scheme for clearing up diphthe: " 
carriers should be employed only against the pathogenic forms 
.BACHMANN; A Russian method of treatment of diphtheria 
carriers is up for discussion which consists of treating 
diphtheria carriers through a stay in gas chambers filled 
with diluted chlorine gas* This method, employing chlorine 
rn weak solution of 1 to 200 000 has been re-examined 
by HETTCHE in trials on a limited number of diphtheria carr5 c 
who had remained positive for the previous 2 to 3 months. 
In spite of several sittings with increased time of exposure 
only two out of twenty diphtheria carriers taking part in 
these experiments became negative. A final opinion is not 
yet possible. For the treatment of diphtheria carriers 
a stay in fresh air or a change of climate is considered of 
great importance which corresponds with the experience of 
pediatricians. With more than 300 diphtheria carriers of 
a reserve-division in the West for instance, good results 
were produced through their transfer in one camp and their 
employment with moderately heavy work in the open air. 
these soldiers diphtheria bacilli were proved only up to 4 
weeks# In persistent cases of diphtheria carriers determin- 
ation of type is necessary. Without hesitation diphtheria 
carriers with type mitis can be adjudged fit for military 
service, 
GLAUBERG: The suggestion for an anatomical cure of 
the upper respiratory passages of diphtheria carriers is 
valuable and ought to be taken to heart, particularly in 
cases of persons inclined to become chronic carriers in 
need of frequent disinfection. To employ this method un- 
conditionally, as the consultant advises, is however, a 
demand that goes too far and which is, because of the con- 
siderably wide distribution of carriers, neither practicable 
nor, with regard to their different importance in epidemio- 
logical respects, necessary. As an encouraging sign it is 
recorded in the discussion of this theme that efforts also 
from clinical representatives, have been made to identify 
the different types of diphtheria bacilli in order to re- 
cognize the dangerous and the usually practically harmless 
strains of diphtheria bacilli. The realization of this will 
materially simplify the fight against diphtheria# 
10# Ridding carriers of intestinal protozoa• 
Oberstabsarzt (Major, MC.) Prof# HAUER 
All intestinal protozoa in question will first undergo 
a review as to their occurrence, the Question of their 
pathogenicity and the causal treatment will be^considered 
briefly* A prominent importance, also in wartime, is to 
be ascribed to the E.-histologicao Besides it, the attack 
of the rare, only as single cases of contact^infection, 
balantidium coli appearing, as well as lambiia intestinalis 
deserve special attention. The rest of the protozoa are 
practically apathogenic and require special consideration 
and eventual treatments only when occurring^in severe forms. 
Yatren appears to be the best treatment available# The cure of amoebic dysentery will be discussed later 
in detail. It is divided into the treatment of the clinical 
amoebic dysentery and (under circumstances folioring 4t) 
the cure of the avirulent enteritis. The latter disease, 
usually without symptoms in clinical respects, represents 
the main source for the distribution of amoebic dysentery. 
The best remedy employed up to the present is yatren which 
also may be dispensed in combination with rivanol tablets. 
More definite information will be given about a new remedy 
against amoebic dysentery, WIA. an arsenic acid-bismuth 
combination, which has been tried out on 122 cases of enter- 
itis during the last year and which has produced splendid 
results. It is probably superior to yatren in regard to 
tolerability and effects against minute forms and cysts. 
Therefore it seems to be an ideal remedy for the cure of 
carriers of amoebic dysentery. It is without effect only 
against the virulent kind of amoebic dysentery but in com- 
bination with emetine, all five cases of amoebic dysentery 
clinically treated up to the present, have been healed and 
cured, which should presage a simplification of treatment 
in many cases if these experiences could be verified on a 
large scale. 
Discussion: 
ROSE: The introduction of an Army order to treat all 
obscure cases of diarrhea, in countries infested with amocb*< 
dysentery, with yatren for the first three days, is emphatic- 
ally warned against. Without taking any position concerning 
the question of whether this method is appropriate for 
countires in which the amoebic dysentery represents the main 
problem, it must be emphasized that in all of the presently 
important theaters of war, amoebic dysentery is of secondary 
importance when compared to bacillary dysentery^and certain 
other infectious intestinal diseases# Of main importance 
is bacillary dysentery. Concerning its treatment, sulfona- 
mides have proved themselves valuable during the last two 
years in such a way that we must advise our troop physicians 
to give prefer&acoeto these preparations in questionable 
cases of diarrhea. The recommendation for the use of yatren 
for the same purpose would only create confusion and un- 
certainty and therefore would be harmful. 
Concerning the treatment of lambliosis, my own good 
experiences with Arcranil as well as TEITGE s excellent 
results through employment of it, in many cases should be 
pointed out. 
FISCHER: Your attention is called to inflammations 
and abscesses of the liver which occasionally occur, even 
many years after an amoebic infection and are not easily 
recognized as such. I saw such a case after a 20 year 
abscence from the tropics. It is of importance to know 
that this kind of disease can run’its course without pro- 
ducing fever, as is shown by one case which had been diag- 
nosed for a long time as carcinoma of the stomach and wriero 
only the autopsy revealed an abscess in the left oi tao 
liver which had broken through below the diaphragm 
servation by Professor LIBSCH, Munich). Every solaier, 
discharged from a hospital with endemic amoebic dysen e y, (North Africa, Southern Italy, Balkans, especially Greece, 
the South of Russia) ought to be given, on the subsequent 
appearance of any intestinal disorder which does not dis- 
appear when treated in the usual manner, a thorough ex- 
amination by tropical specialists. That applies as well 
after discharge from the Army. Only in this way can the 
continued existence of such intestinal infections and their 
sequelae, as have been observed after the first World War 
and up to the present time, be avoided. 
