129 
V. 
PROCEEDINGS OF THE CONSULTANTS * 
COMMITTEE ON FORENSIC MEDICINE 
Translation prepared by: 
U. S. Naval Technical Unit, Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government (U. S.) 130 
1. Death caused by exposure to excessive heat, and from 
combustion. 
Effect of heat, 
Reeierungs-Rat (Government Counsellor) BUETTNER 
The large number of fire catastrophes in aerial warfare 
can be explained by the fact that the enemy finds the means 
of warfare by fire available, which he has only to ignite. 
Eadh flame has at its base glowing parts which emit gas, by 
which it keeps itself supplied as by a gas-works. The flames 
of wood-, petrol, and oilfires show temperatures of about 
600 - 800 Celsius degrees. Much higher temperatures are 
found with metal fires such as the incendiary bombs, with 
which temperatures may increase to 3000 Celsius degrees. 
Only a slight part of the radiant heat emitted is visible, 
and in such a way that e.g. at 700 Celsius degrees red heat 
and at 1100 Celsius degrees yellow heat is shown. For feed- 
ing the fire, immense quantities of fresh air are needed 
which are conveyed from'.the side and from below as the so- 
called "torrent of flames". This air is primarily cold, 
pure, and rich in Oxygen. A scarcity of oxygen in the cent- 
er of the fire is, therefore, improbable. The term "Feuer- 
sturmleiche" is misleading, since these people are mostly 
killed not by the "torrent of fire", but by radiant heat. 
Tie heat acts on the human body by conduction and. con- 
vection of hot air, by contact with solid and liquid matters, 
by cordensing vapors, but above all by radiation. The effect 
of the hot air increases with the velocity of the wind. 
Practically, however, it obtains dangerously high values 
only in closed rooms and immediately over the flame. The 
combined effect of the humidity of the air, the proportion 
of dust and foreign gas is in this case generally insignific- 
ant in our climate. 
For physical reasons (in consequence of the steeply 
rising curve of the transmission of heat with increasing 
temperature) as well as from the way in which the fire is 
built up (hot air above) the result is that the main trans- 
mission of heat takes place by radiation. The intensity of 
the absorption of radiant heat is determined by the temper- 
ature and the expanse of burning surfaces (calculated from 
the angle of vision of the observer) and by the absorption 
coefficient of skin and clothes. Clothes and skin have 
practically no capacity of reflection nor perviousness to 
the radiation of heat. Polished metals, however, prevent 
the effect of radiation by a nearly total reflection. 
With each testing of the effect of heat and. the pro- 
tection against heat it must be clear what the various con- 
ditions are. In particular the relative effect of hot air 
and radiation must be defined, e.g. if the supply of calories 
and the temperature of the skin are the same, the hair on this 
skin in case of a calory supply with hot air, will be con- 
siderably hotter than the skin, while in case of radiation 
they will be colder than the skin. 131 
A protection against the effect of heat is primarily 
afforded by any kind of clothing as it makes possible a 
fall of temperature from the hot outside to the inner side, 
according to its insulation against heat. The desirable 
high insulation for heat does, however, increase the probab- 
ility of catching fire with clothes which do not consist of 
pure wool or silk. Wet clothes and blankets are a protect- 
ion by the cooling caused by the evaporation of the water, 
but only so long as they are wet. 
Fire-proof clothing of polished metal is founded upon 
a completely new principle. The very thin layer of aluminum 
spread on cloth or paper, reflects 80 to 90 per cent of the 
radiation striking it, prevents an adherence of sparks by 
its smoothness, automatically protects the upper garments, 
and is to be developed into protective clothing against 
mustard gas for civilians, by order of the Inspector of the 
13th Air Group Command. 
Comparative experiments before a burning barn with an 
air temperature of 14 C, degrees and a radiation of 5 - 10C( 
produced by a wood fire of 6 - 800 C. degrees 
over a large surface at a distance of 3 meters had the folio 
ing effect: A man, without protective clothing, with steel 
helmet and respirator, retires immediately; a man covered 
with a wet blanket, after 18 minutes the blanket is charred 
in front, the man very much exhausted. A man clothed in th; 
asbestos suit of the fire brigade: temperature on the out- 
side of the asbestos suit more than 180 C. degrees after 
28 minutes, on the upper garments 90 C, degrees, the man 
very much exhausted. A man dressed in clothes with a coat 
of aluminum foil (0.008 millimeter) on parachute silk: 
temperature on the outer surface 54 C. degrees after 28 
minutes, on the clothing 32 C. degrees, the man quite fresh; 
pieces of leather and cloth are charred, the glasses of the 
gasmask are bent. 2# Death from exposure to excessive heat. 
Oberstabsarzt (Major. MC.) Prof. PONSOLD 
The temperatures causing death from exposure to heat 
begin at 50 C. degrees at which point the skin is blistered, 
and at 60 C. degrees necroses occur. Effects of heat on the 
hair are to be recognized from about 150 C. degrees onward, 
particularly about 200 C. degrees. It consists in discolor- 
ation, curling, brittleness, and dilatation of the air slit. 
The hair is not suitable for a differentiation of vital or 
postmortem changes. 
In order to ascertain coagulation of the blood the con- 
dition of the blood of the right ventricle of the heart must 
be examined by using the hematocrit. The routes of entrance 
and exit of the heart are to be closed up carefully during 
the examiantlon. 
Effects of heat on the respiratory Passages• 
Prof. A. FOERSTER 
The speaker reports on changes of the mucous membrane 
of the trachea which he observed with bur*t persons. The 
microscopic examination of the epithelial cells showed swell- 
ing of the epithelium such as may be found at the place where 
the electric current enters. These changes must therefore 
result from the inhalation of overheated air. The experi- 
ments made in this resnect proved the assumption. For this 
purpose oxygen and hydrogen were exploded, and at the same 
time a fire was produced by the explosive substance# Thus 
overheated air developed which was inhaled by the animals# 
This caused the changes of the epithelium of the mucous mem- 
brane of the trachea, or a fixation of the cells by coagulat- 
ion of the plasma. This observation certainly is of import- 
ance in the large scale air raids, for in this case too ex- 
plosions occur which cause fires, and in this case too over- 
heated air develops which men are obliged to inhale# It must 
be assumed, therefore, that during large scale air raids, be- 
sides poisoning by carbon monoxyde and laceration of the 
lungs, inhalation of overheated air also plays a Dart in 
certain cases. 4. Death from burning. 
K. H. ZINCK 
Findings* of recent and earlier dates are shown by de- 
monstration of fine tissues of burnt and scalded persons. 
Also, according to the new material of research of ZINCK, 
there occurs in connection with the burning a primary attack 
on the vascular system, which becomes pervious to blood plas- 
ma containing albumin and leads thus to a loss of plasma wit * 
coagulation of the blood, and finally to collapse. In the 
organs obviously depending upon function (R0ES8LE), 
serous inflammation may occur, which, with large parenchymal 
losses, may cause injuries to the organs that may have fatal 
results. In early cases the intense edema of the brain with 
a hyperemia and a corresponding increase of the pressure in 
the brain are the cause of death. The adrenal gland has no 
central position with regard to a primary attack by poisons 
of albuminous disintegration. It may, however, be exhausted 
functionally, just as the basophilic portion of the hypo- 
physis may become fairly empty and edematous in the case of 
death by burning. 
In the case of hepatic and renal involvement death oc- 
curs not rarely with the clinical picture of hepato-renal 
Disturbances of function pass over into an- 
atomical injuries with burning. The morphological examinat- 
ion reveals which areas have been affected first and the 
nature of the attack. With extensive injuries of the organs 
a-secondary additional endogenous disintegration of albumin- 
ous poisoning follows upon the primary one (vicious circle). 
In early cases attention is to be paid to; 
1. Brain (edema and hyperemia); 
2. Liver (cloudy swelling, dissociation, necroses); 
3. Kidneys (necrotic neohropathy, calcification, 
hyaline degeneration); 
4. Heart and vessels (erythrocytorrhexis, hyaline 
fibrinballs); 
5. Blood (fixation Carnoy and Formalin). 
In late cases: 
1. Liver and kidneys, 
2. Heart and blood vessels, 
3. Brain (ganglion cells), 
4. Hypophysis and suprarenal glands (basophilia). 5_. Effect of fire-storm on the human body. 
Qberfeldarzt (Lt. Col.. MC.) of the Police KRAEFFT 
The observation given in the preceding reports concern- 
ing the injuries to heart and causes of death during fires 
over large surfaces are confirmed. The opinion expressed by- 
laymen that a deficiency of oxygen near large fires has led to 
death in many cases, is disproved by the fact that any defic- 
iency of oxygen should lead necessarily to an accumulation of 
carbonic acid and that the poisoning by carbonic acid should 
be one of the prevailing phenomena. This fact, however, could 
in no case be proved to be the cause of death. 
Discussion following the lectures on death from exposure 
to excessive heat and burning• 
FOERSTER: The same changes can be produced in the lungs 
postmortem though only in the area where the effect of heat 
took place, 
BUETTNER: Concerning the question of the inhalation of 
hot air, the following personal observation by the author at 
200 - 250 C, degrees shall be mentioned. The sensation on the 
face is very disagreeable, injuries do not occur probably on 
account of the already present supply of sweat, except one 
burn at the spot where the spectacles, covered with an insul- 
ating substance, rested. The respiration was not rendered 
disagreeable nor any more difficult, except that the heat bad- 
ly affected the edges of the nose. 
A curve of the time for which the heat can be tolerated 
("Hitzefluchtzeit") is shown, that is to say for that period 
during which the complete physical and mental capability of 
action is still more or less unimpaired dependent on the 
effects of the temperature of the surrounding area. The curve 
is based on observations between 50° C. and 250° C. and on 
calculations based on the following facts; the required 
capacity for action decreases, if the body temperature and 
the temperature of the skin continue to increase correspond- 
ingly, and if the body temperature has increased at least one 
degree as compared to the temperature at the starting point. 
Moreover the apparently highest possible peripheral blood 
supply and the normal development of the warmth of the body 
and clothing are assumed. The time for which that can be 
tolerated is e.g, for 50° C. - 3 hours, ?0° C. - 1 hour, 
130° C. - 15 minutes, and 250° C. - 3 minutes. 
BUHTZ: Reference is made to the vital and postmortem 
changes by the effect of heat, to the need for exact quantit- 
ative spectroscopic and spectral photometric examinations 
(LOEWE-SCHUMM, KOENIG-MARTENS). Cerebral sclerosis with ne- 
crotic hematoma caused by negative pressure in the cranial 
cavity and vacuum are to be considered as postmortem phenomena. 
In the case of cracks in the skull caused by the effect of 
heat, it is often wrongly attributed to a blow inflicted with 
a blunt instrument. OSTERTAG: If there are no well-known assumptions based 
on experiment, the number of unknown factors is so great that 
an indisputable determination of the cause of death is im- 
possible. 
The rapid postmortem changes make a solution of the 
problem difficult. 
In unusual cases one must try to find out what materials 
had been stored in the buildings, which of all these materi- 
als were thus changed by the effect of heat, fire, or water, 
so that a fatal effect may have been produced early. Death 
by carbonic acid is certainly not sufficiently taken into 
consideration, just as little as the effect of gas from de- 
fective sewers. 
For an explanation of all these ouestions it is there- 
fore necessary: 
1. To take into consideration the clinical observation 
of those who have survived, 
2. To ascertain exactly the local conditions, 
3. To carry out the postmortem examination as soon as 
possible. 
MUELLER: The bloating of the dead body probably takes 
place by the formation of vapor. After the decrease of tem- 
perature or after the bursting of a body cavity the bloating 
decreases. 
AMMICH; The frequent very impressive cerebral edema 
occurring rapidly, and leading to sudden death, may also be- 
come intense and may be of long duration without becoming the 
immediate cause of death. A case out of my own practice, of 
a burn of the abdominal walls by the explosion of a hand gre- 
nade, with subsequent death as a result of fecal peritonitis, 
2i days after the accident, with most serious cerebral edema, 
signs of cerebral pressure and hyperemia of the leptomeninges 
is mentioned. In this case symptoms of a central cerebral 
death were not present. 
GHAEFP: A small number of deaths in the fire-storm can 
probably be explained as immediate death by burning. The 
question, as to whether death by deficiency of oxygen is 
really possible I leave open. For the vast majority of death 
exposure to excessive heat must probably be regarded as the 
cause of death. Numerous reports registered by me of the 
experiences of persons escaped from fire-storm showed that 
part of them had perspired freely and had quenched their 
thirst as soon as possible with any kind of water, while the 
other part has neither perspired nor had they afterwards felt 
particularly thirsty. This fact makes one suppose an in- 
fluence upon the heat center (mid-brain) and indicates with 
this kind of fatality that death resulted from heat in the 
manner of heat stroke. Also the quick recovery of those 
saved without any secondary symptoms (no headaches as there 
are after poisoning by CO) points in this direction. Directions on death caused by exposure to excessive 
heat and burning. 
1. Blisters (size and position). 
a. This sign is only of value if there are no 
blisters caused by decomposition. 
b. On the dead body, however, blisters may form, 
but in this case, these are gas blisters. If 
they contain liquid, leucocytes are absent, 
2. Vascular marks. 
The corium tightly filled with detached epidermis in 
consequence of a coagulation of blood accumulated by hyperemia 
due to excessive heat. 
This phenomenon does not concern the dependent parts of 
the dead body, since in them the blood vessels are filled by 
hypostasis (within the livid spots). 
3• CO - hemoglobin in the blood of the heart• 
This finding has value only when the quantity of CO - 
hemoglobin is below 50 per cent. With higher quantities of 
CO - hemoglobin death may be caused by CO - poisonings. There- 
fore, the quantity of CO - hemoglobin should be ascertained. 
The blood should be transmitted in small hermetically closed 
ampules, filled up to the brim. 
4• Soot in the trachea and in its smaller ramifications. 
This phenomenon is of value only if it occurs during the 
burning and not before it e.g. smoke (soot) has been inhaled 
if during the attempt to escape from the flames. 
5. Soot in the stomach• 
Objection as under Mr. 4. 
6• Fascicular arrangement of the bronchial epithelium 
between the honeycombed blisters caused by heat• 
This is a phenomenon caused by heat, since the respirat- 
ory passages are protected and "honeycombs" develop as a rule 
only by inhalation of superheated air. 
7. Fat embolism in the lungs. 
Points to a trauma or scalding. 
8. Local effect on blood vessels. 
?/ith burnings and scaldings which have been survived for 
a short time, a serious injury of the vessels occurs by a prob- 
able "resorption of poison". Even within a few hours histo- 
logical changes of the organs are found. Early death is most- 
ly caused by cerebral edema (increase of cerebral pressure), 
in some cases a single injury of the organs may be fatal (e.g. 
serous myocarditis). 137 
6. Death caused by dust. 
Stabsarzt (Captain. MC.) DESAGA 
The fatal conditions of suffocation by inhalation of 
dense concentrations of dust are discussed. Suffocation by 
dust during an air raid is very seldom observed to be fatal. 
The original report is published elsewhere and may be ob- 
tained from the Aviation Medical Research Institute of the 
National Air Ministry (Luftfahrtmedizinisches Forschungs- 
institut des RDM, Berlin). 
Discussion: 
BAADER: When the aircraft disaster occurred in Antwerp 
I was some hours later at the spot where it had happened. 
The corpses were thickly covered with dust. The children 
who were found still alive had been protected by the skirt 
of a nun, like chickens covered by a hen; but soon after- 
wards they died too. 
HOESSLE: Death by dust is referred to in which case 
the larynx and the whole trachea were filled with gray soft 
mucous mortar, probably inhaled dust, soaked in edema. In 
these cases the mass should be gathered and weighed in moist 
and dry condition in order to ascertain in what ouantities 
it becomes fatal to man. 
BHEITENECKEH: In the Vienna Institute for Forensic Me- 
dicine a case of death by dust was observed some years ago, 
which occurre(j vdien a coal miner, against the regulations, 
advanced to a coal slide and looked up in order to see ■•hethe] 
the coal car was discharged at the upner end of the slide and 
the coal rushed down, raising an enormous cloud of coal dust. 
The miner afterwards was found suffocated by coal dust. In 
this case one could speak, therefore, of death caused by 
dust. 7. Carbon monoxide poisoning and detection of CO• 
Oberfeldarzt (Lt. Col.. MC.) Prof, LAITCHE 
The causes of fatal CO poisoning among soldiers• 
A report is given on the evaluation of the reports by the 
sections of army pathologists concerning fatal but unintent- 
ional CO poisoning (that is to say excluding suicides) based 
on the material of the Report Collecting Station controlled by 
the Consulting Pathologist of the Military Medical Inspection 
Service. The tables shown are based on the evaluation of the 
reports made by U. A. DOEHNER. They are intended to give a 
survey of the causes of CO poisoning, therefore, the comparat- 
ive numbers were given without calculation of any average 
values. 
There were poisonings by: 
I. Illuminating gas, 34 per cent; II* Charcoal fumes, 
37 per cent; III* Motor exhaust gases, 14 per cent; and by 
unexplained and other rare causes, 15 per cent of unintent- 
ional deaths by COt 
Ad. X. Most frequent are deaths causes by irregularities 
in the operation of gas water heaters (20.5 per cent; and 
through carelessness (2.3 Per cent), defective waste-pipes for 
the combustion gas (8.2 per cent), defective stoves (1.2 per 
cent), and unexplained primary causes (8.8 per cent). 5.3 per 
cent of the accidents were caused by gas heating stoves, 0.6 
per cent by gas cooking stoves. 3*6 Per cent' by 'open'"gas 
1.8 per cent by defective gas pipes, and 0,6 Per cent'the 
bursting of gas pipes underground. 
Ad. II. The "charcoal fumes" (poisoning by smoke fumes) 
mostly developed from stoves operated in a faulty manner (16.4 
per cent), also from fires outside the stove (4.7~Per "cent), 
which mostly on account of drunkenness, were not detected in 
time. Burning of the bed when smoking in bed (in most cases 
also under the_,_influence of alcohol), was found to be the cause 
in 1.2 per cent of the cases, «. . 
The full particulars could not 
be ascertained in 15.2 per cent of the cases. 
Ad. III. Poisoning by motor exhaust gas was due to the 
very common bad habit of letting the motor run 1) in closed 
rooms (2.4 per cent). 2) in the open air, but with the car 
closed (6.0 per cent). In 4.1 per cent of the cases death 
was caused by the escape of gases containing CO into the car 
through leaking exhaust pipes. Unknown as regards particulars 
remained 2.4 per cent. 
The causes were the same as those known to doctors in 
peace-time, lack of thought or carelessness and drunkenness 
often playing an important part. A decrease of accidents is 
to be attained only by continuous instruction as to the imminent 
dangers and severe punishment for the non-observance of the 
regulations. Causes which were characteristic for the Armed 
Forces and would require new regulations could not be found. 
New pathological anatomical observations worth mentioning, 
were not made. B_* . Poisoning by carbonic monoxide. 
zt__.CMalpri MC.) Prof, BUHTZ 
Poisonous substances; 
a. Gas from fire, 
b. Illuminating gas, 
c. Technical gases containing CO, 
d• Poisonings by several substances (GO * C02, CO + 
nitrose gases). 
Since the known clinical and pathologic-anatomical change., 
due to acute poisoning by carbon monoxide afford no proof but 
only an indication, the objective nroof must be adduced in sur- 
viving cases, particularly, however, in rapidly fatal cases of 
CO-poisonings’ 
1. By reconstruction of the circumstances (particularly 
examination of the place of occurrence), 
2. Demonstration of carbon monoxide in the blood by mears 
of physical or chemical methods (see report by BREITENECKER). 
As a rule it is only with protracted poisonings by carbcr. 
monoxide and escaping, that the well-known symmetrical focuses 
of softening in the lenticular nucleus can be cited as object- 
ive arguments. 
Statistics: 
Accidents were mainly caused by gas from fires and tech- 
nical gases, a smaller number by illuminating gas. 
During air raids deaths occurred by gas from fires as well 
as by illuminating gas (destruction of gas pipes). 
Murder by illuminating gas was rarely observed, by 
from fires in some cases. Poisonings by gas from fires were 
more frequent in the country, poisonings by illuminating gas 
more frequent in town. 
The number of cases of poisoning by gas from fires, apart 
from large scale air raids, varies according to the seasons, 
corresponding to the heating period. 
Poisonings by illuminating gas, apart from large scale 
air raids, on account of the frequency of suicides, vary ac- 
cording to the seasons, corresponding to the suicides by gener- 
al poisonings used in the household and in trade. 
Suicide by illuminating gas is the prevailing method with 
females* The concentration in corpses with poisoning by illumin- 
ating gas 21 - 81 per cent, on an average 49.3 per cent, with 
gas from fires 20 - 80 per cent, on an average 4-3 per cent. 
With illuminating gas the distribution in the organs is 
equal, with gas from fires there is a strikingly high percent- 
age of it in the kidneys. 
With illuminating gas 99 per cent of the death spots are 
light red, while with gas from coal fires only 68 per cent are 
light red. 
Causes of injuries to health and deaths by Illuminating 
gas. 
A. Accident. 
Defects of pipes caused by air raids, taps and tubes 
partly opened or leaking. 
Leaky plugs or connections of gas pipes. 
Falling off of rubber connecting tubes. 
Accidental tearing off of the rubber tubes in fainting 
fits, attacks of vertigo, and other fits. 
Extinction of the flame caused by draft or boiling over. 
Extinction of the flame of the water heater, radiator, or 
gas range. 
Lowering the flame too much (putting on too large a pot 
filled with cold water). 
Absorption of the odorous substances by steam, (bath, 
sauna) or with poisoning by escaping gas (bursting of gas 
pipes and others). 
IB. Suicide. 
Opening of taps, perhaps combined with taking soporifics. 
Killing oneself and one’s whole family. 
Simulated suicide (Simulation of accident). 
C. Murder. 
Fictitous suicide. 
Combination with soporifics and other poisons. 
Dislocation of gas pipes, of rubber gas tubes which pass 
through the walls of inhabited rooms. Injuries to health and deaths from gas from coal fire. 
A. Accident. 
Gases developed by fires during large scale air raids. 
Defective or damaged chimneys of heating installations. 
Defective stoves (Stoves made of Dutch tiles), unsuit- 
able heating materials, coal. 
Stove doors closed too soon (wrong manipulation). 
Stove doors, stove pipes, flues and chimneys defective 
or not tightly sealed. 
Choked or closed flues and chimneys• 
Defective introduction of flues Ihto stoves and chimneys 
(torn off flues). 
Faulty installation of stove pipes, flue for the smoke 
adjacent room, room in the upper floor). 
Deaths in garages with wood gas generators on autos. 
Crude coke stove in the bed room. 
Stove with slow burning fire (joined to normal chimneys). 
Soot obstructing the draft of the stove and the chimney. 
Difficulty in venting the smoke gases caused by residual 
ashes and chimneys blocked by snow. 
Back pressure of waste gases of a gas hot water heater. 
Closed damper In stove .pipe. 
Faultily installed flues, introduction of stove pipes 
into ventilation ducts. 
Gas escaping from small leaks. 
Influence of the weather on the draft of the chimney 
(defective petroleum stoves). 
Coke stoves, 'e.g. marmalade tins, in closed rooms 
(cellar, bunker, in thawing out water supply pipes). 
Installation of heating stoves in motor cars. 
Live coals falling out of stoves and setting fire to the 
room. 
Hot slag. 
Fire brigade (salvage). 
Coal stoves in auxiliary hospital trains, service- and 
frontleave trains, sauna. Smouldering of combustible material near the stove 
(wood, clothing, linens)• 
When kindling fires (with gasoline) the clothes and 
other substances catch fire. 
Upsetting of lamps (stable lantern, candles) with spread 
of fire to surroundings. 
Smoking in bed (fires in beds), occasionally by hot 
bricks. 
Discarding live matches with resultant smouldering fires 
(burning of rooms). 
Sleeping close to or on the stove. 
C. Murder. 
Stopping up of the flues, coal pans. 
By charcoal fumes in closed bath rooms (murder of the 
stepchildren)• 
Injuries to health and deaths due to technical gases 
containing CO. 
A. Accident. 
Large scale air raids (gases developed by fire), 
hot slag, poison gases. 
"Pioneer disease11 of miners (CO), 
nLimousine disease"• 
Death In garages (cold air). 
Heating with exhaust gases, leaky pipes. 
Suction of exhaust gases. 
Accumulation of gas in insufficiently ventilated rooms. 
Driver Ts seat of trucks propelled by gas produced..from 
wood. 
"Maultier", (poor venting of the exhaust gases). 
Tunnels. 
B. Suicide. 
Dissimulated suicide in garages. 
C. Murder. 
Preparation and administration of CO from formic acid 
HCOOH by the action of H2S04. 
Murder in garages. Concurrent causes of death. 
Natural death, poisoning by alcohol, soporifics, C02, 
CH4, death caused by excessive heat, lack of oxygen. 
1- Recognition of polsonings s 
a. acute 
b. chronic (exhaustion, headaches). 
Exact clinical examination of the blood. 
2. Erroneous diagnosis of poisoning. 
Most frequent when caused by illuminating gas and gas 
from coal fire. Confusion with poisoning by foodstuff and 
by ficporifics. 
Causes of mistakes. 
False history (careless, intentional, to protect crim- 
inals). No history in case of death or unconsciousness. No 
inspection of the place where crime was comnitted (often re- 
luctance of the physician to inspect the place where crime was 
committed; with heating installation, test heating). No proper 
postmortem examination of the body (light red death spots over- 
looked* since the body was not undressed). T'rhen gas from coal 
fire is the cause, often no or only a few light red death spots. 
No blood tests sent in (blood samples not to be taken from 
vessels near the surface on account of a danger of diffusion 
from atmosphere containing CO). Blood must be taken immediately 
from the survivors, since otherwise the test becomes more dif- 
ficult on account of the subsequent secretion. 
There must be no pre.iusticel I The examination must be 
made without prejustice and everything must be considered. 
Examination of the place where the crime was committed (cause, 
tests of air! Poisoning by carbon toonoxide is often not sus- 
pected, because no odor was observed on account of 
a. strong dilution, 
b. filtering off of the odor in case of escaping gases, 
c. absorption of the odor by steam, 
d. soporifics, 
e. intoxication by alcohol, 
f. unconsciousness. 
Prophylaxis. 
a. Proper heating installations and supervision is 
imperative especially at the beginning of the heating season. 
(Bunker, Panje cottages, etc.). 
b. Proper attention to the fire (instruction con- 
cerning the method of heating and the kind of fuel). 
c. General instruction concerning the dangers (par- 
ticularly at the beginning of the heating season). The bunker 
must be left in time during air raids (canary). Testing for carbon monoxide. 
Dozent BREITENECKER 
After a survey of the methods of testing for CO in the air 
the use of salts of palladium, gold and silver, by the oxides 
of manganese, copper, mercury, cobalt, silver and chromium or 
mixtures of these, particularly by iodine pentoxide and the 
filters of gas masks constructed according to these processes 
as CO-gas detector apparatuses and CO-measuring apparatuses of 
the "Draeger Werke”, in the "Auergesellsbhaft" and others, the 
question of ascertaining the content of CO in the blood was 
discussed. 
The Qualitative testing is done best by means of spectro- 
scopic examination, for which purpose a hand-spectroscope is 
quite sufficient. Sodium hydro sulfate (Na2S204) is recommend 
ed as a reducing agent which acts more quickly, and which is 
solid and more stable than ammonium sulfide, such as is laid 
down in Army Manual 396, Navy Service Manual 318, and German 
Air Force Service Manual 96. The lower limit of detection by 
this method is about 20 per cent of CO-heraoglobin. But less 
than 40 per cent of CO-hemoglobin must be ascertained by the 
quantitative method. 
The quantitative proof can be carried out by means of the 
gas-analytical or physical method. Among the former methods 
the best seems to be the iodine pentoxide method (MAY, FISCHIN- 
GER, SCHMIDT). Among the physical methods we mention the 
spectrometric, the colorimetric, the comparison photometric, 
the spectral photometric, and the infrared photometric method. 
Among these the methods of MAY, RANKE, and SEYDEL with the 
comparison photometric apparatus are to be recommended for 
prophylactic examinations, or the examination of survivors, 
while the spectral-photometric method is suitable for the ex- 
amination of blood of every kind, from the living person or the 
dead body even in case decay has set in or there has been part- 
ial combustion of the body. Therefore, this method is recomraec 
ed first and foremost, particularly, as only a few drops of 
blood are sufficient for an examination and the control takes 
only 5 minutes. These methods are adequate down to a lower 
limit of about 2 per cent. Smaller quantities must be ascer- 
tained by gas-analysis but they are irrelevant to our question. 
If there are survivors, it is important that their blood 
should be taken then and there, and sent in for examination, 
with an accompanying letter giving particulars of the poison- 
ing, stating when the person concerned was found, and the blood 
taken, also mentioning symptoms of the disease. In the blood 
taken or in extravasations, CO can be ascertained for a long 
time, in the circulating blood it is quickly excreted by the 
respiration (on an average after 10 hours). In corpses CO can 
be ascertained even after months have elapsed. The blood 
should be without admixture of any substance and should be 
placed in small tubes, brimful1 and closed tightly. With be- 
ginning decay, the stopper must be fastened so that it cannot 
be blown out by the gases of decomposition. In conclusion it is pointed out that it is possible to 
diagnose CO-poisoning from the pathologic-anatomic findings, 
even when the dead person has survived the poisoning for more 
than 10 hours so that the CO has been excreted again from the 
body, except for such small quantities that they are difficult 
to demonstrate. 
Discussion about the reports concerning poisoning by 
carbon monoxide and the proofs of the presence 
of carbon monoxide in the body• 
GRAEFF: The value of the quantitative determination of 
CO-hemoglobin in corpses shrunk by combustion after bombard- 
ment is frustrated by the fact that with these corpses the 
local heating of the organs makes it possible to demonstrate 
CO, or because the hemoglobin is destroyed by putrefaction. 
BUHTZ: Vrith corpses which have been in the CO-atmosphere 
for a comparatively long time, the taking of blood from deep 
lying vessels (cavity of the brain) is required, because of 
the possibility of postmortem diffusion. 
In case of mass-poisonings blood tests must be made im- 
mediately and marked separately with the names of the person's 
concerned. 
In case of mass-poisonings In the same room the most 
widely variable percentages of CO were found. 
„ micro-spectroscopic method, the microscopy 
according t© LOEWE-SCHUMM gives valuable results only down to 
20 per cent. Smaller quantities below 20 per cent may be as- 
certained spectrometrically by means of the apparatus of 
KOENIG-MAHTENS. 
Decreased oxygen plus CO2 must be considered in the dif- 
ferential diagnosis. 
BAADER: In bunkers of the "Atlantic Wall" ("Atlantic 
Fortification") furnished with iron patent stoves, poisoning 
by CO (among them some fatal cases) were observed, though the 
stoves were being attended according to the instructions. r he 
flue for the gases of the stoves is connected direct with the 
hand-grenade pit of the bunker. Control tests have shown that 
if the wind is in the direction of the hand-grenade pit, the 
waste gases of the stove are blown back into the bunker. 
MUELLER: In northern Russia and in the Eastern territory 
a poisoning by CO does not occur with wood heating, even when 
the stove-register is closed” it does, however, occur, when 
coal or coal mixed with wood is exceptionally used and Then 
the stove damper is closed too soon. 
WIETHOLD: Report on cases of poisoning CO in the open 
air and in bomb-proof shelters, the latter by pumping air con- 
taining CO into the bombproof shelter. Remarks concerning the 
estimation of CO in the blood. FLUKY: In case of poisoning by mixtures of CO (gases 
developed by fires, exhaust gases, .emoke) the percentage of 
oxygen in the air mixtures plays an important part. Lack of 
oxygen increases the CO danger to a high degree, while the 
admixture of COp is of little importance as gas which furthers 
the respiration; (Recent investigations by 0. KLIMMER, Wuerz- 
burg). 
Directions regarding poisoning bv carbon monoxide. 
1. When measures ate taken immediately samples are to 
be taken at random from corpses in various rooms. 
2. Blood from deep-seated vessels (heart, meningeal 
sinurs, kidheys, pelvis;, or extravasated blood, bloody 
liquid or pieces of tissue filled with blood are to be sent 
in for the purpose of quantitative proof of CO. Organs too 
much boiled, or roasted, or carbonized, are useless. Of 
juveniles also the hollow cylindrical bones are to be sent in. 
3. The tubes must be filled up to the brim, with the 
test material (blood etc.) and must be closed tight (cork or 
rubber stopper). 
4. The nearest test institute or auxiliary test in- 
stitute must be well-known to the chief of the research group 
for the ascertainment of doubtful causes of death during air 
raids. 
5. With survivors blood must be taken as soon as they 
are found, because of the rapid excretion of the G0# 
6. Information must be given to the competent examinat- 
ion department about the place where bodies were found and, 
if possible, an anamnesis Including a sketch of the place 
where the accident took place. 
7. For quantitative CO test any practical physical 
method available is useful. 
8. Statements should be made about the result of the de- 
termination of CO in the blood or the percentage of CO-hemo- 
globin. Statements of cubic centimeters in the blood should 
be avoided, they must be converted into per cents of CO-hemo- 
globin. The results of the experiment must be given to the 
chief of the research party. 10. Self-inflicted Injuries* 
Qberstabsarzt (Manor, MC.) Prof.#_iOELIJ)H 
If a soldier intentionally injures himself so as to shirk 
duty, this is a case of self-mutilation. If he injures himself 
through negligence, it is to be called mutilation through ne- 
gligence* The cases of mutilation through negligence are hand] 
ed In the following manner: The army surgeons, the physicians 
at the main dressing stations, and the physicians at the hospit- 
als send every case of unaccountable injury, in which self- 
mutilation may be a consideration, to a hospital where a con- 
sultant in forensic medicine is attached. By including so mam- 
men for examination to detect the real cases of self-mutilation, 
the examination of many innocent men is inevitable# Any defam- 
ation of the soldiers to be examined is, therefore, 
avoided# During the examination attention is first paid to in 
juries caused by close-range shots. Burnings are practically 
out of the question with close-range shots from^modern weapons, 
just as is the presence of particles of powder in the wound# 
Near the spot where the bullet entered the textile fabric is 
sometimes roughened and of lighter color with close-range shot 
from a distance up to 10 centimeters# In this case it is the 
question of a loosening of the fabric by gas pressure# Its 
presence is a sign of a close-range shot and besides^this a 
sign that a flat trajectory weapon was used# Tears in the text 
lie fabric are found with shots from small arms up to 12 centi- 
meters# The skin breaks at a distance of up to 2 centimeters# 
A gunshot wound where the skin is broken is an important sign 
of a close-range shot when a breaking of the skin by a fracture 
caused by a bullet is out of the question. The most important 
sign of a close-range shot is the edge caused by the smoke of 
the powder which can usually be diagnosed macroscopically# li 
a macroscopic diagnosis is not possible because the shot was 
fired at comparatively close range or if the textile fabric is 
soaked with blood, the examination must be made by means of 
"Dithizon" reaction# A microscopic diagnosis of the powder 
smoke is very difficult. According to the speaker, it is just- 
ified only in exceptional cases. The edge of powder smoke must 
not be mistaken for an edge caused by grazing or by dirt# If 
the hand of the soldier was dirty, the secretion of the wound, 
the blood, and the dirt combine to a blackish crust which may 
be mistaken for powder smoke# Russian explosive 
cartridges do not generally cause phenomena which could be mis- 
taken for signs of close-range shots. There is, however, one 
exception, namely if the hand of a soldier was just touching 
wood. The explosive incendiary cartridge penetrates the hand 
without detonation. It detonates only in the wood. The powder 
smoke is at the spot where the bullet leaves the hanj# The 
particles of the bullet are not in the hand, but in the wood. 
According to current opinion tracer incendiary qgjwtr do 
not cause noticeable changes at the spot where the bullet enters 
the body. Spent tracer cartridges cause a lining of the channel 
with smoke. Two experiences in practical cases, however, raise 
the question, whether for once a tracer cartridge may not leave 
a trace of smoke around the spot where the bullet entered. 
Special examinations are going on. In case of filter shots a diagnosis is easy if the filter- 
ing object is found (folded handkerchief, "Hindenburglicht”, 
bread, trunk of a tree). Otherwise diagnosis is only possible 
if traces of the filtering object can be proved macroscopically 
or microscopically at the spot where the bullet entered the 
body, which was sometimes done successfully. 
If a soldier asserts that the wound was caused by a long- 
range shot, while it was actually due to a close-range shot a 
self-mutilation must be suspected. Recently, however, the cas- 
es increase in which soldiers, who are mentally normal at first 
pretend that they were ivounded by a long-range shot, though the 
wounds are due to careless self-mutilation through negligence. 
In the instructions on self-mutilation sometimes a sharp dis- 
tinction is made between self-mutilation and mutilation by ne- 
gligence. By this soldiers are sometimes frightened and at 
first tell foolish lies. Such.conduct can now no more be re- 
garded as positive circumstancial proof of self-mutilation. 
The descriptions of the accidents must be demonstrated and 
put down carefully in writing. After that inquiries at the 
unit must be made. If a self-mutilation is to be suspected th 
case is submitted to the military court. If it can be proved 
that the soldier is found not guilty the unit is informed of it 
A copy of the findings is added to the medical report in order 
to prevent a resumption of the cases by another hospital. 
