VG 106 204 /5 ws 8B Cornell Muiversity Pibrarp ee a) | ASBOMBAT Allie a inn olin REPORT ON THE JAPANESE NAVAL MEDICAL AND SANITARY FEATURES OF THE RUSSO-JAPANESE WAR T0 THE SURGEON-GENERAL, U. S. NAVY ws BY SuRGEON WILLIAM C. BRAISTED U. S. NAVY Tokyo, July 15, 1905 WASHINGTON GOVERNMENT PRINTING OFFICE 1906 HIS EXCELLENCY BARON Y. SANEYOSHI. Medical director general, Imperial J apanese Navy. REPORT ON THE JAPANESE NAVAL MEDICAL AND SANITARY FEATURES ” OF THE RUSSO-JAPANESE WAR TO THE SURGEON-GENERAL, U. S. NAVY BY SuRcEON WILLIAM C. BRAISTED U. S. NAVY Tokyo, July 15, 1905 WASHINGTON GOVERNMENT PRINTING OFFICE 1906 EY, Oe KS64S 4] Navy DEPARTMENT, Washington, January 10, 1905. Srr: You are hereby detached from duty on board the U.S. S. Ohio, and will report immediately, by letter, to the Office of Naval Intelligence, Navy Department, for duty. Take passage in the steamer Manchuria, of the Pacific Mail Steam- ship Line, sailing from San Francisco, Cal., on or about Saturday, January 21, 1905, for Yokohama, Japan; and upon your arrival at Yokohama you will proceed to Tokyo and report in person to the United States minister to Japan, and by letter to the commander in chief of the United States Asiatic Fleet, for special duty, comprising observations in connection with the naval medical and sanitary features of the Russo-Japanese war. The officer in charge of the navy pay office, San Francisco, has been instructed to secure your transportation in the steamer sailing the 21st instant .or Yokohama. This employment on shore duty beyond the seas is required by the public interests. Respectfully, Pau Morton, Secretary. Surgeon W. C. Brarstep, U.S. Navy. (2) CONTENTS. Page. Introduction: cae cake necks caches daa wos ete eae Seen ee 5-8 Hospital sships:<22.2455 cer eit acces rece demi eninee dade dee ieee 8-17 FLOSpltalis, 2 2c:.ancige dine ca owed de teedine Kani oma See bereeasee eee aee 17-82 Battle:ships: and cruisers... ¥.cen nie daddeie seek eewyawdstakite cevieeaeeosek ..-- 82-88 ‘Transportation.....22.2.200s0 248 Seisetesetasesbeeeaetee ye eeweemendeeesec si 38-39 The Navy Medical School co... 2.04.22. sccisic noes os Soc deieie aie pee oe eee SERS 39-42 Medical and surgical cases. ...-.----.-------- 22-2 ee ee eee ee eee ee eee eee 42-47 Preventive diledici 6 secre cere Ss enya cemeee mie nawee eRe Renee cost 47-54 Precautions against contagious diseases .....-...--- Rae ioe alee land aware medial 54-56 Quarantine sauce tere cue eats ayes ei ad a te er nnn eh ot te 56-58 The Red Cross nurse... -.-.-- 22-20-2200 ee ee ee ee eee eee eee eee uss eeeertesy 58-59 Sasebo after the battle of Sea of Japan: .......----.-------------------------- 60-73 a. Work in the hospital .....-....----. 2-22-22 2222-2 ee ee ee eee ee ee eee 60-66 bs “Conditions: on thé shipsisccccs2 cc cteeigacnescces cece cecuewse cececuraene 66-71 c. The hospital ship Kobe Maru.....---.------ +2 22-22-22 ee eee ee eee eee 71-73 Notes on first:aid in the army = =~ +1042 sac¢09. 2 sesmee keee eee oneekoesne ses sees 73-76 Army sanitary rules for the men .....-..-..-.------ 0-20-0222 eee eee ee ee ee eee 76-81 NGA LESUNGS jes oo jo Sz iaks sae stsanseylaveyd Sider ap spe san addy Skea stcuhe Wddeee eis ade cam anvaieybse AS Sacre devas 81-82 JAPANESE NAVAL MEDICAL AND SANITARY FEATURES OF RUSSO-JAPANESE WAR, Toxyo, Japan, 15 June, 1905. Sir: In obedience to an order from the Secretary of the Navy, dated January 10, 1905, a copy of which is appended, I have to state that I was detached from the U. S. 8. Ohwo, at San Francisco, on January 12, 1905, and on January 28, 1905, proceeded by steamer Manchuria to Japan, reporting to the American minister at Tokyo on February 16, and by letter to the commander in chief of the Asiatic Station, for duty comprising observations and report on naval medical and sanitary matters affecting Japanese operations in the present Russian-Japanese war. Upon my arrival at Tokyo certain requésts were presented in my behalf by the American minister to the Japanese Government to enable me to carry out my instructions. These requests were all kindly granted except two very important ones, namely, (1) a request to spend a short time at the front with the army or navy under actual fighting conditions, to note the care of the sick and wounded, the organization of first aid, the arrangement and manage- ment of field hospitals, medical equipment, methods of preventing disease, hygiene, etc.; and (2) a request to visit at least one large man-of-war in commission to study the provisions for the care of the sick, first aid, transportation of wounded, care of wounded or disabled in actual battle, and the om organization of the medical corps afloat. While these refusals were a severe disappointment, they really were a consistent carrying out of a policy that the Japan- ese have wisely adhered to from the beginning of the war. The reat kindness and courtesy shown in every other direction fully domenstvated their desire to do everything possible to aid in the work projected. ; However, much of the information desired has been obtained indirectly in other ways. I wish particularly to express my appre- ciation of the great kindness of Baron Saneyoshi, and of thes naval medical corps generally. Everything that could be done to make clear a very difficult subject was done, and even my welfare and comfort looked out for most carefully. In attempting to judge the position of the Japanese medical corps to-day it is necessary to remember that the navy is comparatively young, and so greater credit is due on account of the rapid advances -made to such an eminent position as it now holds. While the posi- tion of the Japanese on an island group has made them always a seafaring people, still nothing worthy of the name of a navy can be mentioned: until about the time of the last shogun. Before this time the more powerful rulers had war ships of the galley type. About (5) 6 1865 a determined effort to found a navy of higher type began, and a number of British naval officers and men were obtained as a nucleus for instruction, and some of the younger Japanese were sent abroad to study seamanship at various places. After the political disturb- ances of the country had quieted down, in 1873, the real building ofa navy began, the naval college was inaugurated, and training ships and squadrons sprang into being. The increasing navy soon felt a need for skilled medical service, and from this necessity grew the present medical corps. The old-time Japanese physicians took up their profession at will by reading Chinese medical literature or studying with older Japanese medical men. As there were no medical schools in Japan, it was found necessary to begin an army, and later a navy, medical school for the instruction and training of physicians and surgeons. So about thirty-four years ago was founded the Navy Medical School at Tokyo. This medical school, unlike our own, gives a complete medical education, and many prominent medical men in the service have received their education here. While it is true that many of the members of the corps have received their education in Germany, some in England, France, and America, yet many have had their complete course at their own Navy Medical School.¢ Thus, within a period of forty years has grown and matured the present medical organization with which we are attempting to deal, with its well-equipped hospitals, its many brilliant surgeons, its medi- cal school, its hospital ships, and all the many modern details required for the care of the health and well-being of a navy of 40,000 men. This introduction is made, as before stated, in order that a due appreciation of the difficulties overcome may add to the well-deserved merit of this most estimable corps of medical workers. All whom I have met are industrious, intelligent, and zealous workers in their special field. While waiting in Tokyo for official permission to visit the hospital ships-and naval hospitals, I was, through the kindness of the redial director-general of the navy, permitted to visit the many prominent institutions of learning and science. In considering Japanese institutions, whether military or civil, it is necessary to remember that the Japanese are struggling from a lower to a higher civilization, and it becomes, therefore, a more difficult problem to make just comparisons with the older European civilizations. Also, one must avoid with care the too prevalent ten- dency to idealize everything Japanese. We are trying to see things and describe them exactly as they are and without adding anything on account of the rather remarkable advances made by this people during the last fifty years. The Japanese themselves look at their present state with a very conservative attitude, and are often aston- ished at the elaborate praise and almost erotic enthusiasm of the foreigner passing through the country. I have heard an American medical gentleman, on being shown one of the poorest, dirtiest, and illy equipped of Japanese hospitals, go into raptures over the institu- tion, using an abundance of superlatives that astonished and puzzled the Japanese surgeon showing hi about These remarks are made 4 Note by Director-General Saneyoshi: ‘‘Gives” should be ‘‘used to give a complete course until twelve years age; since then they enter as navy surgeons by competitive examination after they have qualified as a medical practioner.” c because we find it impossible in this report to find only absolute perfection. There are many defects of organization, construction, and equipment of which the Japanese are perfectly aware, say nothing about to foreigners, and which they are earnestly striving to correct. Japan has been able to roam the world over, to study the institu- tions of all people, and assimilate and copy what has seemed best to her from each nation. They have started with a clear field, and by arate cen the best, have quickly put themselves on a high plane. Very little has been invented or organized de novo. er military organizations are largely drawn from the German, to some extent from the English and French, and very slightly from the American. The people are intensely patriotic; they have just emerged from a feudal condition, where strict obedience was incul- cated, with the most profound reverence for law and official power, a condition where severe punishment was meted out quickly to the offender. The result is to-day that in the army onl navy a disci- pline exists which has no parallel. The members of these organiza- tions are absolutely to be depended on, and their patriotism keeps them constantly at the highest point of efficient activity. If men are told not to drink, they obey; if they are told by their officers how to take care of their bodies, their clothes, their selection of food, they follow implicitly their instructions; hence we see an immense organ- ized body moving as by magic; hence comes freedom from disease caused by careless living. The Japanese as a nation are character- ized by a certain cleanliness, both of body and surroundings, so that here again is a cause of freedom from filth-breeding diseases. At the head of the affairs of the nation are men of superior intelligence and education; they make wise laws and their directions are followed with implicit faith. Again, we must remember that for nearly ten years the Japanese have been preparing for the present mene organizing, studying, planning, drilling, and gathering stores in large quantities against a war that was sure to come. The Japanese have been aided largely by good fortune; thus their fertile islands as a base and home have been untouched and their lines of communication to the battle fields have been easy and unin- terrupted. All during the war things move on in Japan almost as smoothly as though there was no war going on—a war that is taxing the very life of the Government. They have the method of enlistment by conscription, but this is supplemented by a most rigid physical examination, and no weak or impaired personnel is allowed. Thus they start with forces in per- fect health, with a personnel, not tall, but strong, sturdy, intelligent, and active; men who are accustomed to but few luxuries, who have always lived mostly in the open air, whose bodies have not been undermined by alcoholic excesses; men quiet in demeanor, but deter- mined, active, and capable. These are the circumstances that have added so materially to the wonderful campaigns of the Japanese. What, then, can we in the Navy learn from the Japanese in the present war? First, and most important, discipline and unwavering obedience to instructions. The Japanese officer as a rule commands the respect of his men; they look up to him and follow absolutely his directions. The Japanese officer is dignified but approachable, and his demeanor toward his inferiors is kind, interested, and tolerant. 8 The American recruit is, as a rule, bright, intelligent, and. loyal, but extremely difficult to control, es ecially in matters affecting 1s own person. He delights in doing all sorts of dare-devil tricks that only too often end disastrously; he will drink water from almost any source, a ditch or well by the wayside; he delights to forage and com- mits all sorts of intestinal excesses and errors. In these things he is a law to himself, and only long training and much experience tend to change the aspect of his character. ; : Japanese organization is good, but in theory not superior to our own, but practically they excel us on account of their absolute adher- ence to orders. There is but little else that we can learn at this time from the Jap- anese. Their hospitals are good for Japan, but fitted for the care of the Japanese only. Their institutions would not be at all satisfac- tory to our people, nor indeed could they be compared in anyway with the beautiful and efficient hospitals that are so marked a fea- ture of almost every city of our States. They are especially fond of surgery, but it is largely (in the army and navy) emergency surgery. They are gaining much experience and have much practice during this war, but there is little of what we look upon as higher surgery. Abdominal surgery does not flourish; there is but little of it being undertaken. The medical corps of the Japanese navy probably excel us in pathology and bacteriology. They always have at each institution extensive, well-equipped, and actively working laboratories. They take much interest in the work, and it is easy to predict marked suc- cess shortly in experimental work of this character. The Japanese navy surgeon takes his profession very seriously, and is a hard and intelligent worker. HOSPITAL SHIPS. The navy has two hospital ships, known respectively as the Saikio Maru and the Kobe Maru. They were both originally merchant vessels belonging to the Nippon Yusen Kaisha. ‘They are sister ships and practically fitted out alike. During the Japanese-Chinese war the Saikio Maru was made into a converted cruiser and took part in the battle of the Yalu. The Hobe Maru was used during that war as a Lo ship. After the Japanese-Chinese war these ships were returned to the merchant service and fitted out again as hospital ships during the present Russian-Japanese war. The Saikio Maru is a single screw steel ship of 2,978 tons, has a draft of about 20 feet and beam of 30 feet; length, 365 feet. She has four decks—a hurricane deck, an upper deck, a middle deck, and a lower deck. The hurricane deck presents nothing of unusual inter- est except the provision of a small steam launch and eight small 7-me- ter boats. In the series of pictures of the Saikio Maru, No. 3, will be found a hatch cut in the side of the hurricane deck to admit of swinging in a davit or whip. This hatch and davit are used in hoist- ing In patients on stretchers from small boats; and by being enabled to swing the davit and whip inboard when the upper deck is reached, the stretcher can be delivered on deck with great ease. There are two of these davits, one on each side of the ship aft, so that two patients can be taken in at once. An elevator is at hand to carry the patients below to the ward or room assigned. This scheme is worthy “NUVW-OAMIVS dIHS TVLIGSOH IVAVN 3SSNVdve SAIKYO-MARU, SERIES NO. 3. HATCH DEVICE ON HURRICANE DECK FOR HOISTING PATIENT ABOARD SHIP. NAVAL HOSPITAL SHIP SAIKYO-MARU. DISINFECTING APPARATUS. 9 of notice. The upper deck has on the port side from aft forward the dead room, reconstructed from the former closets of the merchant ship. This room is well shown in the series of photographs of Saikio Maru and Kobe Maru, No. 12, and while it is attractive, as shown in the picture, yet there are no provisions for keeping the temperature down. The room is appropriate in that it is remote, with least pos- sible oy of causing annoyance or infection to the remainder of the ship. . The preparing room for patients for operation comes next. It is large and spacious, fitted with a white iron table, the walls of wood painted with white zinc paint, lighted by good ports and with an abundance of electric lights. There are hat and cold water steril- izers; a coil of steam pipes introduced into the hot-water sterilizer keeps the water at proper temperature. A sink and washstand are provided, and provisions are made for the stowing of dressings, opera- ting garments, instruments, and solutions required in operations. Irrigating bottles suspended from the ceiling are at hand and the elevator shaft, on the inner side of the room, gives ease in transfer- ring patients from the wards below for operation. This room opens forward into the operating room, quite a fair-sized room, about 13 by 73 feet. The light is very good, being obtained both from the sky- light above and the ports on the side. The walls are of wood, painted with white zinc paint, and the floor covered with linoleum. There is a good white enamel operating table, white enamel and glass instru- ment stands, and an instrument sterilizer. There is a surgeon’s wash- stand, and hot and cold sterile water, with large irrigator suspended from the wall. Thereis an abundance of electric lights, both standing and portable. There seemed to be a good supply of modern instru- ments of all kinds in very good condition. The elevator is small, just large enough to admit of a patient on a stretcher, and is worked by one man by means of ahand ratchet. Forward of the operating room on the starboard side are several stateroom for medical officers; they are the same as the usual stateroom on steamers, comfortably fur- nished, with good electric light and plenty of light and air. Next comes the mess room, which runs athwart ship. It is quite comfortable, with two mess tables and cushioned transoms. The medical officer in command presides at one table, and the other table is for the junior medical officers and paymaster. The deck house, for- ward of this, contains the paymaster’s room and office and rooms for the engineer officer. A small lounging room for sick officers is also . located here. The forward part of this deck house is taken up with the quarters of the captain. On the starboard side forward, between the deck house and the bow, is the disinfecting outfit in a wooden structure built on the deck. It contains a large sterilizer, as shown in the photographs of this series marked eee? The sterilizer is used not alone for the hospital ship, but also for sterilizing articles for tor- pedo boats and ships when needed. The sterilizer, as will be seen from the Pie eaphs is ae large—about 7 by 5 by 4 feet. On the opposite or port side of the deck is the laundry, inclosed in a wooden structure. It contains a steam mangle, washer, and circular wringer. It is of sufficient size to do the washing for the ship—say 200 people. Aft on the port side are the senior medical officer’s room, a stateroom of about the same size and fittings as the staterooms for the other medical officers, and aft of this the dispensary, well fitted up and 11922—06 2 10 fairly well stocked with drugs, with plenty of light for compoundin and putting up drugs. There is also a room for the repair of surgica instruments, and emery wheels and outfit for sharpening instruments. Surgical instruments from the hospital ship or from the other ships may be sharpened or repaired here. As mentioned before, the sup- ply of surgical instruments is quite extensive, of modern make, and in very good condition. The bacteriological laboratory occupies the room next aft and is particularly well stocked with all needed for this work, with an excellent Zeiss microscope, section cutters, etc. Many of the pathogenic germs were growing, and Surgeon Endo, who had charge, is doing much experimental work in this line. A small room contains the photographic outfit and is used as a dark room. In the stern of the ship, corresponding to the dead room, but on the port side, is a room used for keeping medical records, but on the Kobe Maru fitted as a sterilizing room for surgical dressings. On the main deck are the two main wards—the surgical ward aft of the engine-room space and the medical ward forward. The surgical ward has the elevator to the operating room at hand for the transfer of patients from ward to operating room. The ward is very clean. The bunks are superimposed or double banked. They are made of wood and swing on pivots, which suspend them from heavy single wooden stanchions fore and aft. The bunk is built like a wooden box, with rather high sides. When fitted out with the Japanese mat- tress, quilted cotton-wool pads, blankets and sheets, they seem quite comfortable. Photographs Nos. 4 and 5 of both Saikio Maru and Kobe Maru show this construction very well. There are about 78 bunks in this ward. There are mess tables in the center of the ward. The ventilation is natural, there being no blowers or ventilating pipes for artificial ventilation. Sputa cups are used for the patients. The finish of the floors and surfaces is somewhat