Directions for ridding carriers of intestinal protozoa 
1. Among the intestinal protozoa, the dysentery amoehr 
takes the most prominent position. Dysenteric diseases 
caused by balantidium occur only as rare, always soli- 
tary contact infections. In exceptional cases lamblia 
int&stinalis can produce symptoms of entero-colitis. 
The remaining intestinal protozoa are harmless. 
2. Treatment of clinical amoebic dysentery, caused 
by virulent amobbae should be according to the method, 
outlined in the circular letters of the Medical Serv.i co 
of the Army. The cure of the so-called avirulent en- 
teritis is undertaken either through employment of 
yatren or entero-vioform (3 doses of 2 pills or tablet-: 
per day for 7 days). If need be, the cure is repeated. 
3» Lamblia intestinalis is to be treated with atabrin 
or acranil if obtainable (for 5 days, 3 doses of 1 
tablet each day). 
4. All drugs are to be taken only under supervision. 
11. The threat of malaria to the German population through 
returning soldiers. 
Oberstarzt (Colonel. MC.) Prof. RODENWALDT 
During the war of 1914 - 1918 tens of thousands of 
carriers of malarial gametos returned from the Balkans, 
Turkey and Russia. 
The fear, that these reservoirs of virus might be 
the starting points of renewed, epidemic appearance or 
©ndbnKfcc new-infestations of malaria in Germany proved to 
be without foundation. ROCHT was correct in his assumption 
that Germany is no longer one of the countries able to 
produce malaria epidemics. 
The reason for it is the reduction of the density of 
anopheles in Germany, through agricultural works, to such a 
degree that a transfer, even with the existence of many 
carriers of gametes, seems to have become unlikely. 135 
Attention is directed to an article by MARTINI, "Epi- 
demiologic der Malaria", in which a computation is given 
about the improbability of malaria infections under such 
conditions. 
Measures to ward off malaria, undertaken in a certain 
military district, were therefore unnecessary and it is 
not right to claim the absence of infections as being the 
result of those measures. 
Of course, anopheles still find breeding possibilities 
all over Germany in limited biotropism. Therefore anopheles 
have been found whereever one searched, as in the military 
district referred to above and it goes without saying and 
there was no reason to publish this self evident fact. 
Even if especially hot summers and regions with only 
small,cattle farming ihight increase the possiblities of 
transfer above the usual odds mentioned, ah epidemical ap- 
pearance 6f malaria or re-appearing endemics are to be 
precluded in Germany. 
Discussion; 
WAGNER: In spite of the small calculated possibility 
that malaria may spread over Germany on a larger scale as 
Just reported, clinicians at least have to take into con- 
sideration the occasional occurrence of malaria of local 
origin. In Danzig. a few days ago, a sample of blood taken 
from a child admitted shortly before into a children’s clinic 
was shown to me and it contained, besides numerous sexless 
Plasmodia, gametes. The child came from a small village in 
the neighborhood of Danzig, the lowlands of the v’eichsel. 
Inasmuch as malaria has been extinct for many years in the 
lowlands of the V’eichsel, investigations pointed to a 
worker from the East from near Charkow who had been em- 
ployed on that particular farm since August last year as 
the source of the infection. Examination ’of his blood has 
still to be taken. It is quite possible that the infection 
took place in the very hot latter part of last summer and 
that the disease came now, after the well-known latent stage, 
to an outbreak. 
FISCHER; As an example of the small danger to our 
country, it is pointed out that BAUMANN, in investigations 
undertaken on my suggestions in Wuerttemberg after World 
WAR I. could ascertain only four locally originating cases 
of malaria among which there was one not determined in 
parasitical respects and one tropical case. 
HAUER; Inasmuch as the previous^speaker^has mentioned 
the subject, I should like to remark in addition, that^I 
know of quite a number of locallv oritinating malaria 
fections among the German civilian population. During tho r 
war a schoolboy from Berlin with an ostensible sepsis was 
brought to me which proved to be a tertiana duplr’cata. r o 
patient had never left Germany and had returned from West 
Prussia where he had spent his summer vacation. Investigat- 
ions with the help of the county physician proved that 136 
malaria was practically unknown in that particular district 
and that the infection might have been transmitted by 
Rumanian workers, sick with malaria, who had been employed 
there for some time. Anopheles were present. Before the 
present war, I had been informed by a physician, a native 
of Emmerich, that several cases of tropical malaria had 
occurred in the region of the Netherland-Rhine canal system, 
of which one case (that of a child) ended fatally. To all 
appearances, the infection having probably gone out from. 
ship& which might have brought along their tropical malaria 
from the Belgian Congo. In other respects, however, the 
detailed statements of Oberstarzt (Colonel, MG.) RQDENWALTI 
are of a fundamental nature. 
BACHMANN: If prophylactic treatment against malaria 
is no longer permissable that is contrary to the directives 
concerning malaria issued by the Army B'ledical Inspectorate 
in 1942 in which a complete treatment of soldiers, coming 
from countries infested with malaria, is permitted at the 
beginning or the end of the season for infection. In- 
formation about this point is requested in order to know 
how to act. 