The results of the proceedings at law are sometimes diffi- 
cult to foresee, since the military administration of the law 
is somewhat unstable. Generally the judges examine the cir- 
cumstances very carefully. Sometimes there are surprising ac- 
quittals, particularly if the defendant makes a good impression 
and bears a good character. Therefore, the soldier had best 
make a confession in the course of the trial. Although it is 
not the special task of the medical expert to obtain confess* • 
ions, hewilT be bound in duty to put down in writing the con- 
fession immediately if it is made spontaneously, and to avoid 
suggestive questions during the examination. Otherwise he 
risks a later disavowal of the confession. 
The self-mutilators may be divided into two groups. Some 
of them commit the deed in a fit of emotion (bad news from home, 
severe enemy attacks, death of comrades). They make no prepar- 
ations for later excuses and soon confess everything. The sec- 
ond group consists mostly of veteran^soldiers who are weary of 
the war. They make cunning preparations, think out elaborate 
excuses and are usually found out only by chance. 
The number of self-mutilations has increased only moderate- 
ly since the appointment of consulting medical officers for 
forensic medicine. Their greater increase in the beginning is 
to be accounted for by the fact that the organization of the 
methods of detection was improved considerably later on. Self- 
inflicted injuries through negligence constitute a large pro- 
portion of the total number of examinations. Among these genu- 
ine cases of self-mutilation are hidden which cannot be proved 
with sufficient certainty. A discussion of this question is 
suggested; whether the possibility of legal punishment for mut- 
ilations through negligence should be obtained by a change of 
the laws. To differentiate between a deed committed deliberate- 
ly and one committed through negligence is rather difficult. 
Disciplinary punishments are not always sufficiently severe. 11# Chemo-technical examinations as a means to prove 
Stabsapotheker (Captain, Pharmacy Corps) MAYER 
A report is given on the steps of analytical examination 
in proving chmical artefacts. The analytical course was work- 
ed out in the Institute for Military Pharmacy and Practical 
Chemistry of the Army Medical Academy, Forensic-Chemical Sect 
ion* In the wound crusts of cauterized animals cauterization 
agents could be proved commonly after 1-2 weeks. In order 
to prevent contaminations of the examination material, it is 
recommended that the specimen be sent in the state in which 
it is has been excised, instead of preserving it. 
In the second part of the report the chemical methods 
for ascertaining close-range shots were critically examined. 
The ascertaining of lead by means of "Dithizon" as the only 
chemical proof of a close-range shot is considered to be in- 
sufficient and as too little characteristic. The spectral- 
analysis, by means of which all elements (substances) of a 
close-range shot can be proved objectively and accurately is 
described. As elements of a close-range shot all metals 
characteristic of a close-range shot are to be regarded. They 
are chiefly the metals of the detonator such as lead, anti- 
mony, barium, zinc, and tin. By moans of the spectral analys- 
is the powder smoke of close-range shots can be distinguished 
from the powder smoke of tracer and incendiary ammunition 
which is due to long-range shots. 
Spectral analysis is recommended as means of securing 
the most exact proof of a close-range shot. 12. Malingering. 
Oberfeldarzt (Lt. Col.r MC.) Prof. BAADER 
Malingering presupposes two things: firm will and skill 
of the malingerer and credulity and ignorance on the part of 
the physician. By the leaflets of the enemy propaganda (e.g. 
the so-called sporting-regulations for the Navy) the enemy 
tries cunningly to suggest to the soldier how he can most suc- 
cessfully simulate a disease. Just as the management of arms 
and the propaganda of modern war has been very much perfected. 
also the equipment of the malingerer has improved and, there- 
fore, the physician must know these improved rules of the game 
of malingerers, the speaker explained. The hopes raised in 
the malingerer on the part of the enemy propaganda by the sen' 
ence: ’’The symptoms you find described in this leaflet are 
selected in a way that no physician can ever find out that yen. 
are really not suffering from this complaint, or that you haV’ 
caused it by artificial means’*, are absolutely delusive. As- 
pirants of the medical corps examined the enemy advice in the4 
theses of their own accord and proved that the instructions of 
the enemy propaganda for the production of paralyses of the e: 
tremities, simulation of epilepsy, etc. were altogether too 
difficult and required too much talent for acting. In the 33 
hospitals of the area of the speaker, though special heed was 
given to the subject, not a single case of production of one 
of the diseases recommended in the leaflets has been observed. 
The few simulations of any disease the speaker had seen with: ) 
a year (self-poisoning by thallium, hemmorrhage of the intest- 
ines produced by artificial means by introducing a knitting 
needle into the rectum) were done by methods which are not 
contained in the sporting instructions. The speaker also made 
a survey of the simulations of infectious diseases of the dif- 
ferent organic systems. Most frequent are the simulated dis- 
eases of the stomach about which he was several times consult- 
ed as expert by military courts. Most of them (the simulators) 
were members of the ’’Volksliste 3"* (Volksliste 3 was a roster 
of individuals who did not desire do adopt German citizenship.) 
Discussion on the reports concerning self-mutilation rnd 
malingering. 
BUHTZ: Of the cases of self-mutilation on which an opin- 
ion was given by myself, about half proved to be suspected 
wrongly (accident caused by arms or of some other kind, caused 
by the enemy, disease). In the field most cases concern gun- 
shot wounds in all the limbs and parts of the body, chiefly 
on the left side, while in the home area cauterization and in- 
jections, e.g. of petroleum are more frequent. Intentional 
breaking up of artificial teeth and spectacles was likewise 
observed. The method of examination is described; a report is 
given on a new method worked out in collaboration with WOLKE- 
WITZ and very useful in the field for proving gunshot wounds 
by tracer ammunition (imbedding of glycerine-gelatin with form- 
ation of barium sulfate crystals. He further discusses the 
method of proving or ascertaining whether injuries were caused 
by explosive shells or hand grenades. Measures for the pre- 
vention of self-mutilations are discussed. 
The number of self-mutilations is steadily decreasing and 
is strikingly small as compared with those in the World Wdr I 
(1914/1918). This fact is due chiefly to the national polit- 
ical training of the masses. HANDKB: In Breslau many cases of petroleum injections 
were examined. Determination by an analytic method is similar 
to that given above (combination of hydrolysis, fractional 
distillation of steam, fluorescence and solubility of organic 
dyestuffs). As for the persistence or the traceability of 
petroleum and similar substances it has been ascertained by 
experiments that after four weeks proof is hardly possible. 
According to the literature on the subject, hydrocarbons do 
not penetrate the skin. This proves true for vaseline as roll 
as for petroleum# Experiments have corroborated this. 
LUXEMBURGER; The swallowing of black powder is said toot 
to bring about fever but a general feeling sick and ill. com- 
bined with paleness, perspiration and singultus. Thus the 
pretended disease is to be made more credible. 
JUNGMICHEL: The well-known "Sporting Directions" are no- 
dropped from airplanes France in the form of cigarette 
paper packings called "Gizeh". 
However, I do not consider these directions to be very 
dangerous. They are too "subtle" for the simple nan* The in- 
telligent soldier who intends to commit self-mutilation choos 
es other means, because he realizes, that the German medical 
officer knows these Sporting Directions so that he is bound t< 
be found out pretty soon. 
As for the rest, I would say that on the western front a 
centralized examination place for self-mutilations has hither- 
to been unnecessary, because such cases were and are still wr 
few and far between, owing to the special circumstances. The 
proportion of suicides among outo troops on the western front 
is smaller than that among the male population in peacetime 
in Germany. 13. Psychiatrist expert opinion on self-mutilation and on 
neglect of duty when on guard, 
Oberstabsarzt (Major* MC.) VJ. von BAEYER 
These statements about self-mutilation arc based on 32 
personal observations by the author, 16 of v’hich were cases in 
which his expert opinion had been asked while 16 concerned ex- 
aminations of culprits in a surgical ward which were picket at 
random. Some of the culprits (12) had shortly before come to 
the front from the home area or from the hospital. The major- 
ity are young, even very young, soldiers. (22 delinaucnts 
from 1? to 25 years old). Apart from an officer who had sus- 
tained a concussion of the brain? all the other culprits were 
below the rank of corporal, soldiers of the rank of corporal 
were lacking. Nine of the culprits were previously convicted 
by military or civil tribunals, most of them had been previous- 
ly convicted and were judged unfavorable by their superiors. 
Characteristically the culprits do not^offer a uniform 
picture, the majority, however, are weak, timid, unscable, un- 
steady, and irresolute men. Some of them were decidedly irrit- 
able, unstable in their moods, or desired^to be regarded as im- 
portant fellows, some impressed one as auite infantile without 
being abnormal in any other way. Imbecility of' a sTight or medi- 
um degree was often found, above all among the cases I had to 
give expert opinion on (8 of 16). An attempted suicide, and 
that a non-energetic one, occurs only once in the records of 
the antecedents. Most of the self-mutilators arc bad soldiers; 
as regards their civil and social conduct, however, they arc 
harmless, weak, slack men. 
Among the emotions, fear and anxiety about their life are 
predominant, though this was very rarely frankly confessed. 
Some of the culprits declare,, they wanted only to have a rest 
for some days. Heal states of exhaustion before the deed could 
not be proved in any case. In some cases credible statements 
were obtained on difficulties of getting into touch nth com- 
rades and disagreements with superiors and comrades, particul- 
arly, when the soldiers had come recentl}'- from the former Pol- 
ish areas of the Reich which were only recently incorporated. 
These people often had difficulties in making themselves under- 
stood and are not infrequently made game of by their comrades. 
Altogether one gets the impression that such difficulties furn- 
ish the chief motives fc> the deed. It is, no doubt, good com- 
radship which prevents the individual soldier from making such 
desparate attempts at evading his duty. An understanding psych- 
ological judgement of the motives of the deed is not always 
oasy, it is, however, essential for the juridical decision. 
Strongly marked abnormal reactions arc less important than 
might be supposed. A twilight state or other exceptional state 
of psychopathic nature was not present in any case. Four cases 
came very near to it, depression on account of homesickness, 
reactive depression for other reasons, a particularly intense 
state of anxiety when under fire, and a protected reaction 
which may be considered as abnormal conduct. 153 
Among the cases on which I had to give expert opinion 
there were 2 Psychoses? One man injured himself in the beginn- 
ing of a helplessly paranoid schiziphronosis, another one in a 
state of epileptic twilight between two fits. In the case of 
an officer who had a small splinter sticking in the‘left part 
of the fore-brain which had not been noticed before, the deed 
Fas to be considered as a reaction due to an organic injury. 
The consumption of alcohol is not decisive in any of these cas- 
es, as it is in other cases of military delinquencies. 
Exoneration took place only in the two cases of psychosis 
and in the case of which the reaction was due to some organic 
injury, also according to § 51, section 2, combined with § 42b 
in the case of an asocial, imbecile soldier unfit for military 
service. Extenuating circumstances were often stressed as to 
whether a case is ,!less severe”• The decisions, however, must 
be left to the court. 
Among cases of negligence while on guard duty, only care- 
less falling asleep while on guard duty is discussed in detail. 
Continous lack of sleep and the heavy strain of guard duty on 
the soldier in the main defensive line is to bo taken into con- 
sideration, above all the lack of recuperation caused by the 
frequent interruption of sleep and the monotony of guard duty 
at night. There are, iaoreover, great individual differences in 
the desire for sleep, according to constitution and disposition. 
Causes of an increased desire for sleep are e.g.J bodily and 
mental infantilism, inability to sleep, men suffering from vege- 
tative dystonia (SCHULTE), weakening by infection and disturb- 
ances of the circulation. Some people fall asleep abnormally 
easily in an unattractive environment, though they are not act- 
ually tired. Also with the perfectly healthy person there is a 
limit to the "ability to keep awake” which cannot be overstepped 
in spite of the best intentions and the greatest energy. If, In 
case of a soldier who sleeps on guard duty, - after considering 
all external and internal circumstances, to which also belongs 
examination by an internist - it may be assumed that the limit 
of the ability to keep awake was reached, the careless falling 
asleep is to be denied when no psychical or organic disturbances 
of the brain can be demonstrated. The ability to keep awake, 
however, under given conditions always depends on the personal 
attitude and intention. 
The question as to the sound state of mind (full account- 
ability) arises in case of sleepers on guard duty: 
1. if the resistance to natural desire for sleeping, due 
to psychotic disturbances or imbecility is suspended or reduced, 
2. if the sleep itself is not physiological but is really 
a disturbance of conciousness due to brain-disease. This is the 
x>ase above all with narcolepsy. Soldiers suffering from nar- 
colepsy do certainly often sleep on guard duty. They are, how- 
ever, seldom brought to trial, since the morbidity of their 
fits of sleep, combined with the effective loss of tonus is 
usually recognized in time, and moreover the patients often are 
decent and conscientious men and are not believed^capable of 
any negligence. They are, of course, not responsible for their 
falling asleep on guard duty. 154 
Discussion: 
CHRISTUKAT: It is not possible to give reliable figures 
as to the total extent of self-mutilation, since the criminal 
statistics of war in their present form do not give information 
on this subject* Nor is the age of the culprits to be recog- 
nized which would be important for criminal biology. 
Even the relatively low figures given by Herrn von BAEYEI; 
will show that from the point of view of criminal psychology 
various latent phenomena may be suspected in cases of self- 
mutilation. Therefore, it seems to be advisable to get the 
expert opinion of a psychiatrist, if possible for a proper 
judgement. 
KLIMKE: Emphasizes the need of getting the expert opinion 
of a psychiatrist, above all in order to eliminate cases of a 
morbid character. and toxicologic questions of general and special 
character. 
Professor TIMM 
The forensic proof of poison is based on the medical find- 
ings in the body of a living person or in a corpse, as well as 
on chemical proof of poison. 
In the course of the last decade the methods of research 
and the identification of poisons have been extraordinarily im- 
proved, owing to the development of microchemistry and micro- 
determination, so that a great and decisive importance is often 
ascribed to the results of chemical research. Compared with 
this the diagnosis and the proof of poisonings by medical find- 
ings is still difficult. The clinical-chemical laboratory 
methods are mostly adapted to the differential diagnosis of in- 
fections or organic diseases, the knowledge of the more subtle 
traces of poisons in the body is very incomplete. A connecting 
link is lacking between the medical and the chemical findings 
which would enable the physician to test completely and corrob- 
orate the results of the chemical investigations. 
For the microscopic-histological test of poisonings and, 
for the localized proof of poisons in the section by microscopic 
examination, the darkfield illumination of sections without 
microscfcpical findings and the silver sulfide method have proved 
suitable, particularly for the proof of minute traces of heavy 
metals, and also for proving the presence of the so-called trace- 
elements* Iron is often changed with poisonings. 
Moreover, these methods provide new and wide prospects on 
the course of functional histo-pathogenesis. As an example 
special findings in the island apparatus of the pancreas are 
mentioned, in which in the body zinc is regularly present, as 
an important trace element besides insulin, both of which are 
lacking in the diabetic gland. 
Discussion: 
BUHTZ: The careful and adequate preservation without fix- 
atives in glass receptacles (not metal, particularly aluminum 
vessels) is mentioned. In most cases too small quantities 
(WASSERMANN bottles) kept in unsuitable preservative'? are sent 
in. Besides the samples for a chemical toxical examination, 
parts of organs in formalin must always be sent in fixed for 
histological examination* Cases of poisoning are mostly not 
recognized by the medical practitioner• On the other hand 
poison is often wrongly suspected. 
A report is given on investigations concerning uranium 
nitrate, (radioactivity - photographic plate). 
HEUBNER: I have obtained excellent results with simult- 
aneous clearfield and darkfield illumination for the localizat- 
ion of particles of metal* 
GEMEINHARDT: Very weak methylr-violet solutions are not 
only dyed green to yellow by admixing sulfuric acid, but the 
plain-colored methyl-violet solution is removed* VI. 
PROCEEDINGS OF THE CONSULTANTS f 
COMMITTEE 0 N 
0 T 0 R H I NOLARYNGOLOGY 
Translation prepared by: 
U. S. Naval Technical Unit, Europe, (Medical vSection) 
Office of the Naval Advisor 
Office of the Military Government (U. S.) Early and late surgical and orthopedic treatment of 
injuries to the .jaw and face. 
Tsee Section XV. Articles1 - 5) 
Hemorrhages endangering life as a sequel to injuries 
to the .jaw and face. 
(See Section XV. Articled - 7) 
Medical examination for fitness for assignment as 
listening sentry. 
TSee Section XIV. Article 5) 
Ear protective device. 
(See Section XIV. Article 8) 
1. Determination of fitness for military service of 
registrants afflicted with diseases and de- 
ficiencies of the ear. 
Stabsarzt (Captain, MC.) Prof. MITTERMAIER 
In case of chronic otitis media it is considered im- 
portant to distinguish between the two clinical forms of 
meso-tvmpanic inflammation of the mucous membrane and 
epitvmpanic bone-destroying otitis media. 
Although the chronic otitis media *ith central per- 
foration of the tympanum mv>st in many instances be con- 
sidered as a disease "with tendency to relapses", it may 
be said, however, that the mild form is harmless. Otitis 
media in the majority of cases will be classed as a class 
B disease (fit for active service). A class L deficiency 
(fit for limited duty) will be assumed only if the suppur- 
ation of the mucous membrane cannot be brought under con- 
trol and causes considerable pain. 
Chronic otitis media with peripheral perforation of 
the tympanum: Only cases involving the formation of polyps, 
extensive cholesteatoma etc. will be classed as an L defic- 
iency. These require special and continual observation, 
especially because of the usual seauelae (labyrinthitis, 
meningitis, sinus thrombosis etc.). The epitympanic dis- 
eases which take a more or less regular course, without 
particular symptoms and which as a rule will only require 
occasional medical attendance every few months, will be 
classed as a B deficiency. 
Radical operations should be carried out only if none 
of the specified complications are involved, and if an es- 
sential improvement, that is to say the changing from an L 
deficiency to a B deficiency is likely to result. The dry 
cavity of a radical mastoidectomy is considered^as a B de- 
ficiency. Only in cases of continuous suppuration or ab- 
normal sensitivity to weather conditions will a classific- 
ation as an L deficiency be considered. In more severe 
cases with excessive irritability of the labyrinth, fitness 
for labor duties will be assumed. Fitness for active service in a field unit depends on 
whether or not it is possible to avoid exposure to rough 
weather conditions# 
A discrimination between the two forms of chronic 
otitis media is important in order to secure an appropriate 
treatment. Light and medium cases of inflammation of the 
mucous membrane with tendency to relapses can and should be 
treated by the army surgeon. It may justly be said that 
the efficiency in the service of these man depends largely 
on the experience and skill of the army surgeon. 
Chronic otitis media with bone involvement must be 
given particular and continual treatment by a specialist, 
who has to give the necessary instructions as to date and 
kind of further treatment. 
A brief entry in the paybook. pages 12/13, will be 
made when the outpatient or hospital treatment is over. 
The entry must be signed by the attending specialist, 
setting forth the specific form of chronic otitis media, 
such as otitis media chronica combined with inflammation 
of the mucous membrane, or otitis media chronica with bone 
caries, or otitis media chronica with cholesteatoma. 
Practical experience shows that impaired hearing is 
often undervalued in the general medical examination. 
The inability to hear whispered speech at a distance of 
1 to 2 meters must, however, be considered, as a serious 
handicap in the performance of military duties, consider- 
ing the requirements of modern warfare. The army surgeon 
should be notified in the medical report of the existing 
deficiencies, so that provision can be made for the ex- 
emption from patrol duties, sentry duty at night, assign- 
ment to sound detection units etc. The proper evaluation 
of these deficiencies often leads to a classification in 
the L category. 
The fitness for active service depends also in these 
cases on a suitably selected assignment. 
In case of a malignant aggravation or steady psycho- 
genic defect of hearing it will not be considered suffic- 
ient if the examining surgeon personally has come to this 
conviction. Energetic treatment, best with the assistance 
of a neurologist (faradization) is necessary, until an im- 
provement is admitted. In case of relapse the threat of 
disciplinary action or punishment for malingering should 
be considered. 
Injuries to the ear due to detonations: Light cases 
will improve after a few hours, moderate cases after 2-3 
days. Occasionally the improvement takes up to 10 - 14 
days. 
Defects of hearing due to injuries to the middle ear 
(rupture of the drum membrane, hemorrhages etc.) often de- 
crease considerably in the course of time. The assumption 
is justified that lighter injuries to the inner ear may 
similarly recover fairly often. A prognosis is to be made 
only with the greatest caution. In more severe cases a 
limitation of hearing persists. 159 
Injuries to the ear drum: Even if not followed by a 
suppuration of the ear the afflicted soldier should be 
given a fortnights leave from duty and have the ear treated 
regularly during that time. Many such perforations are 
likely to recover. 
Besides impaired hearing, the attendant phenomena of 
injuries to the inner ear are to be taken into corisiderat- 
ion, such as defective hearing, disturbing buzzing noises 
in the ears, in the beginning hypersensitivity to cold, to 
noise etc. 
About two T-eeks after an organic injury to the inner 
ear has occurred it seems that no further change for the 
better may be expected. The medical opinion of the case 
is to be stated in detail, because it is to be expected 
that after some years a claim will be put in to the effect 
that these injuries by detonation are responsible for a 
physiological impairment of hearing which actually is due 
to old age. 
An ear, once injured, is more susceptible to further 
injuries of the same kind that a sound ear. 
As to disturbances of the equilibrium apparatus as a 
consequence of residual states after diseases of the vesti- 
bule, no important experiences could be made under field 
conditions. (A corresponding change of the list of defic- 
iencies is provided in the new edition (note of the editor). 
This refers to the booklet distributed to physicians for a 
standard system of evaluation of disabilities. A copy has 
been translated by this section.) 
Discussion: 
FTNDLER: Bilateral chronic accumulation of relapsing 
infection of the middle ear should be classified as U 32 
(fit for labor). 
In cases of rupture of the drum membrane caused by 
detonation, suppuration occurs mostly within the next fort- 
night, if it occurs at all. Therefore, these patients 
should stay for about a fortnight at the collecting station 
for casualties of the forces in the field under observation 
of an aurist, or for treatment in the special ward. If 
suppuration of the middle ear sets in they should be sent 
to the hospital, as should those showing simultaneous de- 
ficiencies of hearing. 
THIELEMANN: 
1. According to the experiences in the home army it 
is of no use to determine the degrees of fitness only by 
the values found for their ability to hear whispered speech. 
Experience has shown that a great many of the registrants 
pretend not to hear whispered speech etc. The classificat- 
ion by the aurist should therefore be as follows: slightly 
defective hearing, defective hearing, medium or hla-h degree, 
without an exact statement as to the result obtained with 
regard to the ability to hear whispered speech. 2. Entry of the results of hearing obtained by the 
experienced aurist into the pay-book are to be recommended, 
since the results of the hearing-test obtained by the field 
surgeon examinations vary widely. Similar entries should be 
made concerning the character of any existing infection of 
the middle ear. 
3. There are difficulties as to the classification 
of vestibular disturbances, slight vestibular disturbances, 
such as after injuries to the base of skull, must be con- 
sidered according to the classification table as diseases 
of the inner ear and will be classified as such under U 32 
(fit for labor). In case of disturbances of the equilibrium 
apparatus this classification is not available. The classi- 
fication under L 19 does not always fit the case. 
2. Determination of fitness for military service of 
registrants afflicted with diseases of the 
throat and nose. 
Oberstabsarzt (Major, MC.) Prof. KINDLEH 
The classifications given in army manual 252/4 have 
proved highly satisfactory for the field of nose and throat 
diseases after about five years of war experience. By the 
orders concerning the degrees of fitness, issued in Decem- 
ber 1943, they have undergone an effective simplification. 
The stable frame of the army manual 252/4 has proved necess- 
ary above all for the purposes of the army in training. A 
certain flexibility in the judgement has been found desirable 
for the field array. It is important, particularly in case 
of chronic illnesses, to take into consideration besides the 
symptoms and the objective finding of the disease also the 
previous employment and the present task of the patient. The 
general and medical-tactical situation too (static warfare, 
advance or moving defensive front with heavy fighting, poss- 
ibility of transportation to a special hospital, length of 
absence from the unit during the stay in the hospital, and 
other things) are to be taken into consideration. It 'is ad- 
visable to keep the man with his unit by using palliative 
measures. Moreover it is proposed: 
1. to treat chronic accessory nasal sinuses conservat- 
ively if possible and to classify them as L 34 (conditional- 
ly fit for active service). 
1 
2. To classify ozenas, apart from very severe cases, 
under L 34. 
3. To introduce L 35,1 (conditionally fit for active 
service) for chronic tonsillitis, in order to further an 
early enucleation of the tonsils. 
4. To classify partial traumatic paralysis of the voc- 
al cords as L 18 or L 42 (conditionally fit for active serv- 
ice) provided that neither dyspnoea nor aphonia is present* 
In the case of aphonia, U 42 is suitable. If a plastic oper- 
ation of the vocal cords gives some hope for improvement of 
the voice, U 42 would be the proper classification, at least 
for a certain time. 5, To hospitalize cases of a severe, non-specific, 
chronic laryngitis, combined with hoarseness, as U 42, in 
order to obtain a speedy improvement of the degree of fit- 
ness for active service. 
% 
Discussion: 
Ozena, sure to become a nuisance to those 
closely associated, (confirmation by the snecialist is re- 
quired I) should be classified as unfit for service. 
3. Judgement of general fitness and fitness for active 
service in the German Air Force in case of dis- 
eases of the ears, the throat and the nose. 
Oberfeldarzt (Lt. Col,. MC.) Prof. HUENERMANN 
The soldiers of the German Air Force are divided in 
two large groups namely aviators and parachute troops on 
the one hand, and ground crews on the other hand. Speci- 
al standards of fitness with regard to throat, nose, and 
ears are required only for members of the interception 
services, the selection of which was discussed in connect- 
ion with the army physiology group. Otherwise the stand- 
ards of fitness for the army apply also to the ground 
units of the Air Force. 
The standards set for parachute troops are the same 
as those which qualify for unlimited service in the in- 
fantry, that is to say fitness for active service accord- 
ing to army manual 252/4 of the 1 April 1944. Moreover 
it has been ordered that hyperexitability of the equilib- 
rium apparatus and stuttering as well as a removable dent- 
al prothesis or inability to chew common food without a 
set of artificial teeth must disqualify the soldier for 
parachute troops. 
In the examination by the physician for prospective 
members of the Air Force the following facts must be con- 
sidered: Nasal respiration must not be hindered serious- 
ly, chronic diseases of the nose, of the accessory nasal 
cavities, of the pharynx, and of the cavity of the mouth 
makes a man unfit for service in the Air Force, they 
cause disturbances which render flying activity more diffi- 
cult. Such disturbances are really very important, because 
they easily escape medical observation during the assign- 
ment period and, may interfere with flying operations, when 
there is too little recognition that not only the disturb- 
ances of the pressure equalization of the eustachian tube 
cause considerable pain, but that pain may also arise in 
no lesser degree from the accessory nasal cavities. These 
patients complain Incessantly of headaches particularly bear- 
ing a high altitude flight. During the examination patho- 
logical symptoms are seldom detected unless a special X-Ray 
photogram is made of the accessory nasal sinusis, which 
often show a partial (one-sided) haziness in the photograph 
of the frontal cavities. In this connection reference is 
made to the observations of HERRMANN at Greifswald who has 
described hemorrhages into the frontal sinus cavity during 
dives in planes. In the classification chart this condit- 
ion should be listed under Nr. 34 as L 34, particularly with 
regard to a chronic involvement of the accessory cavities. As to the examination of the ears, the instructions 
for the medical examination for fitness as fighter pilot, 
aerial gunner, and as paratrooper or parachute gunner are 
as followss 
The eustachian tube must not be obstructed, whispered 
speech must be heard at least at a distance of 2 meters. 
Considerable hypersensitivity of the vestibular apparatus 
renders the individual unfit. Contrary to the requirements 
of peace-time, these very strict conditions have stood the 
test in practice so that a modification is not taken into 
consideration from the point of view of the aurist. In my 
opinion great importance must be attached to the fact that 
the accessory nasal cavities which include also the middle 
ear, have a free communication with the nose or the naso- 
pharyngeal cavity, for otherwise considerable pains causing 
discomfort to the flying crew will occur during high alti- 
tude flights and dives and this hampers the execution of 
aerial operations. In addition this pain may also endanger 
the security of the pilot and thus the lifes of the passen- 
gers as well. A diagnosis is difficult, disturbances of 
ventilation are always to be taken into consideration, when 
the patient complains of local headaches and when either a 
distortion of the nasal septum or other evidence of a dis- 
turbance of ventilation are seen. 
4, Judgement for general fitness and fitness for active 
service as regards diseases of the ears* the 
throat, and the nose# 
Special requirements of the Navy• 
Marineoberstabsarzt (Lt. Comdr.. MC») NOACK 
On the part of specialists for diseases of the threat, 
the nose, and the ears, with regard to the^19 special careers 
of the Navy (Friegsmarine) and. to the special standard of 
fitness for the submarine service, the earlier standards of 
fitness must be retained which at the same time give an ex- 
act idea of the fitness of the soldiers for military service. 
Fitness for service on submarines depends on the directions 
published in 1943. For all careers requiring service on board 
cr plane sound ears without any perforations of the tympanic 
membrane are required. Ability to hear whispered speech at a 
distance of 4 meters or 1 meter in one and 6 meters in the 
other ear. Navy radiomen, sound operators and sailors who 
operate the radio direction finder must have unimpaired hear- 
ing (on both sides ability to hear whispered speech at dis- 
tance of 6 meters). Soldiers with mild, mucous mesotympanal 
suppurations are fit for general service in the field. All- 
fetid suppurations of the bone are conditionally fit for milit- 
ary service. Classification in A 33 and B 33 are proposed, in 
which class A diseases mean only mild diseases of the nasal 
cavity without serious disturbance of the respiration, B - dis- 
eases, however, mean more marked narrowness of the nasal cav- 
ities and the nasopharyngeal area which can, however, 
be corrected by surgical operations. The ability to smell is 
to be judged by the rhincloglst not as A 18 but as A 33* Chronic inflammation of the nose and the accessory sinuses 
make a registrant unfit for service at sea and on submarines; 
they are, however, still fit for service in the field and 
should be classified as conditionally fit for active service. 
Ozena is still retained as a class IT disease because of liv- 
ing conditions aboard ship. Chronic tonsillitis must be 
cured by tonsillectomy before embarkation. B 42, ’’inveterate 
hoarseness”, makes a man unfit for service on the telephone 
or microphone (BU), because of the difficulty of making him- 
self understood and inaccurate transmission of orders. 
Discussion: 
UFFENORDE: In the Navy, which requires every man to be 
examined as to fitness for the submarine service, we take it 
for granted that about 10 per cent of the men are unfit for 
service from the viewpoint of the aurist. Of these only 5 
per cent can be cured and made fit for active service by spec 
ial operations: adenoidectomy, resections of the septum, ton 
sillectomy etc. Because of this additional tasks have come 
to our special departments, we have to guarantee a free ven- 
tilation of the eustachian tubes on both sides, for in the 
submarine service not only high pressure but also partial va- 
cuum affect the ears in a higher degree than during tf'orld war 
I, and we have now to deal with irreversible disturbances of 
hearing. Thus I found in the case of an artificer warrant 
officer a one-sided hearing loss of a high degree which had 
developed in five months and which arose during an excessive 
partial vacuum. By a faulty execution of orders the Diesel 
air intake valve had been closed and the motor very quickly 
exhausted the engine-room, the patient felt a marked diffi- 
culty of hearing on both sides and for some days disturbances 
of the equilibrium when getting up in the morning. The hear- 
ing capacity was restored in one ear in a few days. In the 
other ear complete recovery seems very doubtful. This case 
is precisely analogous to the observation of a case of marked 
one-sided deafness lasting for 2i years after the emptying of 
an underpressure chamber. In my case I must assume the ef- 
fect of underpressure, while in the case described by SCHRA- 
DER the deafness was caused by a relative increase of press- 
ure. 
5. Experiences with the ear - battalion of Military 
District VIII. 
Oberstabsarzt (Major. MC.) Prof. PERWITZSCHKY 
Many of the patients suffering from ear diseases go 
from one physician and one hospital to the other and be- 
come therefore a burden not only to the regimental surgeons, 
to the evacuation units, and to the hospitals, but also to 
the unit to which they are assigned. 
According to my proposal the diagnosis of earache and 
its treatment have for some time been entered into the pay- 
book of every soldier, e.g. chronic suppuration of the mucous 
membrane, hospital treatment not required, even with consid- 
erable secretion etc# 164 
This instruction was not of much use because men suf- 
fering from chronic suppuration of the middle ear are over- 
evaluated by the army surgeons because of their exaggerated 
description of their complaints; yet these patients could 
do the heaviest work without difficulty in their civil pro- 
fession, even under unfavorable climatic and professional 
conditions without ever having consulted a physician. 
Starting from these baaes the surgeon of the Military 
District VIII proposed to create a battalion for patients 
suffering from ear diseases. The purpose of the creation 
of this unit is: 
1. To rid units, physicians, evacuation units, and 
hospitals of the above mentioned patients and to place them 
in charge of one physician who is an army surgeon and who is 
thus enabled to observe the soldiers not only in the hospital 
and in the sick bay, but also while on duty. 
2. To reduce the number of men reporting sick, which 
will naturally happen when they know that they are going 
to be attached to a special unit. 
3. To raise the efficiency up to a certain standard 
and possibility of a suitable employment of every single 
soldier according to the kind and severity of his illness. 
4. To place these men under the systematic command of 
energetic officers which is necessary with the patients who 
complain again and again of all sorts of imaginable aches 
and pains. 
5. To provide thorough military training which could 
not be carried out before with a great number of these men. 
6. To improve the possibility of an employment of the 
unit in its entirety, in order to free other units in the 
army administration district behind the lines or at homo. 
7. To send patients suffering from ear diseases, who 
are unfit for military s.ervice, back to the civil section 
where they may be of better use. 
The Commanding General of Military District VIII agreed 
to the proposal of the district surgeon and ordered the ex- 
perimental formation of a battalion for patients suffering 
from ear diseases. 
It is now nine months since that unit was formed, so 
one may be permitted to form an opinion about this project. 
Those assigned to this battalion were patients with ear 
diseases, continuously or constantly relapsing diseases of 
the ears with the following findings; 
1. One-sided central perforation of any size, while 
the other ear is anatomically and functionally sound; 
2. Central perforation on both sides with sufficient 
ability to hear; 165 
3* One-sided total loss of hearing, while the other 
ear is in good condition; 
4. One-sided defect at the posterior edge with slight 
secretion while the other ear is in good condition; 
5. Large one-sided distinct defects of the recessus 
epitympanicus, while the other ear is in good condition; 
6. Radical operation on the ear on one side which 
suppurates frequently with good hearing of the other ear; 
7. Continuously draining ear, following a radical oper- 
ation on one side (tube angle) which requires constant super- 
vision; 
8. All ear diseases that have become dry and that are 
now judged according to B 32, but that are sure to begin to 
discharge again as soon as the patient is on active duty. 
Not fit are: 
1. Soldiers who have additional group L diseases; 
2. Suppurations of all categories with insufficient 
hearing (under B 31); 
3. Indistinct suppurations of the recessus epitympanicus 
with small fistula and cholesteatoma; 
4. Suppurations of all categories with demonstrable 
involvement of the labyrinth; 
5. Operative gunshot wounds in the ear with complaints 
of postcommotional pains. 
The soldiers brought together in the "ear battalion” 
were then divided into four groups: 
Group 1: comprises those whose otorrhea is quiescent 
and who have useful hearing capacity. Monthly control ex- 
aminations are sufficient. This group numbered 209 soldiers 
when it was formed. They were employed for guerilla warfare 
or similar duties. 
Group 2: Corresponds generally to the findings or group 
1, but requires treatments once or twice a week. Strength 
218 men. These patients are fit for dutv in the line of 
communications area (patrol duty, escort}, since the hearing 
capacity has already decreased with most of them. 
Group 3; To this group belong those with considerable 
loss of hearing and in addition an ear disease which re- 
quires treatment two or three times a week. Strength 195 
men. They are employed as a construction group. 
Group 4: This group consisted of those, who were dis- 
charged after a short period of observation, which probably 
would not have happened if they had remained in their former 
units. Strength 33. All companies consisting of patients suffering from ear 
diseases have their depot battalion at home to which they can 
be sent back in a case of more severe illness, and from which 
the units consisting of patients suffering from ear diseases 
are renlenised. 
All the men belonging to an "Ear Battalion" are returned 
to the battalion during their retention in the army in order 
to avoid their former depot battalion, so that after being 
wounded, the round of all the different hospitals could begin 
again. 
It is clear that with the formation of this battalion 
initial difficulties had to be overcome. 
At first it was not easy to prepare the members of the 
Armed Forces which came from various formations and arms of 
the service for their various assigned duties but commanders 
who were selected for this purpose were successful in over- 
coming this difficulty. Of course the regimental surgeon 
must be a specialist who has not only a good military presence 
but who is an expert in the special field of ear diseases, for 
only a well trained and responsible medical officer who knows 
also how to judge the complaints of the soldiers is of use. 