crude, but the ward seemed neat, clean, and sweet smelling. The medical ward forward is built much in the same manner. The spaces between the rows of bunks are sometimes rather narrow, and it would seem somewhat crowded if all the bunks were full. There are about 72 bunks in the medical ward. On the starboard side are dressing rooms, with a good X-ray room and the usual Siemens-Halske machine, with therapeutic attach- ments. The baths and closets are either of the Japanese type or of a modified type, and did not seem to me to be specially worthy of the ship. There is an isolation cell for the insane. It is well padded, with canvas cover, and painted white. In the door is a small sliding shutter to hand in food, and in one corner is a closet, so arranged that the basin for receiving the discharges can be removed from the out- side without ae the patient. At the situation of the cargo ports forward there is left on each side a space for receiving patients, so that a small gangway can be used to take them aboard, or a flatboat coming alongside can easily and expe- ditiously deliver patients at this point. Of course, in a seaway which prevented the opening of these ports this method could not be used. A spare space here can be fitted up with 25 or 30 additional bunks, if needed, and is known as a spare ward; it could be used for convales- cents or for special isolation cases. i § 4 x cee CVoMen: Ja] NAVAL HOSPITAL SHIF SAIKYO-MARU. LABORATORY. NAVAL HOSPITAL SHIP KOBE-MARU. DRESSING STERILIZER. NAVAL HOSPITAL SHIP SAIKYO-MARU. SURGICAL WARD. NAVAL HOSPITAL SHIP SAIKYO-MARU. MEDICAL WARD. "EL ‘ON SAIN3S ‘NUVW-OAMIVS dIHS IVLIdSOH IVWAVN SSANVdvP ‘NOOY AVY-X NAVAL HOSPITAL SHIP SAIKYO-MARU. DISPENSARY. JAPANESE NAVAL HOSPITAL SHIP. REPAIR AND SHARPENING OF INSTRUMENTS. SAIKYO-MARU, SERIES NO. 2. PHOTOGRAPHIC ROOM. 11 The eee are divided for the use of officers, patients, and the crew. They seemed to be in fairly good condition, with ranges and _ hot water, soup, and tea boilers. Outside the wards are folding shelves, which can be used as serving tables for the patients’ food. On the lower deck is the ice machine, a carbon dioxide machine of 1,100 pounds per diem capacity; also cold-storage and refrigerating rooms. They are not used at present, ice being obtained from shore as needed. There is also a large compartment just forward of the engine room bulkhead for the nurses. They may either swing in hammcecks or liein bunks, a certain number of double-banked bunks being provided for them. There is also on this deck a large storeroom, with supplies of dress- ings, medicines, and drugs, some for use on the hospital ship and some for issue to ships of the fleet in case of need. There are also storerooms for the supply of clean clothing for patients. On the main deck certain rooms have been retained for the use of officers. They are simply ordinary staterooms, as used in the mer- chant service. They usually are occupied by one officer only, but could be used by two, if needed. One room is set aside for a we ee officer, as an admiral, but does not differ materially from the others. Male nurses only are employed on these ships. Small wards for infectious diseases are fitted up on the lower deck forward, the crew swinging in the vicinity. It would seem better, as already mentioned, to put the infectious cases on the hurricane deck aft, where they would be entirely separate, especially as these ships are able to stand the additional weight. On the whole these ships are efficient. They did not impress me as favorably as I had hoped. They seemed less spacious than expected, and the finish of surfaces, sanitary arrangements, etc., were not as well looked after as it would seem possible. Still the Saikait Maru was coaling and undergoing repairs at the time of my visit, and this must be taken into account. Our own hospital ship, Relief, at pres- ent awaiting commission at Mare Island, is, to my mind, far superior in fittings and accommodation to any of the hospital ships I have seen. The only thing in which these ships surpass the Relief is in being bet- ter sea boats. I do not think there is anything of special importance that we could adopt from these ships. ORGANIZATION. On the medical side the detail is as follows: Fleet Surgeon Ota, rank of captain, in command of the ship. Fleet Surgeon Aaoki, rank of commander, senior surgeon. Staff Surgeon Endo, rank of lieutenant commander. Assistant Surgeon Imayoshi, rank of lieutenant. Assistant Surgeon Sanno, rank of junior lieutenant. Two pharmacists, rank of lieutenant.* One naval paymaster, rank of lieutenant. The nurses are males, and vary in number according to the needs of the service; at present 45. 12 The surgeon in command receives all orders from the admiralty and transmits them to the captain of the ship. This command is abso- lute, the captain® of the ship taking his directions from the senior medical officer. The captain is not a naval officer, but belongs to the merchant marine. He has entire control of the seaman branch on duty, regu- lating all matters pertaining to them and to discipline. The discipline of the medical branch is in the hands of the surgeon in command. The seaman branch is composed of 1 captain, 1 chief mate, second mate, third mate, chief engineer, first assistant engineer, second assist- ant engineer, third assistant engineer, all merchant marine; 1.pay- master, and 1 clerk, not belonging to the navy. The crew consists of 72 men. Of these 30 are firemen, and the remainder of quartermasters, boatswains, deck hands, cooks, etc. It is to be noted that there are two paymasters. The naval pay- master attends to all matters pertaining to the medical force and sick; he acts also as commissariat. The civilian paymaster attends to all matters in his department pertaining to the crew. For the sick and medical force there are 2 chief cooks and 4 assist- ant cooks. For the captain and crew there are 4 cooks employed. Mess men are not provided for the sick, the work being performed by the nurses. The routine for the day is as follows: 6 a. m., rise; 6.15 a. m., ham- mocks and bunks made up; 6.30 a. m., cleaning of all wards, washing patients, and getting ready for surgeon’s inspection; 6.45 a. m., pre- pare for breakfast; 7 a. m., breakfast; 8 a. m., patients visited by surgeon, general inspection; 8.30 a. m., surgical dressings made, patients in medical ward examined afterwards; 11.45 a. m., prepare for dinner; 12 m., dinner; 12.30 p. m., wards cleaned for the after- noon; 4p. m., prepare for supper; 4.15 p. m., supper; sunset, ham- mocks slung; 8.45 p. m., prepare for general inspection; 9 p. m., inspection. The first Wednesday in each month nurses are inspected as to their clothes, skin, hair, shoes, underclothes, bedding, and hammocks.. Third Tuesday of each month, nurses’ bag inspection. Each Tuesday and Friday the nurses wash their clothes; do not use laundry. Hach Saturday there is a general cleaning of the whole ship. a Note on hospital ships by the Director-General, Saneyoshi: ‘There is a small canteen on both Kobe and Saikio Maru. We used officers of the line in addition to the civilian captains and crew on hospital ships, but we removed the combatants for three reasons: (1) Because there might be some dispute as to the Hague agreement; (2) because naval officers and men might be short and needed; (3) we could not use a cipher code on the hospital ships, but use the universal signaling code, so that there is no special necessity for naval men.” : 13 The general food for patients is divided into four classes, as follows: gre Morning.| Noon. | Evening. No.1 AD! DVCAM irs. a orsreraicss see see sReMiclg sen cheddccinaanareceaenene BBE Tessierchaesertee G5r - Weasiiendeciors Dried bread) (50) Necacwmeeee (50)! |vacwcsnene eef with bone..... G0. deteamceees| 60) leacmearde Fresh fish with bone... 40: lstascuasalbaiainece's 40 Fresh vegetables... -.-- 100 20 40 40 Rice, cleaned... ... 100 60. lesisimscine 50 Cracked wheat. . 35 LOEB: levciesiercsarsess 17.5 Sugar......... 6: laceaeeeees Gs | ssierernervers PO deisetcmesice's 5) lnsesexe sen aD |sesuecomes Parched wheat. . 1 ud: lshaeeuse 5 Presb Drea oscsiuisiersie gs siete ais cts. sie siesarstgins diss aisiomrerasstoeneeacen siete 50: Jacenencce 50: levwceseccis (Dried bread) csc svorisses vieweseneis testes eecaceweeen es! (CO). leeecinwdives (Ce Pecos Beef WIth DONC. oo. cccc aren seanegaseeeEawavsaits tereaseeee es 60 leesesay ex 60) |eseeeeeees Fresh fish with bone Hedcnicah vex Eeeamraeeee sees eae 40! Veeaucs sales atemeinnats 40 Fresh: veretables: «nice cos seescacwowod semmnsesiiadine aokleueGe sa 90 20 35 35 Rice; Cleaned |. jc: ciedie sje esscisctasceicuGee ieisigie Some d aseisls eigteied Scie 80 BO es eegiecsae 40 Cracked wheat Brosh: breads caeciss wee eeasencn seaecanineen setedacecinene vee ence 60. (Dried bread) ......... --| (40) Meat for Soup. dds eiaiaiccayee 100 Fresh vegetables, potato 60 Rice for pug). a big ssrenravetie 20 Fresh milk.... --| 100 (Tinned milk) oD 84 150 50 50 50 60 20 20 20 150 50 50 50 (30) (10) (10) (10) 42 14 14 14 Note.—Tinned milk shall be given by dissolving 10 ‘‘momme”’ of it in 1 ‘‘go”’ of water (2.623 ‘‘go”’ equal 1 is Patients are given 0.25 ‘‘momime”’ of black tea and 5 ‘‘momme’’ of condensed milk at 3 .m. each day. e In ae ae table is used the Japanese ‘‘momme?”’ as the unit of weight. 1.036 ‘‘momme” equivalent to 1 drachm. Besides this, on the hospital ships ape ely nutritious food is allowed the patients as follows: Condensed milk, beef extract, eggs, butter, cornstarch, oatmeal, macaroni, prepared wheat, canned mush- rooms, strawberry jam, tea, port wine, and somatose. From May to December, 1904, the following numbers and kinds of cases were transferred: ‘Wotndéd in battle... 2 sc2 cincddeeceds ccueuaebee sas dae Bese totoeee ee nce 584 Of the above number— NAVY cbc tcne ce ace scm esis. s ens BaeO en Sel Ds os Cae teageees career es can 225 Army and Russian wounded..........-.---------+-- +2 22222222 cece eee eee 359 Injured but not wounded in battle.........------- +--+ +--+ 22 ee ee eee ee eee ee eee 108 Medical cases— From the navy....jc2. + s2c¢-sseeeevs oe se oeteeee tee cys ee teteeeeots 2x OBL From other sources. ..-..--------- kg $d gb geeeckewe ves ees ds eeeeeeeeeee see 103 Infectious, mostly dysentery (navy)... ---------------------------- 22-222 eee eee 147 Voonereal ere iaic ace-sicioccmexie-te ae cevtenes wteaies SON rete Ae ESS ace cect ees 94 14 Hospital ships do not carry a dentist, because the surgeons of the Japanese navy are instructed in the Navy Medical School in some branches of dentistry and are able to make temporary fillings. Each squadron, however, has one dentist employed to do the work of the fleet. The Kobe Maru, the other naval hospital ship, is so much like the Saikio Maru that it is not thought necessary to give a description of her. The blueprint is, however, submitted with a list of the various rooms, wards, and plants in accordance with the letters on the plan indicating the same. Bs ptet of ; The Japanese have many hospital ships in the army, some eighteen, I believe. Some of these were visited, but special mention is made of one of the Red Cross hospital ships, of which there are two. These ships were built as hospital ships and should be of special interest. They are known as the H akuai Maru and the Kosai Maru. _A special effort was made to see the Hakuai Maru, but I was somewhat disap- pointed to find that, although built as a hospital ship, she had been so constructed as to be readily converted into a merchant steamer. This naturally prevented carrying out plans that would look to the construction of a ship for hospital purposes only. This ship is just about the same size as the Saikio Maru of the navy. Her tonnage is 2,636. She has a capacity of 200 patients—300 might be taken in an emergency. There is but one main ward, with a capacity of 114 patients. There are other special small wards for serious cases, with a capacity of 4 patients in each. Aft on the main deck are rooms for officers. They are, however, simply ordinary staterooms with double bunks and a transom, so that they could accommodate 3 officers. The saloon, which is large and spacious, is not used, but could be used by ene patients on the floor in Japanese beds. was surprised in going about the ship to see the things not used— thus, there is a laundry on the lower deck forward that is not used, as the runs are short and washing can be done ashore. There is a circu- lar wringer, a mangle, and a washer. There is an ice machine and a refrigerating room, but not in use as they can carry ice and provisions for the few days of passage. There is a dead room on the after lower deck, but it is not used, as they can more conveniently carry the dead in other places.. There is a distilling apparatus, but it is not used, as they can get good water ashore. In other words, we must remember that these ships have nothing like our own hospital ships had to do during the Spanish-American war, and I seriously doubt if the work could be done in so satisfactory a manner if the distances were not so short. Thus these hospital ships are largely in the nature of specially fitted transports. m going into the harbor of Ujina one morning after the battle of Mukden, I saw seven hospital ships at anchor. It seemed strange at this naval base to see no evidence of battle ship or cruiser, but only the presence of such a fleet of hospital ships. A contagious disease ward, accommodating 35 patients, is situated forward on the main deck, shut off from the rest of the ship by a water- tight compartment. There is a good operating room, a surgeons’ preparing room, and an X-ray room of about the size and situation on the main deck that is found on the Relief. MARU. KOBE-' JAPANESE NAVAL HOSPITAL SHIP. OPERATING ROOM. NAVAL HOSPITAL SHIP KOBE-MARU. o ul, o8 iL Le ° x 2 a iva Oo i = ° ° rd MARU, SERIES NO. 22. KOBE: KOBE-MARU, SERIES NO. 25. LAUNDRY. RED CROSS HOSPITAL SHIP “ HAKUAI-MARU.”? Plan du “HAKUAI-MARU,” RED CROSS HOSPITAL SHIP Bateaux-hépitaux d’évacuation pour malades et blessés de la Société de la Croix-Rouge du Japon. PONT SUPERIEUR Bassorr dammbarcation moe 7 Zosscin of embangatre be Q) awns neu! (qnant fe varssedis PAArMacrer essiHaK secretarre ENTREPONT & chef infrrimier norte porte Rain charken de taree aelerve el 2 td 7 fod Wolate Pic : ele 2 MICMOS CONE feowite “leeve at)" [| 4 be r EEF Soyo] fF fo = Z Pa 7 > be wan 2 I ea z feoutile a [ ; Pete A malades Rowe peur chargemen orve jour charben de /erve ee ee nour chsryement forte pour changement 8 maladies menta/es Cmaladies coplapreuses Disslie a manger de /eguipage PONT iNFERIEUR , - © See eee ee aor mpateal chambre Op machive pour chaufer | pL = legirce | four | Cagrages | Q 1 n n ] nnnnnt cadavres | Tye pour comprimer kstr WL | | | oe soule ACO J il | 7 Fr ] soule er °O chawfeurs jour machmes pour Ecoublle rugiaesaur a Lim on (ODOCNON00000 | ssoute soule soule ues (oer eur. pour machine lecoutwe | lenicerres| mecicun®| | viandas\ four ae a reheat mecnme ecient o— —s oH 5 aM ; NOTA. — Les chiffres indiquent le nombre de lits de chaque cabine: les pointillés indiquent des fauteuils pouvant, en cas de nécessité, faire office de lits. S Doc g27 59 1 15 ‘The one ward of 114 bunks is large and neat, with bunks double- banked, but made of gas piping instead of the usual wooden bunk. They are quite crowded, and in some places it must be very difficult to get the patients into the bunks. The nurses are most all female Red Cross nurses, graduates of the Tokyo Red Cross Hospital. There are 33 female nurses, with 3 head nurses. One head nurse has charge of the operating room, one of the ward, and one of the officers. The head nurses have rooms by themselves, and the ordinary nurses are in a compartment by themselves, fitted up with the same gas-pipe double-banked bunk as seen in the wards. There are 10 male nurses, but they are kept for light cases and for the heavy work of transport- ing and orderly work. The storeroom on the lower deck contained many fine dressings, and there was an abundance of supplies both for use on the ship and for distribution. On the upper deck there is a fine and well-appointed mess room, a smoking aa lounging room for officers, and very good quarters for the officers, both medical and ship’s. : The bathrooms and closets aid: not do the ship credit, being of the Japanese or modified Japanese type. There were some closets and baths of English make, notably the captain’s. . The crew consists of 83, the total personnel of the ship, including medical officers and nurses, being 137. The Red Cross surgeon, F. Mitomi, is in command of the ship. Captain Sekine receives his instructions through the senior medical officer. I asked the captain particularly about this, and he said the system worked well. e attends to the discipline of the crew, and the senior medical officer to the discipline of his own department. Orders from the department come to the surgeon, and he transmits them to the captain. The purser makes out the diet lists or bills of fare on approval by the raedivel officer in command. The purser buys all the provisions and is responsible for quality and quantity. There are 7 cooks employed altogether, 3 extra cooks being for the patients. The methods of transportation are (1) by stretcher or ladder, (2) by the use of large flat-bottomed boats brought to the cargo ports, (3) by the use of a small davit at the cargo port, and (4) by the use of a large crane near the bow of the op The disinfector is on the starboard side, forward, of the upper deck. From observations of the various hospital ships it is easy to see that the ideal hospital ship has not yet been built. While the Japa- nese have many hospital ships and a splendid organization for the care of the sick and wounded aid for their ready transfer to good hospitals, still the experience so far gained in the war demonstrates only the great use of this type of ship, but has not demonstrated the perfection of detail that those interested in hospital zhi have been looking for. It will not be until some Government is willing to spend a sufficient sum to build a ship of this kind, with the single idea of its character and use, that the perfect ship will be found. It is no more possible to pick up any merchant steamer, no matter how fine she may be in her own sphere, and convert her into a prefect ship of the hospital type than it is to convert such a ship into a ee fect man-of-war. A rosoitall ship should be built from carefully 16 | thought-out plans in a civil shipyard, where no previously con- ceived ideas may tend to interfere with the perfect carrying out of her construction. As a rule, these ships are too small. We need plenty of unencumbered space, with light and air. Suchaship should be of at least 5,000 tons, with not too high a free board, with good beam and false keels to keep her steady and give her spacious decks. She should have a speed of at least 15 knots per hour and good coal capacity. She should have at least four good clear decks— the upper deck for air and recreation for convalescents, with the after part of the deck for the purpose of infectious diseases. For- ward on this deck should be the captain’s quarters, with his chief officers and their mess and offices, in order that they may not interfere with the work of the ship below and take up space needed for the sick. The deck below should have, forward, suitable double rooms with baths for officers of high rank, and single rooms for officers below command rank. They should have a mess room with suitable loung- ing and amusement room; aft of this should be the operating room and skylight, with surgeon's preparing room and X-ray room, with all electrical appliances. There should be a good photographic and dark room, the dark room being of use for examination of the eye and for artificial illumination for nose, throat, and ear work. The after part of this deck should be the surgical ward, with its attendant dressing room and a pus-operating room. In the extreme rear should be the laboratories, with plenty of light; a bacteriological and.a chemical labratory, with a small library of reference books. Also a dentist office, which requires special light, with square ports and small skylight. On the deck below, but still above the water line, should be a good medical ward forward, with attendant examining room, and aft a good-sized convalescent ward, with a generous mess room between the two wards. Each ward should have a special zoom for its head nurse, in order that he may always be able to keep in touch with his patients. The after leas of this deck should have rooms for the hospital stewards. In the center, on the starboard side, should be the dispensary, with adjoining room for the pharmacist; on the port side a lari general office for medical records, etc., under the charge of a competent steward; forward of this the room for the pay clerk and a paymaster’s office. The paymaster should also be the com- missariat and have a carefully selected canteen. On the deck below, the berth deck; forward, the crew; next the laundry, dynamo, disinfecting chamber, ice plant, and refrigerating rooms, and several cells, with padded walls, for the insane. Aft there should be accommodation for senior and junior nurses—a large, com- modious room that could be used for study and lecture room in the daytime. There should be baths and closets for their use in the extreme stern. On the lower deck, the hold, should be the storerooms for medical stores, paymaster’s and engineer’s storerooms. Under the refrigerating plant, but at a respectable distance from it, is the mortuary chamber, with apparatus for keeping a low temperature. Each department should have its bath, wash room, and closets in its rear an sts isolated to prevent odors from annoying patients and others. The senior surgeon should have his rooms in connection with the sick officers. The senior assistant, aft, near the surgical 17 ward, and the junior medical officers, 2 or 3, forward, on the deck below the middeck, just forward of the medical ward. All surfaces should be especially plain and smooth, no fretwork, no elaborate shutters or other fancy work to collect dirt and render cleaning difficult. _The galleys should be on the berth deck, near the center of the ship, discharging the odors of cooking into large uptakes and with good natural and artificial ventilation. There should be an elevator—a light-running Otis passenger elevator—from the hold to the upper deck of sufficient size to admit of a patient, stretcher, and carriers. There should be large cargo ports for the admission of patients brought alongside, with small companion ways leading to them; also hatches cut in the upper or hurricane deck for the swinging of small davits for the transfer of patients when needed. Such, roughly, should be the construction of a hospital ship. The organization should be divided into the medical and navigating departments, the senior medical officer being in command of the distinctly hospital parts of the ship. If the ship is under the direction of a naval officer of the line he should have a general command, but not extending to the working details of the hospital organization If a civilian captain and crew are employed, then the senior surgeon should be in command so far as the transmission of official business is concerned, and official orders should be transmitted through him. The Japanese have tried both methods of command and seem to ' think that a civilian captain with a senior medical officer in command is the better method. The command is distinctly a noncombatant one, and so often dis- tasteful to line officers who are desirous of following more distinctly professional routine. The records of a hospital ship should be kept as on any ordinary ship—the same forms and journals, with the addition of a weekly report to the Chief of the Bureau of Medicine and wees Particular attention should be paid to the food and the employ- ment of competent cooks of sufficient number especially looked out for. For the messes there should be mess attendants, the nurses looking out for the food of bed patients. HOSPITALS. The Japanese have four distinct naval hospitals—one at each of the great naval stations of Sasebo, Kure, Yokosuka, and Maizuru. These hospitals were planned about twenty years ago by the present Baron Takenk. then medical director-general of the Imperial Japanese navy. They have been added to from time to time and are, in general, in excellent and efficient condition. They are all built on the pavilion plan, and in the main are arranged in much the same manner, so that each is to a certain extent a duplicate of the other. Plans and photo- graphs have been obtained and will be submitted in order, the plans in the text of the report and the photographs in groups by themselves. In order that there may be no undue repetition, a careful descrip- tion of one will be given, with its organization, and a few explanatory remarks made on the others. The hospital selected for special description is the one at Sasebo naval station. 