ROSE: The fundamental interpretation that a practical 
hazard to our country through parasitic vectors of malaria 
does not exist and will not develop for reasons of entomo- 
logy and climate may be concurred with by all specialists 
of this branch. However, I want to point out that, for 
several years already, through the presence of prisoners 
of war and foreign workers within the Reich, there is prese 
a larger number of carriers of plasmodia than could possibl 
be expected through homecoming soldiers of the Armed Forces 
even under the most unfavorable circumstances. Since 1939 
as result of the enactment of the law that every case of 
malaria within the Reich has to be reported, we already 
have evidence with regard to the consequences produced 
by the mere presence of these foreign carriers in Greater 
Germany. Even taking into consideration the unavoidable 
incompleteness of any of these reports, observations made 
during the last years have unquestionably proved that 
transmission has taken place only in single cases and 
at the worst only very small numbers have been taken sick. 
These actual observations are more reliable proof of 
our interpretation than the best calculation of possibil- 
ities. Furthermore, I do point out that through the trans- 
fer of people of German descent from the East, populations 
of entire villages of Bessarabia and the Dobrudscha, in- 
fested to a high degree with malaria, have been trans- 
ferred to and settled within the Reich in rather closed 
communities. In other words, in these cases one has to 
consider not only the density of the anopheles. With re- 
gard to epidemics, there has taken place a rather un- 
favorable concentration of carriers which uacbnot have to 
expect through the returning soldiers of the Armed Force'. 
In spite of this, according to observat?.ons so far, a re- 
establishment of centers of malaria such as we have in 
East Friesland, Upper Silesia and the southern part 
Steiermark, has not occurred. With regard to preventive 
measures to be recommended to individuals in Germany in order to avoid infections, we point to the pamphlet issued 
oy the department of health and the Robert Koch Institute 
as well as to an article by ROSE (Deutsches Aerzteblatt 
1942, No. 16 pages 102 to 105). With reference to the in- 
fections in the lowlands of the Weichsel, mentioned by 
Professor WAGNER, I should like to remark that we have still 
to figure, especially in the neighborhood of the Weichsel, 
with the persistence of older cases of malaria* I personally 
know of three cases in the vicinity of Bromberg, occurring 
in 1939 which certainly might have been trs&cd to local 
sources of infection. Polish statistics about propagation 
of malaria in this district may not be considered as reliable 
information. 
Opinion concerning the threat of malaria to the German 
population through returning soldiers/ prisoners 
of war, etc."" 
Germany is, on account of the small density of anopheles 
no longer suitable for the development of malaria epidemics. 
A hazard to the health of the population through the 
danger of a re-infestation or the increase of malaria in- 
fections through returning soldiers or prisoners of war 
sick with malaria, or through carriers of gametes among 
them, does not exist therefore. Measures to ward off such 
a danger are superfluous. 
12. Field latrines in subtropics and tropics• 
Kriegsverwaltungsrat (Special Administrative 
Consultant) Dr. VICK 
The covering of the faeces with sand is an insufficient 
measure of expediency. A sure protection against flies 
and hookworms is to be accomplished only with a covering 
of 22.5 to 90 centimeters. The removal of^faeces by means 
of containers, which would have to be emptied, should be 
employed only in exceptional cases. Privy ditches, which 
ought to be narrow but deep, are useful as temporary ex- 
pedients but require some device to keep out the flies. 
The boring of a hole of about 40 centimeters diameter and 
to a depth of more than 5 meters, to be used as privyf is 
of great advantage. A disadvantage is the necessity 
having a boring device. Strongest recommendation for 
satisfying of the needs of our troops by using smoke latrine:, 
which are easy to assemble, simply and rapidly with usually 
locally available means and which offer complete protection 
against flies. For more important, larger installations, 
intended to last for a longer time and in case of a re- 
liable and sufficient water supply, simple water closets 
with provision of chambers for filthy matter, come into 
consideration. Latrines by borer, smoke latrines and water closets 
should be preferred to ditches and bucket privies, because 
they are not dependent to such a degree on closures# The 
most important requirement with regard to latrines is the 
regular care of them. Important centers of traffic should 
be supplied with the most sanitary latrines# In contrast 
to the general principle that all field latrines should 
be built only with locally customary means, the use of 
special trained construction personnel recommends itself. 
Discussion: 
RODENWALDT: The supervision of field latrines though 
personnel, especially trained for that purpose, is imperativ 
During epidemics in world War I, the placing of containers 
with disinfectants at latrines guarded by special guards 
to watch that every one leaving the-latrines washed his 
hands in them was of great value* The pole privy, even 
though liked by the troops, is unquestionably objectionable 
and should best be forbidden. However, during the last 
weeks, I have still seen it being used by our troops all 
over Sicily and Sardinia, even now the source of a serious 
tormenting plague of flies. A better care of hygienic con- 
ditions at railroad stations through special personnel, to 
work with local personnel, is unquestionably necessary. 
Such personnel were assigned during the war at all R.R. 
stations in Turkey and v/ere called disinfection personnel. 
Their tasks were the provision and good care of waiting 
rooms and lodgings, the supplying of drinking wrater of satis- 
factory quality, the erection and supervision of decent 
latrines, and the cleaning up of areas around the stations. 