The successful existence of the battalion depends entirely on 
the quality of the specialist. 
It is very interesting to learn how ear diseases react 
even under the greatest hardships and under narticularly un- 
favorable conditions. In a test of endurance from 27 - 29 
January 1944, which was undertaken in unfavorable weather, 
the following picture was shown with a participation of 35 
N.C.O.’s and 442 soldiers; 
18 men fell ill with angina, 
5 men fell ill with pharyngitis and laryngitis, 
3 men fell ill with bronchitis, 
3 men fell ill with grippe-like infection, 
1 man fell ill with lumbago, 
3 men fell ill with neuralgia, 
2 men fell ill with muscular rheumatism, 
1 man suffered a contusion, 
4 men were after a wounding, hindered in walking, 
21 men fell ill with diseases of the feet, 
1 man had to be sent to a hospital on account of an 
acute cardiac weakness, 
4 men fell ill with an acute relapse (without suppurat- 
ion of the middle ear (otitis media)), 
5 men complained of dizziness without severe disease, 
2 men suffered tearing of ligaments. 
With this I come to the conclusion of my report: 
According to the reports of the commanding officer and the 
medical officer of the unit the formation of this battalion 
for patients suffering from ear diseases, first proposed for 
Military District VIII and carried out practically by General- 
arzt (General, MC.) Dr. WALTER has thoroughly proved very 
satisfactory. 167 
Discussion; 
VON EICKEN; As aurists for the battalions for patients 
with ear diseases younger specialists are being considered 
suitable, who as yet have limited experience in the oto-surgic- 
al area but who have proved to be skilful and energetic in the 
military service. Many of these have not been considered hi- 
therto as specialists. 
MITTERMAIER: With men who already belong to a field unit, 
the regimental surgeon should decide after consultation with 
the specialist, as to whether the patient suffering from ear 
disease can remain in his formation or must be sent to the 
battalion for patients suffering from ear diseases. 
Directions concerning the judgement of the general 
fitness and fitness for military service with 
diseases of the ears, the throat, and the nose; 
experiences of the battalion for patients with 
ear diseases in the Military District VIII. 
The determination of fitness hitherto stated in the table 
of diseases of the otorhynolaryngology have been proved satis- 
factory after a war experience for approximately five years. 
It has been shown, however, that the chronic diseases, partic- 
ularly those of the accessory sinuses and of the ears, must 
not be judged so strictly as is admissible during peacetime. 
Thus the majority of the chronic diseases of the middle ear can 
be diagnosed as class B diseases. Impairment of hearing of a 
high degree, however, renders every case conditionally fit for 
military service as class L diseases. Since a certain proport- 
ion of the patients with ear diseases remains with the unit in 
the main fighting zone, these must be treated by the regiment- 
al surgeon. An instructional pamphlet dealing with the treat- 
ment of chronic diseases of the middle ear to be carried out 
him must be prepared. Following the excellent experiences 
which have been made with the formation of a special unit of 
patients suffering from ear diseases in Military District VIII, 
these formations will be introduced in other military districts 
too. For certain special careers in the German Navy or Air 
Force special requirements are necessary. 
6. Concerning different grades of disablement and the 
awarding of the Found medal to men pounded in 
the field of otorhynolarvngology. 
SS-Obersturmbannfuehrer (Lt. Col., MC. of_ SS- 
froops - Elite Guard) Prof. RAPTH 
Directions: 
Details concerning the different grades of disability- 
are not recorded here again. Instructions on this 
subject are being prepared. (Editor’s note). 
If influence by enemy action is to be assumed in a case of 
difficulty of hearing approximating deafness the wound medal in 
silver may be given. Consequently if influence by enemy action 
is to be assumed in a case if impairment of hearing of a lesser 
degree the wound medal in black seems appropriate. 168 
In case of an injury to the vestibular apparatus, sup- 
posed to be due to enemy action, the wound medal in silver 
may be considered. 
In case of wounds caused by a gunshot into the larynx, 
combined with a distinct disturbance of function (respiration, 
voice) the wound medal in silver is suitable, the wound medal 
in gold may be awarded when such an injury amounts to a com- 
plete loss of the larynx. 
With all awards of wound medals in silver and gold the 
injury must present some permanent damage. 
7. the treatment of frontal-basal gunshot wounds of the 
brain and their sequelae. 
Oberstarzt (Colonel, MC.) Prof. TOENNIS 
I* Frequency and classification. 
Among 4141 gunshot wounds of the cranium 80 per cent of 
the wounds were of the vault of the cranium and 20 per cent 
of the base of the skull. The latter are divided into 
fronto-basal (64.55 per cent) 
temporo-basal (27*37 per cent) 
occipito-basal ( 8.08 per cent). 
According to the kind of injuries of the brain we dis- 
tinguish between locally limited gunshot wounds or depressed 
skull fractures caused by gunshots (75.6? per cent), and those 
caused by the bullet penetrating deeply and destroying the 
brain, those due to either lodging in the wound area (22.54 
per cent), or passing through it (1.79 per cent). 
II. Causes of death. 
1. "Seriousness of the injuries”* Among the causes of 
death among wounded men with fronto-basal depressed skull 
fractures due to gunshots the serious injuries amount to a 
third, with the gunshots where the bullet lodges in the wound 
area to a half, and with the gunshots where the bullet passes 
through the wound area to four fifths. 
As was shown by clinical observation, this is a case of 
Insufficiency of the central vegetative regulation, that is 
to say, the consequence of a traumatic injury to the brain- 
stem. This observation is corroborated by the fact that 76.5 
Per cent of the fatal cases were unconscious for days after 
depressed gunshot fractures and 100 per cent of the fatal 
cares after gunshot wounds with the bullet lodged in the 
wound area. 
2* Infection: Among infections, complications of the 
inner cavity of the skull with the frontal basal injuries, 
direct infect?on of the subdural and subarachnoid spaces as 
well as infection of the basal cisterna are most frequent. 
The indirect meningitis we find during the first week only 
with a primary opening of the ventricle, during the later 
weeks as a result of an abscess breaking through into the ventricle area. The progressive encephalitis of the medulla 
v'hich predominates among depressed gunshot fractures in the 
cranium, is comparatively rare in this case; nor are such 
complications hemorrhages and edema, causing an increase of 
cerebral pressure, frequent with fronto-basal gunshot injur- 
ies during the first week. 
Ilia Treatment of the wound* 
The aim of surgical treatment is to prevent infection of 
the cerebral wound, of the subdural space, and of the fluid 
spaces. The primary infection of a cerebral wound is over- 
come by an radical removal of all fragments of brain, blood, 
and foreign substances, secondary infection by a water-tight 
closing of the opening of the dura by use of orbital tissue 
or of a periosteal flap. 
In order to avoid subdural empyema, the subdural hemorr- 
hages are regularly removed during the treatment. In prevent- 
ing meningeal infection, the removal of the fluid in good 
time has proved very successful in addition to the sulfonamide 
treatment. Among the primary operations of the ventricle the 
rate of fatal cases of meningitis was reduced to 10 per cent. 
Fatal cases with depressed fronto-basal gunshot fractures 
(32.14 per cent) were reduced to a third (10 per cent). 
IV. Final results. 
Of all the cases of fronto-basal gunshot wounds (226) 
observed from the first treatment until their discharge from 
the home hospital, 25.66 per cent died. Of those who sur- 
vived (74.34 per cent), 17.7 Per cent were discharged as un- 
fit for military service. 56.64 per cent returned to the 
Armed Forces, 10.8 per cent fit for military service, 25.22 
per cent fit for garrison duty at home, 21.24 per cent fit 
for labor only. 
Out of 40 cases of fronto-basal depressed skull fract- 
ures due to gunshots only 24 cases (about 10 per cent) had 
to be discharged from the Armed Forces because of a traumatic 
injury to the brain. In only eight cases of bilateral in- 
juries of the frontal brain did the sequelae lead to a dis- 
charge from the Armed Forces. 
8, Fronto-basal gunshot rounds of the brain accompanied 
by injuries to the accessory sinuses and their 
later development. 
Oberstarzt (Colonel. MC.) Prof. PEIPER 
The speaker specifies three groups of fronto-basal gun- 
shot wounds of the brain with injuries to the accessory sin- 
uses, in which the operative method is fundamentally differ- 
ent; 
1. the group of recently wounded cases, 
2. the group of recently infected cases, 3. the group of older cases in which in consequence of 
and insufficient operation, secondary-operations in the area 
of the accessory sinuses and the brain were required, and in 
wh? ch the area of the accessory sinuses is in most cases in- 
fected while the scar of the brain is not infected. 
First he discussed several surgical methods used with 
group 1, with which, if it is not a question of small operat- 
ive openings of the accessory sinuses which can be closed im- 
mediately without any major operation according to the situat- 
ion of the injury, the frontal wall must always be removed 
entirely, including the arcus, while of the rear wall only so 
much is removed that the cerebral wound is easily accessible. 
The speaker asked for a wide extranasal access to the nose in 
any case, even if the ethmoidal cells were not primarily in- 
jured, since otherwise infections occur regularly and the 
frontal sinus does not heal up. In the case of recent in- 
therefore, the anterior and posterior ethmoidal cells 
mtist be removed according to operation. After the 
treatment of the cerebral wounds the dura must be closed, 
preferably by plastic operation with pieces taken from the 
galea or with pieces of amnionic membrane. For these purpos- 
es the excellent effect of a pendunculated piece of mucous 
membrane of the nose, is especially mentioned, which presents 
the natural protection at the base. The 48-hours limit should 
not be exceeded in case of recent injuries. Insufficient or 
total lack of communication with the nose nearly always caus- 
es infections. Infected gunshot wounds must be operated as 
early and as radically as possible. The surgical rules are 
almost the same, a cerebral wound, however, is drained around 
a genuine sponge. This sponge is accessible from the area of 
the bridge of the nose. In cases of infected gunshot wounds 
of the ethmoid bone which require access from the frontal 
sinus to the nose the frontal wall of the frontal sinus had 
best not be left, since gunshot infections heal up badly or 
not at all. In old cases an operation on the old scar should 
be avoided if possible, since otherwise the infected area of 
the accessory sinuses and the scar of the dura are opened 
with the first incision. Before a large pyramid 
of splinters in the brain the source of infection in the ac- 
cessory sinuses must be removed. If the arachnoidal 
bursts open in the infected area of the frontal sinus during 
the operation, a plastic operation is to be preferred to open 
treatment. The ideal is an early operation which presupposes 
the operating surgeonfs thorough familiarity with otologic 
methods. SLt Initial treatment of fronto-basal gunshot Founds of 
the bfraln accompanied by Injuries of the ac- 
cessory sinuses and their later development, 
Oberstabsarzt (Major. MC.) Prof. SEIFERTH 
This report is to be published in "Archiv fuer Hals-. 
Nasen-, Ohrenheilkunde” (Archives for Otorhinolaryngology)• 
The chief task of the initial treatment of gunshot wounds 
in the brain is to prevent infections. The prevention of in- 
fections is still more important in cases of basal gunshot 
wounds in the brain in the area of the cranium* In cases of 
basal gunshot wounds accompanied by injuries to the accessory 
sinuses, secondary infection of the brain and its membranes 
threatens from the wound in the soft parts and in the brain 
and from the nose by Way of the opened up accessory sinuses. 
Besides^this an injury to the accessory sinuses may cause in- 
tracranial complications independent of the brain wound. 
Of all accessory sinuses the maxillary sinuses are af- 
fected the least often in case of basal gunshot wounds. In 
case of gunshot wounds in the maxillary sinuses, comminuted 
fractures and injuries to the brain may occur at the base of 
the skull by the effects of explosion* 
On account of the danger of an infection penetrating in- 
to the inner cavity of the cranium, basal gunshot wounds with 
injuries to the accessory sinuses must be treated surgically 
as soon as possible and at any moment the rounds have been 
inflicted even if injury to the dura and the brain has not 
occurred, or is not to be assumed. The only contrary indic- 
ation for an operation are states like shock and collapse 
with a threatening failure of the circulation. 
The direction of incision by which the cerebral wound 
and the injury of the accessory sinus can be opened at the 
same time, is demonstrated by means of illustrations. In 
operation of the accessory sinuses, the usual methods must 
always be applied because they afford the best access to and 
the best survey of the exposed accessory sinuses, and fre- 
quently give the great advantage that the gunshot wound can 
be avoided and the operation need not take place in the in- 
fected area. 
The exposure and-treatment of an additional injury of 
the orbit is of the highest importance. 
In an opening up of the ventricle the closing of the 
dura must take place as a matter of routine after the second 
day, if no meningitis appears* Besides, in other cases the 
closure can be made even as late as the seventh day. In- 
dications for this kind of early treatment are given. 
An operation wound above the eye-brow is closed within 
the first two days, after the closing of the dura. Access 
to the nose is absolutely reauired in all cases with a prim- 
ary suture of the soft parts. In cases to be re-treated 
surgically the nose is not exposed. In the case of gunshot wounds with the bullet lodging in 
the brain the prospects are considerably worse than with un- 
complicated gunshot wounds of the accessory sinuses, because 
of the larger surface of the wound and the more extensive 
contusion of the brain. A case is mentioned where the splint- 
er, the size of a rice-grain, sticking in the cerebrum was 
followed by a meningitis that was healed up by conservative 
means. 
In the case of gunshot wounds with the projectile lodged 
in the brain, the place where the bullet entered is always 
to be treated first, since in many cases the projectile can 
be approached from the hole at the point of entrance. For 
the treatment of gunshot wounds with the missile lodged in 
the brain an enormous magnet is indispensible. Splinters re- 
maining in the area of the hypophysis which have entered from 
the accessory sinuses or any other part of the facial portion 
of the skull, must be removed by way of the accessory sinuses. 
When, after gunshots with the bullet passing through the 
brain, the missile lodges in the accessory sinuses, the treat- 
ment of gunshot wounds with the projectile remaining in the 
affected part must not be delayed,because intracranial com- 
plications would develop sooner or later transmitted from the 
accessory sinuses and from the untreated wound of the dura 
and the brain. 
When a subdural hematoma is suspected (tautly stretched, 
dark-blue colored dura and symptoms of cerebral pressure) 
puncture is to be undertaken. The exposure of the uninjured 
dura is not advisable. 
Among the complications in gunshot wounds at the base of 
the skull, meningitis is most frequently observed. Patho- 
genetically five forms may be distinguished, which, as regards 
prognosis, are to be judged differently: the infection of 
the meninges from the accessory sinuses with intact dura 
(spreading meningitis), meningitis due to infection of the 
external fluid spaces from the dura-cerebral wound (direct 
meningitis), meningitis as a result of an<infection of the 
ventricle opened by the gunshot, meningitis due to 
breaking through into the ventricle and by late breaking 
through into the ventricle by progressive encephalitis. The 
decision, as to whether it is a case of aseptic or bacterial 
meningitis, is of fundamental importance. With patients suf- 
fering from gunshot injuries with incompletely operated ac- 
cessory sinuses, cases of long lasting meningitis were ob- 
served which showed a severe clinical picture with a pro- 
nounced psychotic componet. 
In meningitis the chief feature of the treatment is^the 
surgical elimination of the primary focus. All meningitides 
were re-treated surgically according to otorhinologic princip- 
les. The additional therapeutic effect of sulfonamide pre- 
parations has been shown clearly in the case of uneumococcic 
meningitis. In the development of an early abscess liquefaction of 
the cerebral tissue plays an important part. The tendency to 
encapsulation is the greater the later an early abscess de- 
velops. vrhen treating this early abscess it is essential to 
limit and to encapsule that zone of tissue which is liable to 
liquefaction and to suppuration. This is achieved by the use 
of a genuine sponge according to the method of PEIPER. 
Special attention is to be paid to the indirect basal in- 
juries of the orbit and the ethmoid bone, which occur with 
communicating fractures in cases of serious gunshot wounds in 
the cranium and. in the base and which frequently result in 
dangerous intracranial complications. The results of the 
treatment of cerebral wounds can still be improved, if these 
injuries are detected and submitted to treatment earlier than 
hitherto while the man is still in good condition. 
Out of 137 soldiers wounded by gunshots 31 (22.6 per cent) 
died; 24 cases were closed injuries, without any opening of the 
dura, 4 (16.6 per cent) of these died; 113 cases were open 
cerebral injuries of which 27 (23*8 per cent) died. 
10. Infected fronto-basal gunshot wounds In the brain 
affecting the nasal accessory sinuses. c?nd 
their sequelae. 
Stabsarzt (Captain. MG.) Prof. GHEIFENSTEIN 
In all cases of gunshot injuries to the upper sinuses an 
involvement of the dura and brain is to be assumed as probable 
until the contrary has been proved. This can be disproved only 
occasionally by clinical and radiographic examination, but 
usually only by surgical control. Every gunshot injury of the 
orbit is to a high degree suspect of being a direct or indirect 
additional injury to the upper acessory sinuses and to the 
brain. About 10 per cent of the cases of fronto-basal injuries 
were combined with the loss of both eyes, not less than 50 per 
cent with the loss, of one eye. Only in very rare cases was 
contusion of some degfee absent* Tn the case of gunshot wounds 
in the cranium, remote from the eyes, the development of an 
early or late ,,spectable-hematomaM is an important indication 
of an injury to the base of the skull. 
In every case of a gunshot wound of the head with the 
missile lodged In or having passed through the cranium, re- 
mote from the accessory sinuses, the possibility of a direct 
or indirect injury to the accessory sinuses must be considered, 
particularly if the area of the upper facial part of the skull 
and the frontal cranium are involved. 
Positive symptoms of an injury to the cerebral-dura are 
extravasation of cerebral pulp or discharge of fluid from the 
wound and the radiographic proof of a gunshot wound with the 
projectile lodged in the skull, or of a deep penetration of 
bone splinters into the vault of the skull. A reconstruction 
of the course of the missile in cases of gunshot wounds of the 
brain, and in case of gunshot wounds with the bullet remain- 
ing in the effected area, a reconstruction of the canal of the 
shot, permit relatively reliable conclusions as to the involve- 
ment of thfc brain whether the missile is present or not. 174 
Special radiographs or the upper accessory sinuses, in- 
cluding an axial picture, stereoscopic picture, and laminated 
X-Ray picture can give important diagnostic and therapeutic 
indications. Usually there is a distinct disproportion bet- 
ween the insignificance of the radiographic findings and the 
seriousness of the picture of the injury obtained during the 
operation. Haziness of the sinuses may have various explan- 
ations? Traumatic-edematous swelling of the mucous membrane, 
hematoma, empyona,or prolapse of the brain. 
A high percentage of fronto-basal injuries caused by 
gunshots are brought up for medical treatment behind the lines 
unrecognized and therefore are insufficiently treated or not 
at all. They are to be considered as having already been in- 
fected after 48 hours. This fact does not exclude particular 
cases in which a primary closing of the dura can still be 
tried later in spite of latent infection. It may be success- 
ful. 
Fronto-basal injuries caused by gunshots are to be treat- 
ed surgically at any time. The risks incurred by the operat- 
ion itself are, however, the greater, the later it is under- 
taken. 
The appropriate treatment of infected accessory sinuses 
requires a thorough mastery of the rhinologic technique, and 
in the cases of fronto-basal injuries of the brain is Just as 
important as the treatment of the cerebral wound which has to 
be undertaken according to cerebro-surgical principles. A 
careful and technically correct execution of the treatment of 
the accessory sinuses is of decisive importance for the pre- 
vention of an additional infection transmitted from the cere- 
bral-dura wound during the healing process and of still grea1> 
er importance for prevention of late complications. 
On principle an infected cerebral duro wound must be 
treated surgically, under visual control, as carefully and 
directly as possible by the shortest route of access. As a 
basis for the direction of the incision, KILTAN’s operation 
is to be considered which according to the peculiarities of 
the injury nay be modified and widened by auxiliary incisions. 
Enough of the injured bony cerebral wall must be re- 
moved to prevent overlooking an extradural hematoma or an 
abscess, and to expose an injury to the dura so that it is 
easy to inspect. 
The treatment of an infected injury tn the cerebral 
dura in the area of the frontal sinus without affection of 
the ethmoid bone must aim at an obliteration of the sinus 
according to RIEDEL*s operation. The removal of residual 
mucous membrane hardly to be recognized macroscooically is 
really successful only with the aid of a small wire brush. 
By this a proper closing of the ductus is 
obtained. Therefore, it is unnecessary to operate at the 
same time the uninjured, uninfected frontal bone and to 
a communication to the nose. 175 
If in the case of a large frontal sinus only la partial 
obliteration of the lateral sections is possible, a communic- 
ation is formed between the remaining, surgically treated me- 
dical portion of the sinus and the nose in any case only after 
a thorough healing of the wound in the dura by a typical de- 
bridement of the ethmoid bone. 
The ideal purpose of our proceedings in case of infected, 
isolated frontal sinus brain injury is to prevent an addition- 
al infection of the nose whether altogether or at least until 
the closed healing of the cerebral wound by limitation of the 
surgical area to the frontal sinus, and to prevent the healed 
up cerebral dura wound as much as possible connection with 
an open accessary sinus system. 
Injuries to the cerebral dura in the area of the ethmoid 
b°ne roof require a complete removal of all ethmoid bone cells, 
including the opening of the sphenoid bone sinus from an or- 
bito-nasal incision, from which the after-treatment of the 
cerebral dura wound is also undertaken. Even if some groups 
of cells do not appear infected, macroscopically we avoid part- 
ial debridement, in order to create smooth wound conditions, 
easy to inspect in the neighborhood of the later developing 
scar. There is no cogent reason fnr including the uninjured 
and uninfected frnntal sinus in the surgical area. 
Injuries to the lamina cribrosa have surprisingly proved 
to be much less dangerous than we were inclined to estimate 
them in the beginning on the strength of prewar^experience 
with the apparently much more virulent genuine inflammations. 
Serious comminution? of the upper accessory sinuses, in 
most cases combined and bilateral injuries to the ethmoid bone- 
frontal sinus, affecting the lamina cribrosa and the orbits 
require an exposure of all affected spaces and of the injured 
dura, often by modifying the external direction of the incis- 
ion and of the surgical procedure. Positive general rules can*, 
not'be laid down, as wide external openings rendering tha*'ln- 
jured area accessible and'wounds in the sott parts freouently 
are already present. 
In case of bilateral injuries t" the upper accessory 
sinuses or comminution of the inter-frontal septum such as 
frequently occurs in unilateral injuries tn the frontal sinuses 
too, a "Median Drainage of the Frontal Sinus” (0. MAYER) has 
proved to be advantageous. 
Missiles are to be removed from gunshot wounds when the 
bullet is lodged in the upper accessary sinus system without 
P0gap(5 to their size and their distance from the cerebral wall. 
This is accomplished by an external radical operation of the 
sinus in question. The idea of trivial injuries cannot be 
admitted in this case. 
Injuries of the dura and the brain at the roof of the 
ethmoid bone offer, according to our experience, a better 
prognosis than those in the area of the posterior wall of 
the frontal sinus. Depressed skull fractures caused by gunshot into the 
thin cerebral walls of the accessory sinuses present, in 
most cases, an open bone gap, i.e. with a decided tendency 
to prolapse. 
The after-treatment of Infected injuries to the cerebral 
dura should be undertaken individually; valuable measures in 
this case are a dilatation of the cavity by "gradual draining 
of the cerebral spinal fluid" and a radiographic picture of 
the cavity filled with air or radiopaque solution. In case 
of complicated, hidden or small abscesses a tamponade by means 
of a rubber sponge is hardly practical. 
Also an apparently spontaneously healed up fronto-basal 
injury must be dealt with by a late operation, if an infect- 
ion of the accessory sinuses is proved. Its performance is 
technically very difficult and is accompanied by greater 
risks than an operation at an earlier time. 
Besides a late abscess and late meningitis the formation 
of mucopyozelene is a serious late complication after injuries 
to and operations on the accessory sinuses. 
Only 12 per cent of all treated fronto-basal injuries 
had already been dealt with before they were sent to the 
special ward of the general hospital in the home territory. 
Discussion concerning the reports on fronto-basal 
gunshot wounds in the brain; 
MUENDNICH: In the discussion on the reports concerning 
an early operation of fronto-basal gunshot wounds MUENDNICH 
refers to his treatise published in "Zeitschrift fuer Hals- 
usw. Heilkunde", 49/1943 (Periodical for Otorhinolaryngology 
49/1943) and stresses the following points of view: 
As regards the location of the incision he remarks that 
the typical incision along the supra-orbital ridge which 
turns medially to the area of the lachrymal bone is prefer- 
able, while a commonly used incision which begins laterally 
just as the first incision, but ands above the root of the 
nose, is to be used only when it is not necessary to expose 
the ethmoid bone. A third location of the incision is ment- 
ioned, which is suitable for gunshot wounds abnve the supra- 
orbital ridge, and which has the advantage that the skin 
wound is situated at some distance from the seam of the dura 
and that the soft parts can be pressed more easily against 
the frontal brain by tamponade. He warns against auxiliary 
incisions the center of the forehead if the is 
damaged externally, since by this the soft parts of the fore- 
head become useless for later plastic operations on the nose. 
They should not be made down to the bone immediately, so as 
to enable one to prepare periostical-galea patches for a 
plastic operation of the dura. 
He points out that if the dura is exposed, operations 
on the accessary sinuses which are not thoroughly carried 
out, may lead even years later to meningitis and wandering 
abscesses. Therefore incomplete debridement of the access- 
ory sinuses is to be discarded. If the frontal sinus is affected without openine up the 
ethmoid bone - from the frontal cranial fossa - the typical 
operations of the accessary sinuses should be avoided. The 
bottom of the frontal sinus is to be left as it is, the mue- 
ous membrane, of the bottom and of the medial wall is to be 
loosened with a rasp and removed. 
In the area of the operation the mucous membrane is 
loosened and turned in towards the ethmoid bone or removed. 
A periosteal-galea flap may complete the closing of the in- 
fundibulum. The ethmoid bone, however, remains absolutely 
intact. By this means the dura seems to be protected in the 
long run against infections spreading from the sinuses. 
(Satisfactory translation of the next paragraph could 
not be made because of blurred text. Editor’s note.) 
MITTEHMAIER: In case of a primary closing of a wound 
caused by fronto-basal cerebral injuries a simultaneous 
routine treatment of the frontal sinus and ethmoid bone are 
rarely required. It is, however, not sufficient only to 
a communication with the nasal cavity. Opening up the 
cellular system of the ethmoid bone means an infection of the 
cells which were removed. A very careful after-treatment 
is required after every operation on the nose. - If surgical 
wound treatment is required, it is perhaps better to postpone 
the operation of the nasal accessory sinuses until a later 
time. 
HUBERT; Of 1000 gunshot wounds of the brain operated 
on by myself at the eastern front 13 per cent were fronto- 
basal ones. For my report I have selected 600 sick-reports 
in order tn eliminate as far as possible faults of judge- 
ment which might arise by differences in the external con- 
ditions. The wounded came mostly from swampy areas; the in- 
juries were mostly caused by shell splinters, their first 
treatment had taken place in the cerebro-surgical depart- 
ment of a base hospital near the front and within 24 to 72 
hours after they had occurred. The time of observation till 
the evacuation into a hospital behind the lines amounted to 
4 weeks on an average. 
Of the 600 gunshot wounds in the brain with which the 
report deals, 80 cases showed an involvement of the accessory 
sinuses. Among 63 fronto-basal gunshot wounds in the brain 
combined with tearing of the meninges which were operated, 
in only 19 cases could a closure of the dura be achieved by 
dura suture or by plastic operation. In 44 cases (70 per 
cent) a water-tight closing of the dura gap had to be given 
up because of 
1, a distinct infection of the cerebral wound was 
evident, or 
2, gunshot wounds with the bullet passing through 
were contaminated to such a high degree that a certain 
physical cleansing could not be achieved, or 
3, by the anatomic conditions, e.g. in case of cerebral 
wounds in the area of the sphenoid bone and of the orbital 
infundibulum a closure of the dura gap was precarious or im- 
possible. In these cases after the surgical treatment ef the 
accessory sinuses a tamponade was performed by means of 
moist DAKIN1s gauze or iodine - iodoform gauze. It assists 
the drainage, preventing at the same time a cerebral pro- 
lapse. The tampon is removed on the ?th day and renewed 
every 2-3 days, until the wound cavity is filled with 
granluations. Lumbar punctures must be performed in order 
to equalize the pressure and to treat a nossible meningitis 
according to the usual points of view. 
Of the 19 cases with fronto-basal injuries to the 
brain which were treated by closing the dura, 13 (3 per 
cent) (sic) died, while among 44 cases of injuries to the 
brain treated with tamponade, 13 died (30 per cent). To 
enable one to furnish a comparative calculation of suc- 
cesses expressed as percentage, comparing the different 
techniques, the figures are indeed too small, apart from 
the various conditions under which the methods of treat- 
ment were applied. The difference between the tyro ratps 
of success (30 per cent minus 16 per cent ■ 14 per cent) 
exceeds by only a little the medium rate of error which 
is computed at ± 10.9 per cent. The figures keep within 
the limits of the losses to be expected with gunshot wounds 
in the brain, as known by experience; they show that even 
with the often indispensable tamponade treatment fair re- 
sults may be achieved. (Editor’s note: This paragraph 
not entirely clear in the German text.) 
WILDEGANSs Most of the patients who sustain injuries 
to the fore-brain do not lose consciousness at the moment. 
The smaller the area affected by the injury, the less is 
a concussion of skull and brain in their entirety, with 
the corresponding clinical picture of unconsciousness and 
irritation, to be exnected. The larger the area affected, 
the more likely are these effects to occur. (Wounds caused 
by ricochet and grazing shots.) Commotio cerebri generally 
develops only if the direction of the effect of the trauma 
is towards the rear cranial fossa (Rhombencephalon and 
ependymal nuclei). Relatively frequent injuries are caused 
by contre-coup (occiput, cerebellum, orbital section of the 
frontal lobes, anterior part of the temporal lobes, windings 
of the brain in the area of the great falx and of the tent- 
orium, between vertex and temporal brain). Only those in- 
juries are to be considered as genuine contre-coup injuries 
when the cerebral sections situated between the area of im- 
pact of the projectile and the remote focus of contusion 
show no rough anatomic changes (propagated skull fracture, 
hydrodynamic forces, straining and tearing of leaving or 
entering nerves or vessels). More frequently there is a 
more or less broad track of contusion which traverses the 
brain in a fronto-occipital or a fronto-basal direction so 
that a continuous necrosis of the diameter of the brain 
appears which extends from the spot where the bullet enter- 
ed to the cerebral surface on the other side. Deflections 
of the bullet occur particularly with gunshot wounds, with 
the missile remaining in the forebrain, when the impact of 
the bullet is in the area of the base of the^skull (Sella 
turcica, Os petrosum), but also the spent missile which 
entered the brain from the forehead, hitting the vault of 
the cranium from within and rebounding from there at a 
corresponding angle into the brain. Thus nearly always.we 
are dpaling with depressed skull fractures due to gunshots. 179 
It is only in exceptional cases that the particles of bone 
are thrown outward, as when the pressure of the explosion is 
directed to the outside, instead of being thrown violently 
into the brain and thus stick to the periosteum or are found 
scattered everywhere in the soft parts. The frontal brain 
has a marked disposition to swell to a degree which is other- 
wise found only with the vertex brain (areas of higher grade 
organization of the brain develop only late). Cerebral edema 
and encenhalomalacia. therefore, often spread in the area of 
the frontal brain very quickly and widely. Nowhere else does 
one see such masses of pulpy, or liquid-pulpy brain substance of 
a yellow color with a russet tone drain off as in cases of 
such injuries to the frontal brain where, because of the 
cerebral pressure in the area of the frontal sinuses or of 
the orbital roof, a drainage towards the outside had to be 
made some time after a primary inadequate surgical treatment 
or after conservative treatment. Only exceptionally did 
these softenings take place soon after the trauma. As a 
rule there was an interval of 2 - 3 weeks between the injury 
and the increasing softening. The results of healing were 
astonishingly good with simple softenings. Corresponding to 
the disposition of the frontal brain to swell, an inflammatory 
cerebral edema with brain abscess may very ouickly lead to 
considerable cerebral pressure which may occasionally become 
perilous even after the drainage of the abscess. 
the forebrain swells quickly it often shows the disposition 
to decrease quickly, so that the majority of prolapses under- 
goes involution. The removal of a prolapse in the area of 
the forehead is to be considered only if a subsequent closing 
suture is possible, when an abscess in the prolapse has de- 
veloped or if a better view of the interior of the brain can 
be obtained by a removal of the prolapse. Danger of an ex- 
posure of the anterior horns or chambers shifted in the dir- 
ection of the opening of the bone occurs only rarely in the 
area of the frontal brain. Pneumocephalus developed frequent- 
ly when the frontal sinus, the sphenoidal sinus, the tympanic 
cavity, the ethmoidal cells, or the mastoid^process were 
opened up. Intracranial accumulations of air in the fluid 
spaces or in the brain itself in case of fronto-basal injur- 
ies are generally the consequences of an involvement of the 
frontal sinus". The air gets into the chambers either direct- 
ly or indirectly by way of the basal cistern (cisterna chias- 
matica and interpeduncularis), through the foramina Luschkae 
into the fourth ventricle and from there into the third vent- 
ricle and into the lateral chambers. Distinct, spontaneous 
ventriculograms were frequently observed. The phenomena of 
such intracerebral accumulations of air are unimportant as 
a rule. Later on a periodical discharge of cerebro-spinal 
fluid or pus indicates a fatal complication. Often the air 
was reabsorbed only after days and weeks following the clos- 
ing of the dura gap and a corresponding treatment. An.in- 
crease of pneumocephalus indicates a closing of the valve or 
a progressive decay of the brain. Fluid fistulae. in the area 
of the forehead sometimes closed spontaneously. In conse- 
quency of the upright carriage of the head in supine posture 
the fluid discharges rather in its natural direction if it 
finds an open passage there. Danger of meningitisafter ex- 
posure of the otherwise healthy frontal and sphenoidal sinus, 
as well as the ethmoid bone cells, is, with a fronto-basal 
gunshot wound which was operated on in time, greater than 
with other injuries of the brain. Surgical treatment assist- 
ed bv sulfonamides brought about an"important improvement in this field. Healing of serious meningitis usually takes 
one to two weeks, sometimes rapid recoveries occur. Large 
doses of S (sulfonamide) are required (see WILDEGANS: Die 
posttraumatische infektioese Meningitis / On post-traumatic 
infectious meningitis, Chirurg 1943,14/). 
Directions for the treatment of fronto-basal gunshot 
wounds affecting the accessory nasal sinuses 
and their sequelae. 
In all cases of injuries to the face and head, partic- 
ularly when accompanied by unconsciousness immediately after 
the injury a fronto-basal injury to the dura is to be reckon- 
ed with. During transport the danger of aspiration is to be 
prevented by a suitable position of the head (dependent and 
turned on the side). The aim of the surgical treatment is 
to prevent infection of the wound in the brain in the sub- 
dural area, and the fluid spaces. A primary infection of the 
wound in the brain is to be overcome by a radical removal of 
all particles of brain, blood and foreign bodies, a secondary 
infection by the water-tight closing of the dura opening. The 
following measures have been particularly helpful; Closure of 
orbital tissue, pedunculated or freely transplanted galea- 
periosteum flaps, free transplanations of fasciae from the 
upper part of the thigh and prepared amniotic membrane. 
In case of fronto-basal injuries to the brain an ap- 
propriate treatment of infected accessory sinuses, which re- 
quires a thorough familiarity with rhinologic technique is 
just as important as the treatment of the wounds in the brain, 
which has to conform to the above mentioned principles. A 
careful and technically correct treatment of the accessory 
sinuses is of decisive importance for the prevention of ad- 
ditional infection of the wound in the cerebral dura during 
the healing process, and of even greater importance for avert- 
ing late complications. If a primary treatment of the wound 
in the dura is no longer possible or no longer required, a 
surgical treatment of the accessory nasal sinuses must not he 
neglected. The infected wound in the brain is to be treated 
surgically according to general surgical principles. In case 
of threatening or actual meningitis a complete meningitis 
treatment (sulfonamide-treatment, previous aspiration of 
fluid) has to be undertaken. 
uelao« 181 
VII. 
PROCEEDINGS OF THE CONSULTANT? ' 
COMMITTEE ON GENERAL HYGIENE 
AND TROPICAL HYGIENE 
Translation prepared by; 
U. S. Naval Technical Unit, Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government (U. S.) A* 
The effect of Gesarol and. Gix on flies. Anopheles 
and Phiebotomes mosquitoes• 
1_. The use of Gesarol and Gix. 
Oberstarzt (Colonel* MC.) Prof6 ROSE 
The need for a discussion of the effect of the new 
agents for disinfestation is shown as follows: 
The group of agents for disinfestation, which are de- 
rived from Pentachlor-diphenylethane, are agents, which, 
through their unusual method of action in the different 
phases of the defense against contagious disease, have pro- 
duced revolutionary changes. These are agents, which poison 
the vermin by contact with their ventral surfaces and which 
are absorbed through their tarsal joints. They are elective 
nerve poisons with slow but certain effect. In consequence 
of their low rate of volatility and insolubility in water, 
they are characterized by an as yet undetermined permanent 
effect after only one application. 