18 The hospital is situated in the naval compound on a somewhat elevated bluff overlooking the harbor and the naval station. Enter- ing the hospital grounds, guarded by the usual porter’s gate, we are directly in front of the administration building, marked ‘‘1”’ on the plan and shown in the series of photographs, with illustration of transportation of patients on stretchers, Sasebo series, No. 34. This building is a large, two-story frame building containing the admin- istrative offices of the chief surgeon and staff, with mess room and officer of the day’s room; also the chemical laboratory and urine- analysis room, marked ‘‘8’’ on the plan. This laboratory is quite extensive and is in charge of an expert pharmacist, who is also an excellent chemist. Careful quantitative and qualitative analyses of water, food, wines, etc., are made here for hospital, medical store- house, and for ships desiring especial work of this kind. From either aod of this building one proceeds through a covered corridor to pavilions marked ‘‘2,” the one on the left being a single- story pavilion for medical ceses and the one on the right being a two-story pavilion, with rooms for sick officers. A surgical ward below is shown in photograph of Sasebo series, marked No. £32,” with Surgeon Kuwabara, assistant director of hospital, in foreground. From the photograph one can get a very good ide of the wards in general. They are spacious, with neat iron beds, usually painted green, with unpainted but very clean floors, the refinements of absolutely smooth surfaces and rounded corners wanting, but still an air of purity and cleanliness throughout. , At the head of the bed is usually some arrangement for patients to keep a few personal articles, either a small shelf or sometimes a little cupboard. In this particular case a small shelf was used. In the center of the ward is seen a huge chimney with open fireplaces on either side, and usually there are adornments in the way of flow- ering shrubs or articles made by the patients. At the rear of the ward is a door leading into a corridor with baths at one side and closets at the other. The baths are the usual Japanese baths made of wood and either square or round. Neither kind is large enough to allow one to lie down in, but they are excellent hot baths when once you ee into them. The round tub has a small compartment at the side, ined with metal for burning charcoal, and this is the source of heat for the water. The closets are the usual Japanese closets, very clean, but to our minds very primitive and disagreeable, and I believe the Japanese think so, too. Gradually the European closet, with ' proper seat and adnexa, are coming into use in some places. e beds in the ward are furnished each with 1 straw mattress, 2 white sheets, 2 blankets, and 1 Japanese pillow. The officers’ rooms are of about 650 cubic feet space. They are very clean, but very plainly furnished, usually without any rug or carpet, a single iron bed, center table, and bureau—sometimes not so much. Usually heated by an open-grate fire. They are efficient, but I fear would hardly suit the fastidious taste of our officers. The upper story of this pavilion—the surgical pavilion—has been taken for the use of officers, and screens are used to make rooms. Around the open fireplace are easy chairs, a place to smoke, read, and play games, and adorned by beautiful aruilciel flowers presented by some princess. At the rear of this ward is a door and corridor with baths and closets, as in the ward below. SASEBO NAVAL HOSPITAL, NO. 32. SURGICAL WARD. SASEBO NAVAL HOSPITAL, SERIES NO 31. OPERATING ROOM. 19 On the first floor of this pavilion, marked ‘‘4,” is a spacious X-ray room, with a large Siemens-Halske X-ray machine with a 60-centi- meter spark, with rheostat, all therapeutic attachments, and many powerful lamps, giving a beautiful, steady, and powerful light of good defining power. Telephone connections are also established in this room. . At the entrance to the surgical ward are neat serving rooms for food, nurse room, surgeon’s room, and a good dressing and medi- cine room, all kept scrupulously clean. These wards are under the charge of female nurses, of whom we shall speak later. Passing through the corridor at the rear of the building we come to a small detached building used to contain patients’ effects. Thus, when patients are received at the hospital their clothes are all taken from them, sterilized, and, with such other effects as they may have, are stored in this storehouse. The hospital supplies each patient with a clean suit of underclothes and a padded ieanene, with socks and slippers, so that no dirt or contagion of any kind can be carried into the hospital wards. This is a most excellent idea. Passing along the corridor we come to detached building No. 5, which is a photographic and dark room, used for developing pictures and also as a dark room for eye, ear, and throat work. Phas room and work is under the charge of Surgeon Kabuto, an expert photographer, who keeps series of all radiographs and photographs. The outfit is very complete. Building No. 6, the next in order on the plan, comprises the oper- ating room, the surgeons’ wash room, ine the room for preparin patients for operation. Photograph No. 31 of the Sasebo Hospita series shows the operating room, which is complete in every detail, as can readily be seen by a glance at the picture. The floor is of concrete, the walls smooth, natural finish; an abundance of natural light from the sides and skylight at the top, and many hanging and portable electric lights. There are sterilizers for hot and ald water in the adjoining preparing room and dressing sterilizers. Steam is furnished for these purposes from the engineroom. ‘There is a small but neat surgeons’ wash room with basins, but without knee and foot pedals. The patients’ preparing room for operations is spacious and complete, the instruments adequate, of late design, and in excel= lent condition. On the whole, the operating room and its adnexa are efficient, the absence of rounded corners and nonabsorbing wall surfaces perhaps a defect. Building No. 7, as will be seen from the plan, is completely detached. It contains the pathological and bacteriological labor- atories. They are well equipped and show the evidences of constant and conscientious work. It is to be noted that each oi these naval institutions possesses in detached buildings well-equipped laboratories of this kind. They are under the general supervision of some one of the staff specially skilled in this work, with usually tables for the individual work of each surgeon. Much experimental work is always going on, as well as the routine work of the hospital. The drudgery of the laboratory, such as making media, cleaning, running incubators, etc., is usually in the hands of a trained assistant from the nurses’ corps. The Japanese excell in this branch and in jee and bend all their energies in this direction. Medicine proper does not seem to attract them so much. Series of pathological specimens of much 11922—-06——_4 20 interest are always to be found and, as a rule, all the pathogenic bacteriological cultures and many others of special interest to the workers in the laboratory. ‘There is always an animal house con- taining large numbers of rabbits, guinea pigs, marmots, pigeons, rats, mice, etc., for the experimental work, and when we consider that these are not distinctly laboratories but simply adjuncts. to naval hospitals the extent and completeness of these outfits is rather surprising and shows the amount of interest and work these gentle- men are carrying on with the ordinary routine hospital work. Buildings marked ‘‘9” and ‘‘9” are one-story pavilions—so- called temporary pavilions—of the usual type built for the war. They have at the entrance nurses’ rooms, serving rooms for food, dressing and medicine room, and at the rear bathrooms and closets of the Japanese style, as already described. The beds in the naval hospitals are usually good, substantial iron beds, with foot and head rods for stretching mosquito netting when needed. Where iron beds are not used, the usual bed made of unpainted pine, with box frame and wooden legs, is used. These wooden beds are seen more often in the army hospitals. Asa rule, it has seemed to me that the naval hospitals are better equipped than most other institutions. Each of the pavilions can accommodate about forty patients, and with a good, large air space. The ventilation is, of course. natural; the sides are usually largely composed of windows, and the ends being usually open give plenty of free circulating air. The patients always look fairly well and seem happy and contented. Building No. 10 is a storehouse for medical stores for ships, and building No. 11 a storehouse for surgical stores for ships. Each hos- pital has these two buildings. Instead of having one general store- house as we have for the issue of supplies to ships and stations, here each naval hospital has these supplies, and can issue them direct to ships or bases needing them, the requisitions for these supplies being granted at once by the surgeon in command of the hospital without referring to the bureau of medicine and surgery, the only exception being in cases of exceptionally expensive things. The medical storehouses are always eal stocked, and contain the usual run of drugs and medicines. They are kept in most excellent con- _ dition under the charge of the pharmacist. The surgical storehouses contain ample supplies of dressings, splints, hospital furniture, first- aid dressings, gauzes, bandages, cottons, splinting of various kinds, stretchers, surgical instruments, many being of the very latest style, in aseptic metal cases, although some old stock with the plush fin- ishing of cases is seen. This old stock is gradually disappearing, and is being replaced by the more recent designs. Boat boxes, emer- omel boxes for transports, special large surgical and medical cases or landing parties and for use on men-of-war are to be found in each storehouse. While this scheme increases the number of supply sta- tions and makes the system more complex than the issuing from a single storehouse, still it seems a wise provision, especially in time of war, to have supplies accessible at once at each naval base, and there- fore the system is commended. Here was demonstrated to me the use of the “Totsuka stretcher,” a description of which will appear under the consideration of methods of transportation. Building No. 12, as seen by the plan, is a pavilion building for the use of nurses. The nurses have bags and hammocks stowed in ham- 21 mock cases. They sleep in hammocks swung in this pavilion; they have their mess tables here; they have their own closets and baths, and when off duty this building is for their use. The idea is most excel- lent, as it keeps the nurses from the patients and allows them when off duty the liberty and freedom of action which can not be allowed when they are berthed in the immediate vicinity of patients. Building No. 13 contains the kitchens, comprising three rooms; containing cooking ranges, boilers, soup kettles and tea kettles, and the various arrangements of Japanese cooking. There are provisions made for the cooking for officers, for the enlisted force, and for the nurses, and cooking can be done both in the foreign and Japanese styles. While I think the general finish of the kitchens could be improved, still the food is well cooked and everything seems neat. The inspection of the food showed it to be of excellent quality and sufficient in quantity. The food is divided into four classes: 1. Full ration consists of curry, meat, bread, vegetables, fish, and tea. (For convalescents.) 2. The same as No. 1, except that the quantity is reduced. (For convalescents.) 3. Consists of bread, eggs, boiled rice, and milk. (For the mod- erately sick.) 4, Fluid diet, consisting of milk, rice soup, beef soup, and canned vegetables. (For the very sick, on the doctor’s order only.) All milk is carefully sterilized, usually in specially constructed sterilizers. By weight, the food of the different classes is as follows: a z 4 = | oa & |%3 Bl a Bg aa) ag (gee ee cae a 4 ne Pg) T8 Ae 5 | 3 bs 5 ~ ° ba 2 ‘ - oa Db : B leeick] ¢ | 2 /88]/2"5) eg) e/31 a l8el gs x |2 GE] 2 a |e ° oo 3 g S$ | sf) a |S |e a | a |e o a 2 |e | a /a n LOO SBE) $120) bce acral we cael acinerees oem 0.5] 1 6 80 20 9a Sewer supe eel copace 5] 1 6 Horses (Sepa 24} 28] 150]... | 1 5 6 4D: |e ads age 42| 99 | 150 5 Bi esciie The unit of weight in the above is the ‘‘momme,” one of which is equal to 3.75 grams. : Besides the above, certain delicacies for the sick may be allowed, if needed, on recommendation of the doctor in charge. It is thus seen that the diet is quite a generous one, rich in nitrogenous prod- ucts and carbohydrates, and not so different from our own. To prepare this food, there is 1 head cook, with 20 assistants, some acting as assistant cooks and some as carriers of food, and act- ing in various capacities about the kitchen. - There are also employed 3 stewards, who supervise the work of the cooks -and distribution of the food. Special conveyance boxes are provided to carry the food and keep it warm. ‘These provisions, of course, vary in the dif- ferent hospitals somewhat. Rice is usually cooked and placed in individual metal boxes for transportation to the patient, and so kept fresh and warm. There are also similar conveyance vessels, closed, for carrying soup. 22 Building No. 14 is the washhouse and laundry, provided with a Nelson & Kreuter washer; also a No. 2 circular wringer, and a good- sized drying room with racks. The ironing of washed material is done by hand. I was told that all the washing for the hospital was done by the laundry, and that not even convalescents washed any of their own clothes. Building No. 15 is an old building formerly a ward, but now used for the storage of old material. It could,however, be used as a ward. Building No. 16 is the disinfection building. This building con- tains one large disinfector, made at the naval machine shops, Sasebo, about 6 feet long by 5 by 4. Disinfection is accomplished under 15 ounds pressure for thirty-five minutes at a temperature of 110°C. The disinfector has a special device for rapidly exhausting and dry- ing the contents. The building is divided into two parts, one part for the reception of contaminated articles, with the door of autoclave opening through the dividing wall, and the other part made for the reception of the disinfected articles when the process is complete. There is, of course, nothing special about this apparatus except that Japanese disinfectors are made larger than ours usually are, and also are generally of Japanese manufacture. No. 17 is a large new temporary building, intended for contagious diseases in case there should be an epidemic or need for more room than in building No. 18. This building has an asphalt floor, is built of Japanese pine, unpainted, well constructed, and battened. It has three Goolaton rooms for serious cases; the beds are of iron, ainted green, with canvas stretched across in place of springs. There is one small ward with 6 beds, and a main ward with room for 24 patients. Atoneend of the building are the usual Japanese closets on one side of the hall, and bathrooms on the other side. In the center of the building is a room with Japanese wooden bunks for nurses; also a serving room, the food being brought from the main kitchen. The building is electric lighted and heated by coal stoves. Building No. 18 is the old ward for contagious diseases. Building No. 19 is the dynamo room and engine house, furnishing electric lights and steam for the operating room, washhouse, labora- tories, etc. No. 20 is the plant for burning garbage. Each hospital is fur- nished with a good garbage burner, and usually with a small out- house to hold garbage for biweekly burnings. No. 20 is a small deadhouse and necropsy room furnished with the usual outfit, running water, etc., to be found in such constructions. The capacity of the hospital is as follows: Patients. ‘Permanent; buildimgss.3.202 65225 ah aanieed Geeks aca eee lee aete cece 212 Temporary buildings ....-.........---. 2222-22-02 02-2 ee eee ee eee eee eee 222 Motil oo recceierereiel ate 2 ais ele dahalerais oe vaehige SiS ate e ES See neces 434 Outside additional barracks that may be used......-.-.-...-.-2---.-2-..--...--- 180 Totwll ssosepiersia teats es soutsjccisie «=< O14 The medical staff consists of 1 surgeon-general, | assistant to sur- geon-general, 2 fleet_ surgeons, 1 staff surgeon, 2 surgeons, 2 senior assistant surgeons, 6 probationary surgeons, 4 Red Cross surgeons. These surgeons are on duty every day from 8 a. m. until 5 or 6 p. m. =a < JAPANESE NAVAL CASE PAPER FOR KEEPING PATIENTS’ RECORDS. HISTORIES. JAPANESE NAVAL CASE PAPER FOR KEEPING PATIENTS’ JAPANESE NAVAL CASE PAPER FOR KEEPING PATIENTS’ RECORDS. SASEBO NAVAL HOSPITAL, SERIES NO. 33. HOSPITAL PARK FOR CONVALESCENTS. 