HORNUtyG; A serious source of propagation of epidemics 
are the railroads. Even in our country in peacetime, the 
removal of faeces by railroad personnel is a very great 
deficiency. The admonition, not to use the toilet during 
stops in stations is of doubtful value. One can observe 
that best, for instance, during winter when there is icy 
snow between the railroad tracks. It is still w'orse, for 
example, in railroad stations in the East# For hours and 
even days, trains remain frequently at a standstill outside 
on end sidings and all faeces fall on the gravel# Then it 
happens f0r instance, that soldiers, detailed to fetch the 
food supplies, wade through this and later put their boots 
into the baggage net next to their army bread. Hospital 
trains, filled w'ith soldiers sick with typhus, are of es- 
pecially great danger in such cases# Officers, in charge 
at stations ought to take care also for the removal of ex- 
crements in the areas of end sidings. Chloride of lime 
must be made available. 
SCHREIBER: I should like to direct the attention of 
hygienists to the conditions in railroad stations. 1 can 
only underline the statements made by the previous speaker 
Oberstarzt (Colonel, MC.) HORNUNG. The latrines#there are 
not at all of sufficient numbers and the most evil^con- 
ditions result from large troop movements and particularly 
from transports of prisoners of war. Suitable field latri~' 
in sufficient numbers must be built# The thorough cleaning up and continual caretaking of railroad stations and their 
immediate surroundings is, however, of utmost importance. 
Within the area of an array corps as well as within the area 
of an army, hygienists have to direct their particular 
attentions continually toward the control of these con- 
ditions. 
HAUER: If only for historical reasons alone, the 
splendid results of our field latrines as well as of our 
smoke latrines, which we had during LETTOW!s campaign, 
(Africa, World War I), deserve mention at this time. The 
troop, as is known, had marched thousands of kilometers, 
changed its position daily for months on end and then again 
remained in the same position for months, sometimes near a 
river. After certain improper conditions at the start of 
the war had been eliminated, our latrine system was the ob- 
ject of a very strict discipline. With regard to epidemics, 
tfre latrines for the main body of the negroes were of par- 
ticular importance. A sanitary orderly, an Askari, was 
posted at the deep, long trenches at all times whp had to 
watch strictly that every one, immediately after evacuation 
of the bowels, covered the excrement with sufficient ash or 
soil. In this way, conditions in our privies remained ex- 
cellent and the dreaded plague of mosquitoes was reduced 
to a minimum. Constructed for the first time in the Cameroon 
in 1913 and used by us in East Africa shortly before the 
First World War, smoke latrines were very welcome to us es- 
pecially in the rear of the front at hospitals, as well as 
in camps for native porters and they proved to be of great 
value. The fact that in a smoke privy no mosquito or mos- 
quito eggs could possibly exist was of particular importance. 
Unfortunately, troops on the march had to forego the erection 
of smoke latrines. 
RONNEFELDT: Points out the great extent of Russian 
railroad stations which makes difficult the use of latrines 
during nights and during overcrowding of stations. For that 
reason, officers at railroad stations should be held respons- 
ible for maintaining satisfactory hygienic conditions at 
their stations. Sufficient local personnel is at hand for 
this kind of work. 
ROOSE: It must be particularly emphasized, that the 
maintenance and care, as well as the continual supervision 
of latrines, is of decisive importance. The troop units 
must employ a permanent latrine seivice in order to establish 
without doubt and at all times the party responsible for the 
hygienic conditions of those latrines. That troops on the 
march or in bivouacs cannot erect permanent latrines is ob- 
vious. However, if a stay is to last more than^24^hours, 
the provision of latrines with satisfactory^hygienic con- 
ditions, has to be arranged. In this troops must 
not be left to themselves and their own ingenuity. This 
point is so important for their health that they must 
supported through supply with suitable materials and device 
and must be taught by instructions (directions and blueprint 
"A walk with the spade” is just an euphonism for a general 
soiling of the area. The finding^that a 20 centimeters hign 
covering of faeces is not of sufficient reliability is im- 
portant. I have verified in the East, that even thick layc-i of soil above corpses could not efen prevent the development 
of carrion maggots and their subsequent changing into flies. 
I found deficiently made graves covered with heavy layers 
of empty and also with undeveloped maggot grubs of carrion 
flies* I support unconditionally the demand by RODENWALDT 
for a prohibition of the pole privy* It is especially the 
open privy trench, with the pole or without it, against 
which we must fight* In spite of all theoretical advantages 
of "squatter" latrines, practical experiences have proved 
that the German does not know ho?: to use it expertly* I 
have not found yet one "squatter" latrine, used by German 
troops* in satisfactory sanitary condition. Concerning 
protection against flies, the problem of an automatically 
closing lid has always produced the greatest difficulty. 
Closing devices, bothersome to users, arc quickly destroyed. 
A recommendsble, practical solution presents a model intro- 
duced to the Airforce which works the locking device not fror. 
the top but from the bottom* The slanting seat is firmly 
connected at a right angle with the locking device* In 
order to use it, the seat must be pressed down* Hereby 
the lid is opened. After use, the seat raised itself and 
the lid closes from below. This model has the advantage 
that the seat does not get soiled by urination. This is 
a very important point in latrines in which special urinals 
are missing, as is often unfortunately the case in spite 
of orders to the contrary. Necessity of camouflage and lack 
of fuel in other places sometimes advises against the use 
of smoke latrines. 