Therefore they bring us a prolonged protection for dis- 
infestation, instead of the effect being temporary and of 
short duration as with all the previous measures taken again, 
louse infestation. If skillfully used, they offer a protect 
ion against the spreading of lice among the troops. This 
method of disinfestation for civilians, which has previously 
been technically impossible, can now be executed on those 
groups of people, who are chronically infected with spotted 
fever and are backward in civilization. The extermination 
of spotted fever has been approached even in the backward 
areas by the systematic use of these agents. In spite of 
that the troops must be fully informed about "Lauseto" being 
used only against infestation with lice and that they are 
safely protected against an epidemic of spotted fever. Be- 
cause of the slow effect, however, no complete protection is 
given against occasional infection by contact with spotted 
fever among the infected civilians. In order to avoid dis- 
appointment, we wish to point out, that single cases will 
remain until the method is applied among the civilians. In 
combating spotted fever, the agents mean an extraordinary 
saving of material and workmen in the establishments for dis- 
infestation. They make an extensive decentralization possible 
as they may be used by the troops under the most difficult 
conditions. 
As regards those diseases spread by mosquitoes and 
other blood-sucking insects, the new agents provide an econ- 
omical possibility for a well planned, treatment of the dwell- 
ing so as to eliminate the infections acquired in the house 
partly from human beings as well as from insects. VTe gain 
thereby an additional resourse of such great importance, that 
in my opinion it excells all our other preventive measures. 183 
These new agents make the execution of the principles of 
complete disinfestation possible. The destruction of the 
agent of disease in the surroundings of the sick persons 
is now possible even in epidemics where previously the well 
planned execution of disinfestation seemed to be impractic- 
able from the technical point of view. 
2. Introductory speech concerning the development and 
character of the disinfestation agents Gesarol 
and Gix. 
Stabsarzt (Captain. MC.) FINGER 
Gesarol and Gix, as well as the agents used for im- 
pregnating cloth against lice, such as Lauseto, Multocid- 
Duolit, contain a so-called Gesarol complex as the effect- 
ive substance which is in its synthesis covered by the 
patent of the German Reich dated 26 November 1943, for the 
benefit of GEIGY A.G. Switzerland. This agent is an organic 
combination, which is produced by the condensation of chloral 
with chlor-benzol and by which the replaceable hydrogen atom 
in the para-position is substituted for a chlorine atom, 
(Pentachlordiphenylethane)• The greatest advantage of these 
agents for combating animal vectors is in their lasting ef- 
fect, which has been sought for but has never been gained 
previously. In general their effect is that of a contact 
poison. The further protection of the troops by these^agents 
depends on the distribution of the necessary raw material, 
which is very difficult to get as it is used for other im- 
portant war purposes. 
3js Report of laboratory experiments with Gesarol. 
Regierungsrat (Government Counsellor) EMMEL 
The experiments done in a laboratory with the Penta- 
chlordiphenylethane preparation called "Gesarol” dealt with 
the method of the action of this chemical substance on 
Anopheles and compared with Aedes, Culex and Musca. 
The results of the investigation concerning the manner 
in which Gesarol is effective indicated that for practical 
purposes the effect with Anopheles resulted from direct con- 
tact with the Gesarol coating. It is sufficient if the 
Anopheles merely touch the poison with their Tarsa (hair of 
arolium). Quite weak visible reactions with a long incubat- 
ion time have been demonstrated to arise from a Gesarol-de- 
posit for some distance at 22 to 33° C. (Gesapon 2 per cent 
and Gesarol spray-mixture 4 per cent). Gesarol does not seem to give any kind of warning in 
the usual way. Anopheles mac. and Aedes aegyptil suck the 
blood through a Gesarol soaked gauze. Flies (Musea dora.) 
seem to notice Gesarol even less. Anopheles may, however, 
escape the further effect of Gesarol due to a fleeing re- 
action which is compulsorily put into action, if the motor 
excitement caused by the poisoning effect is active. We 
drew the conclusion from this, that for practical purposes, 
all areas in the room suitable for the Anopheles to settle 
down, must be treated. 
If the effect of the poison is interrupted, a con- 
siderable percentage of Anonheles die. The ones which re- 
cover lose their legs and are no longer to be considered 
as vectors of malaria. 
Six different stages of poisoning have been different- 
iated on Anopheles. T'Tith the help of them we are able to 
draw effect curves by testing the effect of different con- 
centrations at different temperatures. Low Gesapon con- 
centrations (o.5 and 1.0 per cent) with only a few active 
particles per surface unit, are effective even at 31 de- 
grees, death occurring after about 23 - 25 minutes. Strong 
er concentrations (1.5 and 2.0 per cent) are less depended 
on the temperature as regards the rapidity of the effect 
and the curves generally show a more constant course. 2° 
the average, death occurs after 30 minutes, while the f:. 
manifestation of poisohing is notable af■er 6-9 minutes 
Besides the concentration, that means the density of 
the active substance per surface unit, the form in which 
the active substance has been distributed is decisive. 
Gesarol in the form of crystals is less rapidly effective 
and seems to be less readily absorbed. ]rhen the active 
substance is finely distributed, as occurs by the use of 
the emulgent Gesapon, it is absorbed much more rapidly 
and in addition it seems to be better absorbed. No quicker 
action can be obtained with a stronger suspension, but with 
a stronger emulsion which, in addition does not loose its 
potency even at temperature of 3° C. The death of Anopheles 
will be obtained with a 2 per cent emulsion after about 30 
minutes and with a similarly concentrated suspension after 
about one hour and 40 minutes. In some cases Gesarol re- 
sistance has been observed in Anopheles. This suspension 
spray-mixture is not suitable for impregnating the nets for 
gnats in contrast to the emulsion of Gesapon, because it 
breaks off the web easily after drying. 
Undoubtedly, Gesarol, which possesses a longer last- 
ing effect has opened a new way in the field of combating 
Anopheles mosquitoes in the sense of malaria disinfection 
owing to its special use in the treatment of interiors 
by a deposit on the surface. 185 
iL Experiments In laboratories and in the open air to 
test Gesarol and Gix on insects. Anopheles 
and Phlebotomes mosquitoes. 
Sonderfuehrer (Special Consultant) MAYER 
The examination of the effect of the preparation Gix 
on Diptera showed a high sensitivity for gnats, Anopheles, 
Aedes and Culex to its insecticide effect. The insects 
Musca,^Stomoxys, Fannis and Drosophila have been found less 
sensitive. The cockroach Blatta was only slightly affected, 
while the cornbeetle Calandra was not affected at all. Be- 
sides Diptera families, such as Culcides, Muscides, Bor brides 
Sepsides Phorides, Stratiomyides, Sciarides and Psychodides 
(Phlebotomes) as well as Coleopteres, to a lesser degree 
Hymenopteres, Anachnides, Myriapodes Permaptera and Lepidop- 
tera have been slightly affected. The agent thus has been 
found poisonous for a great number of insects, which are 
hygienically important. 
The agents act as a contact poison and as a gas. In- 
sects and gnats die after touching an impregnated surface 
for a period of only 15 seconds. The insects also die, if 
they only remain in a closed room and don’t touch any im- 
pregnated area. 
✓ 
The agent used as a spraying agent shows an excellent 
effect when applied in a ratio of 1 cubic centimeter of 3 
per cent solution per cubic neter. The robms into ' :f* 
which Gix has been sprayed, retain their toxic effect on 
insects for quite a long time. The more porous the sur- 
face and the warmer the room temperature, the shorter the 
effective time will be. The duration of the toxic effect 
may be prolonged by adding slaked lime. Porous surfaces 
cause a dilution of the agent on the exposed surface. 
Therefore concentration of the emulsion is not so import- 
ant for the effect as the actual amount of the agent per 
surface unit. A more pronounced evaporation of the agent 
is caused by the rising temperature, whereby the effective 
time is decreased. The testing of Gix emulsions showed 
this unlimited stability in our climate. 
Besides these factors the nature of the solvent is 
also of considerable importance as has been proved by the 
testing of two batches, which acted very differently as to 
their physical behavior and to their biological effect. 
The experiments carried out in the open air near 
Berlin and in the southern districts confirmed the results 
obtained in the laboratories. In warm countries the ef- 
fect depending on the material conditions of the treated 
wall, has not been of the same duration, as in moderate 
climates. 
Gesarol used as a spraying agent did not show such 
favorable effect as has been obtained by the use of 
’’Schweinfurtergreen” for combating larva of Anopheles. 
When diluted with dust, even the mixture proportion of 1 : 
50 has not been sufficient when testing it as a spraying 
agent. Hereby an emulsion with oil and en emulgent has been used. Benzol was used as a solvent. Emulsions pro- 
duced with Gix showed the same results. Both the agents 
increased the larvicide effect of the oil, so that in com- 
parison with pure petrol a saving of 99 per cent has been 
obtained. 
The results required, however, a confirmation by open 
air tests which will be carried out; this year. The agent 
Gix may be used as a varnish and a spraying and impregnat- 
ion mixture with good results for combating the troublesome 
insects. Hospitals occupied by fever patients have to be 
provided with screens as the agent cannot prevent the to and 
fro flight of insects. It may be specially indicated for 
the treatment of winter quarters, to protect against culi- 
cides in those districts infested by gnats. 
The same effect is to be reckoned rath when Gesarol 
is used. Comparative tests carried out on Gesarol and 'Gix 
show a slower effect of Gesarol, 
5* Field tests of the effect of Gesarol and Gix on 
insects. Anopheles. Phlebotomes mosquitoes. 
Stabsarzt (Captain, MC.) KRUEPE 
By tests made with Gesarol and Gix based upon the ex- 
periments conducted in laboratories by EMMEL, the usefulness 
of this new contact poison for insects was tested in regard 
to its effect on adult fever gnats under natural conditions. 
In malaria infested districts of Greece, tests with the 
available trial quantities were carried out in 75 billeting- 
rooms located in stone houses or wooden barrack's, part of 
which provided with wire screened windows, 104 open 
troop tents and 711 bednets. Only watery preparations were 
used, mostly in the concentrations indicated for use on sur- 
faces, in a ratio of 0,8 to 8 grams per sauare meter, some- 
times also in a ratio of 16 to 33 grams per square meter. 
The watery preparations, mostly of 1 to 5 per cent and 
exceptionally also of 10, 15, and 20 per cent were generally 
prepared only a short time before their application, and 
were sprayed on all surfaces of the accommodations. which 
were accessible to the insects, using pressure spray pumps 
(Weinbergspritze), with a medium nozzle adjustment. 1 
liter was always used for 6 square meters of surface white- 
washed in brick- or clay houses of unpainted walls or 
tent walls are less suitable. For a room with a surface of 
120 square meters, nearly a quarter of an hour is renuired 
for spraying the necessary 20 liters of solvent. 
The bednets had been impregnated with these contact 
poinsons by dipping them into the freshly prepared solvents. 
After wringing them slightly they were dried in the open 
air. One liter of the solution h€is been used on the average. 
By applying a solution of’l - 3 percent, 10 . 30 grans 
were taken for one bednet or 2 - 6 square meters. The odor of the agents - Gix smelling slightly stronger 
than Gesarol - lasted only a few days and was never felt 
to be disagreeable or uncomfortable, A slight irritation 
of the mucous membrane in the throat and of the conjunctiva 
was caused during the spraying of Gix, A slight cough and 
watering of the eyes followed for one day. After the water 
has been evaporated the occupants had no more trouble# It 
has never been observed that these agents have poisoned 
persons or damaged furniture, clothes etc. 
The field experiments so far carried out, conformed 
more or less to the subtropical conditions of Greece. The 
elective contact poison properties of Gesarol and Gix af- 
fect fever gnats and flies under natural conditions, as has 
already been shown by laboratory test. The properties re- 
mained1 effective for a period of 3 or 4 weeks. This applies 
particularly to the treatment of rooms in stone or wooden 
horses, in which after a single treatment of the room the 
insecticide contact poison effect con'd be observed until 
the 25th day, and that independently of the concentration 
in the range of 0*8 to 8 grams per square meter# In tents, 
however, a remarkable relation of the lasting effect to tr' 
concentration could be observed# The surface concentration 
from 16 to 33 grams per square meter had a similar lasting 
effect of 18 to 20 days, while concentrations of 1.5 to 4.5 
grams per square meter were effective for 2 to 4 to 6 days 
only. The reasons are probably the shaking down of the 
spray from the tent walls caused by the wind, especially of 
the powdered Gesarol which adheres poorly to the walls and 
further by the early ineffectiveness of the active substance , 
caused by the high temperature due to the sunshine on the 
tent walls. 
In contrast to the laboratory tests, the latent period, 
that is the time between the first touch of the insects leg 
with the poison covered surface and the appearance of the 
poisoning is relatively long as well as the total period 
including the different stages of poisoning suffered by 
the insects prior to their death, during th£ very hot sum- 
mertime in Greece. Gesarol has an insecticide effect, 
which kills flies after about 2-4 hours, Phlebotomes 
after about 3-5 hours and Anopheles after about 8-10 
hours. Some of the insects were found dead only after 24 
hours. Generally the strength of the effect was gradually 
reduced after the second week. This was deduced^from the 
prolonged duration of the different stages of poisoning. 
Generally the oily preparation has a more rapid effect than 
the powdered preparation of Gesarol, while Gix has a more 
insecticidal effect than the emulsified Gesarol. It seems 
as if the oily solution can be absorbed better by the Tars' 
of the insects than the crystalline form of the active part- 
icles. The various latent periods for the contact poison 
observed with the different insects are probably due amongst 
other things to the different metabolic situations of the 
day and night insects. 
The bednets for mosquitoes and rooms treated in this 
way, remained perfectly free from Phlebotomes for 3 - 4 
weeks, an observation, which has been confirmed by Stabs- 
arzt (Captain, MC.) Dr. MUELHENS in October 1943 on the 
Isle of Crete. Warning effects by Gix and Gesarol on in- 
sects and Anopheles have, however, not been observed with 
similar clearness. Dr. MUELHENS has observed by his experiments that even 
a few minutes contact with the poison covered surface is 
sufficient to kill the Phlebotomes even though they had al- 
ready left the poisoned surface. During experiments carried 
out in the fields, it could not be ascertained how long this 
deadly effective time of contact lasts on insects and Ano- 
pheles, after they leave the rooms treated with Gesarol. 
It is believed, however, that the insects, having the possib- 
ility of flying to and fro in the rooms and tents, not pro- 
tected by wire screened windows, have been killed by the ef- 
fect of the poison outside the rooms, even in districts with 
great plagues of gnats and insects, where the inhabitants 
had already reported the increase of these insects. 
The kitchen rooms have not been treated. For the use 
of Gesarol and Gix by the troops in the South-east, the fol- 
lowing practical conclusions can be made: 
1• Protection against malaria for the troops. 
By the use of the new insect contact poison there 
is a possibility of keeping the rooms permanently in 
such a condition as to kill the Anopheles right at the 
place of malaria infection, Particularly at^night 
these Anopheles get in contact with human beings in- 
fected with malaria, who serve as their blood donors. 
The Anopheles should therefore be killed immediately 
at the place of contact. This is a good way to obtain 
an effective malaria disinfestation in malaria district, 
especially in military hospitals, sickbays, billets foi 
troops and in the native houses of the neighborhood 
where parasite vectors as well as malaria infected 
people might be living. For medium sized rooms of 
about lg€) square 'about ’1*2 to 2.4 kilograms 
are mefho<faof combating malaria, in contrast 
to combating larvae, it will be possible to have in- 
stant effect regardless of whether the campaign starts 
in May or in October because the insect is combated at 
the spot of the malaria infection. 
2• Protection against pappataci-fever for the troops• 
This is the only treatment of the bednets for mos- 
quitoes which offers an extensive protection against 
bites of Phlebotomes and transmission of pappataci-fever 
Treatments of the rooms, especially in military hospit- 
als, are certainly even more effective. 
3• Protection against insects in kitchen and work- 
ing rooms. 
During my experiments I have observed that com- 
bating flies in the kitchen seems to be more or less 
hopeless as Gesarol is sensitive to heat. For combat- 
ing dysentery-bacilli the treatment of latrines may be 
successful to some extent, Gesarol and Gix are consid- 
ered excellent agents for reducing the nuisance, of flies 
in working rooms and offices, even though general use 
for this purpose is not authorized for reasons not dif- 
ficult to understand. 6»_. Field tests with Glx and their effects on flies 
and Anopheles. 
_Sonder fuehrer (Special Consultant) KBATZ 
Full particulars are given about the results which 
have been obtained in combating insects and culex with the 
preparation Gix. 
The agent has been used in three ways? 
1* In watery solution or in connection with chalk 
for treating walls* 3 Per cent concentration, 200 
cubic centimeter to 1 square meter* 
2. For Impregnating tents and materials* . 
3* The agent being used as spray mixture* 3-5 per 
cent concentration 2 cubic centimeters per 1 cubic me- 
ter. 
The preparation has been sprayed ober the walls and 
furniture in different concentrations with a compressed air 
spray. The concentration for the different ways of applic- 
ation had to.be varied. The range of the concentration war 
between 3 and 10 per cent. The following rule serves as a 
guide: 
I 
The hotter and dryer the climate, the higher the con- 
centration required* 5 per cent of the insecticide effect 
remained on walls in barracks when treated with a concen- 
tration of 3 Per centi In order to obtain a lasting effect 
of 14 days in tents, a concentration of 10 per cent is 
needed. A brisk rain can wash the Gix solution out of the 
tent wals so that after some days the trails must be re- 
painted. 
This agent has proved to be an excellent means for 
killing insects and gnats. It is a definite aid for im- 
proving the hygienic conditions for the troops* 
Discussion following the lectures concerning the 
use of Gesarol and Glx; 
RODENWALDT: The justified enthusiasm concerning the 
effect of Gix arid Gesarol should not tempt us to renounce 
our measures concerning wire screening of windows• 
In the kitchens of Banjoli and in the operating the- 
ater of the central military hospitals in Naples, Gesarol 
has been used with good results, but in those rooms filled 
with sick people suffering from severe burns, the use of 
Gesarol has ended in failure. If many insects fly into 
such rooms from the outside, they have plenty of time to 
trouble sick people. 
Until insects and gnats are so Injured that they are 
harmless, they have adequate time to cause infection by 
flying to and from badly treated latrines or by flying 
into houses where infected people live. Anopheles do not all remain in the houses; some kinds 
of Anopheles fly into the houses in order to suck the blood 
of persons at certain hours without even touching the sur- 
faces treated with Gesarol or Gix. Therefore we must not 
change any of our measures concerning wire screening of 
windows. 
The action of the pharynx pump of gnats does not nec- 
essarily depend on the effect of Gesarol. By holding a 
gnat by the leg and placing the pharynx in the edge of a 
drop of water or blood, the gnat Till suck up liquid until 
it is completely full, even running the risk of bursting. 
The liauid entering by capillary attraction probably puts 
the pharynx pump forcibly into action. Mr. FUELL30RN and 
I have often made use of this proceeding in our experiments 
on filaria. 
LENZ: Almost all information taken from the reports 
gained by experiments can be confirmed by our own observat- 
ions, for instance: the different strong effects of the 
agent, important for practical purposes, varies according 
to the porosity of the surface covered with the agent. I 
wish to mention especially the warning effect of Gesarol 
on Phlebotomes, subjectively demonstrated in our laboratory 
experiments. This is an important fact, as through the im- 
pregnation of the wood the warning given the gnats discour- 
ages them from forcing their way through the nets so that 
the sleepers shall not be annoyed or infected by the insects. 
If the insect can slip through the net and die later on, the 
result is not complete. 
WEYER: The defensive and distant effects of Gesarol 
and Gix which previously have been ascertained only on 
Phlebotomes, must be tested by experiments carried out in 
the open air under the same conditions on insects, especial- 
ly on gnats and flies. Use of strong prophylactics on wind- 
ows and doors must be considered. The further chemical de- 
velopment of the agents should especially concentrate on 
increasing the distant effects. 
The use of Gesarol and Gix for dining-rooms, kitchens, 
and supnly rooms is advisable for combating the insect 
plague, as food and other supplies are not affected even 
by direct contact with Gesarol and Gix. The 
necessary for developing the effect ?s found in the kitchens. 
LENZ: The question asked by WEYER concerning the 
analysis of the method of warning is justified. Tt is 
planned to use it in the coming season of Phlebotomes. 
There are two important possibilities: The effect of^ 
volatilized atoms or by direct contact. The latter will 
be mostly in question. This would mean that the poison 
is felt by the insect almost immediately after the contact 
causing a regular escape reaction. 
RODEN^ALDT: It is a matter of common sense not to re- 
nounce the use of any available agent for such a comprehens- 
ive subject as malaria. Gix and Gesarol shall be welcomed 
as our new weapons. But we should not the other 
precautions, above all not the wire screened windows. MARTINI; has referred to the necessity of combating 
adult insects in billet for many years. In many of his 
works the following instruction can be reads "Kill the 
gnats in the house11. 
For o\nsr a decade Netherlander have combated gnats 
in houses with spray-apparatuses, but they have confined 
the destruction of gnats only to houses with gamete-vectors, 
as was explained at the tropical medicine congress in 1938. 
It has to be remembered that not every Anopheles re- 
mains in the same house where it has sucked the blood of 
infected persons. Therefore it is not at all certain that 
the development of the sporocysts necessarily has to take 
place in this house. According to the biological nature 
of the species and the air currents, the insects often 
leave one house and fly into another or into a stable. 
But it is impossible to treat all buildings with Gix and 
Gesarol. One has to decide, according to the urgency and 
the prospects of the results. 
ROSE: Because of the well-known fact that in some 
districts of the tropics only a few Anopheles remain in 
the house, it is no reason to object against the method 
of treating the interior which does destroy the kind of 
insects that remain indoors. Fe have mostly to deal with 
this kind of Anopheles in Europe. The fact that the gnats 
fly in, bite and fly away again without touching the walls 
of the rooms at all is a rare occurrence. Almost the same 
relations exist between emphasizing by means of warning, 
the necessity of destroying Anopheles and systematically 
engaging in the malaria disinfection by treating the inter- 
ior, as exists between combating venereal disease by in- 
structive lectures concerning the dangers of this illness 
and systematically investigating the sources of infection 
and their elimination. The destruction of Anopheles as 
gamete-vectors within the houses has not been practiced 
by the Netherlander for the past decade but has been re- 
sumed since the introduction of this concept by PARK ROSS 
in 1937. The systematic poisoning of the interior by the 
new contact poison of the Gesarol and Gix-group, represents 
a decisive improvement in comparison with the screening of 
Pyrethrum-preparation used by PARK ROSS. The treatment of 
the interior has to be performed systematically in all 
those rooms; a) where gnats are infected as known by 
experience? b) where they transmit an infection. It is 
quite natural that the use of other precautions for com- 
bating malaria, such as mechanical protection, combating 
incubation and medical protection will not be superfluous. 
The treatment of the interior with Gix and Gesarol can be 
executed immediately after having arrived at a new place, 
'if one is in possession of the agent and a brush. The 
agents become effective immediately. All other precautions 
require much more work and much more time. The fighting 
troops of the airforce live under such circumstances, that 
they can be protected against insects by the use aA these 
agents, while the army in the front line doesn’t derive 
any advantage from the new agents. I consider the des- 
cribed Gesarol-resistance of some insects to be one of 
individual immunity or sensitivity, such as we know from 
the use of other agents. I don’t believe in an absolute resistance# High concentration and a prolonged exposure 
would probably lead to a good result# The volatility of 
the agents proved by EMMEL seems to me a new discovery of 
radical importance# The question is not yet clear, if the 
self-mutilation of the insect is incited in the central or 
peripheral system. In contrast to the statement concerning 
the entire non-poisonous characteristics of the agent for 
human beings and domestic animals, the has to be 
made, that in connection with milk, Gesarol has poisoned 
chickens# I cannot agree with the explanation made by 
RODENTALDT concerning the working of the pharynx pump. I 
agree with EMMEL considering it to be an irritation# It 
has not only been observed on gnats which have lost their 
legs, but also on kinds of insects which do not malm them- 
selves# Besides, the irritation leads not only to the ab- 
sorption of liquid, but also to the absorption of air. It 
concerns a phenomenon which stands by itself in contrast to 
the observation mentioned by RODENWALDT# 
Directions for the use of Gesarol and Gix• 
A. General description# 
The preparations of the Gesarol-group, Gesarol and 
Gix, are agents for combating insects which transmit dis- 
eases in closed rooms (Anopheles - malaria, Phlobotonos - 
pappataci fever,and insects - dysentery and typhoid, fever)# 
These preparations are contact poisons which kill the in- 
sect by a slight contact with the poison and after a certain 
period of latency# These preparations do not prevent the 
insects from flying into the rooms. In order to treat the 
interior, the agent is applied over the walls, and furniture 
and is used for impregnating the bednets# The permanent ef- 
fect of this agent lasts for several weeks# It persists 
longer in a cooler than in a warmer climate, which determ- 
ines the frequency of use of the agent. There is no danger 
of poisoning human beings. 
The preparations, being extremely difficult to obtain, 
are only allowed to be used in bedrooms, especially in mil- 
itary hospitals, sickbays, billets for the troops and air 
raid precaution shelters and similar rooms, where people 
are likely to be infected by insects* The bedrooms of civ- 
ilians must also be treated if they are a source of infect- 
ion for the troops. 
B# Preparations# 
1. Gix (I.G. Industry) oily 
2. Gesarol (Sobering A.G.) 
a. Gesapon oily 
b. Gesarol spray agent, powder 
They are used as follows: 
The oily Gix will be emulsified with water from 0.5 
to 3 per cent according to the climate and the#nature of 
the treated surface as to roughness and absorbing ability. 
Thence the consumption for 100 square meters is calculated; a* By the use of 0,5 per cent emulsion with 75 
cubic centimeters of the preparation, 
b. By the use of 3 per cent emulsion with 45 
cubic centimeters of the preparation. 
The oily Gesapon is produced according to the same 
prescription as Gix (see 1), the concentration, however, 
is between 1*5 and 3 per cent. The Gesarol spray-mixture 
is used as a watery suspension in 3-6 per cent concen- 
tration. 
0. Instruction for preparations. 
The necessary amount of the preparation will be stirred 
with equal amounts of water, in order to prepare an emulsion 
respectively a suspension* The remaining amount of water 
will be added while continuously stirring. The canacity of 
adhering to the wall will be improved by stirring slaked 
lime into the water before adding it to the preparation 
(100 grams in 10 liter water). The preparation^can be added 
to the whitewash used in order to whiten the walls in the 
above mentioned concentration. The solvent lasts for sever- 
al weeks if kept cool, but too much heat is detrimental 
it, especially direct exposure to the sun. It is advisable 
to prepare only as much solvent as is needed. 
D• Instruction for the treatment of rooms• 
The best way of applying the solvent to the walls is 
the use of a back-pack spray, also sprays such as are used 
for fruit-trees or vineyards with medium nozzle adjustment, 
as they are used in combating malaria. Screening apparatus- 
es, for instance are unsuitable because of 
their small nozzles. The solvent can also be applied with 
paint brushes, wisps of straw or other devices of these 
kinds. The treatment must be repeated as soon as the ef- 
fect diminishes, generally after about 3 - 4 weeks. The 
walls of the tent have to be treated with a higher concen- 
trated solvent (up to 20 per cent) until they are soaked 
through. The oily preparations of Gix and Gesarol are 
suitable for treating the tentwalls, but the use of powdery 
Gesarol-spray agent is not advisable. 
By the use of these contact poisons for insects all 
the other precautions for combating flies, Anopheles and 
Phlebotomes (mechanical gnat protection, removal of in- 
cubation areas etc.), are never useless but still must be 
employed with great thoroughness. 
E. Instruction for impregnating nets for gnats, 
The treatment of the nets is necessary for combating 
Phlebotomes as they slip through the ordinary nets. This 
kind of treatment, however, is not to be used for combat- 
ing Anopheles and flies. The nets for gnats must be damp- 
ened with water first and after being wrung out, they are 
dipped into a 1 per cent (Gix) - 2 per cent (Gesarol, Ge- 
sapon, oily) solution. After that the nets are wrung out 
lightly and must dry in the open air, but not in the sun. 
The consumption of the solution is about 100 cubic centi- 
meters for one net by treating damp nets, while one liter 
is used for one net by treating dry nets. The powder Ge- 
sarol spray-mixture is less suitable for treating nets for 
gnats. B. 
Disinfestation. 
Disinfestation with quiet, circulating, and forced 
draft of hot air. TCP-procedure (TRAUTMANN. 
CLAUBERG. PFLAUM;. mobile unit'for the pro- 
duction of hot air. * 
Pberstabsarzt (Major, MC.) Prof. CLAUBERG 
Reference is made to the necessity for the instructions 
concerning hot air disinfestation which differ from one an- 
other in the different military units, coordinating all the 
medical and technical instructions given to the Armed Forces, 
They should conform to the latestj experiences regarding the 
actual conditions of destroying lice in all periods of life 
(60° C. in 5 minutes, 55° C. in 10 minutes) and under dif- 
ferent degrees of temperature in certain hot air systems. 
Deficiencies of the construction as well as the im- 
proper use of the disinfection-apparatus were then dis- 
cussed, in order to eliminate undesirable results (see in- 
structions for hot air disinfection). The disproportion 
between the possible and actual hot air effect of all pre- 
vious disinfestation systems led to the development of the 
TCP-process (TRAUTMANN, CLAUBERG, PFLAUM)• This refers 
essentially to the system of partitioning the rooms where 
the disinfestation takes place, so that the hot air which 
is blown in will be equally distributed and forced with a 
minimum resistance through small metal tubes, shaped like 
a serpent, in the heat chamber of a delousing establishment 
(see drawings). The result of these installations with 
little consumption of material and energy were the follow- 
ing; 
A short heating time and an equal distribution 
of temperature such as has never been obtained pre- 
viously by any installation. An absolute disinfest- 
ation effect is obtained within a short time and 
without any additional long security period. An in- 
crease in the number of people disinfested is poss- 
ible to a larger extent than previously (improvement 
of the entire capacity to 24 times). 
According to the latest findings of experiments, 
leather can be disinfested with hot air 60 - 80° C. with- 
out being damaged after having been previously dryed at 
a temperature of 40° C. Suitable instruments for the re- 
gulation of temperature are necessary. Special care has 
to be taken that the boots are adequately exposed at the 
disinfestation in order to obtain a good result. 
* published in a revised form in the "Zeitschrift fuer 
Desinfektion und Schaedlingsbekaempfung". 195 
Mobile hot air installations for delousing purposes 
require adequate sources of heat in order to meet the spec- 
ial requirement in winter time. A sufficiently high temper- 
ature must be available to heat the installations and to 
kill the insects. The use of low steam-pressure is most 
suitable for the purposes. This eliminates the danger of 
scorching and burning the clothes. Furthermore, arrange- 
ments should be made for quicker filling of the delousing 
chambers, in order to eliminate the possibility of a rapid 
cooling of the delousing chambers, especially when used in 
cold weather and in the open air. 
The heater of the type used in the rapid drying of 
newly built houses and which permits the introduction of 
hot air into given rooms by a hot air compressor will suit 
the purpose, especially in a rapid changing delousing act- 
ion. 
In case of new installations standard machinery for 
the optional use of hot air or steam for disinfestation, 
germinating and decontamination purposes should be preferred. 
8. Disinfestation with HCN. Ventox. TV-procedure in- 
cluding procedure In boxes, touts and trans- 
portable equipment. 
Oberleutnant (1st Lieutenant) GRAFENBERGEH 
Besides the use of hot air for clothing, highly effect- 
ive gases play an important part in the disinfestation which 
is fundamental in combating spotted fever. HCN, Ventox and 
"Jllo-Spezial" constitute suitable delousing agents. These 
agents must be used in a professional manner. A proper con- 
struction of the gas chambers is necessary. They have to 
be gas-proof to a large extent and must be provided with a 
heating device to heat the chambers, as thereby the time of 
exposure and airing will be considerably reduced. They 
should be provided with ventilators if possible. 
HCN is the most effective agent by which with 20 grams 
per cubic centimeter,the lice of all stages die within one 
hour. Preheating of the chamber up to 25° C. is absolutely 
necessary, especially if the clothes are damp. Today it is 
exclusively used in the form of Cyclone, the liquid HCN is 
absorbed by a carrier and packed in air proof cans. 
The chambers of 10 cubic meters capacity with circul- 
ation equipment, produced in large numbers, turned out 
well. The air in the chamber which is kept circulating 
by means of a pump to assure a close contact th the clothes 
is heated in a device and blown over the Cyclone carrier 
so that a rapid distribution and penetration is obtained. 
An automatic opening of the cans will avoid any escape 
of the gas so that work can be done without gas masks. The 
rooms are ventilated with the doors closed bv operating the 
same fan and the intake of fresh air will be preheated. The chamber is free of gas within 10 - 15 minutes and the 
entire work of disinfestation lasts about 70 - 75 minutes. 
The clothes should hang loosely on racks which are very 
suitable regarding the utilization of space and are ouick 
working* In large installations it is advisable to build 
more than one chamber. 
The Airforce uses delousing tents of about 13 cubic 
meters capacity, working on the same principles; the warm- 
ing of the chamber is obtained by a motor heater such as 
are used at the big air bases, or by special hot air stoves, 
provided with hand bellows. By the fact that gas is like- 
ly to escape from the tents the quantity required is twice 
as much as in solidly built chambers, that is 500 grams 
per tent. The ventilation is effected by a rapid movement 
of the side walls. 
The German labor service used transportable gas cham- 
bers which were installed on trucks or trailers and work 
on the same principles. The use of HC*T is so simple that 
quick and safe work is guaranteed if the equipment is prop- 
erly handled. But to its high toxicity special cape has to 
be taken according to the instructions for gas protection. 
Only specially trained personnel are qualified for such 
work, forking with makeshift equipment presents some dif- 
f?culties. 
Less precaution is required in working with a new 
agent "Ventox", a clear, inflammable liquid, which evapor- 
ates rapidly. It has an excellent effect on lice of all 
stages, but is 30 times less poisonous on warm blooded in- 
sects than Cyclone. Ventox is more effective on eggs than 
on the adult insects, this offers a greater security. The 
delayed,fatal effect on insects., caused by this agent, has 
to be taken into consideration in biological controls. The 
insects die probably only after hours following their being 
gassed. The agent is used in the same way as HCN. It only 
differs in that the liquid,which is contained in cans, is 
poured on the evaporator at the very moment of its use or 
sprayed throughout the rooms. 95 grams per cubic meter is 
the minimum concentration at which the mixture could poss- 
ibly explode, therefore 50 grams per cubic meter is normal- 
ly used. ' “ ■ 
Ventox nay also be mixed with tritox, in order to in- 
crease the effectiveness. This mixture has similar good 
qualities and an excellent warning effect, but cannot be 
used by itself, for it shows insufficient effects on louse- 
eggs. Because of the Instability of these two liquids, the 
mixture has to be produced shortly before being used as a 
gas (TV-procedure). 
Jllo-Special is similar to the last mentioned agents. 
It is a mixture of carbon tetrachloride and allyl mustard 
oil. Because of its slighter effect as compared with Ven- 
tox, almost 8 times as much of it has to be used. 
In spite of all the advantages of the gas procedure, 
a limit is set on its use by the insufficient supply of 
these agents and by the danger of poisoning; therefore a 
special training of the staff is required. The gas-pro- 
cedure used in a well organized plan may help complete the 
possibilities offered by the hot air method. 197 
9, Fundamental instructions for combating lice with 
impregnating agents• 
Stabsarzt (Captain, MC.) FINGER 
Two kinds of impregnating agents are being supplied 
for combating lice, in one Xanthogene compounds become ef- 
fective on the respiratory organs, whereas the other, which 
consists of organic halogenous compounds of the pentachlor- 
idiphylethan type, has a poisoning effect mainly by contact. 
The development of the impregnation method with Xanthogene 
preparations is based upon the concept that it should, be 
possible to produce - analogous to the chamber method - a 
toxic zone close to the human body inside the clothes by 
the use of highly effective gases, in which a distribution 
of the noxious vermin is obtained. The experiments carried 
out by REICHMUTH showed a possibility to impregnate textile 
fibres by precipitating the active substances by oxidation. 
This method was originated by FREIBERG and the development 
of the Delicia delousing preparation now being introduced on 
a large scale will afford the possibilitjr of an economical 
use of raw material and ,a particularly effective use of the 
molecular rations of mixture, when comparing the quantity 
of the Precipitated product with that of the basic product. 
Owing to the particular method in which Xanthogen com- 
pounds are used their effect will be limited to a relatively 
short time. These chemical substances have to undergo a 
chemical decomposition, in order to develop their insecti- 
cidal property acting on the respiratory organs. The arom- 
atic halogen compound, used as a contact poison, may remain 
on the fibre for quite a long time, without loosing its act- 
ive properties, because their compounds are effective, just 
as they are without any previous chemical reactions. 
The experiments carried out by REICHMUTH show that the 
effect of these particles depends on a special sensibility 
of the insect‘s legs and the distribution of the insecti- 
cide. The mentioned chemical substances are most effect- 
ive on the finely built nervous organs of the insect’s legs 
when they are used in the finest possible distribution. 