23 There are no quarters as a rule at any of the hospitals for the mem- bers of the staff, all living outside in the city, but at night there is always 1 surgeon and 1 probationary surgeon in charge of the hospital, who have rooms in the administration building. ere is 1 pharmacist with the rank of lieutenant-commander, a commissioned officer, who is also an expert chemist and. who has charge of the chemical laboratory assisted by 2 junior pharmacists. The force of nurses is 36 regular nurses (male), 55 temporarily hired nurses (male), 4 head nurses (female, Red Cross), and 40 ordi- nary nurses (female, Red Cross). The female nurses usually have charge of the surgical wards and special cases. They live outside the hospital grounds, going to and from their homes as they are relieved or go on duty. The surgeon- general in command informs me that they are always detailed in couples, and that he favors their employment in naval hospitals in war time, but does not think they are needed at other times. He states that he is highly satisfied with their work and that they have given no trouble in any way. These female nurses are all from the Red Cross Society, some from Nagasaki and some from Hakata. The subject of female nurses will be referred to again under the head of the Red Cross Society. In the plan will be noticed a tongue of land marked “Park.” This is a large high bluff, commanding a fine view of the bay and sur- rounding country and beautifully laid out as a park for the convales- cent patients. A winding stone stairway leads from the rear of the hospital to the top of this bluff. There 1s a summerhouse and seats amid cedar trees, with flowers. Here convalescents, and particularly pulmonary cases, can sit and breathe the purest of air in the bright sunshine. This provision is not peculiar to this hospital alone, but it is a marked feature of each Japanese naval hospital and one of the most attractive and beautiful ones. It will be noted that in _ each naval compound the hospitals have been given the choicest sites and those best fitted for the care of the sick. The hospital records are most carefully kept, with temperature charts of all important cases, and all injuries, operations, and loca- tion of pathological conditions are noted on diagrammatic figures, a sample of which is attached. As the Japanese usually draw well, some of the representations are extremely striking and true to life. This finishes the description of the Sasebo Hospital; and a few general remarks will be made concerning the other hospitals, calling attention to any special points of interest they may have. KURE NAVAL HOSPITAL. This is one of the largest of the naval hospitals. It is situated on a high bluff, overlooking the harbor and naval station, with moun- tains rising rather abruptly in the rear and on the sides. The hos- pital is on the same general plan as Sasebo Hoe with a large central administration building at the entrance. It is on the pavilion system with three pavilions, one wooden and two built of brick, in the rear of the administration building. The pavilions are all two stories instead of one. Two new pavilions are being built, which will be of the same general plan as those already mentioned. A new 24 operating room of brick is being built and will be very complete. It will be a small separate building between pavilions 2 and 3, and is connected by covered passageway with the various pavilions. It will have a central passageway at entrance leading to the operating room proper; on the right of the passage will be a large surgeons’ preparing room, and on the left a good-sized sterilizing room for dressings and a smaller instrument room. The operating room is of good size, will have cement floor, with plenty of light on three sides and from skylight in the top. The walls will be of hard finish, permitting them to be washed and kept aseptic. The foundation is only built at present, and so it is impossible to give further general details. The present operating room is in one of the pavilions and is well equipped and fitted with many modern ap enances They have the Kneefoot pedal for surgeons’ washstand. The capacity of the hospital is about 350, and 150 more patients can be accommo- dated in a temporary barrack built at one side of the grounds. There is a special pavilion well fitted up, and with some padded cells, for the treatment of the insane, and a — and very-well equipped pavilion for infectious diseases. The usual detached pathological and bacteriological laboratory and a large library, comprising some 5,000 y slutea hoe been donated by the Patriotic Association of Ladies for the use of the patients. There is one large amusement room for the patients, with games of various sorts, where the patients can amuse themselves in bad weather. In fine weather the grounds in the rear of the buildings have been made especially attractive for convalescents, and between pavilions 1 and 2 Surgeon Inspector Ishiwara has taken great pains to fit up the grounds in a most attractive way to present a pleasing prospect for the patients occupying beds in these pavilions. A very good idea of this can be obtained from the photograph of the Kure series, marked No. ‘42.’ There is an abundant supply of pure mountain water having its source in the mountains at the rear of the hospital, and most attract- ive grounds at the rear, of high elevation, for the patients. One special provision was noted in the grounds in the rear of the pavilions, and that was the placing of sputa cups at convenient places for the use of the patients. The X-ray apparatus is the usual Siemens and Halske machine with 60-centimeter spark, in good working order and with good dark rooms and photographic outfit. A telephone system connects the nurses’ rooms with the admin- istration building. ‘A fine separate building has been fitted up for the male nurses in the rear of the grounds: The kitchens are in a detached buildin connected with the wards by a covered passageway, and are neat an quite complete. It is to be noted that the Japanese always have a large ne to carry on the work of the kitchen and the distribution of food. There is a very complete electrical dynamo building to furnish lights and power for the X-ray machine. The building for the disinfection of clothing, etc., is furnished with a specially large autoclave, 10 feet long by 5 feet in diameter. This is mentioned specially because the autoclaves of our hospitals are usually small in comparison. “8 pue z suoTTIAvd usemjeq spunol3 sMoyg ‘éy ‘ON S3IYSS “TV.LIdSOH TWAVN 3YHN™ Nv1d OL JO JVAVN vANsSOM SOH Wid “i e ‘i ie. | @ Wi Y, 1 aguvm Le re 11922—06——5 PLAN OF MAIDZURU NAVAL HOSPITAL, ‘AYVM IWOIDHNS “WLIdSOH IVAVN 2YNM 20 A large patheee plant at the rear of the grounds is in constant use, burning all garbage, sputa, urine, typhoid stools, etc. This appara- tus is in use several times a week, and costs but 45 cents to operate at any one time. __ Twenty-two female nurses from the Red Cross Society are employed in the surgical wards and on special cases, the usual number of male nurses being retained besides. The female nurses employed in this hospital are from the Red Cross Hospital, Tokyo. I was informed by the surgeon in command that they were much liked and well educated. . The series of photographs of Kure Hospital will give a good idea of the wards and grounds and some interesting cases will be noted, particularly of shell wounds. All the special buildings, such as laundry, deadhouse, medical storehouses, etc., mentioned at Sasebo are to be found here. In fact, each hospital is almost a duplicate of the other. No plans of this hospital were obtained. MAIZURU NAVAL HOSPITAL. This is the smallest of the naval hospitals, also the most recently established. It is situated on an elevated plateau, overlooking the beautiful and picturesque bay, which is surmounted by high moun- tains. The harbor is not large, but almost absolutely shut in and with plenty of deep water. From the plan one sees that we have the same pavilion system and almost identically the same buildings as we had at Sasebo and Kure, thus: 1. Administration building. 17. Storehouse for articles to be burned. 2. Water-closet. 18. Insane pavilion. 3. Servant’s room. 19. Infectious pavilion. 4. Hot-water room for drinking purposes. 20. Water-closet and bath. 5. Operating room. i 21. Deadhouse. 6 Kitchen 22. New pavilion, 2 stories. 7. Storehouse for fuel. 23. New pavilion, 2 stories. 8. Disinfecting chamber. 24. Pavilion, 2 stories. 9. Laundry. 25. Linen and clothes for patients. 10. Water-closet. 26. Medical and surgical storehouse. 11. Water-closet. 27. Gatehouse. 12. Nurses’ quarters. 28. Chemical laboratory, pathological and 13. Washhouse for nurses. bacteriological laboratory and phar- 14. Engine house. macy. 15. Washing place for urinals, etc. 29. X-ray and photographic rooms. 16. Garbage burner. The special features of this hospital consist in the finer finish of surfaces in the wards. The pavilion marked “24” is two-storied, the lower story being for surgical cases and the upper for medical cases. The floors are of hard wood, finely waxed and polished, the walls and ceilings neatly painted, and special arrangements made for ventilation, inlets below and a long, narrow central shutter above as outlet. There are also four rooms for special cases. Near the entrance a nurses’ room, a serving room, and a very complete exam- ining and dressing room. At the rear of this ward there are very good bathrooms, also a mess room and smoking room, the floor being covered with what seemed to be zinc. Such a floor lining is unusual, and it was not explained to me just why this material was used except that it could 26 be kept clean. A very good ward conveyance ambulance was in the ward, the wheels pneumatic tired. ; There were many amusements in the wards for the patients. As usual, all clothing worn in the hospital was furnished to the patients. The second story of this pavilion is a medical ward, and is fitted up like the surgical ward below. There were 28 surgical cases and 20 medical cases, the total of cases in the hospital being 88. The sur- geon in command told me they had had about 500 cases during the war, with 19 deaths, mostly from consumption, with some few typhoid cases. Some cases of typhoid fever came from the ships and some from the barracks. They have also a fine storehouse for medical and surgical supplies for the ships, barracks, and other places needing supplies of this kind. ° The Japanese make their own tablets, and have at some of the hospitals, as at this one, machines for making compressed tablets, so that the bottles going out bear the stamp of the hospital as the maker of the tablets. The surgical supplies for ships were all espe- cially fine, the instruments in aseptic cases and up to date in every respect. te the storeroom I saw an American enamel bath tub, to be installed in one of the new pavilions. This would seem to mark a departure from the old wooden Japanese bath’ tub. n the large surgical and medical boat boxes for landing ‘parties were very good hand electric lamps, which would seem to be an excellent thing for night illumination for operative or other work. These large dressing cases are usually supplied only to flagships, whereas we supply the same type of box to most all ships. The X-ray room is new, and is a very fine one, with a new and large Siemens-Halske X-ray machine. On trying the fluoroscopic plate on a case, I found the defining power to be excellent. Cer- tainly the Japanese hospitals are well equipped in this way. They always have, also, an abundance of fine lamps. I have seen as many as 20 or 25 lamps of large size in the lamp racks. In connection with is room there is also a fine photographic outfit and developing room. For examples of this work, see the photographic series of pictures of Maizuru Hospital. The operating room of this hospital is quite new, and it would be very hard to find any fault with it. Canvas slippers are provided at the entrance to slip over one’s shoes before entering. The walls are painted, the corners rounded, there is an abundance of electric and natural light. The photograph marked ‘‘No. 43” in the Maizuru Hospital series shows the operating room in detail and gives a better idea than a written description. This is one of the best operating rooms seen in Japan. There is a special building for the chemical and pharmaceutical laboratory and the manufacture of tablets for the service. This building is under the charge of a pharmacist, who is a commissioned officer and a graduate of Tokyo University. Just why the Japanese manufacture so many of their own preparations, compressed tablets, etc., unless for economy or accuracy, I am not sure, but the com- pressed tablet preparations are very perfect productions. The bacteriological and pathological laboratories are in excellent condition, well equipped, and the usual practical and experimental "NOMIAVd ONILVYadO "Ey ‘ON SAINAS ‘IWLIdSOH TIVAVN NYNZGIVN SAS Ree os 3 es : i ss Maks a ~ie ae ww = \ r y "WOOY AVY-X “by "ON SAIYAS “1VLIdSOH IVWAYN NYNZAGIVN ‘GUVM T1VOIDUNS “Sb "ON SAIHSS ‘“IVLIGSOH TVAVN NYNZAIVW "YOLOZANISIO "8h ‘ON S3INAS “IW.LIGSOH IVAVN NYNZGIVWN “AYGNNV1 “6h ‘ON S3INAS “IVLIGSOH IVAVN NeNZaIVA ‘WOOY OWYNAG ‘0S ‘ON S3IN3S SIVLIGSOH TWAVN NYNZAIVN MAIDZURU NAVAL HOSPITAL. MACHINE FOR MAKING MEDICATED TABLETS. 27 work going on. A small but well-selected library of reference books was noted, and a well-stocked animal house with rabbits, guinea pigs, marmots, rats, mice, etc., for laboratory use. There is a spe- cial room for making aerated water, soda water, and lemonade for the use of patients. : The kitchens are particularly clean and well arranged, with a force of 6 cooks and 1 head cook. The insane pavilion is well isolated, as seen in the plan, and con- tains well-padded cells for the insane. In the infectious pavilion, besides all the other contagious diseases, all tubercular cases are isolated, and the idea seemed proper. The two new pavilions indicated on the plan of the hospital are well under construction. They will be two stories high and increase the capacity of the hospital by 150 or more beds. On the whole, this hospital impressed me as one of the most efficient and attractive I have seen in Japan. YOKOSUKA NAVAL HOSPITAL. This hospital is one of the oldest of the naval hospitals, and while the buildings are old, still it is very comfortable, well arranged, and pleasantly situated. This is outside the naval compound, and as it is the oldest has probably had some influence in the general plan of the other naval hospitals. It is entirely on the pavilion system, and all buildings of one story except pavilion No.6. The list of buildings will show the same similarity as the others: 1. Administration building. 15. Insane pavilion. 2. Pavilion wards Nos. 1, 2,3, 4, 5, and6. 16. Garbage burner. 3. Pathological and bacteriological labora- | 17. Disinfecting plant. tory. 18. Engine house. 4. Eye, ear, throat, and nose room. 19. Storehouse for patients’ clothes. 5. Separate pavilion for nurses. 20. Kitchens. 6. Laundry. 21. Storehouse. 7, 9, 10, and 12 are storehouses for medical | 22. Gate keeper. and surgical stores. and packing house. | 23. Porters. 13. House for experimental animals. 24. Operating room. 14. Deadhouse and autopsy room. 25. X-ray and photographic rooms. The number of patients on March 27 was 136; of these 72 were from the fleet at the front. Of the 72, 11 only were wounded in battle, and the remaining 64 were patients from the Yokosuka naval station. Ending March 11, 490 patients had been received from the front, 70 of these having been wounded in battle. There were no deaths. There is not much to be added to the remarks made on the other hospitals in connection with this one. The wards are clean and comfortable, some of them of peculiar construction, the ward being in the center of the structure, inclosed by glass windows and frames, and surrounding this a broad passage between the walls of the ward proper and the outer wall of the building. The passages are used as mess halls and sitting and amusement places for the patients. The operating room is spacious, with cement floor and plenty of light, both natural and artificial. The equipment is sufficient, and there is a very good surgeons’ washroom, with foot pedals for hot and cold water. There is also a good-sized sterilizing room for dressings. The contagious ward, No. 5 on the plan, is situated on a high plateau in the rear of the grounds, and is particularly favorably placed, with an abundance of light and air. Again, the laboratory, both bacteriological and pathological, occupy an important part in the work of the hospital, and Asakawa’s modification of Widal’s reaction was demonstrated and is now used generally in Japan in preference to the Widal reaction. The X-ray apparatus used here is of English make, the manufac- turers, L. Millen, of London, with an 11-inch spark. It is of older and smaller type than the Siemens-Halske machine, seen in other Hope but the surgeon in command informed me that it worked well. The nurses are in a separate building. No female nurses are at present employed in this hospital or at Maizuru, if I remember correctly. The building for experimental animals is well stocked with the usual supply of animals, and much interest seemed to attach to this part of the work. There is a set of machines for making compressed tablets, and the various storehouses are well stocked with supplies, both medical and surgical, for issue to ships. At all these storehouses the various dressings and emergency boxes, landing parties’ outfits, etc., were examined and will be mentioned under a separate per In general, then, it may be said that the naval hospitals of Japan are well organized, well equipped, and particularly adapted to the type of patients received, the climate, and are situated at convenient points and in specially suitable locations. The special features that they excel in are the operating rooms and outfits, in X-ray and photographic work, in sterilization, in organization and nursing, in disinfection and apparatus for this purpose, and in bacteriological and pathological work. At the same time it must be said that in elegance of construction and finish they do not as yet approach such an institution as the New York Naval Hospital, nor lave I seen anywhere in Japan in any hospital an operating room that could compare with the outfit at the New York institution. The methods pursued are much the same as our own, modeled usually from the German ideas. The grounds are always an attract- ive feature, an air of content and quiet seems to pervade these institutions, and they apparently run without friction. It was noted that each of these hospitals had a very complete canteen, where most of the things sailivan ty required might be purchased. No spirits or malt liquors were for sale. The male or regular nurses are divided into four classes, the highest class ranking as warrant officers, the second class as petty officers, and the third and fourth classes as seamen. They are appointed at any naval station, once each year, on their own application. They must have at least a common school education, and they always receive instruction in a naval hospital for at least eight months, a naval barracks for six months, to learn military bearing, etc., and a final course of six months in nursing at a naval hospital, when they are ready for detail at sea, for ship service, or such other duty as may be required. During the war time many so-called ‘‘tempo- rarily hired’’ nurses are employed. There are also always available 29 poe of well-trained ‘‘Red Cross’’ nurses for the more important work. In concluding the remarks on hospitals it may be of interest to give a short description of a large army hospital, with the various objects of interest seen. The Hiroshima Army Reserve Hospital is selected for this purpose. This hospital is on an enormous scale; it comprises the main permanent hospital and seven divisions (all ar eee pavilions), situated in various parts of Hiroshima. The usual capacity of the entire hospital, with its various divisions, is 10,000, and it is possible to care for 12,000 patients, if necessary. The entire system is on the pavilion plan. The main permanent hospital consists of a main administration building, where the commanding officer and his assistants have their reception rooms, etc. The pavilions are old, and many fitted up for the accommodation of officers. When the number of officers exceeds the capacity of the rooms and the usual quarters set aside for the use of officers, ordinary wards are used, and I saw quite a number of officers using the same accommodations as would ordi- narily be used for men without complaint. Among the buildings of special interest noted was one large repair shop for instruments, fitted with devices for sharpening and tools for repairing instruments, under the charge of skilled instrument repairers and makers. A building for making pore, pills, tablets, etc., for use in the army, with necessary machinery. An extension X-ray outfit, with large dark room, the machine used being, as usual, the Siemens-Halske (German). A patient just brought in from Mukden with a fracture of the tibia and the bullet protruding posteriorly from the bone was placed on the table for inspection, and a large fluoroscopic plate showed the condition very well. The present X-ray machine seemed to answer every purpose well, was large, with a 50-centimeter spark, but a new and more powerful X-ray machine of the same make is to be introduced with a 70-centimeter spark. Large supplies of all X-ray material, plates, etc., were on hand; also a very complete photo- graphic outfit, with good developing room. he general post-office is of interest. It is in a separate building, with quite a large force of clerks. They had handled during the past month 520,000 letters, — one of which is registered. There is an extensive outfit for the renovation of dressings that have been used and are soiled or contaminated with pus, blood, or any other infected matter. The principle of using again dressings once used has always seemed unsafe to me, but the process carried on here certainly seems to restore the dressings to a perfectly aseptic and good condition. The dressings are brought from the various hospitals and sorted by an attendant; they are then soaked in water and thoroughly boiled in water containing soda. They are then placed in vats and covered with a solution of calcium chloride, one-half per cent, to clean and bleach, and then through a rigid sterilization, and dried. Cotton and wool, after drying, are put through picking and carding machines, and come out as fresh and clean, to all appearances, as though they had never been used. The dressings are dried in the sun, and a number of employees were spreading them out. The 30 more important part of the work after sterilization, such as packing and rerolling, was performed by female nurses. The commanding officer informed me that they saved about 3,000 yen a month in iis way, i. e., about $1,500; also, that dressings could be resterilized and cleaned about five times in this manner before being exhausted. uh The canteen is quite extensive, in a separate building, and well stocked with supplies of all kinds except spirits. Here the patients can obtain reading matter, writing paper and materials, tobacco, canned goods, and a thousand and one little things to add to their comfort and happiness. Also special dishes, with the surgeon’s per- mission, can be ordered cooked and sent