UHLENHUTH: During World War I, much experience has^ 
been collected about field latrines* Latrines with "riding 
seat" equipped with lids to cover the openings as protection 
against flies have been of recognized value# Naturally, the 
erection of satisfactory hygienic latrines depends also on 
the kind of warfare (tiHch war of war of movements)• In 
the tropics, faeces deposited freely in the open, are made 
harmless in a very short time through the process of dis- 
solution. Covering with soil is a simple medium* In -he 
discourse I have missed a reference to the important point 
of cleaning of the hands, that is disinfection of.the han-..3. „ 
which we enforced in trench warfare even in the most advancer 
positions. Continued control is necessary. 
tor field latrines in tropics and_sjubtr.opi.es. 
The possibility of erection of latrines depends 
ally upon the length of the stay of a troop unic in a certai 
place and the location of the place itself. With consider- 
ation of these limits observation’ of the following direct- 
ions is necessary: 
1* Troops, staying in one place longer than 24 hours, 
have to build latrines according to orders. 
2. Blueprints of latrines of recognized value as 
well as instructions about the use of material for 
construction of the same are to be distributed to the 
units via official channels and besides through the 
official medical channels to troop physicians for the:; 
enlightment. 3% Erection, maintenance and care of latrines is tin 
concern of the units whereas the job of the troop phys- 
ician is the supervision of sanitary conditions in the 
latrines. 
4. Burying of faeces is not protection whatsoever 
against hookworms and against flies, except when the 
soil covering the faeces is more than 20 centimeters. 
The manner of covering, performed with the so-called 
spadewalk, is only a temporary emergency solution 
is to be replaced by all means through the building 
of proper latrines (see 1). 
5. As an emergency solution, the using of non-trans- 
portable, old gasoline barrels or any other barrels 
can be recommended. Seats and covering lids have to 
be provided for such improvided expedients. Emptying 
of filled and therefore no longer usable barrels in a 
proper manner is necessary (burying). 
6. The removal of faeces by means of buckets, barrels 
and pails, which would have to be emptied regularly, 
may be used only in exceptional cases and when there is 
no other possible solution. When still in containers, 
faeces have to be covered with sand, or still better,' 
with lime-water; a regular emptying and cleaning of 
containers is necessary and a disinfection desirable. 
?• Plain holes in the ground, to be used as latrines 
for a limited space of time only, arc sufficient and 
serviceable. The holes ought to be as deep and small 
as possible, ought to be protected efficiently against 
flies and the seats must have covers to keep out the 
flies for certain. Ventilation, without giving access 
to flies, has to be provided for. 
8. If a borer is available, making bored hole latrinr 
suggests itself, which, v ith a?'diameter of about 40 
centimeters ought to have a depth of 5 meters and more. 
Borers, answering this purpose, are to be provided ac- 
cording to plan. 
9. The use of smoke latrines is particularly to be 
supported, especially where consideration of camouflage 
and the supply of fuel permit their employment. Smoke 
latrines offer, according to experience, an^absolute 
protection against flies. They are of particular 
advantage when several privies can be put up above one 
hole. It is sufficient to keep the smoke fires burnlr: 
during the day. Blueprints and instructions for smoko 
latrines have to be provided for the troops, 
10. Plain holes, borings and smoke latrines, which 
not watertight, ought to be put up in such a way that 
no drawing of water takes place within a radius of 3C 
meters. 11* In the rear areas, water closets, whenever possibl 
at all, are to be preferred as the most suitable type 
over any other kind of latrine. In their construction, 
unobjectionable removal of filthy fluid has to be taken 
into consideration. The size of the lay-out for filthy 
fluid must corresponded to the usage of the■latrines• 
The units are to be provided with blueprints, instruct- 
ions for erection and upkeep of these plants* 
12. Dbvices, certain to keep out flies, are unquestlo 
ably necessary for container latrines, bored hole and 
pit latrines and are desirable for* smoke latrines and 
water closets. The closing device ought to be toleral 
and trustworthy; automatic closing devices are favored 
if they fulfill these conditions. 
13. It is desirable that special personnel are assigne- 
for construction of latrines at main traffic lines to 
satisfy the needs of great numbers (bored hole, smoko 
latrines, water closets with chambers for filthy fluK ; 
After erection of these larger plants which are to br 
used by transient units and single persons, it always 
has to be settled which locally established office 
carries the responsibility for maintenance and care of 
them. 
14. Conditions in railroad stations, particularly 
outside of our borders, deserve our special consider* 
ation. Unobjectionable latrines in sufficient numbers 
and logical distribution are to be put up (latrines 
with seats for Germand, "squatter" latrines for members 
of allied military forces, local populations and. 
auxiliaries). For the part of the army, military 
officers at railroad stations are to' bo held responsib; 
for the erection of and the sanitary conditions in 
latrines as well as for cleanliness of the 
area. Daily removal of excrements, deposited outside 
of latrines, has to be undertaken as the making use 
of latrines, even when present in sufficient numbers, 
is not always to be taken for granted (violations of 
orders, too long distance from troop transport trains 
in overcrowded stations, hospital trains). Those in 
charge of groups are admonished to enforce the use 
of latrines and to take disciplinary measures in case 
of violations. In principle, military police at 
stations remain responsible for clean conditions and 
the removal of waste matter. Chloride of lime, water- 
ing-cans and containers for mixing of lime-water are 
to be made available. 