This fine distribution has been achieved by the described 
substances used as agents acting by impregnation (Lauseto 
of the I.G. Farben plant). The good results which have 
been obtained by the Practical use substances is 
an important progress in combating animal vectors. 
Recent experiments and practical experience gained in 
the field confirm that neither a lowered percentage of the 
reedy emulsion nor a reduction of the active substance ef- 
fects the efficiency even slightly. This means an import- 
ant increase of the use of this method. "Lauseto"-impreg- 
natlon is effective for about 15 months on stored clothes, 
while the protecting against lice on clothes which are be- 
ing worn only lasts for about 3-4 months. If the clothes 
which were stored for 15 months are worn, they will still 
be -safe* for 3-months -to follow. The clothes impregnated 
with "Lauseto” may be washed, but should not be boiled or 
pressed. Soldiers who wear impregnated clothes remain free 
from lice, even if they join comrades who,are infected with 
lice.- It is the aim of our efforts to issue impregnated 
clothes to every soldier in the field. The underwear 
should, if possible, be impregnated right after being 
made, or at least before issuing them to the troops in 
the homeland. The impregnation of the underwear has also 
to be carried out by the troops themselves, as an exchange 
of the clothes during the short time of 3 - 4 months dur- 
ing which the impregnation is effective will hardly be poss- 
ible. 
The production of "Lauseto" and "relicia"-delousing 
preparations is guaranteed in the future after overcoming 
all difficulties in obtaining raw material. 
10. Impregnation agents (Lauseto. Delicia) powders. 
Sonderfuehrer Mssenschaftlicher Rat (Special 
Consultant and Scientific AdvisorTREICHMUTH 
It is common knowledge now that the lice may not be 
checked and away from men bv odors. The irritation- 
receptors of the louse are of different sensitivities 
(valence of senses). The louse is recognized as an animal 
longing for warmth. The efforts concerning lice protect- 
ion have therefore been concentrated on the use of poison 
with a prophylactic effect. 
For the first time prophylactic protection has been 
achieved rith Xanthogene-compounds in the active ele- 
ment is based upon the poisoning effect on the respiratory 
organs of the Bisethylxanthogene. Under the effect of 
these chemicalsjacting by impregnation on textile fibres 
the lice rill die, owing to the destruction of the egg- 
laying and sucking organs. It is not necessary for the 
lice to contact the agent as the vapor passes through the 
fibre. 
The necessity of contact with the chemical arises in 
the use of the preparation on the basis of chloride. A 
solution containing only 0.01 per cent of the active in- 
gredient has been efficient enbugh to kill the lice with- 
in 24 - 48 hours, if only two claws of the insect were 
moistened. 
Besides these experiments, tests were made to prove 
the effect of a fine dispersion of the insecticide and of 
the sensitivity of the noxious vermin’s leg. In Dipheny- 
lenoxyd, for instance, it was observed that the substance 
which heretofore did not lend itself for practical use 
became useful as an insecticide when finely distributed 
on the textile fibre (when ironed). 
According to these findings, more intensive effect 
was obtained by increasing the degree of 
with the aromatic halogenated compounds of Pentachloridi- 
phenylethane gas. These surprising statements, are 
important for practical purposes were based on the dis- 
covery of highly sensitive cells on the feet of the louse. It was confirmed that the special poisoning effect by con- 
tact of Pentachloridiphenylcthane gas results from the 
method of impregnation, through which the best possible 
distribution of the active substance has been obtained, 
in consideration of the sensitive organs on the feet of 
the noxious vermin. 
These results can be applied likewise to the powder- 
ed insecticides. It seems to be of great importance that 
finely distributed powders with poisoning effect by con- 
tact constitute a more rapid and economical method for 
vermin control when spread in boots and socks, and is ad- 
vantageous over the method of treating leathergoods by a 
wet procedure. We know from experience that we cannot 
discard the use of the powdered agent in war tine. These 
procedures will be used most extensively as soon as the 
necessary Quantity of raw material can be produced, as is 
the case for the Russia powder now in use, 
11. Consideration of the toxicology of Insect!cldcs of 
importance to the Armed Forces. 
Oberstabsarzt (Manor. NC.) Prof. FIRTH 
When judging the question as to what extent people 
are exposed to danger when dealing with chemicals for com- 
bating vermin, the absolute poisoning effect e.g. the 
toxic or lethal dose for men or warm blooded animals is 
an essential, but not exclusively decisive factor. It is 
of great importance to recognize the warning effect of the 
agent, which is produced, by irritation of the sensitive 
nerves of the ocular conjunctiva, the mucous membrane of 
the nose and throat and other organs. Finally physical 
and chemical factors Play an important part, such as evap- 
oration, solubility in water and fat, adsorption and the 
possibility of ventilation. The agents for disinfestation 
used for military purposes may be divided into groups, 
according to their chemical composition. 
1. Cyanide compounds. 
Hydrocyanic acid, one of the most effective agents 
for vermin control, which was used during the first World 
TrTar, combines all disadvantages from a toxicological point 
of view. It is the most poisonous agent that has ever 
been introduced and it is, in addition to that, not easily 
detected by the senses. For this reason the use of pure 
hydrocyanic acid is not authorized for military use, es- 
pecially not the so-called "tub-procedure". Only the well- 
Vnown Cyclon preparation may be used for military purposes, 
in which a porous carrier is impregnated with hydrocyanic 
acid in connection with an easily detected warning sub- 
stance. 
The organic Cyanide derivates, Tritox, chemically 
called Trichloracetonitril, as well as Ventox and Acryni- 
tril have been used as agents for vermin control since 
about 1939* , M°st cyanide compounds are active, approximately in 
the ratio of the cyanide portion contained in the molecule. 
This does not apply, however, to Tritox and Ventox. They 
are considerably less active considering their cyanide 
contents. In these compounds the cyanide group is so firm- 
ly linked that even after weeks no hydrocyanic acid can be 
traced in aqueous solutions of Ventox. Both nitriles, when 
inhaled, have only the 40th part of the toxicity of hydro- 
cyanic acid. It was proved by our own experiments that 
their effect on fermentation processes is even less; for 
instance, Ventox exercises only approximately the 100th 
part of the inhibitory effect of acid when 
used in yeast fermentation and cell respiration; when us'd 
for the catalytic-reaction it has even as little as the 
30 000th part of the inhibitory effect of hydrocyanic acid. 
The course of poisoning is also different from that of 
hydrocyanic acid. Apart from the irritation of the mucous 
membranes of eyes and nose caused by these cyanide compounds, 
acute poisoning symptoms such as excitement and subsequent 
paralysis, which are typical manifestations of poisoning by 
hydrocyanic acid, have been observed less frequently in case 
of exposure to cyanide comnounds. Characteristic for ex- 
posures to the cyanide compounds subacute cases of para- 
lysis appearing at a time when the patient is no longer ex- 
posed to the poison. In this respect, Ventox is more simil ... 
to the reaction of Ethylenoxyd. Tritox is the moderately 
strong irritating substance of the two nitrils. Because of 
these properties and because of its ideal possibility for 
ventilation, Tritox can be considered as practically harm- 
less. Ventox is perceptible by its odor even in innocuous 
concentration in otherwise odorless environments to experi- 
enced persons but it has far less of the specific irritat- 
ion effect of Tritox. An ’’upper limit”*at which the smell 
becomes intolerable does not exist, even at 800 - 1000 
milligrams per cubic meter for instance, and many people 
become accustomed to the odor. 
Therefore Ventox, though having approximately the sri-' 
absolute poisoning effect as Tritox, is considerably more 
dangerous in its use. 
The method of simultaneous application of Tritox and 
Ventox, as developed by the medical section of the Armed 
Forces, is considerably less dangerous for men. 
2. Ethylenoxvd• 
The toxic effect of Ethylenoxyd when breathed by men 
and warm blooded animals is about the same as Ventox. It 
may be said that Ethylenoxyd is less toxic. After-effects 
are characteristic for Ethylenoxyd, which combined with 
motor paralysis and convulsions, may lead to death. Ac- 
cording to investigations carried out by FLURY and FIFTH 
this may be due to the intracellular reaction of aldehyde. 
* The "limit of intolerance” is defined as the concentrat- 
ion in milligrams per cubic meter, which, if active for 
one minute, compells people to leave the room. Ethylenoxyd is hardly perceptible by the senses 
(smell, irritation). The possibility of ventilation is 
limited as with hydrocyanic acid. The hazard of Ethylen- 
oxyd and T-gas is almost as great as that of Ventox. 
3• Chlorinated hydrocarbons. 
Carbon tetrachloride and trichlor ethylene are oc- 
casionally used as an additive or a substitute or even 
purely if nothing else is available. Both agents have 
about 1/10 of the toxicity of Ethylenoxyd. It is not al- 
ways easy to detect them by their odor. The danger of 
chronic poisoning must be kept in mind always. Neurasten- 
ic symptoms (such as sleeplessness, loosing of appetite, 
headache, fatigue, gastro-intestinal disturbances) and 
furthermore anemia, liver troubles, disturbance of the 
central nerve systems even to delirium and raving madness 
have been observed. Cautious inspiration often causes a 
state of intoxication, euphoria and "Tri-mania11. These 
agents which are not inflammable offer great advantages 
in their use, but the possibility of the formation of phos- 
gene gas in centers with open fires must always be consid- 
ered. Numerous cases of poisoning from the use of carbon 
tetrachloride in small medical bunkers have become known 
during this year. These agents should therefore not be 
used to a large extent for combating vermins. 
Jllo-sPecial: Jllo-special, which is not easily per- 
ceptible by itself will be easier recognized if ally! oil 
of mustard and carbon tetrachloride is added. Since the 
"limit of intolerance" for allyl oil of mustard lies at 
50 milligrams per cubic meter, Jllo-special could be con- 
sidered as a relatively harmless substance, if the chemical 
composition remains constant. Some alleged cases of poison 
ing, which have lately been caused by Jllo-special, are ex- 
plainable only if the possibility of a different chemical 
formula is admitted. 
4. Chlorpikrin ("Klop"). 
Trichloronitromethane is used for combating vermin in 
France and Russia. It is of great interest to study the 
captured material concerning this matter. "Klop" which was 
used as a war gas by the French during the first World War, 
forms methaemoglobin when used in high concentration for 
combating vermin, but causes toxic edema of the lungs when 
used in low concentration, similar to phosgen. The examin- 
ations carried out during the first World War show that the 
fatal concentration for cats is at 6000 and at 6000 - 1200C 
according to our own experiments. Chlorpicrin has a strong 
irritation effect on the eyes. Owing to its excellent 
warning effect, chlorpicrin is a convenient agent for com- 
bating vermin, from the toxicological point of view, in 
spite of its small possibility of ventilation. ' 5 * Areginal* 
Although no cases of poisoning have previously been 
known in the use of Afeginal, the methylformiate, this 
agent has to be used cautiously because of its typical 
after-effects, which are partly caused by accumulation* 
Similar to all methyl compounds, the formation of toxic 
products has to be considered# An especially disagree- 
able after-effect is caused by the formaldehyde produced 
intracellularly (FLURY and FIRTH). 
6* Sulphur dioxide• 
In contrast to the above mentioned agents,which are 
effective by resorption, sulphur dioxide is locally ef- 
fective, and causes irritation and inflammatory effects 
of the mucous membrane and of the eyes and throat# Sul- 
phur dioxide is relatively harmless and may be detected 
by its smell, even in low concentration, similar to Tri- 
tox. 
7 • Xanthogen-prepa.rat ions . 
The firm C.F. BOFHRINGER, Mannheim-waldhof owns an 
old German patent relating to a product called "Aulino- 
genft. This is an ointment and on oily solution 
Bixanthogen for combating lice and scabies. When mixed 
with sulphur it can be used for treating eczeme, acne 
and furunculosis. 
During the Russian campaign 1941/42 a preparation *. 
was found with the Russians, which also contains Bixan- 
thogen for combating lice, for instance in the so-called, 
"Russian-K soap'1. 
German firms have made use of the effect of Xantho- 
gen compounds during the last year by producing further 
preparations, such as f,Russla-powderM and an agent for 
impregnating washing, the "Delicia" lice preparation# 
while the effective agent Bixanthogen is already contain- 
ed in the BOEHRINGER preparations, it is produced by 
oxygenation of potassium-xanthogenate in "Russla-powder" 
and in "Delicia" delousing preparation. 
The necessary oxygenation is taken care of in ’’Russ- 
ia-powder", whereas a special substance, such as potassium- 
persulfate must be added to "Delicia” for this purpose. 
In the latter case Bixanthogen is more or less absorbed 
by the fibre of cloth. This process is shown in the fol- 
lowing structural formula! 
Kaliumpersulfat 
Bixanthogen 
Kaliumsulfat 
Xanthogen The pure Boxanthogen is colorless and almost odorless. 
The white crystals become yellowish if exposed to the air 
and have an unpleasant pentrating smell, similar to mere a oc- 
tane. In the attempt to distill Bixanthogen it separates 
into its chemical substances, thereby forming toxic products 
such as carbon disulphide. 
The toxicological examination of Bixanthogen, carried 
out with ray colleagues Dr. POSTEL and Dr. SCHOLZ, showed 
no special results on mice except a numbness during the 
first exposure*, when they were exposed to the vapors of the 
preparation for 20 days for 2-4 hours daily. The vapor 
of the substance is obviously too weak to cause any damage 
to the animals by inhaling the vapor which is developed by 
the preparation. The patch test with bixanthogen showed no 
irritation on the human skin, even when exposed for several 
days. If, however, the skin of a puppy-dog was dabbed with 
a solution of 10 per cent of Bixanthogen, in benzine every 
other day for about 3 weeks, the epidermis, as well as 
hair will come off. This ishows the keratolytic effect- of tJ e 
preparation, which is caused by its sulphur contents. No 
other general effects were found in the animals (the increase 
of weight has been perfectly normal and the urine has shown 
no findings). The substance causes, however, specific irrit- 
ation of the conjunctiva of the eyes as well as of the mucous 
membrane. There is no objection to the use of 
preparations from the toxicological point of view, although 
we must admit that the very strong and unpleasant smell will 
often spoil the pleasure of using these preparations. 
8. Condensation products of chloral with halogen 
hydrocarbon (Gesarol-preparationT. 
The Swiss firm of GEIGY owns a German Patent of 1943 
relating to a group of substances for combating insects, 
which constitute condensation products of chloral with dif- 
ferent aromatic compounds such as benzol and its derivations 
with aliphatic compounds, such as urethane, formanid etc. 
The condensation products of this group of substances, in- 
cluding chlorbenzol or fluorbenzol are of special interest: 
Chloral 
Chlor(Fluor)benzol 
Th© compound which is derived from chlorbenzol is contained 
in the agent acting by impregnation for washing used for 
combating lice, Called "Multocid", which has only recently 
been produced by the firm SCHERING as well as “Lauseto" 
produced by the I.G. Farben plant. The agent for combating 
insects called "Gix" contains the fluorine compound. 
The substances which are insoluble in water, are, ac- 
cording to our own experiences without any notable effect 
on rats, when used subcutaneously in doses up to 2 grams 
per kilogram/body-weight in aqueous solution. Cats which 
are injected Intramuscularly with a stronger dose of the substance mixed with olive oil, show serious disturbances 
of the nerves, twitchings and muscular contractions. 1 
gram of the fluorine compound used per 1 kilogram/body- 
weight of the animal still has a deadly effect. The chlor- 
ine compound has at least the same poisonous effect. The 
substance showed neither any irritation of the skin of the 
animal nor of the skin of men, this has been demonstrated 
by our own experiences. These substances have no disturb- 
ing effect on the mucous membranes such as the conjunctiva 
of the eyes. 
The Gesarol-preparations, which are already on the 
market, consist of a solution of the effective substances 
in an organic solvent and as far as their toxicology is 
concerned have to be considered from a different point of 
view according to the nature of these solvents. A greater 
percentage of chlorinated hydrocarbon, such as trichlorethy* 
lene, complicates its use. In this case impregnation has 
to be carried out in a well aired room, especially on hot 
days, in order to avoid any injuries of the attendants. 
No case of poisoning has up to now become known in the 
use of Gesarol preparations apart from nausea caused by un- 
suitable solvents, such as Trichlorethylene for instance. 
At present examinations are being made to determine whether 
or not the above mentioned nerve effects of the effective- 
substance are of toxicological importance in practical use. 
Discussion of the lectures concerning disinfestation; 
HUENE* It would be desirable to establish comparable 
data concerning the capacity of all delousing establish- 
ments. It is difficult for instance, to establish the num- 
ber of persons r’ho have bo be disinfested within a certain 
tine (8 hours) as the different units and branches of the 
Armed Forces need a different amount of clothing racks per 
person, owing to their different equipment (it varies bet- 
ween 1-6 clothing racks). The number of racks needed 
should always be considered when making any statements with 
regard to the capacity of delousing establishments. 
In cases of delousing chambers with hot air ventilat- 
ion a double ceiling with a distance of 20 - 25 centimeter 
between each ceiling has always proved, very satisfactory. 
The hot air blown into the double ceiling will heat at 
first the wall opposite the blowing tube and then the ad- 
jacent wall of the delousing chamber, whereas the chamber 
will remain cold on the side where the air is blown in. 
In order to obtain regularly distributed heat it becomes 
necessary to insert special baffles (bricks placed vertic- 
ally or horizontally) which deflect the stream of hot air. 
Deflecting sheet material baffles for a uniform spreading 
of the heat have proved very satisfactory. 
The results of an examination concerning the spread- 
ing of the heat may be laid down in illustrative curves. 
The temperature can be ascertained by a maximum thermo- 
meter at a certain time and in different places, or with 
a pyrometer at different times and in different places of 
the chamber. KREUSER; The experiences of the Eastern front (Middle 
East) have shown that the simplest methods have to be used. 
Therefore portable delousing boxes have been produced in 
bulk for each army (collapsible and transportable on small 
carts, capacity, 5 outfits). The method "f impregnation 
has shorn an extensive freedom from lice among the fight- 
ing troops. The troops are usually infected with lice and 
shotted fever by contacting civilians, therefore it is nec- 
essary to consider more generally the disinfestation of 
civilians. The disinfestation stations of the Armed Forces 
medical service, in collecting stations and hospitals re- 
present another important barrier. Turing the establish- 
ment of these delousing stations the medical officer must 
instruct the technician according to his own experience in 
this field. 
HARMSEN: In comparison vTith Russia the possibilities 
for physical disinfestation in the Balkans are reduced due 
to the enormous difficulties in getting raw material. The 
work of the plants is frequently interrupted by shortage 
of fuel. The guerilla warfare in the mountains makes the 
supply of portable disinfestation equipment almost imposs- 
ible. The results obtained with ’’Delicia” were more im- 
pressive. Units, which had always been infected with lice, 
remained free from lice for several weeks. It is import- 
ant to impregnate the washing and clothing of the prisoners 
of the guerilla warfare units as soon as possible, as they 
are, almost without exception, all infected with spotted 
fever and the disease would spread epidemically in and be- 
yond the PW-camps, in spite of the disinfestation of the 
PW* s. 
PETER; The simplest methods for delousing purposes 
have also to be adopted for the Airforces in the theater 
of war. The development of the new and complicated in- 
stallations is therefore unnecessary. Only medical units 
are able to supply ’’Lauseto” and other agents for disin- 
festation in time, as has been demonstrated by a long ex- 
perience. The impregnation of underwear has to be super- 
vised by the medical staff. 
WEYER; Great importance has to be attached to the 
makeshift methods for disinfestation at the front, behind 
the lines, and in the home country. It is difficult to 
disinfest the body as well as leathergoods, furs, rubber 
etc., which is due to further shortage of the effective 
chemical agents for combating insects. Practical suggest- 
ions for such makeshift disinfestation are very welcome. 
ROSE: In spite of the enormous progress obtained by 
”Lauseto”-impregnation the use of gas and heating methods 
should hot be given up entirely. It should at least be 
used until the necessary supply is available without dif- 
ficulties. We have also to consider the danger caused by 
the production failures. For this reason the use and pro- 
duction of ’’Delicia” should not be abandoned as it is still 
more efficient than the use of disinfestation with hot air. 
Although ’’Lauseto” is superior in its effect, ’’Delicia” 
might be used if the former is not available. I am^also 
in favor of the request made by HUENE not to determine the 
capacity of delousing establishments according to^the num- 
ber of people or number of outfits. There is a risk of spontaneous combustion in installations for disinfestation 
with hot air caused by dangerous contents of pockets, as 
well as by the oily clothes. We have to consider that oil 
has very often a much lower ignition temperature than the 
clothes themselves. This leads to spontaneous combustion 
in the chamber even if the construction of the chamber is 
perfectly designed. 
REICHMUTH: It is emphasized that no definite decision 
should be made as to the use of these products. "Lauseto" 
and other preparations are good if sufficient quantities 
are available. As to the entire field of disinfestation 
a change of the products to be applied has to be expected; 
but we cannot yet dispense rfith the well-known preventive 
measures which have proved satisfactory. 
FINGER: I am glad that during the discussion the 
question has been raised whether the physical disinfestat- 
ion can be eliminated by the use of the chemical disinfest- 
ation applying the impregnation method. It is my opinion 
that this can be done. The main problem, however, is the 
question of the organization by which all units may be 
supplied with siff'icient agents fdr impregnating all the 
underwear. This depends above all on the supply of raw 
material. It 5s necessary to further the development of 
contact-poison in the manufacture of the presently used 
chemicals as we depend on raw material which is available 
only with difficulties. Therefore we have to find ways 
and means to overcome the bottle-necks in case of unfore- 
seen events. I should like you to come to a decision now, 
as to whether or not the use of the contact poison for im- 
pregnation will be exclusively adopted in the future. 
Directions for the use of agents for disinfestation: 
I, Physical disinfestation. 
1. a. Simple instruments with static hot air (principle 
of a baker’s oven) 90 degrees Celsius for 90 min- 
utes. 
b. Instruments with agitated hot air without regul- 
ated flow EE-instruments (VONDRAN) 80 degrees Cel- 
sius for 60 minutes. 
c. In case of a possible introduction of TCP-instru- 
ments e.g. motor driven instruments with regul- 
ated flow of hot air should be used. 80 degrees 
Celsius for 15 minutes. 
One should be guided by the principles 
that only instruments easily handled will 
prove successful. In the army. The instruments 
mentioned under a. are used for the army in 
the field, b. & c. for border areas (railway 
marshalling yards, ports of embarkation, air- 
ports) and for the home country. 
2. The disinfestation has to be decentralized to the ut- 
most in the army. The infestation has to be combated 
freouently in the troops, squadron etc. 20? 
3. If ovens are not available locally the troops have to 
use the delousing boxes of the army, which are collaps- 
ible and transportable on small horse carts. These 
boxes are specially recommended. A great number of 
drawings of these boxes will be distributed to all 
units, Airforce administrative areas etc., so they may 
produce this box themselves. In emergency cases, mass- 
production is advisable in consideration of the exper- 
iences made by some army units, alrfores, etc. 
4. Some units still use instruments for disinfestation 
with steam although the frequent use of steam damages 
the clothes more than a disinfestation with hot air at 
the above mentioned temperatures. The following times 
of application and temperature have to be observed: 
96 - 100 degrees Celsius (steam flowing without press- 
ure) for 45 minutes beginning when the steam starts to 
flow from the outlet valve located at the bottom of 
the chamber. 
In such installations the steam will be in- 
troduced at the ceiling of the chamber; a sheet 
metal'gutter will be fastened below the opening 
where the steam enters in order to catch the con- 
densed water. The clothes must not be packed too 
tight and they must be hung on suitable racks. 
5. Suitable racks have to be used for any kind of disin- 
festation with damp or dry hot air in order to avoid 
a too tight packing of the clothes. The drawings 
which show instruments for delousing purposes should 
also show drawings for clothes racks. 
6. The temperature has to be regulated frequently during 
the disinfestation. If no thermometer is available, 
the so-called testpipes have to be fastened at a place 
where unfavorable heating conditions prevail. It is 
recommended to use Naphtalln, Anasthesin and Pyramidon 
as indicators for test material. The melting point of 
Naphtalin is 80 degrees, of is 90 degrees, 
and of Pyramidon is 108 degrees Celsius. In hot air 
devices the thermometer has to be fastened in the lower 
third of the box.in steam devices at the outlet opening. 
7. In installations working with agitated hot air (lib) 
or with forced draft of hot air (11c) the directions 
for use have to be carefully adhered to. 
8. It has been observed that combustible contents of pockets 
or oily clothes often catch fire. Therefore it is ad- 
visable to remove these combustible contents of the 
pookets and to delouse the oily clothes separately. 
9. The capacity of the delousing chambers is 3 outfits per 
squafce meter of floor space. One outfit consists of: 
1 jacket 
1 trousers 
1 coat 
1 hat 
1 set of underwear 
1 blanket equal to 1 coat 20?a 
As regards the capacity of Installations with agitated 
hot air (11b) and installations with forced draft hot 
air (11c) please refer to the appropriate instructions. 
10. Leathergoods and furs, as well as clothes made of rubber 
must be washed in a 5 per cent cresol solution and have 
to be dryed before disinfestation. 
Chemical disinfestation (II) is the method of 
choice for all clothes of this sort. 
II. Chemical disinfestation. 
1. The chemical disinfestation has been proved satisfacto.. 
for the use of agents acting by impregnation for wash- 
ing. Especially the preparation "Lauseto” has shown 
good practical results for combating lice and as is kn 
from experience affords a simple and effective means 
which may be used in various ways. 
2. If the use of impregnation is not possible, the clothes 
blankets and beds may be sprayed with the agents. 
3. If the impregnation of the washing cannot be carried 
through, the former delousing methods have to be used 
(see sections I & II). The procedure mentioned under 
3 is an emergency measure. 
4. The greatest value of the agents acting by impregnation 
is their practical use by the troops. It is advisable 
to impregnate the stored washing and equipment of sold- 
iers. Impregnated washing must be marked as such. 
5. The 1 per cent emulsion of "Lauseto" has to be used as 
a rule for impregnations and for the emergency method 
of spraying. 
6. The most suitable use of the agents acting by impregnat- 
ion for washing ("Lauseto" and "Delicia") is guaranteed 
by the following schedule: 
a• For the troops: 
Used in the shower-room of the unit, to avoid ex- 
cessive waste of material. 
b. Used in the medical service (main dressing station, 
motorized medical rescue squads of the Airforce 
and in local field- and base-hospitals). For im- 
pregnation all underclothes, bedclothes of sick 
and wounded soldiers, as well as of the medical 
staff; further for impregnating cotton padding 
and bandages for large plaster of Paris casts. 
c. Used in collecting stations for injuries, centers 
of evacuation, also for hospital trains, ships and 
aeroplanes. Used for impregnating or spraying all 
outfits straw-matrasses, blankets, as well as the 
clothes of sick and wounded soldiers. d• Non-combatant personnel of the Armed Forces* 
The distribution priority depends on the degree of 
the infestation and has to be decided locally* 
7* Besides these procedures the agent for disinfestation 
can be used in the form of gas for gas chambers (hydro- 
cyanic acid, Ventox, TV-orocedure) Jllo, Areginal and 
others can* be used according to the directions which 
were effective previously, except sulphur dioxide or 
formaldehyde vapor. For delousing chambers in tents 
"Jllo" must not be used. The inside walls of the de- 
lousing chambers have to be of such nature that the gas 
will not be absorbed -(smooth walls, cement with suitable 
oil paint). 
8. The previous experiences have proved that the supnly 
and distribution of chemical agents for disinfestation 
should be taken care of through medical official chan- 
nels. The use of these preparations should systematic- 
ally be supervised by the medical services, as it has 
already been done. 
131 _The flea nuisance on the Ionic and Aegeen Islands. 
Cause and Controls 
Flottenarzt (Naval Surgeon) Prof. Z5CHUCKE 
The flea nuisance in the area of Greece is limited to 
a sharply confined center and often becomes so intense that 
in some units one man is infected with an average of 100 
fleas per day. 
This is of little consequence from the medical point 
of view, apart from a skin disorder, which causes sleepless- 
ness and sometimes a reaction of hypersensitiveness of the 
skin* Ih summer ulcers occurring on the leg below the knee 
are sometimes due to scratched flea-bites. It has to be 
siderrd that there is a slight possibility of transmitting 
plague.'from rats and kala-azar from infected dogs. 
It is a remarkable peculiarity of the flea nuisance in 
Greece that the fleas are not only to be found in stone hous- 
es, wooden barracks or bunkers, which were already inhabited 
before being occupied by our army or enemies, but also the 
fleas attack tents and underground positions soon after their 
establishment - which have never been occupied before nor 
used for agriculture purposes - especially when the ground 
consists more or less of dry sand. The human is known 
to be a specific nest-parasite in the temperate spend- 
ing the entire time of development on the host. Despite 
this fact its resistance against lack of food (up to 18 
months) and the absence of a specific monophagy (the desire 
for only one kind of food), - it can even live on the blood 
of cold blooded animals - allow it a great freedom of move- 
ment. The larva being sensitive to dryness as well as to 209 
moisture probably does not find favorable conditions of 
life during its development, which lasts between 9 - 200 
days in our climate in the open air. 
The following theoretical possibilities for explain- 
ing the peculiarity of the flea nuisance in Greece are un 
der discussion: 
1. The nuisance is not caused by Pulex irritans, 
but by fleas, the main hosts of which are animals 
living in communication with men namely: 
Ctenocephalus canis and Ctenocephalus felis, 
Ceratophyllus fascinatus (europ. rat flea and 
plague vectors), 
Ceratophyllus gallinae, gallinulae, columbae, 
hirundinis, 
Xenopsylla cheopis (trop. and subtrop, rat flea 
and plague vector), 
Spylopsyllus cuniculli and Leptopsylla musculo 
(rare)• 
We have investigated this problem, but due to tho 
shortness of time we had to restrict our investig- 
ations to two districts, the Isle of Aghina and 
the north coast of the Peleponnese (Lutrakion), 
My colleague STAUDENMEYER found in both cases ex- 
clusively pulex irritans being parasitic on the 
skin of man and Ctenocephalus canis on dogs, al- 
though both were living in bunkers in close com- 
munity. These statements don’t allow extensive 
conclusions to be drawn from them for man may suf- 
fer sometimes more from dog-fleas than from human 
fleas and on the other hand, the dog seems to be the 
most important secondary host for human fleas. The 
possibility of being affected by animal fleas has 
always to be considered and this Problem has to be 
settled in each individual case for the interests 
of effective combat. 
2. Pulex irritams doos.nfct require any protection of 
human dwellings in the subtropical climate of 
Greece, as they are able to pass their development 
in the pen air, especially in dry sand. The pro- 
pagation of the fleas by laying the eggs in the 
sand, has already been observed and for that reaso n 
the possibility of a develoment in the open air 
has been presumed, but this is contradicted by the 
consideration that the larva does n6t find adequate 
food in the sand for it lives above all on human 
detritus in the form of ephithelial scales and 
especially on remainings of the blood which are 
excreted, almost unchanged with waste matter by 
adult fleas. As the fleas also live on detritus 
of plants, such as dust of cotton wool and corn, 
this second possibility cannot be refused without 
any further investigations. 3* It is known that the human flea occasionally 
wanders about in large swarms; it may be possible 
that the desire for swarming is favored by the 
dry-hot climate of the Greek summer* 
A definite explanation of the prdblera concerning the be- 
ginning of the flea nuisance in Greece cannot be given, 
owing to the insufficiency of the literature available to 
the investigator. The following directions for removing 
the flea-nuisance are suggested: 
First of all the kind of flea living as a parasite 
on man has to be determined, dealing with animal 
fleas the host has to be combated or disinfested* In the 
combat against rats and mice their cadavers have to be re- 
moved quickly, as the fleas turn from cool cadavers and 
attack secondary hosts. For military and ethical reasons 
it is prohibited to keep dogs in advanced positions* It 
is desirable and understandable to the owner of dogs that 
they are required to clean them regularly with a 5 per cent 
cresol-soap solution or with a dry treatment of insect 
powder. The flea brood has to be combated by scrubbing 
the rooms and furnitures with a thin cresol-soap solution, 
but even dampness alone should be effective, provided that 
sufficient liquid has been used and not dried up. 
Both methods will prove effective only in the long 
run. An immediate effect on adult fleas can be obtained 
by disinfestation of the room with hydrocyanic acid, tri- 
tox, Jllo or sulphur dioxide (not to be used in bunkers) 
also by a fumigation with Naphthalin (the latter being 
very scarce lately). 
A certain effect can be obtained in rooms full of 
fleas by the use of the following emergency methods, such 
a spraying liquid with insecticide action, strewing in- 
sect powder or Naphthalin into the clothes, picking up 
fleas or catching them with the aid of individuals who 
attract fleas. At least it is recommended to air the 
room daily, to beat the clothes and bedclothes and ex- 
pose thorn to sunshine and strew them with paradichlorben- 
zol (Globol). 
Discussion: 
EMMEL: In the dry desert district of the Gyrenacia 
it has been repeatedly observed that the development of 
the flea larva depends to a certain extent on the degree 
of the humidity of the surrounding medium. During the 
drought the flea attacks people in those tents where the 
floor is covered with mats, which are slightly sprinkled 
with water for cleaning purposes. The fleas caught are 
human fleas (pulex irritans). 
MUEHLENS: Concerning the flea nuisance I wish to 
mention that I was attacked by fleas in pure sand far from 
any settlement. A large quantity of fleas could be seen 
on the beach of a small Island near Crete, where boats 
were landing regularly. In July with the ripening of the 211 
grapes the fleas disappeared. The fumigation with tritox 
has shown good results in combating fleas especially when 
used in bunkers or caverns in Africa. A significant re- 
duction of the fleas nuisance was obtained by washing out 
the prison camps with large quantities of water performed 
by the fire brigade. 
WEYER: The fleas and the dog fleas have no share In 
the transmission of leishmaniasis (a disease due to infect- 
ion with a species of leishmania). But there is still some 
confusion as to whether or not certain apathogenic flagel- 
lates are permanent or temporary parasites. 
A considerable source for flea nuisance in billots 
are dogs and their kennels, which are n°t kept clean. 
This kind of flea nuisance consists of dog fleas. The me- 
dical officer should bo able to decide whether this flea 
nuisance consists of human or animal fleas. Mass-breeding 
places for fleas are amongst other animal stables, such as 
horse and donkey stables. 
ECKSTEIN: It is of great importance to find the orig- 
inal source of the fleas, as the indigenous non-military 
personnel often bring fleas from their homes into offices. 
This is given as an instance in Hierachin on the Isle of 
Crete and in Hamburg at St. Pauli. In both cases people 
were infected by human fleas. 
In Hierachin on the Isle of Crete fleas were observed 
in great masses on the sand in the barracks-yard, which 
was defiled by the rubbish of the adjoining houses. Even 
in Lappland masses of pulex irritans were seen in billets 
built on sand. 
STELLWAAG: As far as I have experienced the fleas 
jump on any man or even on any moving subject. The fleas 
do not prefer a certain kind of man, the effect of the 
bites is due to the man’s sensitivity. Some people don’t 
feel any reaction of the flea bites and therefore believe 
they have not been biten at all (similar conditions are 
1 nown in lice and bugs). Every human being may serve as 
bait for fleas. 
The firm of ’’DEGESCH” in Frankfurt am Main has tested 
Gix on fleas. After having sprayed the floor with Gix the 
flees disappeared for about 3 weeks, after that one by one 
appeared again. A second treatment carried out after about 
4 weeks has removed the fleas entirely. 
KHUEPE: The flea nuisance was also removed in tents 
by spraying damp Gix and Gesarol. 
ROSE: Valuable and rare substances such as Gix and 
Gesarol should not be employed for combating fleas. These 
agents have in the first place to be reserved for combating 
those vermins which as transmitters of epidemics endanger 
the readiness for action. Keeping dogs with the 
troops for other than official purposes has to be prohibit- 
ed for different reasons (madness, carrier of leptospira, 
reservoir of epidemics, leishmaniasis, transmitter of 
cysticercus and other diseases, carrier of vermin). The order to avoid any unnecessary hazard and dogkeeping can 
only be allowed in the field according to service regulat- 
ions# The medical service can only suggest it and has to 
set a good example for other* within its own area. 
Instructions for combating the flea nuisance on the 
Ionic and Aegean Islands. 
In the Balkans the flea nuisance, which is limited 
locally, has to be considered by each case, if they con- 
sist exclusively of human fleas or parasites of dogs, ro- 
dents, cats or chickens* In the first case the precaut- 
ionary measures have to be executed firstly against the 
proper hosts. The dogs and their kennels have to be clean- 
ed regularly with a 2? per cent cresol water solution and 
cadavers of rats and mice should be removed immediately so 
that their parasites cannot attack human beings*. In com- 
bating human fleas it is most important to destroy the 
brood by daily scrubbing with disinfection agents and by 
using a large amount of liouid, such as a diluted cresol- 
soap solution, sea or salt water. 