in for officers. ; The large general storehouse was visited, and contained an immense supply of drugs in all shapes, dressings, surgical instruments, splints, hospital furniture, and transportation apparatus, with various sur- gical and medical field boxes for use at the front, nurses’ emergency bags. There wasa large assortment of splints, wood, metal perforated, and felting.» Many articles made of bamboo were seen; thus the army bamboo stretcher with rubber apron cover, complete, cost about $1.50 apiece. Bamboo cradles for protecting injured legs from weight of bed clothes, 7 cents; bamboo crutches supplied at a cost of 8 cents. In a separate building is the operating room. This is under the charge of Surgeon-Major Tanaka, assistant to Doctor Sato, of well- known fame, who is surgeon in command. The operating room is light and well equipped, with adjoining sterilizing and surgeons’ pre- paring room. The fs are kept flooded with solution of bichloride of mercury, and special foot gear is worn in the operating room. Many cases of traumatic aneurism are operated upon. Surgeon Tanaka told me that he had operated on 110 cases already. They are usually dissected out and the vessel ligated above and below and. the intervening portion removed. Many interesting surgical cases. were seen. Enucleation of the eye is frequent for injuries of the eye and gunshot wounds. I was shown a large bottle full of enucleated. eyes by Surgeon Tanaka. All the milk is carefully examined in the laboratory daily and thor- oughly sterilized by steam in a large special sterilizer. In the series of photographs will be found some from Hiroshima. army hospital—one showing a large dressing ward and another a large. dressing ward with the patients being dressed in the presence of Chief Surgeon Sato. There are also some excellent X-ray photographs of bullet wounds of various parts, together with two plates showing bul- lets extracted from wounds. This plate should be compared with a. similar plate of pieces of shell removed from patients in the naval hos- pitals. The two plates are interesting as showing the difference in the projectiles producing wounds in the army and navy. A visit to the various divisional hospitals from the main hospital was made. These hospitals are all on the pavilion plan, temporary in character, and connected by covered passageway. The third division, poe small, was particularly attractive, extremely neat, even the sand between the pavilions being swept and carefully streaked. The capacity of this division is 560 beds, and there were 480 patients under treatment. No operations are undertaken at this: EXAMPLE JAPANESE RADIOGRAPH. BULLET WOUND OF FEMUR, HEROSHIMA. EXAMPLE JAPANESE RADIOGRAPH. BULLET WOUND OF LEG, HEROSHIMA. EXAMPLE JAPANESE RADIOGRAPH. BULLET WOUND OF NECK, HEROSHIMA. EXAMPLE JAPANESE RADIOGRAPH. BULLET WOUND OF FOREARM, HEROSHIMA. BULLET WOUND OF SHOULDER, HEROSHIMA. EXAMPLE JAPANESE RADIOGRAPH. EXAMPLE JAPANESE RADIOGRAPH BULLET WOUND OF KNEEJOINT, HEROSHIMA. “VWIHSOYSH ‘TINS 4O GNNOM LATINA “HdVYEDOIOVY ASANVdv? AIdWVXa ‘OBaSVS LY GSGNNOM WOYS GSAOWSY ‘SSTISSIN IVAVN JO SadAL Fo Of b g Qa A * 28 0 TYPES OF ARMY MISSILES. REMOVED FROM WOUNDED AT HEROSHIMA, *VWIHSOUSH LV G30NNOM WOY4 GSAOWSY "SSTISSIN AWHV 40 SAdAL Auhmtn dente ‘Sy Nd ¢ v6] IZ zal. NX -X Be co _ & a ” LS? oO wy al “AWIL ANO LY G3QN3LLV 3d NVO SLNAILWd OOF auaHM ‘VWIHSOUSH ‘ANOOY ONISSSYG 31 hospital. If an operation 1s needed, the case is sent to the main hospital for operation. There were 10 Red Cross female nurses, 59 male nurses specially employed, and 13 regular army nurses. There are 14 pavilions and 1 administration building; also 1 very com- plete new laboratory (pathological and bacteriological). In each pavilion there is 1 regular army nurse in charge with 5 male tempo- rary nurses to assist. Three of the pavilions have 3 female nurses and 6 temporarily hired female assistants and 2 male helpers. Each nurse has about 10 patients to care for. The serious cases have a special female Red Cross trained nurse. The serious cases are always placed in the 3 pavilions attended by female nurses only. Each divisional hospital has its own pay officer, who attends to the commissariat, clothing, traveling expenses, etc. There is in these temporary hospitals 1 chief surgeon’s room, 1 officer of the day’s room, 1 office for (1) records, admissions and discharges, (2) business orders, (3) post-office. There is one reception room. The pharmacy is nicely arranged with a dispensary and counter, with spaces for the delivery of medicines for each pavilion. All pre- scriptions are specially inspected before being issued. The Chief Surgeon Kokobu is much interested in bacteriology and showed me a growth of micrococcus which he thinks is the cause of kakki. He finds the micrococcus in the blood, urine, and feces of kakki patients constantly and in no other cases. His associate, Surgeon Okada, thinks the same, and both look on kakki as a toxemia from this micro- coccus. There is a fine large amusement room, tastefully decorated in Jap- anese style, and stocked with various Japanese games. The room can also be used for lectures and music. A neat little complaint box was noted for the patients to drop written complaints in. These complaints are addressed to the chief surgeon and seen by no one else. The idea was to promote confidence between the patient and chief surgeon. No one has access to the complaint box but the chief surgeon. A senior and trusted patient in this hospital looks after the conduct of the patients; also reports to the chief surgeon any lack of care and kindness on the part of the nurses toward the patients. The chief surgeon thinks the pavilions under the charge of the Red Cross nurses are models. : The temporary pavilion consists of a pine structure of one story, unpainted, about 3 feet from the ground and resting on piles. They may consist of one or two wards. At the entrance to the ward is a nurses’ room, a serving room, and a medicine room. The wards con- tain from 40 to 50 beds, built in Japanese style, the body of the bed being an ordinary box. The legs are of wood, and the height of the bed about 23 feet. The wards are light, as the sides of the pavilion are largely composed of glass windows. The wards are usually heated by one or two Japanese stoves, which consist of charcoal embers in ashes, the whole being incased in a receptacle of some kind, generally known as an hibachi. Food is brought from the kitchens in conveyance boxes, covered to keep it warm, and served at the bed. In the rear of the ward are the usual Japanese closets and baths. Sometimes a pavilion will be split up into small rooms for the care of specially serious medical or surgical cases. The beds in these hos- pitals usually have a mattress, 2 quilts of cotton wool, and 2 woolen blankets, with a Japanese pillow. 32 The sixth division, Hiroshima army reserve hospital is the largest of these temporary hospitals. It has 33 pavilions, with 72 wards and a capacity of 4,500 patients. There were 1,300 patients in the hos- pital the day of my visit. It contains 2 large amusement rooms, has a very large dressing ward, where 200 patients can be dressed at one time, a special bath house with 10 bathrooms in Japanese style, each room accommodating about 30 bathers at a time. ; This hospital is a reception hospital, and so situated that patients can be brought directly up the river from the hospital ships or trans- ports to it. They are bathed, given hospital clothes, their records verified, and from here distributed to various hospitals. ; Each division hospital has a well stocked canteen in a separate building in the grounds. ; A fire brigade stands watch day and night, to be ready in case of need. BATTLE SHIPS AND CRUISERS. Through the kindness of the surgeon-general, permission was ranted to visit such men-of-war as might be in any of the Japanese arbors. Very few of these ships were present at the time of my visit. One battle ship, one second-class cruiser, and one third-class cruiser were visited—one at Maizuru and two at Yokosuka. The points particularly desired to be investigated were the arrange- ment of the medical department—the outfit, the provisions for the care of the sick, the personnel, the arrangements for the care of the wounded in battle, and the transportation of wounded. As most of the Japanese ships are of foreign construction, it is not surprising that they differ but little from our own, and aside from the actual experience gained in war there is little that is new or particu- larly instructive in these ships so far as relates to the medical depart- ment. The battle ships usually have three medical officers—the larger cruisers two or three, and the smaller cruisers one. There is no one corresponding exactly to our present hospital steward. There are usually two or three nurses, the surgeon doing his own compounding or detailing such parts as may be safe to a senior nurse. With the fleet there is one surgeon-general. In this connection it is to be noted that the Japanese have one surgeon-general of superior rank, who is known as the director-general of the imperial navy, and four secondary surgeon-generals, who are placed at different naval stations, such as Sasebo naval hospital, at Port Arthur, at Yokosuka, and one with the fleet, so the use of the term surgeon-general, unless understood, is somewhat misleading. There is ale one expert phar- macist with each fleet and one dentist.¢ The arrangement of the sick bay is usually on the berth deck for- ward, as with us, and they contain a few bunks, a larger number of hammock hooks from which to swing hammocks, an operating table, desk, a small prea with a limited amount of drugs and dress- ings, a closet, and that is about all. A storeroom for drugs is usually located in some other part of the ship, usually on a dene below the @ Note by Director-General Saneyoshi: ‘‘There are three or four expert pharmacists of commissioned rank in each naval hospital (not with fleet). A dentist in each fleet is hired only recently for a trial, so we can not say whether it will be continued or not at the end of the present war.” WARD OF TOKYO RESERVE HOSPITAL. JAPANESE TEMPORARY HOSPITAL. 33 berth deck. The choice of dressing stations in battle depends on the character of the ship. Concerning the management of the wounded on men-of-war dur- ing action the following is submitted from the surgeon-general: Dressing stations on men-of-war during actions —Dressing stations naturally differ accord- ing to the kind of the vessel, but at least two are fitted up in each vessel at places most con- venient to bring in the wounded. Cases of bandaging material are sometimes placed at localities difficult of access, such as the engine room, passages to the magazine, etc. Dressing stations are selected at places safe from the enemy’s fire and most convenient to carry in the wounded. They are generally placed within the protection of the side armor and above the water line. Of course it is impossible to select safe places in unarmored ves- sels. In the majority of vessels one dressing station is fitted up forward and another aft, one under the care of the chief surgeon and the other under the care of his second, assisted by nurses, sick-bay attendants, and such detail as may be made. The method of treatment. is the dry sterile bandaging, but there have been some exceptions. During actions, major surgical operations are not generally made, but on some rare occasions such operations have been made. The size of the dressing stations differ, according to the size of the vessels, and except in some few cases it is difficult to get sufficient spaces for the purpose. In armored. cruisers and battle ships a dressing station and a room adjoining to it generally has a space sufficient to take in £0 wounded. Special attention is paid to the ventilation of these rooms. Lighting of dressing stations—Lights of such rooms are increased by one or two electric lamps of from 16 to 32 candlepower and one portable electric lamp. Besides these, several candles are also lighted to be prepared against sudden extinction of the electric lights. Every dressing station is fitted with operating tables. For this purpose dining tables are used, but most of the larger vessels have light iron operating tables. It is very inconven- ient to bring medical materials from the dispensary in time of action, and most of the ves- sels have them stored at places near the dressing stations. The materials and appliances for dressing stations differ more or less according to the opin- ion of the surgeon in charge, but each dressing station is equipped with materials sufficient to give first aid to the wounded, together with materials necessary for surgical operations which may be required during actions. It is found convenient also to have surgical instru- ments in comparatively well-protected spaces rather than in dispensaries. Bandaging materials are disinfected once a month to keep them disinfected as far as possible, and in case an engagement is expected they are disinfected on the day before. It is also necessary to have a large quantity of drinking waier to give to the wounded. As splints in time of actions, tin perforated splints, to make them light and to promote evaporation, are found very convenient. They are cut to required sizes with scissors. As carriers for the wounded, cooks, stewards, mess attendants, rope repairers, and fire brigade are employed, and the regular nurses and sick-bay attendants assist the surgeons. In a flagship which has a naval band, members of the band are also employed as carriers. They are trained to give first aid to the wounded, and are more careful and better suited to be carriers than any other branch. During an action one-half of the carriers are placed on the upper and middle deck at safe places, such as behind casemates of the engaged side, behind the unengaged side of the conning tower, etc., and whenever any casualties occur they are sent from there to bring in the wounded. The number of carriers differs according to the size of the vessel, and generally half of the carriers of a vessel are placed within the protected part of the ship. Method of carrying the wounded practically used—The wounded, both those who can walk and those who can not walk, are carried to dressing stations by hand. A kind of stretcher Inade of split bamboo was tried, but hand carrying proved to be more convenient. In case of carrying mortally wounded or the dead, the stretcher was found very serviceable. To remove the wounded from a ship to a boat they are fastened to ordinary stretchers and are lowered down from davits. They may be carried down the ladder, but bamboo stretchers were found more convenient. Each carrier is furnished with four small bundles of gauze to give first aid to the wounded. Carriers are also provided with a piece of india-rubber hose about 3 feet: long to stop bleed- ing when necessary, at the rate of one piece for every three or four carriers, but the hose was very rarely used. In the navy, larger bundles of gauze are desirable. The treatment of the wounded by car- riers is only to dress a wound so as not to expose it. © Some very unfortunate accidents have happened during the vari- ous engagements. Thus on the Hiyei, at the battle of the Yalu, a shell exploded in the ward room, which was*being used as a dressing 34 station, killing the surgeon and his attendants and destroying the dressings and surgical instruments. During the present war, as a rule, the Japanese surgeons have found it usually practicable to perform operations during action, but it is fully realized that this was only possible on account of the small number of wounded. On the other hand, on some of the Rus- sian ships the loss of life was so great and the wounded so numerous that the surgeons, I am told, were completely paralyzed and unable not only to perform operations, but even to make the necessary dressings. After careful consideration of this point with many naval surgeons the idea of immediate operation is not considered to be feasible. The fact that naval battles are not, as a rule, of long duration, that the attendant confusion would detract from the ability of the surgeon to do his best for his patient, would seem to make it far preferable to -delay operation if possible until after action had ceased, giving care- ful first aid to the wounded and seeing them placed in protected places, where they would not be tramped upon or further injured by any of the accidents attendant on the engagement. Cases of severe hemorrhage or wounds threatening life would of course be exceptions to this rule and require immediate attention. Such, in the main, has been the principle upon which the Japanese have acted. Usually the larger part of the dressings and drugs are kept below decks in a storeroom where they would be safe from harm and could be drawn upon if any accident should occur. Before battle the crew are said to be especially prepared; thor- oughly bathed and clean clothes put on, to prevent as far as possible the contamination of possible wounds from dirt or infected fragments of clothing. First-aid packages are issued to the crew and carriers, who have been instructed in their use. The first-aid package is practically the same as ours—with bandage, compresses, safety pins, and triangular bandage. In battle ships and armored cruisers, places for dressing stations are carefully selected in protected places, but in unprotected cruisers the wardroom is usually selected as the dressing station. On the Chiyoda the surgeon very kindly fitted up the wardroom completely as thes do in time of battle. The mess table was used as the oper- ating table, and all dressings, anesthetics, restoratives, sterilizer for instruments, etc., were placed in easy reach. Irrigators and solutions, with basins and pans, were ready for use. The instruments were in a modern wooden aseptic case, although they have now many fine metal cases. The stretchers were the ordinary bamboo and canvas stretcher, which is shown under the head of transportation methods. It is to be noted, however, that in actual battle the Japanese have found that stretchers are usually troublesome and delay the rapid conveyance of patients to the surgeon, so that many are simply picked up by hand and carried in this manner to the dressing station. The Japanese usually have an abundance of dressings, good long bandages, gauze, and lint ready to use, and first-aid packages. There are quantities of gauze and other pads ready to apply at once. The tourniquets in the storehouses shown me were those of the American navy pattern, with the black wooden ball and canvas strap. Pieces of elastic tubing are also freely distributed to the carriers to use as tourniquets. 