15. In hygienic respects, the "squatter" latrine is 
theoretically of greater advantage than the latrine 
provided with seats but the expert use of it cannot 
be expected from members of the German Army because 
of lack of experience. For that reason the latrine 
with seats is to be preferred for Germans. 16. During cooperative working with groups of people.' 
used to different latrines, their strange latrine 
habits are to be taken into consideration and the 
foreign people have to be provided with a sufficient 
number of latrines corresponding in construction to 
the ones they are accustomed to. 
1?• The^maintenance and supervision of latrines is 
just as important as the choice of a practical and prr 
er construction type. An arrangement of a continuous 
latrine service within the units is to be insisted on 
at all times, A single cleaning during a day is not 
sufficient. There must be no doubt at any time what- 
soever who is carrying the responsibility with regard 
to the condition of strictly maintained cleanliness in 
the latrines, 
18, It is recommended to provide in the immediate 
neighborhood of latrines a possibility for washing 
the hands or cleaning the hands with a disinfecting 
liquid, e,g, a 2 per cent solution of Lysol. 
Evaluation of the serological test for lues in regard 
to its diagnostic value with omission of Wasser- 
mann’s reaction. 
Professor JAHNEL 
Undoubtedly, Wassermannfs reaction can be dispensed 
with in examination of blood. It is advisable to employ 
several flocculation reactions, especially MEINICKE’s 
clarification test II and either the KAHN test ot the 
citochol reaction (resp. MUELLER’s (Rudolph) agglutination 
test). The lentochol reaction according to SACHS-GEORGI 
and the MEINICKE turbidity test are less sensitive but 
possess a good specific character. With omission of 
Wassermann*s reaction, the employment of two more sen- 
sitive methods, such as MEINICKE1s clarification test II, 
KAHN test, citochol reaction and also MUELLER1s agglutin- 
ation test comes into consideration,is recommended in 
addition to one of the mentioned, less sensitive methods. 
Positive reactions to lues tests, sometimes of 
particular severity, are not always caused by Syphilis.^In- 
jections of serum of different types (tetanus, diphtheria, 
etc,) can produce at times, but not always, positive^re- 
actions to lues tests, especially to MEINICKE1s clarific- 
ation test II, MUELLER’s agglutination test and to intra- 
lumbar injections of meningococci serums even in the spin' 
fluid. 
Positive lues reactions, sometimes,of particular 
severity, appear in a certain form of bronchitis and also 
in cases of malaria the latter of which I had the opport- 
unity to examine, in collaboration with FISCHER, in a larrr 
number of cases in the hospital for tropical diseases in Munich. MEINICKEfs clarification test II seems to be 
frequently negative in cases of bronchitis. In cases of 
malaria a positive result of this test is relatively seldom 
seen, which occurrence might also occasionally/ happen to 
the lues test. In spite of that, a negative MEINICFE 
clarification test, when reactions of other lues tests 
have been positive, can give a hint about the non-specific 
nature of the disease. 
The false, positive reactions usually subside within 
a few weeks without further lues treatments. During the 
progress of other diseases, temporary positive lues re- 
actions are also observed at times, usually in less intens- 
ity in cases of scarlet fever, herpes simplex, ulcus nolle, 
and lymphogranulata inguinalis. Positive reactions of a 
more severe degree may occur with monocytic angina, en- 
docarditis lenta, leprosy and of course with frambesia, 
which is very closely related to lues. According to the 
literature, they are supposed to have been observed also 
with recurrent fever; in cases of North African recurrent 
fever (cases in the hospital for tropical diseases in Muni6' 
Professor FISCHER), positive lues reactions in serum were 
not observed by us. In case of doubt, repeated blood tests 
at not too short intervals and examination of the spinal 
fluid are recommended. Positive serum reactions should 
give special cause for inquiry into the history of the 
patient with regards to facts about syphilis and symptoms 
of the disease itself should be taken into consideration. 
Furthermore, the fact that syphilitics nay contract other 
diseases is to be taken into consideration (eczema, tuber- 
culosis, tumor of the brain, etc.). 
Requested remarks from Stabsarzt (Captain, MC.) SCHROEE 
with"reference to the Previous discourse• 
With regard to the question of judgement of the dia- 
gnostic value of flocculation reactions, the tabulated re- 
sults of I? 000 examinations, undertaken lately, of all 
flocculation reactions will be exhibited, which permitted 
the ministerial order concerning the serum diagnosis of 
syphilis, dated 1? August 1942, with inclusion of^the 
complement fixation reaction, the particular significance 
of which consists in the fact that the same serum had been 
employed with all methods. 
With regard to questionsabout the sensitivity, spe- 
cificity and non-specificity of a certain method, they 
lead to the following observations; 
1. The MEINICKE clarification test II is doubtless 
not only the most sensitive reaction but also the mos1 
specific reaction because it produces the strongest 
reaction results in all stages of lues. Its disad- 
vantage consists in the fact that it possesses also 
the largest non-specific reaction rate. 2. Outside of the field of technical and optical 
sources of errors, i.e. the doubtful reactions in our 
studies, the SACHS-GEORGI reaction has no non-specific 
reaction rate. In cases of lues II, III and lues 
latent, it possesses a 100 per cent specificity even 
though the latter does not show similarly strong re- 
actions as the MEINICKE clarification test II. It 
is the least sensitive reaction and fails therefore 
in untreated cases of lues in a ratio of 1:33 when 
conpared to the MEINICKE1s clarification test II. 