Adult fleas can be destroyed in the easiest v>ay by 
the use of poison gas (hydrocyanic acid, tritox, Jllp' or 
sulphur dioxid) carried out by well trained troops for 
vermin control, or by the method of spraying, which is an 
emergency means for disinfestation. Gix must temporarily 
be reserved for combating Anopheles and Phlebotomes. Daily 
airing and exposing the bedclothes to the sunshine is. ad- 
visable. Reports on respective experiences will be forward- 
ed by courier to the hygienist in care of Admiral of the 
Aegean, whose office identifies the transmitted fleas and 
examines samples of the room-sweepings picked up from the 
floor fissures. These samples, like fleas, keep well for 
practically unlimited periods if kept dry in test tubes. 
Combating bugs in the field and in the homeland* 
Sonderfuehrer (Special Consultant) Dr. ECKSTEIN 
At first attention is drawn to the fact that the dif- 
ferent disposition to react often leads to a false im-» 
pression of the bug. Referring briefly to the cause lead- 
ing to the present condition of combating bugs, the dif- 
ferent methods of combating are briefly discussed in 
connection with the interesting details as to the life of 
the bugs* 
The importance of wooden houses for the propagation 
of bugs is specially referred to and it is shown that 
overheating of the rooms makes the use of sulphuric acid 
evuupL more difficult. 
It is demonstrated that the close living together 
in the crowded cities leads to a higher danger of the 
spreading of bugs in these areas. 213 
The constant moving of equipment is of particular 
importance as regards the spreading of bugs in the billets. 
The measures to combat the bugs should therefore also ex- 
tent over the most important sources of infection. 
As the beds built into the walls of the barracks make 
combating of bugs even more difficult and favor the pro- 
pagation of bugs, the beds should never be built in. 
All useless boards have to be removed and a greater 
tidiness in the barracks must prevail. 
As we are not able to destroy bugs with good results 
every where and under all circumstances, methods have to 
be examined which are likely to give independence from 
gases which are difficult to procure and use. 
It is important to arrange a well trained organization 
to combat bugs at home as well as in the field. 
As the viewpoints of individuals with regard to bug 
combatihfe is often wrong, particular attention has to be 
paid to a comprehensive and general enlightment of the 
Armed Forces. This is of particular importance at home, 
in order to have the ground well prepared for legal measures 
to be taken in the time to come. 
Discussion: 
REICHMUTH: The gap between gassing methods and strewn 
agents must be bridged over for combating bugs under the 
present circumstance. This was achieved by ’’Atota-compres- 
sor dust method", which has proved to work well as was 
shown by laboratory and practical results. This method 
is suitable for such rooms as are provided with electric 
connections or with bottles of nitrogen and it has already 
shown good results in large barracks and in all those rooms, 
which cannot be made tight. 
The best prospects for success ..in combating with con- 
tact agents is now offered by ’’Room prophylaxis”. The 
conditions for the application of ’’Room prophylaxis” are 
based on the sensitivity of the bugs legs, on the effect 
of the distribution of insecticidal agents and on the toxic 
effect previously observed in Gesarol, diphenylamine and 
other chemicals. 
These experiments do not exclusively concern the de- 
velopment of insecticide, but their further object is, to 
study the effect of dispersion produced by various emuls- 
ions and suspensions upon substances with different poros- 
ity. Furthermore it will be examined how far the partic- 
ular object of room prophylaxis can be realized, especially 
in combating bugs by adding a mixture of the different in- 
secticides to chalk or oil paint. 
All previous investigations carried out in laboratories 
seem to justify the hope that room prophylaxis can be ex- 
ecuted by means of insecticide paint and therefore the 
practical application may be expected in the near future. KRUEPE; Two rooms of a wooden barrack infested with 
bugs were treated by me with 2 grams of emulsifiable Ge- 
sarol* In one room stood fixed beds and in the other self- 
built wooden beds. After 5 days the soldiers were still 
suffering from bug bites. The observations were not con- 
tinued after 5 days. It may be that after the time of my 
observation the bugs still came out of their hiding places, 
so that the immediate effect observed on fleas and gnats 
was not produced in the case of bugs. 
MUEHLENS: I was able to destroy all bugs with Gesarol 
in a large sleeping room tiled with stone slabs and furn- 
ished with iron bedsteads. The bugs lived in the mosquito- 
nets and in the mattresses. The fumigation with Gesarol 
was conformed with spraying guns and motor compressors. 
In barracks and native huts shingled with wood, reed 
and clay, Wiich infested with bugs, I piled all the 
clothes and equinment of a squadron in one room and fumi- 
gated it with Cyclon B in an emergency. The huts were 
scrubbed and sprayed with a cresol solution, the walls 
whitewashed and by this method the huts were almost free 
from bugs. 
ROSE; A discrepancy was observed in the reports con- 
cerning the first test with Gesarol, MUEHLENS has obtained 
good results, while KRUEPE did not observe any effect. 
Comparing these two statements it appears that MUEHLENS 
has fumigated the walls while KRUEPE only sprayed the walls. 
This is probably the reason for the different results. 
ECKSTEIN; The failure of tests with products similar 
to Gesarol for bug combating is often only illusive, since 
the destruction of bugs needs a certain latent period and 
will become effective only under certain circumstances, 
sometimes only after 10 days. Such a delayed fatal ef- 
fect will in most cases escape observation. 
LAUN; The use of Gix for combating bugs is not to be 
recommended, as I know from my experiences. The barracks* 
walls being sprayed with Gix showed no success, even bugs 
sprinkled with Gix survived. 
KLIEWE; Motor driven devices for disinfecting, dis- 
infestation and detoxicating purposes have been demonstrat- 
ed • 
EMMEL; I know several cases where the kennel of dogs 
were covered with fern-leaves for combating the flea- 
nuisance when no other products were available. W© had 
the impression that dogs did suffer less from fleas when 
the fern-leaves were renewed more often. 
LENZ; The question concerning the biological combat 
of bugs by spider has lately been proposed again. On the 
strength of my Information and of my own observation's in 
Greece I am convinced that the spiders in practice are of 
no special importance for combating bugs. In the South 
East there are several kinds of spiders which attack' and 
suck the bugs, but don’t search for them in their hiding 215 
places. Only if the bugs were chased systematically, 
the snider play an important part in their destruction. Be- 
sides, sucking a bug takes quite a long time. It would be 
necessary to breed a certain amount of sniders in order to 
have good results. The possibilities of this method are 
thus very restricted. 
TaRTLER: Is there any nroof that cockroaches extermine 
bedbugs? 
By coating the walls and furniture with a mixture of 
cattle gall and chalk good results have been obtained in 
my military district. A definite judgement cannot yet be 
given, but it would be worth while to gather all exneriences. 
ECKSTEIN; Cockroaches only eat bugs in case of need. 
Cockroaches and bugs don’t exclude each other. That does 
not mean that they live in the same rooms. Bugs like to 
live in dry places, while cockroaches prefer damp places. 
It is possible to find bugs in one corner of the room and 
cockroaches in another. 
14, Immunization against diphtheria and scarlet fever. 
Introduction• 
Oberstarzt (Colonel. MC.) Prof, ROSE 
The immunization against scarlet fever and diphtheria 
has been recommended except for a few restrictions by the 
consultant hygienist on the occasion of the third conference. 
The directions for use are given in the Report of the third 
Conference of the Special Medical Consultants, Section VI, 
Article 4, The results of the recommendation given at that 
time have to be checked after on year. A desire was ex- 
pressed especially from the clinics to be acquainted with 
the gathered results of the immunization. Furthermore we 
have to check whether the technical recommendations given 
one year ago have showed good results or if a modification 
is necessary. It is of great importance to answer the 
question whether the immunization affords anv provable pro- 
tection or not. The burden placed on the troops and on the 
medical service by every immunization lg bonsiderable# Im- 
munization reactions cannot be avoided even if utmost care 
is used. The advantage of the immunization must be estab- 
lished beyond doubt or has at least to be made plausible 
to .iiake us accept the responsibility of a compulsory im- 
munization of the troops. The psychological indication 
to immunize only to be sure that nothing was neglected 
cannot be considered sufficient, considering the difficult- 
ies involved for troops and the medical service. The 
value of the immunization against diphtheria has been 
established in civilian medical practice by shifting the 
age level of the nersons suffering from diphtheria. In 
the case of scarlet fever a similar advantage has not yet 
been proven. During the resettlement of the German popul- 
ation from foreign countries the immunization against scar- 
let fever appeared to be the principal advantage of a clear- 
ly recognizable reduction of scarlet fever mortality rate 
of two and a half times. 2Sli Present experience in prophylactic Immunization 
against diphtheria and scarlet fever. 
(Experiences of the Army). 
Oberfeldarzt (Lt. Colt. MC.) SEIFFERT 
The after-effects of immunizations which often occur 
in prophylactic measures against diphtheria are divided 
into primary reactions caused by the injection and second- 
ary effects caused by bacteria. The reactions of the 
first group usually corresponds to the reactions caused 
by other immunizations. However, they are different in 
the respect that they show a higher frequency of phlegmons 
and abscesses. The latter are considered to be specific- 
ally allergic and resemble the Arthus phenomenon. The 
incidence and rigour of the reaction increases r,ith the 
age of the immunized people. By appropriate dosage the 
reaction may be reduced to a tolerable degree. The aver- 
age reactions to the immunization are such that there are 
no objections against the immunization of adults. 
The secondary reactions caused by bacteria are more 
serious and often appear cumulative and may lead to seri- 
ous diseases and even to death. Instances are quoted. 
It is characteristic that haemolytic streptococci■have 
always been found in these cases. Classifying these bact- 
eria it was found that the same bacteria were consistently 
present in each abscess following an immunization. They 
are probabljr injected into the bodv with the serum. The 
contamination of the serum is usually due to the fact that 
the personnel who administer the immunization are suffer- 
ing from angina or catarrh. In particular cases of injury 
due to vaccination the streptococcus may have been inherent 
in the immunized personnel. A localization of streptococ- 
cus is possible at a place where the immunization took 
place and is favored by the local damage of the tissue, 
which may produce toxoid and absorbans in allergic patients 
The damage caused by prohpylactic immunization against 
diphtheria differs characteristically from the reaction 
caused, by other immunizations. 
In order to prevent those secondary reactions, the 
persons have to be immunized with the proper dose and 
with special precautionary measures as to sterility. All 
persons suffering from angina and catarrh or even persons 
who are in contact with people suffering from angina and 
catarrh and scarlet fever should be eliminated from those 
administering immunizations. Great care has to be taken 
to administer an exact dose and in the mixing of the serum 
in tuberculin gyringes or with a correspondingly diluted 
serum. "Schick’* testing is difficult to carry out when 
mass-immunizations are made. It is not yet definitely 
clear whether toxoid (anatoxin) causes more serious re- 
action on elderly persons than "adsorbat" serum when they 
are used in corresponding doses. On the contrary its 
application may be more convenient for adults. No final results can be given as to the success of 
vaccination of the Army. But these diseases seem to re- 
duce and to be less serious. Immunization in case of ac- 
cumulated diphtheria which may be carried out without 
injuries (no negative phase) are not always successful. 
Diphtheria stops mostly by itself, when occurring in closed 
circles of persons and Hien carriers are eliminated. Even 
when carrying out the immunizations to a large extent a 
great number of diphtheria cases must still be expected 
under the present epidemic conditions. Immunized persons 
may bec'ome vectors and suffer from diphtheria which is dif- 
ficult to recognize. 
If a general immunization against diphtheria is 
carried out, one can only expect a partial effect of the 
immunization. A certain risk of immunization damage 
cannot be avoided. Through the army toodloal service a 
general immunization of the troops can be carried out. 
But before introducing it, the situation should still be 
cleared up more, as to which steps have to be taken in 
order to positively eliminate any immunization damage. 
If there is no general immunization, special groups of 
persons who are considerably endangered should be immuniz- 
ed by special order. The routine immunization of re- 
cruits under 18 years of age is recommended. It should 
be even more convenient to have these men inoculated by 
other non-military services before drafting them. 
The limited experiences obtained by the prophylactic 
immunization against scarlet fever are on the whole ident- 
ical to those obtained in the prophylactic immunization 
against diphtheria. It would be advisable to gather some 
more experiences on adults before introducing a routine 
immunization. Limited immunization should only be carried 
out by special order on groups of persons specially en- 
dangered. A general prohpylactic immunization of soldiers 
under 18 years of age should be taken into consideration. 
16. Prophylactic immunization against diphtheria and 
scarlet fever in the German Labor Service. 
Arbeitsarzt (Medical Officer of the German 
Labor Service) SCHWARZ 
Since Autumn 1942 all registrants for labor service 
in the Reichs Labor Service were frequently immunized 
against diphtheria and scarlet fever when drafted. These 
two immunizations were made on different occasions and 
later on simultaneously. An inoculation against!typhoid- 
paratyphoid was then intercalated between the inocul- 
ations against diphtheria and scarlet fever. 
An effect of the immunization against diphtheria on 
men could not be observed during their labor service. The 
effect of the inoculation against scarlet fever was more 
favorable. The reason for the unsatisfactory result of the im- 
munization against diphtheria is due to the present short 
period of labor service and the long period reauired for 
the inoculation to become effective. The reason for the 
better effect obtained with the inoculation against scar- 
let fever,'carried out at the same time and under the same 
conditions, cannot be given as yet. 
In case of the diphtheria epidemic in community billets 
it is not possible to dispense with the immediately pro- 
tective inoculations, since they have a quicker effect than 
inoculation with adsorbatserum, which requires a long time 
to develop sufficient antitoxic immunity. 
The intercalated typhoid-paratyphoid inoculations bet- 
ween the two inoculations against diphtheria and scarlet 
fever did not show any disadvantageous effect on the im- 
munization against these diseases. 
17. Experience with Immunization against diphtheria and 
scarlet fever in the 1st submarine training 
division. Pillau. 
Marlneoberstabsarzt (Lt. Comdr.. MC.) TOLK 
Due to the fact that sailors of 17 - 25 years of age 
live very closely together on ships such as "Robert Ley” 
or work under similar conditions in diving tanks, there was 
a much greater possibility of transmitting diseases before 
immunization against diphtheria and scarlet fever was in- 
troduced. (242 cases of scarlet fever and 35 3 cases of 
diphtheria occurred within 3 years.) 
In October 1941 1600 men were inoculated twice with 
0.2 cubic centimeter within a period of 4 weeks. 94 cases 
occurred prior to the second injection while in the 3 weeks 
after the second injection only two persons suffered from 
this disease. The disease disappeared entirely. No com- 
plications due to the immunization have been observed. 
The examinations of immunized soldiers of the front flotil- 
las showed no infection during the year following. In 
spite of that as a result of the bad experience noted by 
CLAUBERG this sort of immunization of men serving in the 
Navy was forbidden. 
1500 sailors were immunized with scarletina toxin 
in October 1942. After the third injection no case of 
scarlet fever was observed while some of those sailors 
who had not been immunized became infected. 
Encourared by the good results and the excellent 
tolerance observed to the immunization, a combined im- 
munization against diphtheria and scarlet fever was car- 
ried out in January 1943? at weekly intervals in the 
following order: Diphtheria 0.1, ecarlatox I, scarlatox 
II, diphtheria 0.2, scarlatox III. These immunizations 
showed no complications. After the third injection against 
scarlet fever and after the seventh week following the first 
immunization against diphtheria, cases of both diseases were 
entirely suppressed. 219 
In Summer 1943 a combined Inoculation with diphtheria- 
scarlatox was carried out on two training divisions of the 
submarine service. In both cases scarlet fever was quick- 
ly and absolutely reduced. Of a total of 46 cases in 7 
weeks after the infection of sailors of the first training 
division of the submarines, only 8 cases occurred between 
9th week. In spite of these incidents, the im- 
munization must be considered a success. Among the sailors 
who were not immunized 15 cases of diphtheria occurred, 
showing the prevelance of the disease. In the second train- 
ing division of the submarines there were 37 cases of in- 
fection with diphtheria, but after the seventh week this 
disease disappeared entirely. Therefore, in June 1943 the 
Surgeon General of the Medical Corps of the Navy gave the 
order to introduce immunization against ', diphtheria and 
scarlet fever for all sailers serving in the Navy and in 
the submarines. The results of the immunization of sailors 
attending the course of instruction could become apparent 
even in the next group. Owing to the difficulties in get- 
ting the necessary serum, only 57 Per cent of men were im- 
munized before entering the next course. During this course 
only one case of diphtheria and none of scarlet fever oc- 
curred, while out of the 43 per cent of the sailors not im- 
munized 41 were infected with diphtheria and one with scar- 
let fever. 62 per cent of the Immunized sailors did not 
suffer from diphtheria or scarlet fever during the follow- 
ing course, while out of 38 per cent of the sailors not 
immunized 8 were infected with diphtheria and 2 with scar- 
let fever. 
This proves that the immunization is very important 
for sailors serving on board submarines, as immunization 
has shown very good results on 13 000 sailors up to 25 
years of age. Immunization should therefore be adopted 
generally by the Navy. The immunization carried out on 
45 000 persons shows only very.few'complications 'when • 
asepsis is Observed, if ■thennbyklis performed sterile,' -o 
since only 11 persons suffered from abscesses of medium 
size* Furthermore it was observed that the course of the 
disease was a very mild one among sailors who had not re- 
ceived the full course. 
18« Immunization against scarlet fever and diphtheria 
among young "Luftraffenhelfer" * in 1943• 
Oberstarzt (Colonels MC.) Prof. ROSE 
♦ A special group of the "Luftwaffe" (Airforce) con- 
sisting of personnel between 15 - 20 years of age 
who were not assigned to combat duty and were used 
principally to assist the older and higher trained 
personnel in maintenance of aircraft and anti-air- 
craft guns. 
The practical purpose of the immunization of the 
younger gpound force personnel of the Airforce was in the 
first place aimed at a control of the disease rather than 
of gaining scientific experiments. These would have re- 
quired a card file system to register the result of in- 
oculation and observation of each individual "Luftwaffen- 
helfer". The data reported by the surgeons of the camps show 
that out of 10 000 inoculated helpers about 44 became in- 
fected with diphtheria and about 39 with scarlet fever. 
80*7 per cent of the diphtheria cases occurred before and 
during the immunization and 19,3 per cent after the im- 
munization, while 85.4 per cent of the scarlet fever cases 
occurred before and during the immunization and 14.6 per 
cent after the immunization. 
As regards the observation period, It can only be 
said that on the whole it was much shorter before than 
after the immunization. 
In contrast to the opinion of the chief of the div- 
isional medical service, the opinion of the camn surgeons 
Is altogether favorable regarding the results of the im- 
munization. Four surgeons out of eight consider the im- 
munization to be a specific success and that the cases 
nf infection after the immunization are disproportionate- 
ly milder than the cases occurring before the immunization. 
Before judging finally whether this was a successful 
or unsuccessful measure, the sources of possible error 
have to be discussed and it should be examined which factors 
are decisive besides the inoculation, in order to explain 
the obvious differences between the cases before and after 
the inoculation. 
Besides the insufficiency of the statistics concern- 
ing the neriod of observation, it should be pointed out 
that the figures given which appear to be precise and well 
founded are onlv the result of a simple addition of num- 
erous individual reports, which came from different sources 
and show many mistakes common to medical mass-statistics, 
namely incomplete registration, incorrect reports, erroneous 
diagnosis, and the many errors due to the individual manner 
of compiling the reports, discrepancy in the evaluation of 
the cases etc. 
The question whether the differences between the 
figures are only the expression of the fluctuation due to 
the season of the disease has to be answered in the nega- 
tive. The result gained by the inoculation is so uniform- 
ly and equally good, from the epidemiological point of 
view, that it is suspected that the progress is influenced 
by some other fact. This contrast was confirmed by the 
result of my experiments made on Germans during the re- 
settlement. I point out the fact that the service of the 
uLuftT affenhelferf! is different from the service of our 
training regiments and technical schools. The main problem 
in latter is to combat scarlet fever and diphtheria which 
occurrs epidemically. The "Luftwaffenhelfer" soon after 
their first training are detailed into small groups. Only 
in the beginning of their service are they concentrated 
into larger groups but in the middle and toward the end 
of their service they are dispersed in small groups. This 
should have a favorable epidemiological effect. The de- 
cision whether this large influence is due to the immuniz- 
ation or to the conditions of a life under enemy action 
becomes practically impossible, because the 
control groups |Jere not* available in contrast to scientif- 
ic experiments. I should like to warn you against attri- 
buting the extremely favorable course of the epidemic be- 
fore and after the immunization exclusively to the immu- 
nization. 220a 
Furthermore I also refVr to the fact that the nLuft- 
waffenhelfer" were at the beginning of their service still 
exposed to the contact with other pupils in the schools and 
with their sisters and brothers, while the source of infect- 
ion, produced by direct contact with other persons is much 
inferior, but not entirely eliminated, after they were draft- 
ed to the Airforce. 
The following 5 injections with adsorbat-serum were 
administered: 
On the first day the first injection against diphtheria, 
on the 8th day the first injection against scarlet fever, 
on the 22rid day the second injection against scarlet 
fever, 
on the 28th day the second injection against diphtheria, 
on the 36th day the third injection against scarlet 
fever. 
The reasons for not inoculating individuals or post- 
poning the inoculations ate the following: diphtheria in- 
oculation carried out in the school or in the Hitler-Youth 
before being drafted, having had diphtheria or scarlet fever 
during the two years previous to being drafted, local nec- 
essities, immunization against typhoid and paratyphoid being 
of more urgent necessity. Counter indications, such as 
skin disease (especially pyoderma) chronic otitis, encephal- 
itis, epilepsy and other general diseases of all kinds. 
In addition, the completion of the inoculation was 
deranged by transfers, assignments, furloughs and subseement 
drafting or discharge, drafting for the Labor Service, for 
the Army or as a leader for the Hitler-Youth, etc. 
1 
The reported number of immunization must be considered 
more critically, since the evaluation of the incidents 
(infiltration, abscess, elevation of temperature? scarlet 
fever, exanthem, psychogenic collapse, etc.) the subjective 
factor is of primary importance. The same kind of incidents 
were observed which has reported from the Army. 15L*—IfeciLements and smear-tests in diphtheria and sc a r 1 et 
fever. 
Oberarbeitsarzt (Medical Officer of the German 
Labor Service; FREITA_G 
The committee ras acquainted with the statistical data 
and it was considered justifiable to cancel the directions 
concerning partial isolation and bacteriological examination 
of the contaminated areas in case of diphtheria and scarlet 
fever in the German Labor Service camps. Investigations re- 
vealed that only 3 Per cent of diphtheria and scarlet fever 
cases and 12 per cent of the cases with additional diseases 
possibly be^influenced by the partial isolation - in 
case of diphtheria - and by the examination of the contamin- 
ated areas. The first mentioned percentage is very low, on 
the other hand the benefit of the troops with regard to per- 
formance of active duty and to the general organization is 
considerable if all measures of isolation and of examination 
of contaminated areas of troops are eliminated. Under these 
circumstances even a higher incidence of infections would 
be the lesser evil (sic). According to our experience the 
infection with diphtheria and scarlet fever remained limited 
to a small group of persons. 
The special importance of the clinical treatment of 
men in a unit suffering from diphtheria and scarlet fever 
is emphasized. 
Discussion; 
CLAUBERG; The fact that the injuries caused by im- 
munizations are no longer trifling meets with general ac- 
ceptance. The presence of hemolytic streptococcus in 
abscesses caused by immunizations against diphtheria are 
due to a break of asepsis. In view of the results caused 
by the inoculation against diphtheria which were contra- 
dictorily evaluated by the referees, the calculation of the 
theoretical probability is missing. The use of the extens- 
ive material in Berlin (Deutsches Aerzteblatt 1944, # 4) 
permitted the proof of the success with mathematical pre- 
cision. Attention was drawn to the hesitancy concerning 
the simultaneous immunization in the Army, which was ex- 
pressed at the last meeting. Although accurate tests re- 
garding the necessary and appropriate antigen quotas for 
immunization against scarlet fever have not yet been carried 
through, the importance of these tests is stressed. If 
new cases of diphtheria occur, examination of the environ- 
ment is considered unnecessary if the units have already 
been immunized. The question concerning paradoxical dis- 
sociation arises in the sense of an increasing incidence 
of the infection in non-immunized persons within the im- 
munized troops and it is recommended that this matter be 
cleared up. 
KROEGER: The following remarks seem to be relevant 
in connection with the arguments made by CLAUBERG. 
In the evaluation of the diphtheria results in the 
Service the application of the SCHELLING formula 
was not possible as the group of non-immunized persons 
was missing. As already mentioned by SCHWARZ all men 
were immunized unless they happened to be ill on enter- ing the service* Therefore another method of evaluation 
has to be applied and the conditions of the civilian 
population must be compared with that of the troops. The 
conditions of the civilians showed good results concern- 
ing the general epidemiology of both infections* 
The results in the Labor Service refer to about 
900000 men who were immunized. These immunizations have 
been administered to adults, in contrast to the immunizat- 
ion of children mentioned by CLAUBERG. 
The directions concerning the simultaneous immunis- 
ation against diphtheria epidemics were given in April 
1943 to the troops with the "Directions concerning medical 
service". The danger of sensitization are usually over- 
estimated. The Labor Service tried to prevent danger of 
sensitization by using serum from cattle and sheep as 
passive components of the inoculation. 
ROSE: The statistics made on the "Luftwaffenhelfer" 
are not sufficiently reliable to justify a mathematical 
evaluation. The exactness of the evaluation cannot com- 
pensate for the shortcomings of the original material* 
Besides, the control group of unimmunized persons is not 
available within the "Luftwaffenhelfer" as this immuniz- 
ation was carried out as a practical means of protection 
and not for scientific experiments. 
PETER: The control of the theoretically probable 
rate of success of the protective immunizations gives a 
false impression of security which does not exist because 
the numbers of persons unimmunized or immunized, are not 
exact. This is the case in almost all medical statistics 
during the war years, due to the extensive resettlements 
of the population. 
WAGNER: In order to prevent injuries caused by 
streptococcus it has to be remembered that streptococci 
are widespread seasonal agents. Schoolchildren may 
easily be immunized at the appropriate time of the year, 
while the time for immunization for troops and Labor 
Service depends entirely on the conditions of war and on 
military requirements. 
KRUEPE: Concerning the question whether injuries 
were caused by injection at the locus minoris resistentia, 
I should like to refer to the observations made by MB® 
that pneumococci have been found in abscesses caused by 
infections after injection of solvochin as proposed for 
the treatment of pneumonia. 
TOLK: Abscesses caused by immunizations Luer!s 
glass syringes should not be used for inoculation, be- 
cause the doctor as well as the medical personnel are 
able to touch the piston with the fingers so that^it is 
no longer sterile after once being used (observation in 
our own units). KREUSEH; Investigations of the surroundings are still 
necessary for military hospitals in which the danger of 
combined infections has to be considered. For instance, 
the mortality rate of spotted fever raises up to 15 - 20 
per cent in case of mixed infection with diphtheria. 
It should be avoided that persons suffering from 
scarlet fever and diphtheria are together in one ward, as 
it is very likely that persons who have just recovered 
from diphtheria may be infected with scarlet fever, even 
if they seemed to be immune before. 
Instructions for immunizations against diphtheria 
and scarlet fever. 
To the instructions for immunization against diph- 
theria and scarlet fever given at the third meeting ’’East" 
the following supplements were proposed; 
1. A general immunization against diphtheria and 
scarlet fever will not be recommended. 
2* The leading medical officer has to decide in 
each individual case whether immunization has 
to be carried out or not. 
3. The medical personnel who are very likely to 
be infected because of their work in the diph- 
theria-wards should be immunized only if the 
conditions of their immunity require it. 
4. The serum has to be shaken thoroughly before 
each immunization is administered in order to 
mix the adsorbates in an equal ratio. 
5. Immunization against diphtheria and scarlet 
fever can also be carried out with the mixed 
serum of di-scarlatox ”Asid” or ’’Behring”. 
20. Pappataci fever. 
Introduction. 
Oberstarzt (Colonel. MC.) Prof. HOSE 
The treatment of pappataci fever and its vectors, 
the sandflies, was put on the agenda of this committee 
in to conclude the group of diseases common to 
countries with hot climates which are important in the 
areas in which the German Army has operated thus far. 
Though pappataci fever is a harmless disease^as seen 
from the point of view of the individual patient, it may 
cause considerable losses and impair the efficiency 
the troops at critical moments, when it sets in epidemic- 
ally. The practical experience of the three last years 
has shown that fighting the breeding-places of the sand- 
flies, as recommended in manuals, is pure theory not borne out by practice. So far, we know neither any re- 
liable means of fighting the larva nor any methods of as- 
certaining the breeding places suitable for use by the 
army surgeon. On the other hand the first experiments of 
indoor-control with the new contact-poisons f,Gesarol,r and 
rfGix" has yielded such excellent results that we may ex- 
pect a decisive progress in disinfection against pappataci 
fever through the application of these poisons. 
21# On.Epidemiology and control of pappataci fever• 
Stabsarzt (Captain. MC.) MUEHLENS 
I 
Pappataci fever is a brief febrile disease of short 
duration encountered in countries with hot climates which 
has a favorable prognosis without any complications. 
It is important because of its epidemic occurrence 
among foreigners, its very high morbidity rate and its 
high tendency to relapses. 
Epidemiologically important is the vector, the phle- 
botomus pappatasii. 
In Crete the sickness rate of the single units varied 
between 0 and 90 per cent in 1942 and 1943. That 10 per 
cent did not fall ill though they were exposed as much as 
possible is not regarded as due to natural immunity. The 
soldiers who did not fall ill were rather generally not 
bitten by sandflies. There were never any sandflies in 
the mosquito-nets above their beds, whereas there were 
plenty of these Insects in all other mosauito-nets. 
The greatest number of sandflies are observed in old, 
narrow and dirty villages, where flat mud-roofs are pre- 
dominant, but new brick-buildings and barracks were soon 
infested with sandflies, even if they stood somewhat apart. 
In Crete the phlebotomus pappatasii occurs even at altit- 
udes beyond 500 meters. Units in villages at an altitude 
of 400 meters were affected with pappataci fever, even up 
to 35 per cent. 
Sickness rates (In per cent) of pappataci fever 
and influenza. 
Month 
Crete 1942 
Crete 1943 
Sicily 1942 
Pappatacl 
Tnfl. 
Pappatacl 
ihfl. 
Pappatacl 
Infi.- 
January 
0.60 
0.47 
_ 
0.24 
February 
- 
0.60 
- 
0.75 
- 
0.25 
March 
— 
0.70 
- 
0.80 
- 
0.23 
[April 
0.10 
0.50 
0.04 
0.98 
- 
0.19 I 
Lfay 
0.76 
0.58 
0.44 
0.54 
- 
0.31 
June 
9.05 
0.70 
4.17 
0.39 
- 
0.51 
July 
7.75 
0.38 
7.39 
0.14 
- 
0.63 
August 
6.69 
0.17 
7.7 6 
0.11 
0.30 
0.48 
September 
3.91 
0.28 
5.48 
0.08 
0.54 
0.34 
October 
1.20 
0.20 
2.60 
0.11 
- 
0.30 
November 
0.30 
0.30 
- 
- 
- 
0.25 
December 
0.10 
0.40 
- 
- 
— 
0.2 7 225 
Sicily has different epidemiological conditions and 
a climate slightly different from that of Crete, but these 
do not fully explain the great difference of the sick rates. 
The annual peak of the sickness rate generally occurs 
in June. Owing to cool weather in the Spring of 1943 the 
peak of that year shifted to July. The beginning and the 
end of the pappataci epidemics coincide exactly with the 
flying time^of sandflies. It begins at the end of May 
and lasts till October including the months with average 
temperatures of 20 degrees Celsius, and more. 
In Crete the dry and hot south and south-east are more 
liable to pappataci fever thaA the north and west. Units 
having snent but one summer in Crete were affected twice as 
much as those living in Crete for the second year. Con- 
trary to former notions immunity is acquired but only to a 
limited degree. With some units the percentage of re- 
lapses amounts up to 30 per cent. There was a proportion 
of 6200 patients affected the first time and 1261 relapses, 
498 of which occurred within three weeks after the first 
attack and the other 772 within the same year. Relapses 
after short changes of station within the island or to the 
continent are frecuent. Some soldiers were affected as 
often as seven times. 
The term ”pappataci fever" is unknown to the Greek 
population and Greek surgeons, though the disease also 
occurs among the natives. 
The duration of the disease is reported to amount to 
2-3 days generally. In Corsica a variety of the disease 
with a duration from 4-9 days is said to be prevalent. 
In southern Crete the duration of four days was predominant. 
Of 319 patients, 111 were ill for four days, 69 for three 
days, and 84 for five days. 
Control measures cannot be started directly against 
the etiological agent, since one can lay hold of it neither 
in man nor in the open. A certain mechanical protection 
against the transferring inject is difficult too and has 
not yet been put into practice. A disinfection in the in- 
sect by killing all the sandflies in sick-rooms, similar 
to the malaria-disinfection proposed by Oberstarzt (Colonel, 
MC.) Prof. Dr, HOSE, may be effective, even if not com- 
pletely successful. 
Regardless of other considerations something should 
be done fight the sandflies systematically, since they 
are a nuisance in the house and often disturb the night’s 
rest. 
If pyretheum compounds are used, it is most important 
that the upner parts of the rooms are adequately exposed 
to the vapor since the sandflies,with hardly any exception, 
sit directly below the ceiling in the upper sections of 
the wall, which is out of reach of the ordinary sprayers. 
Only by using vanor-generators can all the sandflies in 
the room be killed. It is often necessary to repeat^the 
application within the same night, since many sandflies will be new arrivals. Poisons retaining their effect a 
long time are more efficacious. Here, formalin and sol- 
utions of cresol, and best of all, the captured English 
preparation Malariol did valuable work. Since the intro- 
duction of the preparations Gix and Gesarol the problem 
of fighting the full grown sandflies is practically solved. 
Besides treating the walls and ceiling, the impregnation 
of the mosquito-nets is of importance, as otherwise the 
numerous sandflies Hitting in the nets escape. Sometimes 
the impregnation of the nets along will do. 
Mechanical protection is difficult, because the in- 
sects are so tiny. Particular attention should be paid to 
the danger of the insect’s entering from the adjoining rooms. 
The normal mosquito-nets with 17 meshes per inch .afford; 
protection'*. ~-Therflefc§s‘sdryet}idth^ofi$©fc&ea*is 26 ffceshes, but 
such narrow mesh materially impedes ventilation. 
For the time being, insufficient knowledge of the 
breedinr-places makes it impossible to kill the brood. 
Personal experiments to locate larva and chrysalix 
failed. General cleaning aiming at the destruction of all 
supposed breeding-places renuires enormous labor and pro- 
mises only inadequate results. 
22. Recent experience with pappatacl.j£eyeiL1_jLy^ 
• aspects and treatment. 
Stabsarzt (Captain. MC.) Prof. HOMING 
As regards the clinical aspects of pappataci fever, 
the main problem is the suppression of the dubious and 
questionable diagnosis "Papp". It has been proved many 
times, that the diagnosis Pappataci is used much too^often. 
Th"5 s is dangerous, particularly in relation to malaria, 
and especially malaria tropica, which must always be care- 
fully excluded before the diagnosis nPapp" is made. An- 
other danger is that of overlooking the frequent vague in- 
fections of short duration, several of which have been 
epidemiologically defined. This was through reports of 
their appearance accumulated locally and temporarily and 
in making the premature diagnosis pappataci only to set 
one’s mind at rest diagnostically. On the whole by com- 
mitting oneself to the diagnosis pappataci, one will too 
easily set aside an unprejudiced the Pat- 
ient and an advance on fresh lines of scientific research. 
It is strictly required, therefore, that at least 
some of the following symptoms are manifested, before the 
diagnosis Pappataci is made; either the appearance of a 
group of cases locally and#temporarily, which renders the 
diagnosis relatively certain (such as in the case ge- 
nuine influenza) or? in the individual case; a quite typ- 
ical fever-curve, violent aching in the head and loins, 
conjunctivitis (so-called Pick symptom), no enlargement 
of the spleen, a moderate leukopenia, typical sandfly-bite. and scratches ‘caused by them. Only when at least 3 - 4 of 
the symptoms mentioned are present should the diagnosis be 
made. All other clinical symptoms are more or "less irre- 
gular. Even the long period of convalescence so often men- 
tioned applies but rarely. Despite the seemingly mild 
symptomatology the diagnosis can be made clinically, even 
in the case of Patients suffering from other diseases at 
the same time, e.g. malaria or typhus, pappataci can be 
quite satisfactorily discriminated from those. 
The question of immunity is difficult to answer, be- 
cause of the lack of efficient diagnostic laboratory-methods. 
It is supposed that the ostensible frecmency of relapses 
in the same season is largely a result of unreliable diag- 
nosis, as genuine relapses are very rare. On the other hand 
relapses in the following years certainly occur frequently. 
As regards treatment for pappataci fever, no measures 
are necessary other than treatment for subjective complaints. 
23* Essential facts concerning the fighting of sandflies• 
Mar.-Reg.-Rat (Government Counsilloy. Navy) WEYER 
The sandflies which are limited to tropical and sub- 
tropical countries are injurious to health in many ways* 
They are of most practical importance as agents of Leish- 
maniasis. Within the Mediterranean region pappataci fever 
requires Particular defensive measures against the sandfly 
vector. The principal difficulties in fighting sandflies 
are their small size and their living in hidden places, be- 
sides the fact that we know relatively little concerning 
their way of life as compared to the more important gnats. 