85 The number of carriers, who can also apply first aid, of course, varies with the size of the ship, but usually there are from 40 to 50 in a good sized battle ship. Thus the surgeon has plenty of aid, and is expected only to look out for the wounded as they come to the dressing stations. After battle the wounded are transferred as soon as practicable to one of the hospital ships, which is usually at hand, or to a tem- porary or base hospital. As soon as their condition will permit, they are sent to one of the home naval hospitals, and kept there until their condition allows them to go to their homes or return to the service, as the case may be. In places difficult of access, such as turrets, the engine room, and magazine passages, substations are established to give immediate attention to the wounded in these localities. When compared with the elaborate outfits that are installed on our own modern battle ships, it is difficult to see what we could adopt of special value. The Japanese outfit is efficient, but it would be difficult to place any of them in the same class as the outfit on such a ship as the Ohio. The Japanese fully realize the necessity for placing the sick bay, operating room, etc., inside the protected parts of battle ships and cruisers, and are agitating this point for future construction. The possibility of total destruction of surgeons and outfit, under present conditions, on most of the ships is obvious. Some of the cruisers, I am told, have the sick bay and medical outfit nearly amidships. The necessity for the transfer of all material, instruments, and surgical outfit at time of battle, to remote dressing stations is a great annoy- ance, and makes much unnecessary work, lowering the efficiency of the department. The food furnished on the Japanese ships seems to be well cooked and of sufficient quantity; the galleys were clean and neat. Arti- ficial ventilation is not attempted in many of the ships. Heat is usually furnished by grates in the cabins, and by the Japanese stoves in other parts of the ship, where there is any attempt to furnish warmth. The water is usually supposed to be distilled, but this is not always the case. When the water supply is supposed to be pure, the tanks are often filled from shore. The men are encouraged to bathe and keep clean, and bathrooms are supplied for this purpose. The men coming off duty in the fire room, take a bath at once, and get inclean clothes. I could not find that ‘‘shower baths” were used in any of the ou The crew, when not provided with baths, use salt water in buckets. The supply of fresh water for washing clothes is limited. Altogether, the arrangements for heat, washing, and bathing in the ships visited, were primitive. The beds were clean and sweet- smelling, but not attractive. PORTABLE EMERGENCY OUTFITS. The emergency bag for surgeons is a neat little black leather bag, with shoulder straps, that can be used on landing parties or other- wise; it contains 1 bottle sulphate morphia; 1 hypodermic syringe; 1 small aseptic metal instrument case, containing 2 scalpels, 1 curved bistoury, 1 pair dressing forceps, 1 silver catheter, 1 pair scissors, 1 36 saw shutting like a knife, 1 probe, 1 grooved director, needles, silk, and thread. : . The nurses’ emergency bag is larger, and contains 1 large knife and saw for making or trimming splints, etc.; 1 medicine box contain- ing 1 bottle brandy, 1 bottle carbolic acid, 1 bottle stomach pills (soda and gentian), 1 bottle acids salicylic and boric, mixed (1 to 3), 1 box antipyrine tablets, 1 box Dover’s powders, 1 box Johnson's adhesive plaster, 1 tourniquet (American Navy pattern), 1 pair scis- sors, 4 first aid packages, 4 packages absorbent cotton, 3 triangular bandages, 6 gauze alles bandages (24 inch), soap, candlestick and candle, safety pins, and matches. The first-aid package contains 1 bandage 3 meters long, 24 inches wide, 3 pads of gauze, safety pins, and 1 triangular bandage; the whole being protected by oiled muslin and outside protective wrapper. In the storehouses are found two sets of emergency outfits: (1.) For issue to transports consisting of 1 large surgical case, 1 large medical case. (2.) For issue to battle ships and for issue to landing parties, etc., I large surgical case, 1 large medical case. These large boxes are similar to our own; they are well supplied with instruments, sterilizer, pans and basins, antiseptics, dressings, splints, hand electric lamps; also with drugs both fluid and tablet form, and a small outfit for the examination of water sufficient for a qualitative analysis only. The following extracts from a former report of the medical director- general of the imperial navy on the Chinese-Japanese war gives a most clear and excellent idea of the Japanese location of dressing stations, the transportation of wounded, and the care of wounds on battle ships in time of action: The surgery of a ship ought to be conveniently placed for collecting the wounded from the various parts of the ship, and also in places least liable to be disturbed by hostile shells. In the men of war of former days, as in the time of Nelson, there was a wide hatch extend- ing vertically from the upper deck to the bottom, and below the water line, which was admi- rably adapted, being in the center of the ship, for spacious surgery. Nowadays this part is occupied by the engine rooms, coal bunks, etc., leaving no room for the wounded. This difficulty is experienced now in every ship; the surgery must be placed at the fore and aft of the ship and consequently two are necessary, forit would be inconvenient to convey the wounded from one end of the ship to the other, especially so when the water-tight doors were closed, necessitating a very roundabout communication between the fore and aft of theship. But, as in almost all ships there was no room for surgery at the fore or aft below the water line, therefore places like the lower deck were chosen, which is above the water line and not quite free from the intrusion of hostile shells, so it was the general scheme that two surgeries, one at each end, should be established. But some ships lacking room had to be content with only one surgery. In the Matsushima, two surgeries were established—one on the upper deck of the fore part, and another on the waist of the lower deck. Both were destroyed by shells and the explosion of ammunition; and at this time the chief surgeon of the fleet was seriously injured and some of the wounded persons then receiving treatment were killed. This caused also a great loss of surgical instruments, etc. In the Yoshino, one of the surgeries which was placed in the ward room at the rear of the lower deck was twice struck by hos- tile shells, but luckily no one was injured except a nurse, who sustained a slight wound. We see, therefore, that any part that is above the water line is not free from the danger of being struck by shells, and is, of course, unfitted for a surgery; but, in the absence of room below the line, there is no alternative but to be content with what is obtainable. In order, therefore, to facilitate the conveyance of the wounded and avoid a wholesale catastrophe, it is prudent to have two surgeries; but this division has also its disadvantage, for, dividing the surgeons, nurses, and surgical implements that are anyhow limited in quantity in every ship, affords much inconvenience in treating many wounded men at the same time. In nave! battles sometimes 50 or 60 are wounded at one time and in one place. Sup- 37 posing this should occur in the fore part of a ship, the wounded will naturally be brought to the surgery in that quarter; and the surgery is suddenly overfull and short handed; although only urgent measures of relief are taken in a fight, yet even then it is impossible to pay proper attention to all the wounded. At the same time, the medical attendants in the other surgery may have nothing to do, and yet they are not able to help each other, which is a hindrance to successful treatment. Conveyance of the wounded.—Apparatus for the conveyance of the wounded can no more be uniform in size and construction than ships can. Various kinds had been provided for use on board, one like an easy chair, net hammock, Macdonald’s or Gihon’s stretchers, etc., and the men had been drilled beforehand in their use. But during the actual engagement it was found that stretchers of all kinds were cumbrous and troublesome and of very little use for the speedy conveyance of a large number of wounded to the surgeries during the noise and confusion of the battle. Hands alone were therefore employed aboard the ships and the stretchers were laid aside. Conveyance by hands alone is prompt and convenient, even if there be many wounded persons at one time; for every man that is uninjured can gen- erally be useful for carrying wounded men; and so during the actual battle our men were obliged to resort to this method. But even then a seriously wounded person requires the assistance of three or four men to get him up or down stairs, and there is always a great deal of confusion in the removal; also, in the conveyance of patients who have sustained fracture or extensive burns, this method certainly aggravates the injury; and from this point of view carrying on stretchers is far the better. We have still a great deal to learn about the conveyance of the wounded on ships, but it is a sine qua non that some handy way like the bare-hand method must be resorted to at the time of the actual engagement, and therefore ship’s crews should be also drilled in this method of conveyance. After the battle, in transferring the wounded from one ship to another, and similar cases, the bare-hand method is not needed, for the wounds have by this time been properly treated, splints and bandages have been applied, and there is time enough to lay the patients com- fortably on stretchers. On such occasions field and other stretchers on which the wounded erson could lie full length were made use of; the patients were let down by means of pul- ie and sent out through hatches or port holes without the slightest hitch. Treatment of the wounded. —In regard to the treatment of the wounded we have already stated that at first only urgent and temporary measures of relief were taken, such as to disinfect the surrounding skin, to extract foreign bodies when they could be easily seen and removed, to staunch hemorrhage by compression or torsion, and in case of a fracture to apply splints. This is inevitable during battle when little individual care can be given to the patients; when the battle was over, proper treatment was accorded in the order of the urgency of the respective wounds. At the time of the second treatment the wounds were again disinfected within and around, any foreign body that was recognized by exploration was removed, splints that were found not to have been properly applied were renewed, and soforth, * * *, It is true that shell wounds are extremely disposed to suppuration, that the conditions on board ships during action were likely to soil wounds; and besides, the surgeries were all in unsuitable locations. These were unavoidable circumstances, but there are still other points to which further attention should be called. With shell wounds sustained in parts covered by clothes a soiled piece of cloth is frequently found remaining within, and there were not a few cases in which these foreign substances were taken out in the hospital to which the patients were admitted many days after injury. This must have been one of the causes which promoted suppuration, and great care should be taken to examine the wounds well with the finger @ lest such foreign substances be left behind; for as the inside of the wound is very irregular the cloth pieces can not be washed out by mere irrigation with an antiseptic solution. Again, we have seen that on account of the loss of vital function the wound sur- face can not resist even a few microorganisms if once admitted. The surrounding tissués should therefore be strictly disinfected, care being taken at the time that. the disinfection should cover a larger area than that which is protected by dressing materials. The inside of the wound can not be expected to be perfectly cleansed during the confusion of fighting; so if the quantity required be not so large as to cause poisoning, a solid antiseptic like iodo- form may conveniently be sprinkled into the wound.b Next, materials for dressing may be preserved with care, but as many days must necessarily elapse before they are actually used, and as their absolute purity can not be assured, there is a need of having on each a some handy apparatus for disinfecting them immediately before use. It is a fact too we known to need mentioning here that everything that touches the wound should be clear, still it is well to insist on it once for fear it should be neglected in future actions, @ Note by Director-General Saneyoshi: “At present finger probing is forbidden, especially at time of first aid.” a, b Note by Director-General Saneyoshi: ‘‘In such cases we now use boro-salicylic powder.” 38 TRANSPORTATION. The Japanese have various methods of transporting their wounded. Some methods have already been mentioned in speaking of hospitals and battle ships. The bamboo stretcher is most commonly used; it consists of two long bamboo poles as handles, with either a canvas body or woven bamboo, as shown in the photographic representation. To keep the handles apart, there is a jointed iron bar at either end that keeps the handles apart when in use, and by breaking the joint allows the stretcher to be folded when not in use. Sometimes these stretchers are made without the bar, and sometimes small iron rests are attached to keep the stretcher from the ground when not being carried; these can be seen in illustration ‘B.” The stretcher, with canvas and spreading bars, with leg, body, and chest straps, is used to lower or hoist patients trom or into a ship; an illustration of this is seen in the hospital ship illustration ‘‘A.” When carrying a patient long distances ashore, shoulder straps are attached to the handles and assist the carriers to sustain their burden. An illustration is given also of the stretcher invented by Surgeon- General Totsuka, of the navy; the diagram attached shows its con- struction. The stretcher is intended to enfold the patient and is bound around him by the body bands; the cords at the top and bot- tom are to carry the stretcher by, or a pulley can be used with attached whip and the patient hoisted through a hatch or over the side of a ship, the bamboo splints forming a perfect protection to the patient. The patient can also be dragged along a deck or allowed to slide down a ladder, the bamboo framework on the outside acting as a smooth sliding surface for this purpose. This stretcher is thought very highly of in Japan. Its cost is about $4. Another interesting transportation apparatus is shown in diagram marked ‘‘canvas chair.” The construction, as will be seen, forms a canvas seat with sides and back of canvas, with body straps to hold the patient in position and hanging rope drops for the arms and a rope loop for the head; above it has beckets and an eyelet ready to hook in a tackle and whip. This I have seen demonstrated on the battle ship Chin Yen. It takes up little if any room when not in use. It is completely ready for hoisting when the patient is seated, and makes a very convenient method of hoisting a patient through hatches or in turrets or over the side of a ship. The explanation of construc- tion will be found in the marginal notes of the diagram. Patients transferred on shore are usually conveyed on the bamboo stretcher (see photographic series Sasebo No. ‘39’’); usually two carriers only are required. If it rains, or for any reason the patient needs protection, a rubber blanket on small iron supports, forming a sort of roof frame, is used. In the cities in transporting patients the most frequent method of transport for patients able to sit up is the jinrikisha. Long lines of these conveyances are often seen carrying patients from the transport to the hospitals, and they make a very easy and pleasant mode of conveyance. Ambulances are rarely seen, still they have them, usually two- wheeled carts with a body long enough for the patient to lie down, and an overhanging cover something ke the extension top of a car- riage. Long handles projecting in front are for the runners to pull them. An ambulance like our standard Navy ambulance would create a great deal of surprise. BAMBOO AND CANVAS STRETCHER. an JAPANESE STRETCHER, BAMBOO, SASEBO, SERIES NO. 84. ADMINISTRATION BUILDING, TRANSPORTATION OF SICK. TRANSPORTATION HOSPITAL SHIP TO HOSPITAL, SASEBO. “YAHOLAYLS VANSLOL SDSS epee ep \ a ale Md pny : ‘ , z ee ented [eee p= Lay ap td 52 | 75, pen TPT fs re Pragrce Gers Dery 47 Ke ——_ rf 77 — —— be 7 teeeS (sod mn Re (i KN WD S2>> aw 22 OX RANA TION ABOARD SHIP. ETHODS OF TRANSPORTA HOWING JAPANESE M ILLUSTRATIONS S TRANSPORTATION HOSPITAL SHIP. BY STRETCHER AND GANGWAY. SEVERELY WOUNDED ON THE WAY TO A HOSPITAL SHIP. TRANSPORTATION OF WOUNDED TO HOSPITAL SHIP FROM SHORE. 39 Transportation in trains is usually in third-class carriages, the patients being able to sit up. Occasionally I have seen a real hospital train made up of third-class carriages, with wooden bunks and attended by nurses, but usually patients are kept at the nearest base hospital until they are able to travel. Sometimes, I understand, that freight cars with straw on the bottom may be used, the patients being laid on the floor of the cars. : Transportation from ships to shore or to hospital ships is accom- plished by cua yins the patient down the side ladder, as shown in photographic illustration No. 30, by means of whipping them over the side, as described in the article on hospital. sibs or in trans- portation from hospital ships by the use of the cargo ports and small boats or flatboats. When, for instance, a hospital ship reaches a port like Ujina,. she may be met by flatboats, something like a large house boat. This is moved alongside the hospital ship, the cargo ports opened, and the patients easily carried aboard the flatboat. This boat then proceeds to the shore and the patients are transferred to jin- rikishas or stretchers and carried to the hospitals. If, however, the patients are to go to one of the divisional hospitals of Hiroshima, as the seventh, the flatboat may carry the patient almost to the hos- ital door and transfer them in this manner. Where large flat- oats can not be obtained, small boats or junks may be used for this transfer to or from the shore. There is finally the method of transferring the patients by hand, which, as seen in the note of the surgeon-general on transportation of wounded in battle, is usually adopted. THE NAVY MEDICAL SCHOOL. The Navy Medical School was established about thirty-four years ago. It was organized on account of the need for trained medical men of the new schools of medicine, then being introduced into Japan; that is, the European medical culture in place of the old Japanese school, founded largely on the Chinese teaching. he buildings are situated in the grounds of the war college at Tokyo. There is one principal building of wood, which contains the administration offices, the library, class and lecture rooms, a room for the stowing and demonstration of stretchers and methods of transportation, with other models for teaching purposes, and the X-ray room. The building is old, but evidently answers its purpose. The library is of fair size and contains a well-selected assortment of medi- cal books, all in Japanese or German. No American professional works -were noted. This statement is true of most of the institu- tions visited, except the medical school in connection with charity hospital, where the library consists largely of American text-books. In the War College building proper, a large brick structure, rooms are set aside for the use of the medical school. There is a large and well-equipped chemical laboratory, with worktables for 15 students. Here is given a complete course of qualitative and quantitative analysis, with special work in various other lines, such as examina- tion of water, food stuffs, etc. Another room is set aside for pathology and pathological anatomy. There are worktables for 20 students here, aid the fittings are good 40 and complete. There is quite an amount of interesting material, pathological specimens in abundance, both in the cut and the natural state. Material for use here is drawn largely from the charity and university hospitals. A professor from the university attends and teaches in the medical school. Various foreign physicians of well- known fame in Japan have been connected with this school in the past, but the Japanese are fully able to carry on the work and princi- pally from their own corps. In a separate building, under the charge of Doctor Yabe, of the surgeon-general’s office, is the bacteriological laboratory. The building is rather an old wooden structure, but the interior is an extensive and well-equipped laboratory, with every facility for teach- ing and for Bepewinanial wore The war has for the time being closed the institution, as all officers are needed for detail to duty. It must be remembered that the course of instruction includes, besides the various branches of medicine and pharmacy, instruction in the sciences, and that many medical officers receive their com- plete medical education in this institution.2 I quote from the regulations a translation of the rules governing the Navy Medical College, which may be of interest: THE REGULATIONS GOVERNING THE NAVY MEDICAL COLLEGE. ARTICLE 1. In the Navy Medical College navy surgeons shall be taught in the higher branches of the sciences. At the same time surgeons, probationary assistant surgeons, and probationary assistant apothecaries shall be taught in sciences, and shall be trained in the discharge of their duties, so as to make them competent naval surgeons and apotb- . ecaries. In the Navy Medical College sanitary examination of clothing, food, etc., shall be made. Art. 2. In the Navy Medical College there shall be the following officers: The chief of the college, adjutant, superintendents, professors, chief pay officer. Art. 3. The chief of the Navy Medical College shall direct the business of the institution under the supervision of the chief of the medical bureau, navy department. Art. 4. The adjutant shall manage the general affairs of the college under the direction of the chief. Arr. 6. Professors shall undertake to give instruction in various branches of science, under the direction of the chief. Art. 7. The pay officer shall, under the direction of the chief, manage the business of the accounts and pay. 2 Art. 8. Besides the officers mentioned in article 2, there shall be in the college clerks and skilled clerks, who shall discharge their duties under the direction of their superior officers. Art. 9. The naval surgeons, probationary assistant surgeons, and probationary assis- tant apothecaries who are receiving instruction and training in the medical college shall be called the students of the Navy Medical College. Art. 10. The students of the Navy Medical College consist of the following three kinds: (1) surgeon students, (2) students of elective courses, (3) probationary assistant surgeons. Art. 11. Students of elective courses shall be appointed by the minister of marine from among applicants of medical inspectors (holding the relative rank of captain, commander, or lieutenant-commander), and of surgeons (holding the relative rank of senior grade lieu- tenants of more than three years’ standing). Arr. 12. Surgeon students shall be appointed by the minister of marine from among navy surgeons. Arr. 13. All the surgeons, probationary assistant surgeons, and probationary apothe- caries shall be appointed by the minister of marine, students in the institution. Art. 14. The students of the elective course shall prosecute the study of that branch of science they elected. Arr. 15. Certificates shall be given to surgeon students and medical students when they have successfully finished their courses. aNote by Director-General Saneyoshi: ‘‘Complete? A kind of postgraduate course only; the word ‘complete’ is misleading.” 41 Art. 16. If the chief of the medical college thinks any of the students to be incapable, he shall report him to the chief of the medical bureau of the department. If the chief of the medical bureau thinks the report to be reasonable, he shall forward it to the minister of marine, who may then order such student to leave the college. 