3» Between the degree of sensitivity and the non- 
specific incidence of these reactions we find all 
other methods with various degrees of strength but 
yet with sufficiently exact specificity for the single 
stages of lues. 
Observations of the various methods considering their 
specific and non-specific reactions discloses a certain 
important relationship, i.e. corresponding reactions upon 
specific as well as non-specific events. That holds es- 
pecially for the relations of MEINICKE tests among them- 
selves and as well, as already discussed by Professor 
JAHNEL, for the KAHN test and the citochol reaction. 
The above described observations yield the practical 
and logical conclusions: 
1. that the MEINICKE clarification test II as well 
as the SACHS-GEORGI reaction ought to be the basis 
of any combination of flocculation reactions; 
2. that only KAHN’s test, the citochol reaction or 
MUELLER’s agglutination test come into consideration r 
a possible third additional reaction. Under field 
conditions, the agglutination test proves itself toe 
difficult of execution in technical respects. 
Discussion: 
BLUMENBERG: Points to the fact that the disdaining 
of Wassermann’s reaction has been caused solely by non-sci- 
£H%ific circumstances. Particularly for evaluation, this 
reaction produces splendid results. The percentage of 
non-specific, positive exanthemas with spotted fever is 
very minimal as compared with the not inconsiderably high 
ratio occurring with flocculation reactions. 
CLAUBERG: The omission of Wassermann’s reaction^which 
I proposed at one time, has been in the meantime justified 
through experience gained in 50 000 serological tests under 
taken in my institute with the use of flocculation reaction 
alone. Even in case of rare, in the beginning not sero- 
logically determined cases, there was no need to make use 
of the Wassermann reaction. The same goes for proof of r 
in the blood as well as for the detection of lues in the 
spinal fluid. Through examination of^our material, in 
collaboration with clinicians and advisory councilors, it 
has been proven in addition that the third flocculation or - 
ation, requested by the office of the Minister of Inten for the civilian sector as a substitute for Wassermann’s re- 
action (in order to clarify questionable cases) is not un- 
conditionally required. We get along very well with two 
flocculation reactions only. 
UHLENHUTH: If Wassermann's reaction cannot be employed 
under wartime conditions because of technical difficulties 
and one must limit oneself to the MEINICICE clarification 
test and the lentochol reaction, then I still maintain the 
view that Wassermann!s reaction should not be considered 
obsolete. For decades Wassermannfs reaction has proved 
its value and ought to be employed again when conditions 
are normal. It must not be brought into discredit. For 
a diagnosis, which involves such a great responsibility, 
one ought to make use df all recognized methods in doubtful, 
cases. 
Directions for the serological diagnosis of lues• 
!• With renunciation of Wassermann!s reaction, the 
serological diagnosis of lues must be undertaken in 
every case through: 
a. use of the complete MEINICKE clarification 
test II, 
b. the lentochol reaction. 
2. Interpretation of results of both reactions shall 
be made according to degrees of strength + to + 4* by 
which too keen differentiation should be avoided. 
3* The informing of the sender about the results of 
both reactions has to be performed in the following 
manner: 
* r doubtful (undecided) 
- positive 
+ ♦ s strongly positive 
4* With regard to clinically or serologically doubt- 
ful cases a repetition of the test after an interval 
of 2 or 3 weeks is necessary. For a satisfactory judg- 
ing of the results of the reaction, a careful filling 
out of the covering letter accompanying every blood 
sample, by the physician, is imperative. 
5. The same directions, 1 to 4, apply to the sero- 
logical proof of lues in spinal fluid. 14* The standardization of cerebro-spinal fluid diagnosis 
in the Hygienic laboratories• 
Stabsarzt (Captain, MC.) SCHROEER 
The standardization of spinal fluid diagnosis is im- 
portant for the following two reasons, which are: 
1* without standardization, a useful basis for adjust- 
of^claims for pensions as well as fitness for 
service in the war, cannot be established and 
2* because without standardization the admonition to 
conserve in wartime especially with regard to concen- 
tration of material and personnel, cannot be adhered to. 
It appears necessary first of all that in order to ac- 
complish this purpose, all methods, pertaining to spinal 
fluid in so far as they do not find a better and more suit- 
able procedure right'at the bedside, should be carried out 
and supervised by the same people in the same location and 
should not, as in most military districts up to now. be 
handed over to hygienic, clinial or chemical laboratories 
depending on the kind of method which is to be employed. 
The necessary orders should be prepared with exact direct- 
ions about technique and evaluation of the methods in 
order to avoid conspicuous differences between the different 
laboratories of the Armed Forces. Furthermore, the large 
number of methods, employed for the same purpose and of 
equivalent value, has to be reduced to a degree which satis- 
fies the practical, clinical purposes rather than the 
scientific ones. 
In particular, the following additional proposals are 
made to supplement the preceding suggestions; 
1. Methods proposed are: macroscopic observation, 
cell count according to FUCHS and ROSENTHAL; cell- 
staining according to MAY-GIEMSA; estimate of the 
total protein through centrifugal methods such-as the 
improved NISSLE method; two globulin reactions, to be 
exact, phase I reaction according to NONNE*-APELT-SCHUMM 
as well as the sublimate reaction according to WEICH- 
BRODT; flocculation reactions such as the MEINICKE 
clarification test II, the KAHN and SACH-GEORGI test, 
complement fixation reaction; the mastic test with 
mastic-lumbo test as a standard mixture; determination 
of the quantity of sugar according to HAGEDORN and 
JENSEN; for bacteriological diagnosis the direct smear 
stained according to GRAM, with methyl violet according 
to ZIEL-NIELSEN and for bacteriological cultures chief- 
ly the use of ascitic fluid, blood and endoagar culture 
mediums as well as grape-sugar bullion for enrichment. 