But more important is the fact that their habits of breed- 
ing do not allow any intense activity against the larva 
since the larva does no live in water, but on the ground, 
in rubble, vegetable refuse, etc., where they are difficult 
to locate; are never found in large numbers in a narrow 
space, as the gnat larva in the breeding-pools, and do live 
where the effect of chemical poisons is prevented by mech- 
anical difficulties. The small size of the full grown 
sandflies allows them to creep though the meshes of ordin- 
any mosquito-nets, at least if they have been fasting. 
The detailed knowledge of the sandflies is limited, 
because of special considerations. They have no striking 
morphological characteristics, which might afford the 
basis for synoptical determining tables. We still know 
too little of the importance of single species as vectors. 
For this reason there has been no clear-cut mode af attack 
against the sandflies as yet. On the other hand we know 
that some species are of particular importance, owing to 
their frequency and habits of life alone. To this group 
belongs for instance the phlebotomus pappatasii, which is 
supposed to play the principal part in transferring pappa- 
taci fever within the Mediterranean region. Since the 
phlebotomus pappatasii is a particularly large specias, it is of practical possibility to differentiate it from other 
species. Lastly, our knowledge of the habits of life and 
Breeding••'r'f"'the-'sa&dflies'is 3till“ quite incomplete in many 
important respects. Owing to the various habits of life 
of the different species, supplementary observations, which 
are urgently needed and for which we have an opportunity now, 
are of practical use only if we are als0' able to different An*, 
iate the single species. For this reason, a modicum of 
systematic knowledge is indispensable even to the non-ento- 
mologist occupied with fighting sandflies. If a limited 
geographical ajsa'with onjjy a few iraore frequent species is con- 
cerned, such a person will even get along with slight rudi- 
mentary knowledge. He must be acquainted only with the prin- 
cipal features of the life habits of the sandflies and with 
the methods suitable in each respective case. Some import- 
ant characteristic features are illustrated by the example 
of the male hypopygium and the female spermatheca of phlebo- 
tomus pappatasil and phlebotomus sergenti„ 
24. Essential facts concerning the biology and fighting 
of "sandflies. ~ 
Major Prof. LENZ 
Measures against a noxious insect must be founded on 
exact knowledge of its structure and its biology. 
Only in exceptional cases is it possible to fight 
the sandfly larva in mass breeding places. The insects 
generally occur in innumerable individual biotopes where 
they cannot be fought practically. In hot arid regions 
they find the high degree of moisture necessary for the 
first few stages of development of the larva only in deep 
wall-fissures and other deep small holes. 
The full grown insects can be killed direct by chem- 
ical means in their daytime resting places, in bedrooms, 
and stables. These daytime resting places are certain 
dark nooks situated chiefly in the upper part of the room. 
More efficient and easier is the use of the wall 
coating compounds Gix and Gesarol which retain their ef- 
fect for weeks and kill the sandflies more effectively. 
It is even more to the purpose to prevent the sandflies 
penetrating into the rooms by closing the windows with 
narrow meshed wire and to protect the sleepers by bed-ne s. 
The wire-netting must have a maximal width of meshes oi 
0.8 - 1.0 millimeter, that is 24 - 27 mesches per Inch. 
Fabric gauze must have still narrov/er meshes or must con- 
sist of threads of strong fibre* Most efficient is the 
use of bed-nets, impregnated with Gix o* Gesarol, since 
they may have wider meshes, viz. are more permeable o 
air, and yet prevent the sandflies from penetrating through 
the warning effect of the impregnation. Discussion: 
HARMSEN: During the months from January to April we 
observed, particularly on the Dalmatian coast district, in 
all hospitals minor epidemics 6f infection, corresponding 
to the clinical picture of pappataci fever and some even 
reported as such. After a sudden rise of the fever to mor§ 
than 39° C,, the temperature will remain high for three or 
four days and then drop rapidly. The main symptoms are 
violent headaches, which virtually cannot be allayed, and 
conjunctivitis. In most cases there are no catarrhal symp- 
toms, no enlargement of the spleen and no typical finding 
of the blood. The feverishness was followed by a long state 
of exhaustion and slow convalescence. Malaria, spotted 
fever and so-called grippe infections could be positively 
excluded. Evidently it was a disease closely resembling 
pappataci fever, if it was not identical. There was no 
possibility of sandflies being the vector. Pappataci fever 
has been particularly frequent in the Dalmatian-Bosnian 
region for a long time and it seems probable that the virus 
can also be transferred by other means than by sandflies. 
HOERING: I once more warn not f© generalize about the 
diagnosis of pappataci fever. Similar infections, even if 
occurring in groups like that recently observed in Albania 
in winter, must not be diagnosed as panpataci fever. 
Three weeks after the close 6f the nanpataci fever 
season, several cases of pappataci fever were suddenly ob- 
served again in November 1943 in a hospital for tropical 
diseases at Salonika, after the heating system had been 
started when the nights became chillier. This had evident- 
ly stimulated some surviving sandflies to activity which 
were still capable of transferring the disease. 
WEYER: The problem must be whether the pappa- 
taci virus can be transmitted by the sandflies to the follow- 
ing generation and how the first few cases of pappataci 
fever are to be explained, and, lastly, whether other spec- 
ies besides phlebotomus pappatasii are involved in trans- 
ferring the disease in the Mediterranean region. 
X"e need further data on the occurrence of sandllie-., 
particularly of phlebotomus papnatasii, in order to determ- 
ine the northern boundary of distribution of this snecias. 
The data available as yet are incomplete and partly unre- 
liable. The dependence of distribution on the climate 
must also be examined more closely. 
ZSCHUCKE: In Istria three day!s feverishness will be 
followed by a 2 - 3 week’s convalescence with such violent 
nervous disorders (Headaches, insomnia, depressions, lack 
of appetite), that the diseased Italian soldiers are by 
policy exempted from outdoor service for several weeks. 
The ouestion arises, whether the same was observed with 
our soldiers in the region of the Aegean Sea. LENZi The fallacy of diagnosing pappataci fever during 
seasons when there are no sandflies is a well—kno'?Tn fact, 
and has been confirmed by my systematic researches, which 
showed that the first cases of pappataci fever are always 
diagnosed in spring, when the first sandflies appear, and 
that they cease in fall, when the sandflies disappear. 
During the whole pappataci period of summer the curves for 
freouency of sandflies and for the sick rate show the same 
tendency. 
As for the question of virus-reservoir in winter I 
have begun to make experiments with the objective of prov- 
ing the transmission of the germ to the next generation of 
sandflies. Though these experiments have yielded only ne- 
gative results so far, the possibility of obtaining positive- 
results in the end is not yet excluded, since the breeds 
available must be considerably increased and means must be 
found to work with larger numbers of patients. 
The pappataci cases in November mentioned by Stabsarzt 
(Chptsdiifl MC.) Prof. HOERING seem to be a further confirmation 
of the theory of a transmission of the germ to the next 
generation of sandflies. I regard them as the results of 
an infection caused by a second generation sprung from in- 
fected sandflies which propagated in the course of summer. 
This second generation was evidently forced to premature 
puppation and development into full grown sandflies by the 
heating of the building begun in November. The full grown 
sandflies then caused the infection. 
STELLWAAG: Wire-netting as"naniW ah required for pro- 
tection of the windows against the sandflies cannot always 
be supplied and in addition is disliked for its interference 
with ventilation. w© understand that even gauze with wider 
meshes impregnated with poisons like Gesarol may be used 
(which '"ill scare away the sandflies). On the one hand 
these preparations being scarce are not available every- 
where, and on the other hand the wire-netting is heated 
by solar radiation to such a degree that the effect of 
the poison will decrease rapidly (evaporation). But to 
repeat the impregnation many times does not pay. Perhaps 
an attempt at usine the gauze with wide meshbs' covered 
with glue to which the sandflies will stick would be worth 
while. Caterpillar glue may be dissolved in carbon tetra- 
chloride and sprayed on wire-netting. Since the sandflies 
alight on the gauze and then creep through it, a gauze with 
comparatively wide meshes might answer the purpose (even 
againtt culicides). A disadvantage of this method is that 
a gauze treated in this way readily becomes soiled, but 
even so it ought not to be difficult to clean it with a 
brush. 
Information leaflet on pappataci fever; 
1. Pappataci fever (three-day fever or dog fever, other 
names should not be used) is a virus disease and is 
characterized by a fever rising rapidly after an in- 
cubation of 3-8 days, but dropping again on the 
second to fourth day, which is associated with very severe headaches (feeling as if the head was bursting) 
with^pain in the muscles, conjunctivitis, cyanotic 
fascies, anoresda and intestinal disorders# In most 
cases there is a remarkably pronounced relative brady- 
cardia. A leucopenia occurs, but there is no enlarge- 
ment of the spleen. The patients usually feel very 
ill, are freauently weak and much depressed psychically. 
Headches and giddiness will often outlast the deferves- 
cence by a few days. The average duration of incapacity 
for duty amounts to five days, the duration of post- 
febrile symptoms to a fortnight at the most. The prog- 
nosis is very favorable; cases with fatal issue pract- 
ically never occur. 
2. The vector of the disease is the pappataci sandfly 
(phlebotomus pappatasii), a small (1 - 2.5 millimeter), 
greyish yellow gnat, hairy over its whole body. Char- 
acteristically it holds its wings at rest like an angel, 
which is different from other gnats. It dodges any 
attempt to catch it. Its bite causes violent itching 
and often violent reactions of the skin. 
The virus circulates in the Patientfs blood only dur- 
ing the first two days of the disease. It can be ab- 
sorbed by sandflies only during this period; the sand- 
flies in their turn can transfer it again to man by 
bite after a process of ripening and increase which 
takes 6-8 days. 
3* The diagnosis has often been made even in regions in 
which the vectors do not live at all, viz. the disease' 
cannot occur. But even in regions in which the disease 
is spread, the diagnosis has been erroneously applied 
for short or even lingering infections, etiologicaliy 
obscure, though epidemiological considerations, season, 
and manner of occurrence positively excluded pappataci 
fever. 
4. Before filing his report, the army surgeon should 
convice himself that there are sandflies in the area, 
without which the disease cannot occur, if necessary 
by consulting a hygienist or an entomologist. Among 
the present areas of operation the occurrence of sand- 
flies may be expected in the whole South-East (altit- 
udes exceeding 600 meters excepted) particularly in 
the coastal districts of the Mediterranean during the 
period from summer to early fall (from the end of 
May to September). 
5. Under certain circumstances pappataci fever may af- 
fect large numbers of the troops within a comparative- 
ly short time and incapacitate them for duty, even^ 
if only temporarily. In the region in which the dis- 
ease is present,danger of infection exists, above 
all if the troops are billeted in towns and villages, 
since man will create places^for refuse there, which 
promote large scale propagation of the agents. Des- 
truction by war with accumulation of debris and rubble 
also creates favorable breeding-conditions for the 
sandflies. Tent camps will not be affected as a rule. 6. As regards differential diagnosis. malaria, particularly 
malaria tropica, must always be excluded first. In all 
events the thick smear must be examined with this in 
mind. On the 'rhole the diagnosis of pappataci fever is 
to be made chiefly by exclusion. Other infectious 
diseases in their initial stage (particularly those 
with conjunctivitis, such as spotted fever, smallpox* 
measles, dengue, even hepatitis epidemica etc.) and 
above all, the frequent non-characteristic febrile in- 
fections (Influenza) produce quite similar clinical 
Pictures. 
7. Pappataci fever, once overcome, generally leaves behind 
a relative partial immunity. Relapses have been observ- 
ed even after a fortnight. Several relapses may occur. 
B. The treatment is symptomatic: bed-rest, fever diet, 
with possible use of antineuralgica (with hardly an:/ 
effect). Sulfonamides are of no effect. The most ap- 
prehensive patients should be calmed by pointing out 
the favorable prognosis. 
9* The disease can be prevented through protection from 
sandlfy-bites. The normal mosquito-net does not answer 
the purpose owing to the small size of the sandflies. 
Only with at least 10 threads per centimeter afford 
any protection, but they considerably impair ventilation 
and passage of heat from under the net. The small range 
of flight of the sandflies (about 50 meters) may have 
the result, that, according to the situation, some rooms 
are violently infested while other rooms in the same 
building are not infested at all, and that in isolated 
houses, even sleeping on the roof will afford some pro- 
tection. 
10. Particular attention should be paid to the protection 
of specialists (such as flying personnel, signal corps 
men), since their being affected by this otherwise 
comparatively harmless disease makes itself felt more 
than in other branches of the service, 
11. Measures of defense: It will hardly be possible, as 
a "rule, to eliminate the breeding-places. They are 
to be found in crevices of the glound and the walls, at 
stables, in heaps of refuse, dung, and straw etc. 
They require a certain moisture and darkness. Mass- 
bfeeding places are destroyed houses etc. 
12* The full grown sandflies can be killed in their day- 
time resting places in bedroomsand stables (dark, 
draught-proof nooks, mostly near the ceiling) by dir- 
ect spraying with chemicals (preparations containing 
pyrethreum, such as Flit, Detmolin, even diluted sol- 
utions of cresol or formalin). The method of using 
Glx and Gesarol as a wall coating is more reliable 
and easier, since they retain their effects for weeks. 
The most suitable method is the use of bed-nets im- 
pregnated with Gix or Gesarol (moisten the 
water and then immerse them in a solution containing 
1 per cent Gix or Gesarol). 23 3 
VIII. 
PJ5_0_C_E_E_D_I_N_G_.S 0J?_ T_H_E C_0_N_S__U_L_T ,A_ 
C. OM M I.T T E E 0_N_ 
INTERNAL MEDICINE 
Translation prepared by: 
U, S, Naval Technical Unit, Europe, (Medical Section) 
Office of the Naval Advisor 
Office of the Military Government ( U. S. ) 234 
Present experiences.while carrying out immunizations 
a£ainst_di£hteria_and_.gcarlet_f eyer_Isee_Secti.2 
Concerning the need of calcium in the f.opd of troops 
(see Section 14, Article 9) 
Ik Experiences in the formation of "Stomach battalions!1 . 
Prof, .yAFAL.\J?NHAUSElJ 
In July 194-3, a special unit for patients with gastric 
Complaints (abbr, "M-battalion") was first formed in the 
VIII. Military District, The reason for this was the in- 
creasing number of patients with chronic gastric complaints 
which led to an intolerable overcrowding of the internal 
medicine departments of hospitals and dispensaries. The 
"M-battalion" was to provide profitable employment with con- 
sideration of the special needs of these patients especially 
as to their diet and their assignments. At first, all 
military personnel ol* the military district under treatment 
with these conditions (L52) were examined by an experienced 
specialist to determine their fitness for the "M-battalionn, 
All those considered unfit because of a serious disease 
were discharged. The rest formed the nucleus of the "M- 
battalion" which was meant to be a training unit for the 
creation of field formations. In the long run it turned 
out to be useful to establish a special hospital for gast- 
ric complaints in Freudenthal where this "M-battalion” was 
stationed which was used also as a hospital for the recept- 
ion of patients with gastric and intestinal complaints. 
That meant that all patients with gastric and intestinal 
complaints coming back from hospitals to the VIII Military 
District were transferred to this hospital for a final 
of their fitness. Thus the increase in strength 
of the "M-battalion" was well regulated. 
The men of the M-battalion can be divided into two 
groups. Besides the small group who have only gastric 
complaints there is the other, much larger group, whose 
gastric complaints are overshadowed by other functional dis- 
orders and those oomplclDts are only one symptom of the 
sick individual. Previously these men were sent from one 
hospital to another and a great number of them never receiv- 
ed complete training anywhere. They are the type of weak 
plaintive individual who takes too gloomy a view of his com- 
plaints and constantly refers to them. It is the most im- 
portant task of the "M-battalion" to train these persons 
and to increase their efficiency as much as possible. The 
individuals with only slight gastric complaints and whose 
ailments are chiefly psychic will be treated by a psychothe- 
rapist. If he thinks them fit to be trained, they will stay 
in the "M-battalion" in spite of their slight gastric com- 
plaints, so that they will no longer be repeatedly haunting 
the sick bays and hospitals. Only those psychopaths who 
Cannot be trained are regarded as unfit and are discharged. The care and treatment of the MM-battalion11 has to be 
undertaken by an experienced internist who cannot be deceiv- 
ed by the psychopaths deceptions. 
Every man in the MM-battalion" is listed on a card in- 
dex of the army physician which contains all important his- 
tory and examination dates with the findings* record 
will be given to the accompanying army physician when the 
men are assigned elsewhere for service. The army physician 
divides the individuals into three classes according to thei:. 
respective fitness. The classes are formed into platoons 
or companies according to the number in each group and the 
only difference will be the duration and the severity of dutp 
The training course of the 11 F-battalions11 presupposes nothin, 
and will be held in two courses of six weeks for individuals 
and groups including all branches of infantry service. 
Observation of the weight is considered to be an im- 
portant factor for the justification of a sick reoort, If 
an Increase of weight develops during the treatment for a 
gastric o’omplaint, the latter will usually not be of much 
significance. Because of this fact, a great number of sick 
reports can be rejected as unjustified. Necessary medical 
examinations are to be carried out in th« sick bay 19 poss- 
ible, which is provided with all the paraphenalia required. 
On the one hand the patient must feel that the physician 
treats his complaints seriously, on the other hand he must 
know that occasional complaints such as pyrosis and a filin'- 
of pressure do not justify release from service. The ment- 
al attitude of all men of the,rM-battalionM has to be con- 
tinuously observed and supoorted by the unit nhysician and 
the unit commander. The success of the battalion depends ol. 
their personalities, It has generally proved a failure to 
select officers out of the group of men suffering from 
gastric complaints. The officers must have a proper under- 
standing of the balance between demands and efficiency and 
even when off duty they must take continuous care of their 
men. This duty will be too gr~at a strain for officers who 
are ill themselves. On the other hand, however, it is po- 
sitively astonishing what able and energetic officers can 
develop from their men. Such company commanders succeeded 
in making fit about 90$ of their patients for active service 
after a period of training. 
To guarantee a constant treatment of the men of the 
”M-battalion" they must be prevented from gaining admiss- 
ion to other hospitals by reporting sick with other format- 
ions, especially during their leave. This was done by 
making an entry on page 12 of their pay book that in case 
the bearer reports as sick he has to be transferred to the 
special hospital at Freudenthal if he is able to travel. 
This measure materially diminished the freeuency of sick 
reports during leave. In the same way men requiring hospit 
treatment from active field units are sent back to the 
special hospital at Freudenthal (except for instance in 
of infectious diseases and wounds etc,) Even if sending t>;.. 
back to other hospitals cannot be avoided, it is urged by 
the entry in the pay book that they be sent to Freudenthal 
as soon as they can be moved. It is only in this way that a uniform and permanent supervision and treatment of the 
patients aan be achieved and this is considered to be one 
of the most important tasks of the special hospital 4 
The advantage of the "M-battalion" has been evident 
in VIII Military District, You can observe everywhere a 
decrease of work in the dispensaries and internal medicine 
v/ards of the general hospitals in the home country as re- 
gards the men with chronic gastric comolaints whereas they 
used to be sent there again and again. The active units 
coming from the Freudenthal special hospital have proved 
very efficient. It must be stressed, however, that such 
a success is only attainable if the gradual training is 
done in the way described above, which aims at educating, 
training and leading the patient in a sympathetic but ener- 
getic way and to keep him in that special unit under any 
circumstances. This task can be performed only by officers 
who are not only able but also keen on this special task. 
Z*. iiSJismacii_Batialioi}»-^rid-diotarx>iSaintsnanco_.ln^thx: 
field pd jesorvo armyA 
J*£jtl.K4i£ES 
All men ?/ho suffer only temporarily from diseases such 
as enteritis, bullet wounds in the stomach} etc,, 
are not suitable for the MM-battalion'f . Only those men are 
to be discharged as unfit for active service v/ho suffer 
from that kind of gastritis which leads to a permanent in- 
fluence on the physical condition with a steady decrease of 
weight in spite of medical treatment. All men with ulcers 
are fit. They are treated, if necessary, in our special 
hospital until they have been thoroughly studied including 
X-rays and gastroscopy. It must be borne in mind that be- 
ing free from pain alone is no criterion of the ulcers 
being properly healed. Chronic ulcers which recur at short 
intervals are to be regarded as unfit. It is a special 
task of the ’’M-battalion" or rather of special hospital 
for gastric complaints to separate the diseases which are 
mainly functional from those which are mainly organic and 
to ascertain if possible the degree of activity with ulcer- 
ous processes. The differential diagnostic symptoms with 
a florid ulcus or a scar described in detail. It must 
bo borne in mind that the ulcer complaints may be the mani- 
festation of a fictitious neurosis which affects the inter- 
nal organs. This was emphasized by NOME, with whom I fully 
agree after my year of experience with the 11 M-battalion"# 
Especially suitable for the "M-battalion" are all those case 
with scars.’’ Even patients with stomach resections ’ ’Suita 
if the remaining portion of the ttomach is* largb'/ohdugh'the 
condition satisfactory and if only small in 
flammatory changes can be detected* Patients with-a small 
stump. requiring frequent feeding, and with serious inflammat- 
ions‘are to bo discharged as unfit, “The most important prit. 
cipld for admissioh•to decide tne- question, whether or n 
the efficiency can- be increased, $>r at least can the pain bo 
alleviated by, dieting* That is why patientp.uwith cholecyst 
tie-> gall-stones andy-inflamination of the bilepduct, dysente: 
are admitted* 'The dietpry supervision and treatment; 
important* V The troops get the food ration of group III, which contains 
700 grams of bread, 4-0 grams of fat and 1200 grams of veget- 
ables and potatoes per day and 700 grams of meat per week. 
They get white bread instead of black bread. Because of the 
different kinds of patients in the battalion, as for instance 
with diseases of the liver, gastric and intestinal complaints 
and the indigestibility of artifical fats, artifical honey 
and jam, the fat ration was given as butter. Vegetables 
are usually prepared. Potatoes are served as mashed potatoes 
by adding milk or skimmed milk. This diet was given not 
only in the home country, but also to the troops in the field 
The necessary diet kitchen utensils such as meat choppers, 
potato mashers, pots and pans, sieves, bolters, griddles, 
ladles, colanders etc., are brought along from the former 
location. 
When sent on field duty the troops need additional 
medical eouipment besides "T.S.A.'1 (the normal set of Medical 
Supplies and Equipment for the Armed Forces), an X-ray appa- 
ratus (heavy) a scale and endoscopes, gastric tubes, etc. 
The units have to be fully" equipped with medical instruments 
and kitchen utensils before a battalion is sent into the 
field. The supply of the required medicaments must also be 
provided. It is necessary, that the army ohysician and the 
army officer make every personal effort to carry through ever 
measure contributing to the ultimate success. In spite of 
the physical strain of field duty the number of men suffering 
from ulcers has become much smaller than previously when 
they were on duty in the home country. 
The MM-battali onsprove that it is nossible to mobilize 
still larger reserve forces and this measure will at the same 
time be useful and advantageous to the patients themselves, 
ers„ co n_2 or ning_^M-battel ions 
KATSCH: Not every officer suffering from gastritis is 
capable of leading a stomach battalion. If he is able, how- 
ever, his example will be of great value. 
It is still difficult to find the right officers suffer- 
ing from gastritis for the stomach battalions. It has to be 
avoided that persons needing special diets being treated 
according to L 52 should be admitted to the stomach battalion 
Above all they are not to be kept for any length of 
time but are to be discharged as soon as possible (for in- 
stance after heoatitis, after a cecum operation, after her- 
niotomy) R 
GUTZFIT; The efficiency of stomach battalions has been 
variable when used for covering and mopping up operations 
according to their training in the home country and accord- 
ing to the consideration and security of the special condit- 
ions of the location of their activities. They were used 
successfully when an energetic and intelligent corps of 
officers as well as an able army physician trained and se- 
lected the men in the home country and where in the field 
the possibility of thorough medical supervision as well as 
the appropriate diet was maintained. The efficiency of the 
M-battalio depends absolutely on the fulfilment of these 
last two conditions. Tod hasty order for formation, insuffi- ciency of staff (cooks, medical officers, commander or tech- 
nical equipment. X-ray apparatus, instruments for stomach 
examination and treatment, field kitchen utensils etc,), 
prevent the efficiency as well as the distribution of the 
units over too wide an area. The rate of sick reports was 
about 10% of the men with a battalion on guard duty,of these 
only half of the soldiers suffered from gastric complaints. 
With a third battalion which was distributed over a larger 
area kilometers) the number of sick reports was much 
higher (up to 35%), The number of sick men depends further- 
more on the Dualities of their leaders or the commanding 
officers. Therefore should be assigned to the unit 
while it is being formed and they must be selected carefully* 
It does not matter much, whether they are suffering from 
gastric complaints or not, A general prohibition of smoking 
is not necessary, nor is a general exclusive supply with 
white bread. In one battalion only 50% of the men needed 
white bread. The prohibition of smoking and supply with 
white bread are therapeutic measures and are to be decided 
in each separate case according to its individual merits* 
SCHUERMEYER: In the Navy we have an experience of about 
three years with ’’dietary'* units. After a central ”M-battal- 
ion” has been established in the naval collecting hospital 
the Patients are distributed from there to the suitable units 
which provide the appropriate circumstances* The fitness for 
service of the patients has been increased materially and 
the number of sick Reports has decreased a great deal. The 
establishment of a dental clinic in addition to the diet kit- 
chen Is of importance. 
BAADER: The "M-battalion” of the VIII Military District 
stationed in Lille has stood the test well. 
SCHLUETER points out the difficulty of taking care of 
the ”M-battalions” by an army physician if they are used in 
an unsuitable way (e.g. guerilla warfare with the danger of 
being surrounded by the enemy temporari iy). 
UHLENBRUCH: According to the theory of the ”M-battal- 
ion”, those patients classified in the group L52, who are 
often psychopaths and disposed to depressions are to be 
imbued with a positive soldierly bearing. In the long-run, 
we ta’ e the risk that on the other hand soldiers coming from 
field units who have performed their duty previously without 
bothering about their gastric complaints (the achievement 
of men with chronic gastric complaints are often surprising) 
may use every effort to be sent back to the special battalion? 
This danger would increase if other groups of patients 
should be formed into special units. 
2*- 
QU£ £ H a sX—iib£ i £ _ Bfi £ i1 n p s s _ f o r _ 3. q £ j. v§_ wax 
S£££,Us* 
eldar.zt_iLt^£^^MjtC^j^ProfJ,KATSCH_ 
Physical work is advisable for all kinds of trained 
diabetic patients with a reasonable attitude. They are 
healthy under certain conditions which does not always mean 
iiv, for service under certain conditions, at least not for 
a patients by any means. The dieting must not interfere 
w?+hm^h.Wlth the necessity of having their meals in common 
with their comrades. Slight modifications of the military 
etary would provide certain possibilities of extension anc selection. In the life of a soldier, the necessary regular- 
ity of meals, which is important for most diabetic patients, 
especially those under insulin treatment, is difficult. 
Physical strain after an insulin injection is apt to decrease 
the blood sugar considerably and even if no unconsciousness 
and convulsions occur, the consequences are not only redueed 
efficiency but include cerebral reactions like stubbornness, 
states of intoxication and frenuently violent 
Diabetic patients might be employed in special local units 
of the German Labor Service with a settled routine. Units 
for diabetic patients should be subject to static conditions. 
Their fitness for service would be more limited and narrowly 
circumscribed than that of a "M-battalion" kept to a certain 
diet. Such an organization is in general not to be recommend- 
ed , 
Patients affected with mere renal diabetes are fit for 
service. Some patients with slight diabetes who need no in- 
sulin are fit for service under certain conditions, especial- 
ly officers and persons of higher rank. The use officers, 
sergeants, medical officers and administrative officers who 
need insulin, in some special cases even troop officers as 
reserve troops is to be recommended, if possible in their 
native village, so that an appropriate diet will be guarant- 
eed. 
Untrained diabetics of the rank and file who need in- 
sulin are unfit for service, especially if they have had 
no military training and should not be drafted* 
Seriously wounded diabetics who need insulin cause great 
medical difficulties. 
As to the ouestion of disability due to active war ser- 
vice for diabetics still other causes of manifestation are 
to be considered besides an inherited disposition for a 
special disease. Diabetes may be caused b'r aggravated: 
li by different kinds of infections, alsi suppurat- 
ing wounds in individual cases aftei4 hepatitis epide- 
mics, protracted malarial fever and typhus, 
2| by severe infectious pancreatitis and traumatic 
pancreatitis , 
3. by wounds in the head caused by bullets, symptoms 
often appeared after an interval of delay, 
4. by concussion of the brain (but only exceptionally} 
by a coma occurring during the time of service if 
the aggravation factor could not be compensated by 
hospital treatment, 
6, by physical and mental strain if it can be proved 
that It considei*Hblyr'©xceeclb the*average. This question 
is very difficult and reouires great responsibility on 
the part of the specialist. 240 
7, the same may be said of hormonal changes by per- 
manent effects. 
8. by medical treatment if it was inappropriate or 
not given in time. 
The next sentence in the German text is garbled (Editors 
Note,) 
Disability for active service cannot be caused by aver- 
age physical strain or heat in a southern climate or frost- 
bite if no serious Infection occurs. 
he- lit us,* 
Erof^ssor^NONNENBRUCH 
Even before insulin was discovered KOHLISCH, CARL v, 
NORDEN, and FALTA demonstrated the favorable effect of a 
diet rich in carbohydrate and lacking protein and fat on the 
diabetic patient. It is the same with a diabetic treated 
with insulin. The normal diet of to-day has proved very 
favorable in this respect. By the additional food tations 
for diabetics approved by the chamber of ohysicians of the 
Reich, the fat and protein rations have been doubled. With 
this additional ration the diabetic oatient gets 1 gram of 
fat and 1 gram protein per kilogram of his weight and has 
to supply the deficiency of calories with carbohydrates, so 
that even with this additional food he depends upon an 
ample supply of carbohydrates. Owing to the nresent scar- 
city of insulin it is an important question whether the 
cutting of additional food rations and the making up of cal- 
ories by carbohydrates instead of protein and fat leads to 
an increased use of insulin. If so, we would better dispense 
with the additional food in order to save valuable insulin. 
According to our experience the food of a normal consumer 
with its low content of protein at present has served very 
well and led to no increase of the use of insulin. There- 
fore it is to be recommended that the diabetic be granted 
the food of a normal consumer. Diabetes itself does not 
exclude a fitness for active service. The fitness for ser- 
vice depends on every individual case on the intelligence 
and strength of mind of the diabetic. In a case of my own 
a seriously sick diabetic (a youth) grew into a well devel- 
oped young man and succeeded in oassing the final school 
certificate examination by adeouate treatment, he applied 
afterwards for service in the air force, concealing his dia- 
betes, and did his duty satisfactorily for several years ih 
a heavy anti-aircraft battalion. Some months ago when he 
was proposed for the rank of a reserve officer the diabetes 
was discovered during another medical examination and he was 
declared unfit for service. The young man was in excellent 
spirits during the years of his service, because hw was con- 
vinced that he was now at last fully appreciated. As a sol- 
dier he ate the normal food of the field kitchen and in 
addition to it took 80 units of depot insulin and additional 
injections of old insulin whenever he felt that he needed 
them. The discharge from service depressed him deeply. 241 
&l£SU££l£I)-2£_ll2fi-2£££U££C£.££££££&ilie-dla£££££ 
GRAFE: Because of the war it was necessary to increase 
the ordinary pre-war supply with carbohydrates (about 100 - 
150 grams). Besides that NONNENBRUCH and his collaborator 
FEUCHTINGER, tried increasing the supply of carbohydrates to 
about 350 grams as granted to a normal consumer but if 
possible with the same amount of insulin. The of a 
diet rich in carbohydrates oi4 free choice of any food is not 
new nor did Dr, NONNENBRUCH say that. In some cases it is 
without doubt possible to secure a higher tolerance of 
carbohydrates without increasing the supply of insulin pro- 
portionally, We have in our hospital all the time about 
30 - 4-0 diabetics so that we are able to study all these 
questions of diet with a great many people and on a large 
scale. The examinations in civilian as well as in military 
hospitals showed that the cases described by NONNENBRUCH and 
FEUCHTINGER are exceptions and not the rule. Moreover it 
would be very interesting to know what happened afterwards 
to these patients, 
4-3 cases of not too serious and serious diabetics who 
needed insulin showed that an increase of the supply of 
carbohydrates of 24% meant an increase of insulin of 28% 
an increase of carbohydrates of 30-70% on an average (460) 
an increase of insulin of 30%, an average increase of 86% 
of carbohydrates an increase of insulin of about 4-6% and an 
increase of carbohydrates of 14-0? an increase of insulin of 
about 70%, In all these cases the supply of carbohydrates 
has been increased to at most 3f)0-3$0 grams, in most cases 
only to 250 - 300 grams. 
The result of this large number of examinations, which 
is verified by numerous observations of the civilian depart- 
ment of the hospital proves that an increase of the supply 
of carbohydrates is of course possible but that at the same 
time the Quantity of insulin has to be increased though the 
amount will always vary and be insignificant. 
In one case the supply of carbohydrates was increased 
temporarily from 300 grams to 600 grams with the catastrophic 
consequence that extraordinarily high excretions of sugar 
occurred with an immediate decrease from 400 grams to 80 grams 
sugar per day. The excretions of sugar were so strong that 
insulin had to be injected, and so that even 101 units of 
insulin were reouired to make the sugar dianpear from the 
urine. It took five weeks before the severe injury to the 
carbohydrate metabolism had been removed and the former 
state had been obtained. Such a case shows how dangerous 
it may be to increase the supply of carbohydrates extensively. 
The continual clinical examinations have the advantage 
of being very exact. More important, however, is the ruestio:.: 
of how the situation develops when the patient is at home. 
Continual investigations of the treatment of diabetics give 
the best information about this subject. Prof. 0BERDISSE and 
his collaborators (FLECKENSTEIN, NAGEL and BEUEL) traced the 
fate of 190 diabetics who underwent treatment at the hospital 
during the last five years. This showed a distinct improve- 
ment of the condition of nearly all diabetics during the 
first few years of the war with ordinary food and the usual 
additional supply of carbohydrates of 120 - 140 grams on an 242 
average. Their condition was even better than in peace 
time. This improvementrchanged to an aggravation as a rule 
since we have used larger quantities of carbohydrates (up 
to 250 grams) in the outpatient department. In all cases a 
compensation of the carbohydrate metabolism was tried, t i ... 
though it was not possible to do this with the same exactitude 
as in peace time. Thus we had to put up with an increase of 
blood sugar up to 0.17? and excretions of sugar up to 15 grams 
per day. We observed that the demand for insulin increased 
on the whole by about ten units per 100 grams of carbohydrate. 
Even in this case the result is the same, an increase of the 
supply of insulin, though a comparatively smaller one than 
the increase of carbohydrates* 
# 
In my opinion we shall have to make a compromise by 
granting the diabetic patients who need insulin, who at 
present are one half of them, a medium quantity of carbohy- 
drates from 200 - 250 .grams. To discontinue the granting 
of additional food to diabetics is not possible, 
SCHENCK: There are two tendencies regarding the judge- 
ment of the granting of additional food to diabetics, 
a) increase and steady recourse to the maximum rations 
of additional food, 
b) discontinuance of the granting of additional food 
with the aim to release food for other purposes. 
The latter tendency is of vital importance at present 
to diabetics and to patients with gastric complaints. The 
statements on which the demands for discontinuation are based 
are neither well founded nor true, 
A discontinuation of the supply of additional food for 
diabetics is out of the question and not intended. In the 
first place because the psychological effect would be very 
unfavorable. In the second place, it would require a com- 
plete change of treatment of mahy thousands of diabetic > 
patients which would be impossible at present. In the third 
place because the observations on which the demands for dis- 
continuation of the granting of additional food are based 
have not yet been reexamined sufficiently, 
SCHULTEN: The increased demand for insulin during the 
war is not only caused by an increase of the consumption of 
carbohydrates by diabetics but also by prescribing insulin 
Tor nondiabetic patients, above all those suffering from 
hepatitis. This latter should be stopped altogether, because 
iV ia useless, 
LANGE: In the IV, Military District a special unit has 
been formed for diabetic personnel.According to the status 
Of 15 April 1944> 1229 diabetic patients had not been drafted, 
U9 had been discharged as unfit for service. After setting 
aside indispensable diabetics 360 are available for active 
duty. They are employed for guarding prisoners, A physician 
experienced in the treatment of diabetes was assigned to that 
unit. Experience with these measures is to be described later 243 
Directives concerning the treatment and evaluation 
2X_Mab5txg_lsil.it usA 
The aim of the treatment of diabetes is a regulation of 
carbohydrate metabolism with a tolerance of carbohydrates as 
high as possible and a supply of insulin as small as possible, 
Whereever it is possible an approach to our present food 
ration which contains little protein and fat is to be obtainec 
An individual treatment and control of the food intake is 
necessary in every single case. 
Cases of mere renal diabetes are fit for service. Dia- 
betics with a tolerance of more than 500 grams of carbo- 
hydrates without insulin are also fit for service. Those wit: 
& limited tolerance, as also those in need of insulin, have 
to stay at their place and are fit for service in the reserve 
and have to maintain themselves. This especially applies to 
soldiers on active duty, higher ranks,and officers. 