3 Arr. 17. A surgeon student who is promoted to a higher rank while in the college may remain at the college until he shall have finished his course. _ Arr. 18. In case of war or emergency the minister of marine, if he thinks it necessary, may recall the students of the medical college to duty. The minister of marine may appoint those who are thus recalled to duty as students of the medical college again without con- forming to the provisions of these regulations. Art. 19. The medical college may open an extraordinary course and may summon sur- geons and apothecaries on duty to instruct them in some required branch. RULES OF THE NAVY MEDICAL COLLEGE. ArtTIcLE 1. The chief of the Navy Medical College shall frame rules concerning educa- tional affairs and discharge of duties of the officers attached to the college and shall enforce them, with the approval of the chief of the medical bureau of the navy department. Art. 2, At the end of each collegiate year the chief of the medical college shall inspect the results of the examination and of the investigations made by the students and shall sub- mt them to the chief of the medical bureau of the navy department, with his opinions about them. Arr. 3. At the close of every year the chief of the medical college shall call a council of the professors to discuss the progress that has been attained and improvements to be made, and shall prepare a report on education, which he shall submit to the chief of the medical bureau of the department. Art. 4. When the chief of the medical college intends to hold the ceremony of granting the diplomas, he shall first receive the approval of the minister of marine to do so. Art. 5. In final and any other examinations the chief of the college shall select questions from those prepared by the professors. Arr. 6. The chief of the college shall nominate one who shall guide the students of elect- ive courses in the study of the branch they have selected. Art. 7. The chief shall make sanitary examinations of clothing, food, etc., and shall report the results to the chief of the medical bureau of the department. Art. 8. The collegiate year of the surgeon students’ course and the elective course shall commence on the 10th of January, and that of the medical student course shall begin at the time the students are admitted to the college. The summer vacation is from the 1st to the 31st of August, and the winter vacation from December 21 to January 9. The prin- cipal may, however, lengthen, shorten, or otherwise change these terms, if necessary, with the approval of the chief of the medical bureau of the department. Art. 8. (2) The surgeon student course and the elective course shall be each one year, which may be lengthened or shortened more or less. The course of the medical students who are surgeons shall be six months, and that of the medical students who are probation- ary assistant surgeons and probationary assistant apothecaries shall be regulated by the regulations governing the training of probationary assistant surgeons and apothecaries. Arr. 9. The surgeon students to be admitted shall not be more than 15,and the elective- course students shall be not more than 5. Arr. 10. Surgeons who desire to become students of elective courses shall select the sub- jects they intend to study and shall send an application to the minister of marine through the regular channel. On receiving such applications the minister of marine shall order the chief of the medical bureau of the department to see whether the applicants are competent to prosecute the study of the branch they have selected, whether they have learning enough, and whether they are of good conduct. Art. 11. At the close of the course a student of the elective course shall write the results of his investigation of the branch he has selected and shall submit it to the principal of the college. : Art. 12. Surgeon students and students of the elective course shall attend the college from their own lodgments, but the medical students shall be lodged at the college. Arr. 13. Articles which the students require for the prosecution of study shall be pur- chased at their own expense, but books, instruments, etc., necessary for study may some- times be loaned. , Art. 14. When the principal of the medical college thinks it necessary to open an extraor- dinary course, he shall recommend it to the minister of marine, stating the kinds of sur- geons to be taught, the subject, and the term. Surgeons to attend such an extraordinary course shall be detailed by the minister of marine. When such extraordinary course is fin- ished the principal of the college shall report it to the chief of the medical bureau of the department. 42 The complement of the Navy Medical College is: Principal (sur- geon with rank of captain), adjutant (surgeon with rank of lieutenant- commander or lieutenant), 3 superintendents (surgeons, lieutenant- commander or lieutenant), 4 professors (surgeons with rank from cap- tain to lieutenant), chief apothecary (rank of commander), paymas- ter (rank of lieutenant), 1 clerk, 1 expert clerk. Besides the above, 2 assistants and 3 writers. ; The class of students at our Naval College would correspond to the Japanese probationary surgeon. t is to be noted that they make provision for 15 surgeons to take the regular course and for 5 surgeons to take the elective course of one year’s duration; that these surgeons are of the rank of senior lieuten- ant, lieutenant-commander, and commander. In other words, they make provision for keeping their older surgeons well up in the medical work of the day. It is to be noted that we have been able to do the same, and our Navy Medical School to-day is one of the most notable features of the present administration. REMARKS ON MEDICAL AND SURGICAL CASES SEEN MOSTLY IN ARMY RESERVE HOSPITALS. The following classes of disease were noted in different places: In the naval hospitals proper very few cases of special interest were found, and the number of patients was small, many wards being vacant. Most of the patients were convalescents. No operating seemed to be taking place, although some very interesting results of operation were seen. The long period of comparative inactivity of the navy and freedom from acthal battle is probably the cause of this. Also the excellent state of health of the navy has undoubtedly caused the paucity of cases found in the hands of the naval hospitals. 1. Typhoid fever is not prevalent. There were seen in all only 12 cases, and these in the army reserve hospitals, mostly of mild type and contracted outside of Japan at various places at the front. The treatment of these cases is symptomatic. They depend on good nursing, diet, and sponging. Strychnia is a favorite tonic. In no place did I see or hear that tubbing or cold baths were in use. On the whole, both army and navy seemed very free from this disease. 2. Typhus fever: A few cases of typhus fever were reported to me on April 15 as being at the Red Cross hospital, Tokyo.* 3. Pneumonia: Occasional cases of pneumonia were seen in vari- ous hospitals, with many cases of attendant pulmonary troubles, such as acute and chronic bronchitis. 4. Tuberculosis (pulmonary) is quite prevalent and seems to be on, the increase, probably due to the hardships of the campaign, expo- sure, etc. The Japanese strike me as a people who would be particu- larly liable to consumption whenever their vitality is lowered. They are all trying for a tuberculin treatment in almost every laboratory, but no marked success is reported. The treatment is symptomatic and climatic.? a Note by Director-General Saneyoshi: ‘“Typhus usually here means typhoid, the true seas fever being called eruptive or ecanibecuions typhus, and so surely these were ordinary typhoid fever. After the manner of the Germans here most people do not use the word typhoid, but say simply ‘typhus,’ or, literally, ‘intestinal typhus.’ ” 6 Note by Director-General Saneyoshi: ‘‘Statistics do not show any larger mortality from tuberculosis here than those in America or Europe. The apparent increase of tuber- cular cases is due to the more accurate diagnosis in late years.” 43 5. Venereal diseases are quite prevalent, gonorrhea claiming the largest proportion of cases. In the cities and towns it is very com- mon. At nearly every hospital more or less venereal cases are seen. The seaport towns furnish the greatest sources of infection. In the navy venereal diseases are in abeyance, owing to the lack of opportu- nity for the men to obtain shore leave. Usually venereal diseases form, perhaps, the largest proportion of cases during the year. The Japanese carry out the ‘‘compound”’ system to a certain extent, the women in these compounds being examined once a week and the men are given instruction in the care and prevention of venereal diseases, but they are by no means held in restraint by these measures. Among the laity gonorrhea seems to be looked on lightly and not much atten- a is paid to it. The profession, however, are fully aware of its results. 6. Smallpox is not prevalent. Only one case was seen and that at the quarantine station at Hiroshima. It was supposed to have been contracted in Korea. Vaccination is carried out so carefully that smallpox is rare in Japan proper, but cases may be brought in from the island of Formosa or from Korea or China. The island of Formosa seems to be a béte noire in the way of disease to Japan, and pest, cholera, smallpox, and malaria are supposed to be more or less endemic there at all times. 7. Several cases of cerebro-spinal meningitis were reported to me as being at the Red Cross hospital, Tokyo, on April 16, the origin of the cases unknown. Spinal puncture was said to be the method of treatment used. 8. Three cases of erysipelas were noted, probably from infected wounds. They were isolated and were being treated with anti- streptococcic serum. These preventive serums are usually obtained from the serum institute. These were not in a naval hospital. 9. Kakke or beriberi: In the army kakke is quite prevalent; in the navy it is not so. There is practically at this time no kakke in the navy. On the other hand, in the army reserve hospitals were seen ard cases of kakke. For instance, on April 16 it was pee to me that there were some 340 cases at the Red Cross hospital. At the reserve hospital at Hiroshima I saw some 26 cases and there may have been more. One series of these cases was very interesting, consistin of kakke complicated with malaria, kakke complicated with typhoi fever, kakke complicated with tuberculosis, kakke complicated with acute Bright’s disease, kakke complicated with pneumonia. The charts of these cases were very interesting, and, as in a case of kakke with Bright’s disease and oedema, it is easy to see how the kakke might be entirely overlooked. The diagnosis in this case was made by the examination of the urine, the quantity of the albumen, and the character and kind of casts determining the diagnosis. As kakke is usually without fever it is comparatively easy to diag- nose as the disease progresses from the deep-seated pain, the super- ficial anesthesia, the cedema or atrophy of muscles, loss of reflexes, and the condition of the heart. From an interesting series of patho- logical specimens at the Tokio Imperial University, of kakke heart, I was ecatled to gain a good idea of the condition as it exists in the patient. The kakke heart presents a marked dilitation of the right ventricle, with a flattening of the base of the heart and a change in the apex. While the older surgeons still cling quite tenaciously to 44 the theory that kakke is due to food conditions, notably rice, still there are many who think that the disease is due to some micro- organism and the symptoms to be the result of a true toxemia. In this connection I would mention again that at the third divisional hospital at. Hiroshima Surgeon-Major Kokubo showed me a growth of micrococcus, “Micrococcus Kokuba,”’ which he feels quite sure is the cause of kakke. He finds it invariably present in the urine, blood, and feces of kakke patients and no other patients. He also thinks that kakke is without question a toxemia. In this connection I quote on the other side the résumé of an article by Baron Saneyoshi, as follows: (1) The only persons who are attacked by kakke in eastern countries are those who use rice for their daily food, and on examination it has been ascertained that the nutritious sub- stance of their diet is generally below the physiological standard, and if the diet be improved so that the various nutritious ingredients do not fall below that standard, kakke will cer- tainly be prevented before it comes to light. (2) The extirpation of kakke in the Depanper navy since the year 1884 is entirely to be attributed to the improvement in the scale of diet, and no other hygienic improvement has been recognized as having had anything to do with this result. (3) Instances of kakke prevalence in our country that have been greatly reduced or totally extirpated by the ee of diet are to be found not only in our navy, but in army barracks and prisons all over the Empire. (4) It is an indisputable fact that kakke is most frequent in warm or hot seasons. This, we believe, is because, owing to the inertness of the appetite in those seasons, the Japanese are apt to take nothing but plain meals, as “ chazuke-meshi,” boiled rice with tea. If such be used too often or exclusively the disease will break out in the coldest season just as much as in the hottest. (5) It is evident that kakke is liable to prevail in crowded places, such as barracks, fac- tories, and prisons. Persons in these places get their food served to them regardless of their own choice of dishes, with a consequent increase in the quantity of rice. They are thus very liable to the disease. Such persons will enjoy immunity from the disease, no matter ne low or damp their places of abode may be, if only they are able to make free choice of ood. (6) If we make investigations about instances of kakke prevalence in districts that have not hitherto been visited by it, it will surely be found that the disease has been taken abroad by people who take rice in large quantities. (7) The increased prevalence of kakke in Japan within the last twenty or thirty years is to be attributed to an increased supply of rice in all districts and also the increase of people boarding in other people’s houses. The prevalence of the same disease in Brazil is, we believe, to be accounted for on the same grounds. (8) The circumstances attending all the prevalences that have come under our knowledge show that kakke can not be regarded as an infectious disease. (9) Our observations about kakke in Japan and the East show that it has always an inseparable connection with the use of rice in comparatively larger quantities, together with a Jack of other nutritious substances, i. e., albuminous and fatty substances. On the other hand, its prevalence in a lunatic asylum in Ireland constrains us to think that the disease may occur without the use of rice. (10) If we use proper diet, kakke will certainly be prevented at any season in any place. Neglect of dietary precautions will always be followed by an outbreak of this disease. The treatment of kakke is symptomatic, beginning with free purga- tion, pain diet, and heart tonics, diuretics, etc., as may be indicated. Undoubtedly the change in the Japanese navy ration in 1884 did away with kakke, and the present ration, so nearly approaching our own in quality and quantity, keeps the navy practically free from this dread disease. Kakke has been to the Japanese in the past what typhoid fever was to our army in the Spanish-American war. , 10. Diphtheria: No cases of diphtheria were seen in the military hospitals, but cases were noted in the infectious ward of the Tokyo 45 hospital. The use of antidiphtheritic serum will be mentioned under preventive medicine. 11. Malaria: Very few cases of malaria were found anywhere. Japan is peculiarly tree from malaria, and while it had mosquitos they are not of the type Anopheles and are not supposed to convey the malarial parasite; but in Formosa many cases of malaria occur and also on the mainland.¢ 12. Scurvy: Quite a number of cases of scurvy were noted from time to time. They were all cases received from Port Arthur, some Japanese and some Russians, and the surgeons told me they were undoubtedly due to poor food. These cases presented the character- istic lesions of the mouth, with atrophy of muscles, loss of power, and extensive ecchymosis of the lower limbs. They are all doing well under antiscorbutic treatment.® 13. Dysentery: While dysentery is not a specially marked feature of the statistical returns, still it is quite frequently met with—bacillary dysentery. This disease is so common in Japan and the sources of infection from old cases so many that it is not surprising that there should be at least a noticeable number of cases. Most of the cases do well. If the lesion is high up, involving the small intestine, the prognosis is bad. A full description of this disease will be found in the article attached, by Doctor Shiza, the discoverer of the B. dysen- terica. It will thus be seen that on the whole the Japanese are pecu- liarly free from disease, especially anything in the nature of epidemic troubles. Undoubtedly this condition is le to their sanitary meas- ures, the supply of nutritives and suitable food, and the rapid transfer of the sick to proper and adequate hospital care. On the surgical side, the following cases of interest were noted: 1. Gunshot wounds of the spinal cord: Six cases of this kind were seen in one ward. The injuries were of different portions of the cord, with attendant symptoms following the distribution of the nerves. None of these had required spinal operation. Some seemed to be improving rapidly and others gave evidence of more or less permanent paralysis of the parts involved. The treatment was rest and quiet, operative measures tentative. 2. Eye wounds of many interesting varieties were noted in the different hospitals. Some cases of penetrating wounds behind the eyeball had healed, leaving the eyes intact, but with more or less disturbance of vision. Enucleation of one or both eyes happens frequently. At Hiroshima hospital were seen as many as 50 enu- cleated eyes for gunshot wounds. After the healing of operation very re artificial eyes are furnished, and often it is difficult at first glance to notice the absence of the natural eye. 3. Many skull wounds, both penetrating and nonpenetrating, from bullet wounds or from fragments of shell or from explosive bullets, were seen. Some very remarkable results follow injury and loss of brain substance. The Japanese do very excellent brain surgery, and usually get good results. @ Note by Director-General Saneyoshi: ‘In summer or fall we get a fair number of cases of malaria, and then there are some anopheles besides a large number of culex in the most parts of Japan, even in Hokkaido.” » Note by Director-General Saneyoshi: ‘‘Only those Japanese taken and held as pris- oners by the Russians developed scurvy.” 46 4. In the navy nearly all the surgical cases are the result of shell wounds, splinters, fragments of bolts, bolt heads, and pieces of steel. The cases differ very materially from those found in the army hos- pital. The wounds are usually very extensive flesh wounds, with injury to vessels and nerves, with frequent compound fractures of the femur and long bones, and are very prone to suppurate unless the utmost care is taken in cleaning and dressing them. Many cases of fractured femur were seen with very fair results; union generally good, mobility fair, with usually some shortening and some deformity. A number of cases of fractured patella were noted, had been opened and wired, the general result good, unless the knee joint had been involved, when there was a stiff joint. In this connection it is desir- able to compare the photographic plates of missiles removed from wounds in the army and the plate of missles, shell fragments, bolt heads, etc., removed from the wounded of the navy. 5. Injuries to the nerves were often noted with either absolute loss of function or function disturbed to greater or lesser extent. In many cases resection of injured nerves had been perforrned and the results varied a great deal. Some cases were totally paralyzed, as far as the muscles supplied by the involved nerves were concerned, and in some cases there was evidence of gradually returning function. 6. Penetrating wounds of the chest from bullets were frequent, and usually do well if let alone, the most frequent cause of trouble being from hemorrhage, if a large blood vessel is involved, or from sepsis if foreign matter is carried into the wounds. On the whole, the cases of sepsis in this variety of wound are quite infrequent. A protective dressing, with rest, is usually all that is needed. 7. Wounds of the face are sometimes quite ghastly, as when the lower jaw is shot away or portions of the nose and upper maxilla. The Japanese are very clever in these cases and do remarkably good plastic surgery. In one case in which the lower jaw was shot away the flaps taken had reproduced a good chin, and an artificial lower jaw of celluloid filled in in such good shape that but little disfigure- ment resulted, and the jaw and teeth seemed at first glance perfectly natural. Wounds from explosive shells are frequent. 8. Amputations: Few amputations are seen. The Japanese are very conservative in this branch of surgery. However, in a trip through the various hospitals some amputations of feet, legs, the =e hands and arms will be noted. The results ail seemed good, and the patients are supplied with most excellent artificial members by the generosity of the Empress. The illustrations will show examples of this work, and the patients seemed to use the artificial members with ease and good function in a very short time, as they eagerly demonstrated to me by walking and using the hand and arm. 9. Traumatic aneurism from gunshot wounds is an especially noticeable surgical disability. They occur in all vessels and locations, and particularly in the military hospitals the surgeons are prone to show you many specimens of his kind. Professor Tanaka, at Hiro- shima, told me that he had operated on some 110 cases at the hos- ee The method consists in dissecting out the aneurism and igating the vessel above and below, cutting out the intervenin portion. The results are generally very satisfactory; the collatera circulation soon establishes itself. "SUNLOVANNVW ASANVdVf “O37 TVIOISILYV “SYUNLOVANNVA ASANVdV? "WHY TVIOISILYV EXAMPLE JAPANESE ARTIFICIAL LIMB. 47 10. Appendicitis: But one case of operation for appendicitis was seen in all the stretch of hospitals from Tokyo: to Nagasaki. The Japanese think we are daft on the subject of appendicitis and always mention it witha smile. It may be that they are less prone to appen- dical troubles than we, on account of a lower type of living, or it may be that cases pass unnoticed. The latter hardly seems probable.