2* With regard to methods concerning spinal fluid em- 
ployed in hygienic laboratories, the following stipul- 
ations have to be made: a* In contrast to flocculation reactions, which 
have to be employed as standard methods in one 
laboratory^in each military district, the comple- 
ment fixation reaction ought to be made use of only 
in exceptional cases in a few testing stations, 
favored by transportation facilities and situated 
near the front, which might have to be chosen from 
one case to the other according to needs* The com- 
plement fixation reactions, necessary for the 
diagnosis of gonorrhea, tuberculosis, trichinosis, 
Weil’s disease, echinococcus, etc. should be avail- 
able at the same place. 
b. Quantitative estimates of sugar content could 
be performed as before, in chemical laboratories 
and 
c. the qualitative globulin reaction in the 
hospital immediately after the spinal puncture. 
Discussion: 
BLUMENBERG: Calls attention to the technically simple 
fuchsin-sublimate reaction according to TAKATA and ABA, 
valuable in differential diagnostic respects, which shows 
not only the amount of protein but shows even with certain 
limits also the type of protein bodies. For standardization 
of methods in laboratories, I make the proposal that the 
T.A.R# (TAKATA-ABA reaction) be used in place of the WEIGH- 
BRODT test. 
ZSCHUCKE: Under field conditions, the quantitative de- 
termination of protein according to NISSLE, will be hindered 
by the lack of an electrical centrifuge or sometimes through 
lack of electrical current. Very much more to be recommended 
under primitive conditions is the RHAQUI albuminometer by 
SICCARD and CANTALOUBLE which has given a good account of 
itself in Africa, a procedure which permits the reading off 
from a graduated tube after it has been left standing for 
12 hours, the pro mill content of albumin precipitated by 
a chemical and physical process. 
WAGNER: If clinics expect satisfactory results from 
serological tests in laboratories, they must keep in mind 
that splinal fluid must be delivered to the laboratories 
in condition permitting a satisfactory examination* Re- 
grettably, this is frequently not the case inasmuch as 
spinal fluid samples, during the process of withdrawal and 
during further necessary handling, are much polluted by air 
and dust germs, especially through formations of earth-spores. 
This pollution impairs not only the bacteriological examin- 
ation but through fermentive activity of saprophytes causes 
chemical changes of the fluids, e.g. with regard to prttein 
and sugar* Therefore, clinics- have to aim at obtaining 
spinal fluid under aseptic conditions and preservation in 
these conditions. Among the proposed examination methods, 
the normo-mastic reaction has proved its value for many shears and - in contrast to the gold reaction, is to be recommended 
as a comparatively simple one in technical respects* Every 
serologist is able to perform a mastic Solution test, A 
separation of the analysis of the sugar content in spinal 
fluids and transfer of it to a chemical laboratory impairs 
the standardization of examinations and is unquestionably 
not necessary. 
PANSE: Clinics are able to employ to full advantage 
the development of differential spinal fluid diagnoses 
only when results of examination are absolutely reliable, 
complete and comparable among themselves. Frequently it 
is not the case yet, standardization is necessary. Partic- 
ulars about the type and numbers of reactions to be employed 
in every single case as well as directives for their proper 
employment are to be established and issued. To be ex- 
amined are: appearance of fluid, number of cells (if 
possible in the hospital), reactions according to PANDY 
and NONNE, determination of the total protein, normo-mastic 
or gold-solution reactions (LANGE test; 2 and finally tests 
for lues. Examination of protein relations is desirable. 
For the total protein test, mastic and gold-solution tests 
as well as for the protein relation, exact technical in- 
structions are of particular necessity. I propose the 
issuance of a leaflet on this subject as a basis for senders 
and laboratories. The accompanying note, used for specimens 
submitted for examination, is not sufficient to cover par- 
ticulars about spinal fluid.' Representation of mastic and 
gold-solution tests should best be done in a diagram because 
the frequently employed repredentation in rows of figures 
is not elastic enough and besides, the basic schema, used 
as a foundation, does not vary. Exact comparisons are then 
not possible. 
Directions for the standardization of cerebro-spinal 
fluid diagnosis. 
I. The diagnosis of fluid is incumbent on 
a. clinicians 
1. for observing the macroscopic appearance 
2. for the count of cells, 
3. for the reaction according to PANDY; 
b. hygienic laboratories (in addition to a 
possible bacteriological diagnosis) 
1. for a repeat-examination of the macro- 
scopic appearance (xanthochromia, cobweb- 
coagulation, etc.), 
2. for the estimation of the total protein 
through centrifugal method, 150 
3* for the mastic test with standard 
mixture of lumbo test and graphic evaluation 
4. for the lues diagnosis according to 
directions given for this particular purpose 
II. Results are to be put into a special pamphlet, 
containing also the exact clinical data, which has 
to be filled out by the clinicians to be forwarded 
to hygienists in order to supplement the accompany- 
ing note with regard to lb above.