Diabetics without military training who need insulin 
are not to be drafted. 
Diabetes is in most cases inherited. Diabetes acouired 
only after pancreatitis or following injuries in the bead is 
a very rare case. Even with an inherited disposition for 
that disease are causes producing the symptoms and 
aggravating them which accelerate the outbreak and lead to 
a more serious prognosis. Such -.are, besides serious injurie 
to the stomach and the brain serious, especially chronic, 
infections, suppurations or previous states of coma. In all 
cases the question of the influence of war has to be ans- 
wered in the affirmative , Physical strain cannot be made 
responsible for the onset or an aggravation of diabetes. Ex- 
ceptions are only possible if it can be proved that the pat- 
ients have undergone excessive and abnormal physical and 
psychic strain. Each case must be judged on its own merits 
and it is sometimes very difficult to arrive at a definitive 
deci sion. 
5. Concerning the treatment and evaluation of rheumatism 
Ag££flYat io&_and_psychi ioriA 
Qberfeldarzt ( Lt. Col. Prof. BECKMANN 
In the winter 194.1/4-2 polyarthritis had a high incidence 
in two armored tank regiments which were living in overcrowd 
conditions, as a senuela of an angina epidemic, of 
the soldiers were afflicted with the disease for about a 
yeat and their number did not decrease until older men were 
drafted into these regiments. This observation emphasizes 
the idea that it is chiefly the tonsils which ar° a focus of 
polyarthritis among younger men. The therapy of acute poly- 
arthritis has to be started with a big dose of salicylate 
(&-1Q grams) or pyramidon (2-3 grams). They have to be 
administered until the acute inflammations have subsided for 
the most part. Then the dose should be reduced slowly by 
stages. Intensive therapy with large doses for only 2-3 
days has proved a failure. As soon as the tendency to a 2U 
fixation of single joints manifests itself passive exer- 
cises have to be started. In milder cases the patient may 
be urged to exercise his limbs himself, even during the 
initial stage. Very early hydrotherapy (thermal baths) may 
be applied in individualized plans as soon as the temperature 
has become normal, even if the blood sedimentation rate is 
still high. Usually the sedimentation rate returns to normal 
again relatively quickly with the baths. The most important 
thing is the exercise of the limbs , Greater mobility is 
the chief the exercises are the way and the hydrothera- 
peutic measures are the means to make the exercises easier. 
In order to strengthen the reaction of the body all other 
physical measures are to be employed (mud baths, underwater 
massage, slowly increasing individualized gymnastics, later 
on walks under supervision and sport.) 
Cases of acute and chronic polyarthritis must not stay 
too long in the general internal medicine wards. If no 
appreciable progress has been attained six to 
weeks, they are to be transferred to a special hospital for 
patients with rheumatism. On the other hand, not every heal- 
ed polyarthritis has*to be treated by baths. This is only 
to be considered if disturbances of function still exist. 
In this way the long duration of the disease might be 
shortened considerably in many cases. A separate estab- 
lishment of general hospitals, soecial hospitals, for rheu- 
matic patients and hospitals for convalescents as proposed 
by TICHY is not required. Complete convalescence can be 
achieved in a special hospital for rheumatic patients. It 
is not necessary that the patients should have become free 
of all complaints. The further supervision has to be under- 
taken by an army surgeon who must be thoroughly informed in 
this field. By this plan it is possible to render the major- 
ity of the patients fit for service again in well appointed 
special hospitals. Chronic and constantly relapsing cases 
are to be discharged in due time as unfit. 
Vegetative dystonia is much more freouent with rheumatic 
patients than with other diseases (6$ as compared to 3,8$), 
Psychic fixation is freouent in the beginning in of 
persistent pain, but disappears with increasing improvement 
and increasing ability to move. It very seldom gro?/s worse. 
Simulation of polyarthritis was observed in on.ly one case. 
For the treatment of sciatica the same points of view 
obtain. Exact diagnosis and exclusion of all other organic 
changes are required, (arachnoiditis, meniscus prolapse, 
sacralization, static moments, etc.,) and these procedures 
are best carried out in a special hospital for rheumatic 
patients or on observation wards. Sciatica showing no im- 
provement within four weeks has to be transferred to a 
special hoopltali We shall succeed in rendering fit for act- 
ive service a great many sciatica patients within 6-8 weeks 
by special treatment which lays oarticular stress on systemat- 
ic muscular exercise. Chronic and relapsing cases are to be 
discharged as unfit. Among 89 serious stubborn cases definite 
deterioration was observed in only one case, while in two case: 
there was a suspicioh of deterioration and in 12 cases strong 
psychic factors played a role, 5U cases suffered from in- 
volvement of the nerve root (in the form of arachnoiditis) was 
observed and five from intervertebral disc prolapse. Strong psychic influences are much more frequent with sciatica pa- 
tients than with polyarthritis patients. 
To be successful it is essential that the special 
hospitals for rheumatic pati°nts have available a sufficient 
number of well trained personnel (women trained in gymnastic 
exercises and masseuses). The baths are to be given in the 
hospitals if possible. Of special importance is the super- 
vision and care of the patients by an army surgeon after 
their discharge from the hospital. 
6X Concernl ng._the treatment_and_evaluati on_of_Rh^umatic 
fever and Neuritis, Aggr a vat i o n_and_ Psychic 
Fixation^. 
Stabsarzt (Captain M.C.),Profa_PANSE 
I think a psychiatric concept of rheumatic fever may 
contribute considerably to a solution of the complicated 
problems of the rheumatic diseases. Though modern invest:? 
ations of rheumatism have widened considerably the knowledge 
of etiology and pathology, the physician and the patients 
still cling to traditional and vaeue notions concerning 
rheumatic Often a diagnosis is established which 
has no objective basis. This causes vague misgivings to 
the patient and induces him to fear that he may be afflictc 
with the disease. The results are those frequent psychogei 
symptoms and fixations accompanying rheumatism concerning 
which I intend to speak principally% 
Acute articular rheumatism, rheumatic fever, implies 
a psychic burden by its organic conseouences e.g. with myo- 
carditis, inflammation of the serous membrane, or during 
relapses which cause psychogenic reactions. This is especi. 
ly true with the numerous cases of chronic and relapsing 
arthritis which may be differentiated from genuine rheumati 
fever and must be traced back to focal infection. The fre- 
quent uncertainty as to the etiology, the vague nature of 
the complaints, the resultant diagnostic uncertainties and 
the attempts to find the focus aggravate the feeling of bei: 
sick and draw the attention of the patient to the physical 
processes, by which a hypochondriacal psychogenic attitude 
may easily be caused which in time becomes fixed and can be 
removed only by effective suggestion therapy. 
The more localized the rheumatic symptoms are the mor 
freouently will the forms of strong psychogenic reaction- 
be transformed from a general hypochondriacal dejected att 
tude with the typical " facies psychogenica" to circumscri; 
relief attitudes, anomalies of attitude and contractures of 
the affected parts. The great numbers of localized infect:, 
arthritis of the spine and several larger joints are to be 
specially mentioned. The soldier at first is led to close 
self-observation by the steady dull pain and the increase 
pain with certain movements. Relieving, evading and prote 
ive postures are assumed which may become grotesoue, ster> 
typed and quite unconscious. The resultant state can be 
plained etiologically only by close cooperation of the in' ist« with the orthopedists and the psychiatrists with the 
neurologists. Even serious changes of posture and contract- 
ures which have considered to be organic for years, have 
been proved to be psychogenic and susceptible to removal. 
These psychic influences are by no means alv/ays hysteric- 
al, that is they are not so often malignant as is generally 
supposed. Chronic rheumatic diseases are often unconsciously 
caused by a steady fear of disease and an abnormal fixation 
of the attention on the processes of the body. They are seldom 
really hysterical or demonstrative and have therefore nothing 
to do with genuine deterioration or simulation. The latter 
is the case far more often with acute neuritis and neuralgia, 
with which patients often show a tendency to evasion. The 
more chronic these states are, e.?, with sciatica, neuralgia 
of the brachial plexus or freouent acute infectious polyneu- 
ritis, the more the psychogenic processes resemble those of 
rheumatic fever. 
The psychic reactions are due to autosuggestion and can 
be removed only by suggestion therapy. Every well planned 
and purposeful program of therapy carried out by a physician 
with healthy optimism is valuable in this respect, and can 
avoid the development of psychogenic influences. Aimless 
diagnostic and therapeutic attempts have the opposite effect. 
If, however, psychogenic influences have once appeared, only 
consistent suggestion therapy will be successful. 
The following procedure has proved especially successful 
even in the most serious cases. The treatment by suggestion 
begins by using a diagnostic apparatus with unobtrusive opti- 
mism and with a number of special examinations adapted to the 
complex of complaints. The "favorable" result is assured 
every time and the eventual certain cure is stressed. All 
the time the physician must systematically avoid permitting 
the patient to know whether he considers his condition as 
psychogenic or organic. The physician must not allow any 
doubt or other influences to be reflected in his manner no 
matter how well justified they may be. a powerful gal- 
vanic current is applied at short intervals together with 
verbal suggestion. This treatment represents an impressive 
experience, the effect of which practically never fails with 
a man who is well prepared by suggestion therapy. It is ad- 
visable to reserve the treatment itself to the neurological 
wards of special hospitals adequately equipped for the pur- 
pose and containing a large number of organic cases for the 
physician too has to be thoroughly familiar with this treat- 
ment and surroundings furthering the suggestion are indis- 
pensable. 
Directions for,.the ,treatment^of rheumatic fever and 
neuritis 
1, Cases of polyarthritis or sciatica showing no parti- 
cular tendency to improve within four weeks have to be 
sent to a special hospital for rheumatic patients, 
2, A thorough elimination of all foci of infection is 
absolutely necessary. Salicylate or pyradidon treatment 
in high doses is not to be carried through for a short 
time only, but until the acute symptoms have disappeared. 
Then the dose may be reduced slowly. Passive or active exercises are to be applied early. 
Hydrotherapy may be begun aftor the fever has subsided even 
if the sedimentation rate is still above the normal, 
3, The special hospital for rheumatic patients must 
have at its disposal a rhinolaryngologist, an otologist and a 
department of dental surgery. Baths shall be furnished in 
the hospital if possible. The hospital for rheumatic patient-; 
should be fitted out with sufficient personnel (personnel for 
gymnastics, masseuses), 
4., Psychogenic influence and disposition to aggravation 
(mostly in the form of comulsary and relief attitudes) are 
more rare with polyarthritis than with sciatica and 
kinds of chronic neuritis. Psychic guidance by a physician 
is essential. Serious and persistent cases shall be to 
a neurological ward established for that purpose as soon as 
possible, for a proper treatment by suggestion. 
2* Corjcerr}in£_the_evalu,ation_of_non-or£^nic_heart_disoasns 
(vegetative, postinfective and other types). 
Oberstabsarzt (Major M.C.) Prof. BANSI 
Non-organic heart diseases are extraordinarily frequent* 
Their evaluation is very difficult especially for younger 
physicians who adhere too much to the minor findings of the 
technique of diagnosis in their judgement. The evaluation 
of this big grouo of soldiers with strong subjective heart 
complaints was discussed even during World War I,(WENCKEBACH), 
If organic heart complaints are to be set aside after 
a thorough general examination and detailed clinical study, 
a clear opinion is to be given* 
Classification 
1* Hypertonia without anatomical dilatation of the 
heart and involvement of the kidneys, 
2, Disturbances of the circulatory control center, 
3* Vasoneuroses, including angina pectoris spuria 
nervosa. In addition are to be mentioned: 
4., Postinfectious instability of the circulation, 
5. Heart complaints after injuries to the lungs and 
6, Neurovegetative disturbances of the central regula- 
tory mechanism chiefly on a hormonal vegetative 
basis. 
Hypertonia: Variable systolic pressure without anatom- 
ical changes of the heart muscle which can be observed very 
often with young people is unimportant (Class A-defect). The 
same applies to abnormally high and slowly decreasing blood 
pressure reaction to exercise. Blood pressure which is con- 
stantly above 14.5 without involvement of the kidneys and 
\Bart hypertrophy are to be considered as class B-defects 
Q.iv<r>'rdt«g' ter th© Regulations*of last yetir, Ope must search for infectious foci as a cause of hypertension. 
Disturbances of the conduction mechanism: Uncomplic- 
ated ventricular extrasystole which does not increase with 
work is not important (class A-defect). If the extrasystole 
increases with work or if it is of multifarious origin, 
myocarditis must be supposed. The latter is usually a sequel 
of chronic or acute infection. Aft«r three months another 
examination and evaluation of the symptom which was considered 
as a Class L-defect previously must be carried out. Supra- 
ventricular extra systoles are to be considered as a Class 13- 
defect just as is sinus rhythm which appears in the state of 
rest, if no other symptom' of a heart muscle defect can bo 
ascertained, 
Essential paroxysmal tachycardia prevents the fitness 
for service during the attack. According to the freouency 
of those attacks a Class B-or L-defect must be supposed if 
other organic findings are absent. The same applies to 
the electrocardiogram (EKG) finding of the so-called Kent's 
bundle, in which case •ccasionally abnormal conduction 
mechanism may set in with exercise. 
The most frenuent of all obscure non-organic heart 
troubles are the circulatory neuroses of patients suffer- 
ing from neurocirculatory asthenia. These patients are in 
most cases very unstable and generally inefficient indivi- 
duals with numerous subiective complaints and symptoms con- 
nected with the vascular nervous system. They are not easy 
to train and are, especially if symptoms of the sympathicus 
are oredominant, usually very uneconomical workers (ergo- 
tropic type of Hess, Graves' disease). They reach the limit 
of cardiac efficiency with a low level of consumption 
even if trained to use the vagus as a spare part (protect- 
ive measure) for better utilization of the oxygen in the 
blood and an adequate increase of the volume of the single 
heart beat (Histctropic type of Hess), In spite of this heari 
failure has never as it is with organic 
heart diseases, such as old vitium cordis and unrecognized 
endocarditis. Those patients usually do not complain much 
and occasionally decompensate acutely if subjected to special 
burdens. The majority of these vascular neurotic persons 
are absolutely fit for service and can often be trained 
together with healthy soldiers (class A-defect). Only very 
serious chronic tachycardia (the pulse has to be counted 
also at night) with a considerable general decrease of 
efficiency is to be judged as Class L-defect, on the basis 
of clinical judgement. They are to be evaluated in an ob- 
servation hospital or a corresponding medical institution ox 
the field army, to prevent their shirking service by a pro- 
longed stay in a hospital, Sven individuals with heart com- 
plaints caused by angina without anatomic causes, which occur 
very often among juveniles are fully fit for service. One 
must be careful not to overvalue insignificant electrocardio- 
graphic deviations such as slight lowering of the ST deflect- 
ion in leads II and III (loss than 1 millimeter ), bow 
shaped transition of the S deflection to the ST deflection* 
negative T3 with high P2 if T3 rises with deep inspiration. 
Generally the electrocardiogram is overvalued and important 
diagnoses and corresponding evaluations should be deduced only 
from the EKG showing the physiological response to work. 249 
Many deviations of the FKG may become retrogressive and need 
not be due to an irreparable lesion of the tissue,-' 
Postinf °f the circulation must be 
watched closely, especial1y with the younger soldiers, in 
order to prevent permanent damage. 1 hey'appear after the 
usual infections, such as hepatitis, diarrhea, Volhynia- 
fever, tularaemia and above all after typhus. Hypertonia 
after typhus must be mentioned. It probably has a central 
origin, as also the not infrenuent increase of blood pressure 
after diphtheria. It is these young soldiers who care- 
ful medical treatment after infectious diseases, to prevent 
these young men who are still at the stage of adolescence from 
overwork, Postinfectious hypertonia of young people with a 
disposition to collapses must be mentioned. In the electro- 
cardiogram the border-line pictures which I mentioned are 
to be found. The prolongation of the PQ interval is a fre- 
quent sign of a toxic heart involvement. If a decreasing 
PQ prolongation appears in th° FKG on exercise with trained 
individuals, it is not %»• be considered as pathological. 
Young soldiers with uostinfectious functional irregularities 
of the circulation should be released from hard work for 
three months. The findings should be checked during a period 
of three months. 
Systolic murmurs are often misinterpreted. One ought 
to ascertain whether they disappear with deep inspiration 
or change their sound when the patient is recumbent, which 
will prove their accidental origin. Even the roentgenolo- 
gical measurements of the heart, must be regarded with dis - 
crimination. Not every large heart is diseased. The athletic 
heart caused by excessive sport activities in early youth 
is a symptom (,pay attention to the kind of sport). Heart 
complaints with persons with injured lungs are intelligible 
even if no abnormalities of the pleura appear in the X-ray, 
or abnormalities of the autonomic nerves can be demonstrated. 
If functional disturbances of a greater extent exist they are 
to be considered as a class L-defect, It is important to 
calm the men about the "ball in the chest" which is often 
very harmless* 
Let me mention in conclusion the simple neurovegetative 
disturbances of the regulation of circulation: 
1, The border-line cases of hyperthyroidism compared 
with the real picture of thyreotoxicosis and Graves1 
disease^(situational hyperthyroidism considered as B 
41). 
2, The disposition to spontaneous hypoglycemia without 
direct primary hyperfunction of the pancreas v/hich may 
appear in addition ta bulemia during periods of weakness 
of a marked vasomotor character (BI52) 
3, Tetany syndrome vfithout evidence of hyperfunction 
of the parathyroid glands. Often somewhat infantile 
young soldiers are concerned (Bl^) 250 
A. Syncopal vasomotor attacks manifesting themselves 
by orthostatic collapses or cardiovascular syncope. The 
attacks are as a rule very rare and appear only after 
overstrain. According to the frequency of attacks they 
are to be considered as B or L defects. 
If organic findings can be excluded after a thorough 
general and special cardiac examination, the physician 
has t» realize the fact that every one has to do his 
duty by the community to his utmost. It is the large 
group of the less efficient that are oft°n protected 
with unwarrantable lenience while war selects with the 
utmost cruelty the best of our meople* 
st urbane esA 
Stabsarzt (Captaip M.Q r } Prof . RUEHL 
Fxaralnations of the circulation can be only a link 
in the general medical evaluation and presupposes a know- 
ledge of the history and clinical, roentgenological and FIG 
findings. Their chief problem is - establishing the general 
capacity of the circulation as well as the functional differ- 
ential diagnosis that is the differentiation of he disturb- 
ances caused by the heart from those caused by t' e vessels 
and the discovery of latent defects. The latter i s important 
especially for deciding the question whether they are organic 
or functional. 
The kind and the amount of tke strain imposed have to 
correspond to the desired purpose. Customary work loads, 
such as physical work (in relation to the weight of the 
body) are as a rule to be preferred. An exact adjustment 
of the work load is imoossible on principle. Any transitions 
are possible from the simple sitting up in bed to sprinting* 
Certain regulations may be given only for certain frequently 
returning purposes (e.g, enlistment and outpatient examination 
The work load imposed most not b'- too small (30 to AO knee-1 
bends, or running up and down a staircase of 10 Meters length 
twice a minute). 
It is important to consider the patient’s attitude to- 
wards the strain of daily life (history) also the observations 
during gymnastic or military exercise. Thus an Impression 
of the processes is obtained which will complete the moment- 
ary impression, derived from examination of the circulation* 
The processes of circulation and respiration which occur 
with the simple strain of physical work are so complicated, 
that their evaluation requires the greatest caution. Above 
all the extraordinary influence of the vegetative nervous 
system is to be considered and this is particularly strong 
during the usual short test. rxtcrnal influences (lack of 
sleep, nicotine, fever etc.,) and psychic factors play an 
important part. The facto£ of training may have a decisive 
effect. Therefore we are justified in speaking rather of an 
examination of the regulation of the circulatory nerves than of an examination of the function of the heart. We point 
out the importance of repeated attempts to differentiate 
the nervous influences , 
It is correct to call cyanosis and dyspnoea after 
work an indirect sign of a disturbed general circulation 
(aside from nervous tachypnoea) when pulmonary factors 
e.g. emphysema, are excluded. Also, observation of the 
general attitude especial1y of the expression of the 
face are of importance. Ascertaining how long the patient 
can hold his breath after deep inspiration has the dis- 
advantage that it depends on the will-power of the sub- 
ject and can therefore be used for military purposes only 
under certain conditions. 
Decreasing or constant blood pressure with increasing 
frequent pulse at the same time is to be considered as 
poor or uneconomic action of the heart. Steady deep in- 
spiration and frequent pulse after work are signs of an 
absence of work economy. 
Nervous factors have such an important influence on 
the height of blood pressure, that a calculation of the 
quotients from percentage changes of amplitude and fre- 
quency as a basis for Judgement is to be denied, A 
venous stagnation (with insufficiency of the left heart 
it can be recognized by decrease of vital capacity after 
work) can be ascertained only after a genuine failure of 
the heart while an evaluation of the values of the vital 
capacity has to take into consideration the psychogenic 
factors , 
It seems doubtful whether the variations shown in 
the work kymograms (enlargement of the silhouette of the 
heart with a reduction of the deflections ahd a change 
from type I to type II according to STUMPF) may be uti- 
lized for evaluating heart conditions concerning whose 
nature one is not certain apart from the technical difficult- 
ies, These doubts are due to the nervous influences on 
the muscle contractions of the heart and to the uncertain- 
ty about the decision as to what is to be considered as the 
normal state. 
The usual strain of work, with a measurement of' the 
blood pressure and observation of the inspiration may be 
combined profitably with the making of an 
gram during work. It is sufficient to ascertain the values 
shown by the EKG, three or five minutes after work, accord- 
ing to the directions on EKGs, The FKG during work is 
without doubt one of the most important practical function 
tests. It is,however, able to demonstrate only latent 
defects (e.g. coronary insufficiency or myocardia) but it 
never shows anything efficiency of the heart 
because its contour is only the manifestation of a process 
of excitement. A critical Judgement of the EKG findings 
is very important because of usual overvaluation. 
Changes which are caused by frequency must not he considered 
as symptoms of disease. Prolongations of P° after work, 
enlargement of ORS in the form of intraventricular disturb- 
ances of the conduction mechanism (the utilization method of 252 
Schellong is of no use for practical purposes) freOuent 
appearance of extrasystoles especially thos"> with different 
origin of the stimulus and certain ST downward deflections 
than 1 millimeter with normal gauging) are to be re- 
garded as pathological. Most is the ST downward deflection 
in leads I and II, as well as in leads II and III with a 
right deflection (Rechtstyp) at the same time not only in 
lead III. Marked T flattenings or iso-electric T are to 
be considered as pathological only in leads I ahd II* 
The seriousness of the FXG changes can be used only under 
certain conditions as a basis for judging the degree of 
anatomic lesion. It is of great general importance that 
changes based on electrocardiographic findings alone never 
justify the diagnosis of coronary insufficiency or myocar- 
dia, As a matter of orinciple th diagnosis shall depend 
altogether on the general clinical decisions and shall not 
be established by the physician who judges th'* findings of 
the EKG. 
The influence of nervous factors is to be recognized 
also for the EKG under work load which can proved very 
distinctly in the EKG in cases of so-called orthostatic 
strain, I think that the ST downward deflection occurring 
with it are no manifestation of disturbed blood circulation 
in the coronary arteries nor are they due to haemodynamic 
causes. They depend also only partly on frennency* Their 
disappearance the administration of justi- 
fies the supposition that they are only nervous vegetative 
changes in the contour of the EKG, The EKG under anoxia 
has so far been only of theoretical importance as a test 
of functions, A practical wider application is made 
difficult by uncertainty about the limits of the normal 
state and by doubts about the harmlessness of the method 
if practised by unexperienced persons. 
Besides the t~sts of the functions of the whole cir- 
culation and of the heart, another eeually valuable field 
of circulatory examination is to be mentioned which is un- 
fortunately often neglected, namely the testing of the 
function of the peripheral circulation. Those methods 
which make it possible to test the peripheral circulation 
independent of the effieiency of the heart (Schellong test) 
with recording the systolic-diastolic blood pressure and 
pulse freouency immediately , 2 and five minutes after 
simple (active) standing up is recommended for practice. 
Greater lowering of the diastolic as well as the systolic 
blood pressure (more than 20 millimeters) indicates a 
pathological disturbance of the regulation of the peripheral 
vessels. It must, however, be pointed out that such patho- 
logical hypodynamic or hypotonic disturbances of the regu- 
lation as well as orthostatic collapses ar° to be observed 
comparatively seldom, because the strain is too weak. 
To increase the strain on the perioheral circulation, a 
special method has been developed which consists in having 
the patient stand up ten minutes after an injection of 1 
milligram of histamine combining thus the mere orthostatic 
mechanical strain with a dilation of the capillaries of the 
patients (measuring blood nr°ssure and the frequency of the 
pulse up to ten minutes after standing up). The criterion 
far judgement is the following collapse itself. This method has proved useful for estimating the predisposition for 
collapse. Pathological collapse reactions were found most 
often with injuries due to infection from pneumonia during 
convalescence from focal toxicosis as well as with a hypo- 
tonic complex of symptoms, but not with psychogenic collapses* 
The method, however, still requires a'more widespread ex- 
perience and cannot yet be used in the army. 
The preceding report had to be confined to the simple 
tests of the function of the circulation as practicable in 
army hospitals. Regulations are practically impossible. 
In every single case the general medical judgment is de- 
cisive * 
DVS£U?sipn of„tfro reports_.CQ.ncernin£._gyaluatjpn_«f_ 
£ii.Qic_hQa?t di sedges. Vegetative dis^urh- 
aa5fij§_££„the_re£ulatioa_of_circula,tip£__Xj20St -ijj- 
fectfrve and other types) and Tests of Circulatory 
li^ctioiU 
KOHBROCK: The eases of latent typhus without a rash 
which not detected in the army and without direct clin- 
ical symptoms indicating a simple infection are now more 
frequent. They concern patients who are to the hos- 
pitals with subjective heart complaints, r/e find with 
them objectively, not only insufficiency of the peripheral 
circulation but above all insufficiency of the heart muscle 
associated with the complaints of a coronary insufficiency. 
Roentgenology and electrocardiography give us no information 
either at rest or after work. Often a specific sounding 
second tome of the aorta -indicates a progressing aortitis 
while in some this second tone of the aorta is almost 
a sign that the patient has had typhus. The WEIL-FELIX 
reaction will then confirm the supposition. Altogether the 
number of patients with latent tyhpus to be greater 
than is often supposed. Some cases of peripheral paralysis of 
unknown etiology at first or such cases as showed persistent- 
ly recurring low temperature who had had influenaa or even 
angina in the army were found to have a positive WEIL-FELIX 
reaction of at least 1:200, 
GUTZEIT: For the diagnosis of non-organic disorders 
of the circulation, the record and the general impression 
made by patients are much more important than any single 
symptom. The younger and inexperienced medical staff 
officers need constant instruction and training in this 
respect. It is of psychological importance to not give 
hhe patientsany information about the diagnosis of symptoms 
(EKG, pressure) and in case of unimportant symptoms 
or absence of objective findings to declare that the person 
14l>s in-sound health, 
BOHNENKAMP* All doctors agree th’.t no adequate diagnos- 
is can be based on single EKG findings or roentgenological 
finding alone in case of non-organic disorders of the heart 
and circulation. But the group of inefficient soldiers 
having pronounced disorders of the circulation whether iso- 
lated or general disorders of the central machanisra (change 
of stumpf type I to type II etc,,) is to be regarded with 
suspicion and should be followed up to be evaluated by the 
use of every available clinical method and exercise test including EKG, roentgenology and especially roentgen- 
kymography and the determination of the time for tension 
and relaxation according to Blumherger, Impressive 
experiences are reported. A physician in good physical 
condition and an excellent sportsman who had been observed 
for a long time developed a block in conduction after short 
service in the war though his EKG showed an alteration 
which had been considered as insignificant etc, 
BOCK; There is no standard simple method of testing 
iin£iion_of_the_£i 1oji.il, In the general range of 
a complete clinical picture, the time of circulation is 
to be ascertained, especially the difference between the 
period of action of decholin minus the period of action 
of ether. This enables us to measure the efficiency of 
the left ventricle. The standard value is not above 
seconds. An increase of the decholin-ether difference in- 
dicates a poor propelling efficiency of the left ventricle 
(further particulars about ether decholin fluorescence 
process of BOCK and FINK are given in the Congress report 
of the Deutsche Gesellschaft fuer Innere Medizin, Wiesbaden, 
1936), 
The following statements apply to all stand-up tests 
as functional tests. Anybody may have an orthostatic 
collapse. It depends on the manner of standing. Deeper 
inspiration and slight movements of the leg muscles will 
further the venous reflex considerably and delay or avoid 
collapses considerably. The conditions for such tests must 
follow certain strict rules, 
SCHULTEN: A differentiatioh of local heart disorders 
and vegetative disorders of the regulation of the circulation 
is of practical importance. Many physicians even specialists, 
recognize only the former which arr in reality rather scarce* 
Only the heart disorders e.g. after diphtheria are to be 
regarded as more serious. A great number of patients with 
disorders of the regulations are fit for service and are 
to be judged, strictly. 
VOLHARD: Do you m»t think genf 1 ernen that it would bene- 
fit these vegetatively unstable persons mor° than a 
hospital treatment if they could live in the same surround- 
ings as these here in Hohenlyehen, If they could have 
such an excellent treatment with slowly increasing strain by 
gymnastics and sports under such an experienced leader, I 
do not doubt that we should succeed in improving their con- 
stitution and in making their heart and circulation more 
ef fici ent # 
GUTZEIT: I should not treat patients with functional 
non-organic heart complaints, except chronic tachycardia and 
postinfective symptoms of weariness, in hospitals, but 
discharge them as fit for service. Experience teaches us 
that in spit'' of my efforts for y°ars to carry our exercise 
and work therapy it is not carried out in most hospitals 
and that the patients in convalescent homes get better 
only if strict medical control is guaranteed, but in the 
most cases the latter is lacking. ANTHONY: With men In the Air Firce too we find, dis- 
turbances of thra regulation of the circulation after great 
strain. A treatment in convalescent homes or hospitals 
carried out sufficiently early which lays a special stress 
on athletics and snort proved to be very effective for 
the purpose of making th~ ">ati°nts fit for active service 
within a short time, 
DELIUS: As to non-organic heart and circulatory 
diseases, it is recommended to differentiate between local- 
ized heart complaints or disorders and disorders of the 
regulatory mechanism. The latter can be classified etio- 
logically as infectious, toxicologic and constitutional 
cases and those due to old age, In a pathogenic respect, 
no heart disease but only functional disorders of the 
vegetative system are to be This has been 
proved by experiments. In a symptomat o logi c respect, we 
distinguish between hypertonic, hypotonic and normotonic 
disturbances of the control mechanism. The hypertonic 
ones are similar to the complex of symptoms thyreotoxi- 
cosis, Hypotonic disturbances of the control mechanism , 
perhaps hyposympathicotonia, are frequent with old men 
in the form of extreme exhaustion. They are vagatonies 
causing general inefficiency, Normotonlc or poikilotonic 
fiisturbances of the control mechanism are di?f:cult to 
deter ine by bllod pressure and records but : n most 
bases they are easy to ascertain by stand-up by 
keening a record of the electrocardiograph and the reaction 
of the blood pressure. The orthostatic changes in the 
shape of the ENG are certainly due to the influence of the 
heart nerves. In pathogenic respect :t is perhaps a case 
of vasomotor coronary insufficiency. We vn*w they can be 
influenced pharmacologically, 
/ 
Por purposes of evaluation it is to be recommended 
that patients with postinfective disturbances of the re- 
gulation and some other hypotonic disturbances of the re- 
gulation appearing as extreme exhaustion, be treated tem- 
porarily with consideration and to exercise them in a 
cautious way. Some constitutional disturbances 
•f the regulation mostly hypertonic, are to be considered 
as chronic with typical “failures”. They are to be 
classified as fit under certain conditions. The other 
disturbances of the regulation can be -judged as class 
A-defect, 
BANSI : Eor particularly serious constant tachycardia 
with considerable restriction of activity an evaluation ,3 
an L 49 deficiency should be possible in an observation 
ward or a correeponding hospital department of th« army, 
Postinfectiore circulatory instability : s to be judged as 
L 4.9 for 8 weeks and even up to 3 months, 
RUEHL; I am pleased to that we all that 
the ENG deflections in the stand-up test are of vegetative 
nervous origin and unimportant. The effect of the #2 
deficiensy test'makes us deny a coronary insufficiency. 
The Gynergen test cannot be carried out in a military en- 
vironment. The histamine-stand-up test cannot cause heart 
damage as the dose of histamine (l milligram) is too small. 
The Jarisch-Hezold effect is not at all likely to cause 
heart damage. 256 
The determination of the time for circulation yields 
useful results only in case of pronounced insufficiency* 
The tests of the function of the circulation have their 
proper use in border-line cases. 
General Directions about; 
a.* Freouent nqn-crganic heart diseases end vege- 
tative disturbances of the ¥unctional 
disturbances of the circulation without organic find- 
ings are extremely freouent, I suggest the following 
discrimination for practical purposes: 
a) Essential hjrpertonia without involvement of 
the heart and without kidney findings are to 
be classified according to deficiency B 49. 
The unstable increase of Mood pressure of 
juveniles due to the vegetative system of juveniles 
hw to be classified"1 aa-'.-a' class A 49 defi- 
ciency, 
b) Ventricular cxtrasystolo is harmless if it 
disappears after exertion (A 49), Multi ocular, 
ventricular a£d supraventricular extrasystole 
may be a sign of myocarditis (focal toxicosis) 
and should bo given a preliminary classification 
as L 49 with secondary examination after 3 months. 
Paroxysmal tachycardia is to be regarded as a 
class B or L defect according to the frequency 
of attacks even without organic heart findings* 
c) of vasoneurosis, also those with 
anginoid cimplaints, are to be considered as 
class A-defects, Only the rare casps with chronic 
tachycardia (above 120 beats) persisting 
after long with a considerable limitation 
4f efficiency can judged as a class L defect 
ijj an observation Ward or correspondin’' depart- 
ment of th* army* Soldiers with tachycardia 
caused by increased sympathicotonia afe less 
efficient and hard to train, but do not suffer 
from heart disease. They are fit for service 
(A A9) 
d) fvftry infectious disease may leave behind a 
circulatory instability disappears after 
weeks -©* aonths and needs careful control, A 
reexamination after three months at the latest 
should be routine, 
Syatftlie noises which are loudest above the 
pulmonary area and become louder with deep in- 
spiration or in recumbent position and which dis- 
appear nearly or completely with deep exhalation 
or on standing up are accidental and unimport- 
ant, A moderate dilatation of the heart in the 
X-ray without clinical findings is frequent and 
is not caused by an enlargement of the heart 
(athletic heart of the sportsman)* e) Heart complaints after Injuri-s to the lungs, 
also without organ.i zation of the pleuropericard- 
itis, are caused by irritation of the vagus or 
symphaticus (disposition for extrasystole and 
fainting fits), and should be classified accord- 
ing to L-49 but only if a considerable functional 
disorder exists 
If vegetatively unstable patients are haz'd 
to train they are to be transferred to hospitals 
for patients with slight disorders and with work 
therapy, 
b* Tests_pf_the_Functipn_pf_th^_Ci Test of 
the function of the circulation can only be a link 
in the general medical judgement and must be based on 
the record of the disease and on clinical roentgeno- 
gical and FKG findings. 
Their tasks are the following: 
To determine the limits of the capacity of 
the circulation to bear strain and to discover 
latent defects b'* functional differential diag- 
nosis, A constant test load is impossible. 
Special norms can be fixed only for particular 
frenuently recurring purposes in which case too 
slight a strain upon muscular exertion should 
not be chosen. The attitude during the strain 
of daily work and soort are also to bo consider- 
ed , 
The circulation and respiratory processes 
depend so much on the vegetative nervous system 
(psychic and external influences, training 
factor) that we can only with extreme caution 
infer a lack of efficiency of the organs from 
the result of a test of the function. 
The respiration as an indirect symotom of a 
disturbed efficiency of the general circulation, 
as well as cyanosis and dyspnoea are useful 
symntoms besides observation of the general atti- 
tude (expression of the face of the exhausted 
patient). The measurement of the length of time 
a patient is able to hold his breath after deep 
inspiration can be used only under certain • •n- 
di ti ons. 
If the amplitude of the blood pressure becomes 
smaller fcr remains the same, uneconomical heart 
efficiency may be supposed, Continued rapid 
breathing and pulse rate is a symptom of poor 
work economy. Calculation of ruotients out of 
percentual changes of amplitude and frenuency 
as a basis for evaluation is rejected. 
The usual strain by work may be combined pro- 
fitably with the making of an FT'G during work. 
Though the latter gives no indication of the 
efficiency of the heart, because its shape is 258 
only an expression of a process of stimulation 
it is important that electrocardiographic diag- 
nosis should be based on a general examination 
by a specialist and not be made only by the 
doctor who reads the FKG, 
For testing the regulation of the peripheral 
circulation an orthostatic strain such as the 
stand-up test is to be recommended. A consider- 
able lowering especially of the diastolic as 
well as the systolic blood pressure (more than 
20 millimeters), indicates a pathological disturb- 
ance of the peripheral regulation.