* 11. Many cases of extensive burns occur, especially in the navy. There is nothing special to say concerning these painful wounds. The dressings are usually simple asceptic, nonstimulating dressings. Occasionally a case of keloid is seen, resulting from the scar formation. 12. Frostbites, particularly of the feet and fingers, are very fre- quent, and many of these are seen in the reserve military hospital; few, if any in the naval hospitals. They occur from exposure to the cold, especially in cases that are wounded and left for a time on the field, and most of them came from the battlefields of Manchuria. Every grade of inflammatory reaction is seen in these cases, from simple ulcerating surfaces to gangrene of different members. Quite a number of amputations are required for this condition. PREVENTIVE MEDICINE. Studies in preventive medicine are carried on, especially at the Institute for Infectious Diseases and the Serum Institute, and quo- tations given below are taken from the official pamphlet of the work of the institute. Under this head come such diseases as smallpox, dysentery, typhoid fever, erysipelas, tuberculosis, pest, leprosy, tetanus, venereal diseases, and the eruptive fevers, such as measles, scarlatina, etc. Smallpox.—This disease is not common in Japan at present. Vaccination is general and has proved wonderfully efficacious. In the navy all recruits are immediately vaccinated and revaccinated if necessary. By the navy regulations all persons must be revaccina- ted every five years. The Japanese manufacture their own vaccine; that made at the vaccine farm at Tokyo, under the management of Doctor Umeno, is perhaps the best. This farm was visited and the entire process of producing the glycerinated lymph was demonstrated tome. The following article, with illustrations, given me by Doctor Umeno, gives a complete description of the process, together with the organization of the farm and will be of interest: The buildings on the farm consist of a main building, a stable, a quarantine house, and a few other buildings. : Main building: From the front entrance, on the left are an office, a room for vaccination, and a room for specimens; and on the right are the president’s office, a library, and a laboratory. Going straight from the entrance, and the other side of a corridor, are rooms used for making lymph. In the specimen room are provided for reference over 100 utensils for vaccination, both foreign and Japanese, apparatus necessary for vaccination, specimens of calves, and of tables for vaccinating falas, In the library are kept about 300 volumes of foreign and Japanese books and magazines on bacteriology, medical science, veterinary science, and animal gynecology. The laboratory is on the northwest corner of the the main building. All equipments necessary for bacteriological experiment with lymph are here provided. On the northeast corner of the main building is the vaccination room, where is provided all necessary apparatus. a Note by Director-General Saneyoshi: ‘‘I fancy Japanese might be even more liable to appendicitis than Europeans or Americans, for our food contains indigestible materials, such as vegetable fibers.” 11922—06——-10 48 Disinfection room is for disinfecting calves which are to be vaccinated or from which the lymph is to be collected. Here are found disinfecting apparatus and a washing basin. The room for operating upon calves is on the southwest corner of the main building, amply supplied with necessary utensils and medicines. The triturating room is on the east side of the disinfection room. Here the collected variolous matter is triturated and diluted. And here there is complete apparatus for collecting, triturating, and diluting the variolous matter and also a large refrigerator for cold storage. The bottling room is on the north of the triturating room, separated from the main entrance by a corridor. Besides the apparatus for bottling, there is provided an ice chamber, where the lymph for sale is preserved. : To facilitate disinfection the basement of all these rooms is entirely cemented, and every possible care is taken to keep the rooms clean. Stable: The stable consists of three buildings—Nos. 1, 2, and 3. Both Nos. 1 and 2 will accommodate 30 calves, while No. 3 will hold 28. There is a diagnosis room and a dissection room. The quarantine station, in which newly purchased calves are kept, is on the west side of the main building and about one hundred yards from stable No. 3. It is large enough to accommodate 28 calves and has attached to it a barn. Work .—Before the work of the institute is described it would be well to refer to the non- humanized lymph discovered by Mr. Umeno, under the direction of Professor Kitasato. It is a well-known fact among physicians that the hymanized lymph, though it is very powerful, is liable to become the medium of conveying germs of other diseases, while on the other hand the retrovaccine is weak in effective power, though the danger of its trans- mitting other diseases is much less. But the nonhumanized lymph, discovered by this institute, while minimizing the defects of the above two kinds, combines the merits of the two. Hence it can be safely pronounced the best vaccine lymph ever found. The attempt to make lymph without the medium of the human body has long been tried. The greatest obstacle lay in the fact that if vaccination is continued from calf to calf its effective power would gradually become so weakened that it would finally become non- effective. Physicians used to attribute this to two reasons: (1) That the calf’s bod weakens the effective power of the lymph; and (2) that animal lymph contains a very sma. quantity of virus. But according to Umeno’s experiment the result is just the other way. The cause was found in the wrong method of inoculation. Its scientific treatment has been minutely recorded in Saiking-Zasshi, No. 66. Its main points are as follows: “The quantity of virus in animal lymph is much greater than in humanized lymph. Unless, therefore, it is diluted before inoculation the very existence of superabundant virus will hinder its growth. The portion of the calf’s body inoculated should be small and the vac- cine must be carefully nourished, otherwise its effective power will not be preserved.” This theory was proved to be well founded by practical experiment, and this new method ’ of producing lymph without passing through a human body was at last adopted. If, therefore, the lymph is sufficiently diluted and inoculated into the belly of the calf over a small surface, it will continue to produce the same result however often it may go through the calf’s body. It is now nearly four years since the introduction of this method in the institute, and the lymph does not deteriorate or lose its power after passing through 130 calves, but rather its effective power has increased. The following is the method of producing nonhumanized lymph: Calves: The calves to be used for producing lymph are robust and from 2 to 4 months old. They should be carefully examined for skin and other diseases, and particularly for the existence of tuberculosis by the tuberculin test. Original lymph: The original lymph used for inoculation ought to be the very strongest, but that which is not mixed with other bacilli. The method of making this lymph differs from the ordinary method in this—that the vaccinated surface is made smaller—that is, the proportion to be inoculated is 3 square centimeters for every 4 kilograms of the calf’s weight, and that, in order to sterilize, the lymph to be used ought to be mixed with diluted glycerin containing 1 per cent of carbolic acid in the proportion of one to four. Method of inoculation: When calves are to be inoculated the hair of the belly is first shaved, the parts thoroughly disinfected with soap and alcohol, and the skin wiped with sterilized cotton, and three or four lengthwise scratches made with the lymph knife (fig. a) invented by Umeno, and over these scratches cross scratches are made. The depth of the scarification differs with the thickness of the skin; but the general rule is to cut not so deep as to draw blood. If too large a quantity of serous fluid should come out it must be carefully wiped off with a piece of cloth and then the lymph rubbed over the scratches. After completing the vaccination the wound is covered with sterilized cotton, on which a cotton wana cloth is placed, and the calves are led into the stable. 49 The vaccinated. portion of the body will swell up a little and become red on the third day. On the fourth day it will be greatly inflamed and the calf will show signs of uneasi- ness, with a temperature of 39.5° to 40° C. On the fifth day the temperature will reach as high as 40° to 40.8° C., and the vaccinated part will still be greatly inflamed and exhibit a white tinge on account of the pus and vaccine vesicles, because of thickness of growth will have a flat surface. When it reaches this stage it is the proper time to collect the tissue. Method of collecting tissue: The inflamed portion is first to be moistened with sterilized water, then washed with soap and 3 per cent carbolic acid solution, rubbed with a piece of cotton, and the moisture carefully wiped off with a piece of sterilized cotton. Then, standing on the left of the calf, which has been placed on its back, the skin is pressed from a little behind the row of the vaccinated portion with a stretcher (fig. c) in the left hand, while with the lymph collector (fig. b) in the right the vaccine vesicles are scratched off from the hinder part toward the front. Then the rows of vaccine vesicles thus scratched off one by one are put into a small dish. When this is all finished a mixture consisting of ten parts of iodoform and ninety parts of charcoal dust is put over the wounds. Mode of preparation: The tissue thus obtained is weighed and ground by the Doering’s lymph-grinding mill. When it is sufficiently ground the carbolic acid glycerin is mixed with the vaccine in the proportion of four to one, the result being five times diluted lymph. A glass tube with a stopper at the bottom is used to remove the spume (fig. d). The spume is easily removed by turning it in a centrifugal apparatus, as it will come up on the surface. After the removal of the spume the ane ad is taken off and the fluid collected. When this is done a perfect lymph is produced. In order to offer it for sale it is put into a lymph tube by a lymph sucker and sealed at both ends. The lymph sucker (fig. e) is a glass tube having a rubber ball at one end and at the other wu rubber stopper with a small hole in the center, into which a lymph tube is inserted in order to fill it with lymph. The rubber ball also has a small hole, which is intended to regulate the passage of the air by the motion of a finger placed upon it. The effect of nonhumanized lymph: Not only does it produce a perfect vaccine vesicle on calves, but it also has a good effect upon the human body. It produces the regular form of vaccine vesicle. The inflammation of the inoculated portion is medium, containing no pus of a bad nature, while internally it is well filled. The whole system exhibits symp- toms of illness, with a slight fever of from 38.5° to 40.5° C. The vaccine vesicle will desic- cate in the usual number of days. While its effective merit is the same as ordinary lymph, its superiority consists in the total absence of any medium which introduces infectious diseases and of abnormal inflammation. Besides its positive result is always sure. As proof of this it has greatly lessened the figures showing the difference between the number of vaccinated cases and the successful results. It has also considerably increased the number of successful results of the second or third vaccination as well as the first. ‘ When calves are inoculated by intravenous injection, either with humanized lymph or retrovaccine, the number of vaccine vesicles which grow on the body has been very small, only one or two appearing on the face or atone the anus. But when nonhumanized lymph is used so very many vaccine vesicles grow not only on the skin, but also upon the mucous membrane, that in one of the animals used as an experiment were found as may as 260 vaccine vesicles. The accompanying figure shows a calf on whose skin numer- ous vesicles are developed after ten days of intravenous injection of vaccine virus. This fact speaks for itself of the greatness of its effect. Not only is this lymph superior to any of the former kinds, but the expense of producing it has been greatly reduced. 50 The following is the amount of lymph sold in each of the years named: Tubes. T8009 oe a ee be 2 oe eee ein aie sla ga eee eee ees mee 525, 392 ONS coop Se a ease eg einige omer ate sea en Oabs 442, 860 VOOM omc cn de Jo.2 zcio Atssausidantaveie 8s Secs ME eeen Pe vie Se See teee GSS Vee 450, 747 NOO2 och doe (553 22 be qa Biycicie ated Roden eee es aaeeetehere cetaces 656, 985 1903 (January to August).....-.---.-.---- +--+ +2 ee eee eee eee ee eee 663, 980 Totals snveres aaa dusacsen eet Shas Aeieddese nee cote ae ees ee 2,742, 164 The price of one lymph tube, which contains a sufficient quantity for five vaccinations, is 5 sen. But to those who purchase it for charity half the price is charged. About three-fifths of the total amount is sold in this way. For orders from foreign countries, 30 sen per tube is charged. ; ; Dysentery: The dysentery to be considered is the dysentery of Japan, the bacillary dysentery of Shiga. This disease has proved a great scourge in the years gone by, but through the efforts of Doctor Shiga not only has the bacillus been isolated, but a successful mode of inoculation, which gives very interesting results. Concern- ing this the following extract from the pamphlet of the institute states: The dysentery prevailing in Japan and other countries of the temperate region is different from the amebic dysentery of tropical lands. Its bacillus was discovered in 1897 by Doctor Shiga, and it is generally accepted throughout the world to be the cause of this disease. It is a bacillus resembling that of typhoid fever. Antitoxic serum made out of this bacillus is exceedingly effective for remedial purposes. According to the result obtained by the experiment in 1898 and 1899, there were only 15 deaths out of 165 patients. The rate of mortality was therefore 9.1 per cent. At the Hiro-o hospital, the number of deaths being 11 out of 88 patients, the death rate is 12.5 per cent against 30 or 40 per cent of the ordinary treatment. Not only is the merit of this treatment so apparent in our own institute, it is also tried in various parts of the country with a very satisfactory result. Prophylactic inoculation of dysentery also shows hopeful signs. We use sterilized agar culture as in the case of cholera, and inoculate twice. ts effect on the patient bein: more violent than in cholera, we inoculate according to Doctor Shiga’s method, sterilize bacteria and antitoxic serum, at the rate of 50 per cent in the first instance and the second at the rate of 80 and 20. By so doing the patient can stand the treatment without sus- taining a violent effect. We have already tried prophylactic inoculation on £0,000 persons, and the results have been very favorable. In August, 1£00, for example, dysentery broke out in a little village, Koai, in Aiko country, in the prefecture of Kanagawa, end 28 persons fell sick in the course of a month, whereupon all persons in the village above 4 years of age were required to be inoculated. The result was almost miraculous. With the excep- tion of two persons only, who contracted this disease on the day after the first inoculation, all escaped the grasp of this dreadful contagion. The following table gives an idea of the extent of this disease in e apes and the mortality in the absence of the treatment of Doctor iga: Year. Number of |Per cent of | Number of cases. deaths. deaths. 20.4 8, 706 24.2 11, 208 23.7 16, 844 24.7 41, 282 24.5 , 089 24.5 12, 959 26.0 22, 356 25.4 23, 189 24.6 22, 392 22.8 23, 763 22.1 10, 265 26. 29 231, 064 51 Typhoid fever: Besides the ordinary prophylactic measures taken to prevent the disease, the products of the bacillus of typhoid fever may be inoculated or antitoxic serum used. According to the experiments lately tried by using the latter method, it has been found to be a decided improvement on the old method. Only 36 persons died out of 203 patients in our hospital, viz, the rate of mortality is 17.7 per cent. When typhoid fever prevailed in various districts, complete success was obtained in checking its wide spread by means of prophylactic inoculation. Tuberculosis is quite prevalent. The Japanese navy regulations are very specific on the immediate isolation of these cases and give minute directions to surgeons to be on the outlook for them. At the hospitals isolation is the rule. At Maizuru the tubercular cases are isolated in the contagious disease wards. Concerning this the institute pamphlet states: The remedy and prevention of this disease is one of the principal subjects which we are most earnestly investigating. It is, however, a great source of mortification that in spite of our effort in experimenting with Koch’s original tuberculin, new tuberculin and the newest tuberculin, which we made in our institute, we have not yet met complete success. For diagnosis and particularly in the case of bovine tuberculosis, original tubercuiin is largely used. Other topics for our careful experiment at present are the difference between the bovine and human tuberculosis, the merit and demerit of antitoxic serum, and the effect of prophylactic inoculation. 3 Erysipelas: ‘‘ By inoculating the sterilized bouillon culture of ery- sipelatous streptococcus around the inflamed portion, we have obtained a very successful result in dealing with this disease.” Pest or plague: No cases of ‘alaccie have been found, and I have heard of none in Japan. At many places, such as the Army Med- ical School, rats were being examined and a careful watch is kept for this disease. A pest serum and vaccine is manufactured at the serum institute described as follows: The bacillus is cultivated in a slanting tube of agar for forty-eight hours within an incu- bator at a temperature of 32° C., and it is mixed in the physiological salt solution as emul- sion and sterilized by heating for thirty minutes in a water bath of 60°C. Using this the horse is immunized by subcutaneous injection. 0.1 to 0.05 cubic centimeter of serum obtained from this immunized horse is strong enough to entirely destroy 74th part of one platinum loop of very virulent pest bacillus, rovvsse00 Of one platinum loop of which can kill a white mouse 12 grams in weight. In the year 1901 this serum was examined in Tainan isolating hospital (Formosa), adopting the so-called alternative method—i. e., the odd numbers of cases were injected with serum only, the even numbers receiving no injections, but early extirpation of buboes and general systematic treatment. The results of this examination were as follows: Nonserum treat- Serum treatment. ment. Number. | Per cent. Number. Per cent. Number of cases 56: lis cecesewes OG Senos 37 66. 07 21 37.5 19 33.93 35 62.5 Nors.—The death rate of nonserum treatment of plague in the same hospital from 1898 to 1900 was 54.04 to 60.48 per cent. . By this method of serum treatment the death rate is therefore very low, showing a great improvement over any other. 52 The following is the amount of serum either sold or freely distrib- uted in each of the following years: Bottles MOODS Jc2. vse ie An eis aa Ss auigtee eee hres eioereceneed See aeeees 370 TOOL. cctinioivelions a2 oe de ce Saba aun ane Se we Se eee se iesee eee te Soe eeeee 830 LOO 2: fie cencesctacceie kau dGied ecb pcioemowiens sENR RSME a ye tee GEE Ss. 1, 309 1903 (January—August).......-.---------- 2-2 eee ee eee ee ee eee eee ee 1,268 Ob aloes ate, 2 Oona dearer eB PAu AS SoRoiaa Fela pSemeee Ske Se 3,777 One bottle contains 40 cubic centimeters. The method of producing pest vaccine is not different from that of making the above-mentioned material used for immunizing horses. Only in this case 6 milligrams of pest bacillus are mixed in 1 cubic centimeter or 0.8 per cent salt solution containing 0.5 per cent carbolic acid. The quantity of the vaccine to be used differs with age. In the first instance of inoculation, 0.5 to 1 cubic centimeter, and in the second, 1.0 to 3 cubic centimeters is injected under the skin.. The number of persons who received this treatment in Formosa and Osaka is no less than 200,000. It was very rare for persons who received this treatment to contract the disease. This should be reckoned, therefore, as good a preventive measure against this con- tagion as the destruction of rats. The following shows the amount of pest vaccine both sold and dis- tributed in the following years: Bottles. 1900s 64s aac Same lotae oS ee eee eiehases Heecceerene et aeateeeaeeses 3, 232 DOO se eet hea Oo 8 ee MOA eee LC ROMA Mean a ene RO 5, 288 MOOD cic CA IAG SOREN Totes eat S NSA OE Pehla doh HPSS (See ae, tates an cee NE dere ds 2,135 1903 (January=August).. . s