SAF Monograph 1

MILITARY MEDICINE THROUGH THE AGES By BG(RET)(DR)Lim Meng Kin

ABSTRACT The article sheds light on the plight of casualties, both the wounded and diseased, in times of unsettling conflict and details the rise and fall of medical systems which were set in place to resolve them. While the question of whether man or microbe had been a more threatening enemy to the military, an examination of historical records and statistics will reveal that the greatest threat on the battlefield is actually microscopic. However, efficient systems should be set in place for evacuation and the treatment of wounds as these factors are of paramount importance in determining the outcome of a war. From the dismantling of elaborate medical structures following the fall of the Holy Roman Empire, to the establishment of the first School of Nursing by Florence Nightingale, readers are given a thorough insight of the development of military medicine through the ages.

He who would become a surgeon should Thou should bind fresh meat upon it the first day: thou should apply for him two join an army and follow it strips of linen, and that afterward with - Hippocrates1 grease, honey and lint every day until he (460-377 BC) recovers.

Military medicine has its roots in antiquity. Instructions concerning a gaping wound in Evidence of war surgery in ancient Egypt is his head, smashing his skull: “Thou should afforded by mural paintings and bas-reliefs palpate the wound. Should thou find that 2 found in the temples of Kranak and Luxor. smash in his skull deep and sunken under The Edwin Smith papyrus which dates back thy fingers, and he discharges blood from to 3000 BC, contains detailed descriptions both nostrils and ears, and he suffers of the treatment of commonly encountered from stiffness in the neck, thou should war wounds such as the following concerning say concerning him—an ailment not to be head injury: treated. He should rest and be kept at his 3 Instructions concerning a gaping wound in mooring stake.” his head, penetrating to the bone: “Thou should lay thy hand upon it and palpate Hippocrates himself, the father of medicine, the wound. If thou should find his skull almost certainly derived his surgical skills from not have a perforation in it, thou should the battlefield. Infact, war was the only school say regarding him—an ailment I will treat. of surgery in his day because the Athenians, in 2 Military Medicine Through The Ages their idealism to ‘make gentle the life of the medicine, making sure he is situated forward world’ had decreed that bearing of arms by ‘so that those wounded may find him.’ civilians was not consistent with civilisation.4 The doctor’s preventive role in sniffing out Professional soldiering, of course, was environmental hazards is also mentioned: something else—hence Hippocrates’ advice to follow the army to perfect one’s surgical skills. A common practice of the enemy is to poison the wells on the roadside, the articles of food, the shades of trees, and the fuel and forage for cattle; hence it is incumbent on a physician marching with the troops to inspect, examine and purify these before using any of them, in case they are poisoned.6

But concerning field hygiene, none matched the Old Testament Jews whose were governed by regulations as binding as the Mosaic code. Detailed instructions pertaining to the prevention of the spread of communicable diseases were spelt out, right down to the nitty-gritty of sanitary waste disposal:

Designate a place outside the camp where you can go to relieve yourself. As part of your equipment have something

Wikipedia/National Library of Medicine of Library Wikipedia/National to dig with, and when you relieve yourself, dig a hole and cover up your excrement.7 Engraving of Hippocrates by Peter Paul Rubens, 1638. Another not-so-recent idea is health and The treatment of war wounds also received fitness promotion. The fitness of the ancient mention in the Chinese classics. An interesting Greek armies was ‘founded upon daily exercise account is given of the legendary physician Hua from earliest youth to ripe manhood, under T’o treating an arm wound of General Kuan the supervision of experienced and practised Yu of the Three Kingdoms’ fame, by cutting leaders.’8 Healthy diets and gymnastics were his flesh and scraping the bone. As the proper prescribed for the prevention of bodily ills attitude toward pain was to bear it without and as an auxiliary in the treatment of general any sign of emotion, much was made of the or organic disorders.9 insouciance of the general who played chess while the surgeon operated.5 But when healthy and fit young men are thrown into battle, many would inevitably No less military-minded was India’s Susruta become casualties. Xenophon, the general who (4 BC) whose medical treatise includes a chapter led the epic retreat of the Ten Thousand Greeks on advice to the physician accompanying the (415-400 BC), noted that casualties were a army on the march. According to Susruta, costly drain on fighting strength: ‘There were he should be fully equipped with a supply of many unfit for action—namely the wounded, SAF Medical Corps Monograph 3 those carrying the wounded, and those who The motivation for care of the wounded bore the arms of such carriers.’10 The wounded was not solely humanitarian. The Romans were usually carried on the backs of comrades. recognised it as a military necessity. The Tactics On one occasion, Xenophon publicly scoured of Emperor Leo (886-912 AD), a classic treatise a bearer for trying to bury a wounded man to on military science written in the Byzantium get rid of his burden. period, contains an impressive passage on the absolute necessity of medical personnel to The motivation for care armies and ends with the following charge to the commanding general: of the wounded was not solely humanitarian. The Give all the care you possibly can to your wounded, for if you neglect them, Romans recognised it as a you will make your soldiers timorous military necessity. and cowardly before a battle, and, not only that, but your personnel whom you ‘Roman’ medicine was largely imported might preserve and retain by proper from Greece, but the significant Roman consideration for their health and welfare, contribution was undoubtedly the organisation will be otherwise lost to you through your of military medical support. At about 100 own negligence.12 BC, as the Romans began to structure the 6000-man legion, the military medical The dismantling of the Holy Roman Empire system became part of this structure. At after Charlemagne’s death in 814 AD, coupled legion headquarters was an office-doctor, with the advance of feudalism in Europe, led variously titled as Medicus Legionis or Medicus to the splintering of large armies and with that, Militarus.11 Under him, for initial medical care their elaborate medical structures as well. at the 500-man cohort level, was a Medicus During the Middle Ages, medicine, along with Ordinarius, a non-commissioned medical scientific inquiry, sank to low levels, remaining officer. Still under him, at the century level there for several centuries. As scholars of Capsarri of 60 to 100 men, were the , or the church picked over the bones of classical wound dressers. Unarmed sanitary personnel antiquity and argued over religious dogma, called Deputati followed the fighting columns many well developed medical procedures, at a distance of 200 feet in order to bring mainly Hellenistic in origin, were lost. Prayers, the severely injured out of danger during an unctions and laying of hands were the order of engagement. The saddles of their horses had the day. Pharmacology regressed to a simplified two ladder-stirrups on the left side and flasks herbalism practised in monasteries.13 of water were carried to revive the faint. The bearers received a piece of gold for every The pharmacopeias of the day consisted wounded soldier rescued. mainly of ingredients compounded from the As time went on, an extensive military parts of different animals. Field medical chests hospital system – the Valetudinaria – was built, of the period included oils of vipers and angle- one per legion. The standard floor plan had 60 worms, beetles, ear-wigs, powdered mummies, 14 wards or one per cohort, with special rooms etc. Perhaps the only positive development for surgery and the storage of drugs. Thus we in this age of Faith was that the Crusades see in the Roman model, a foreshadowing of (1096-1272) gave rise to religious orders such the modern concept of echeloned medical as the Knights Hospitaller and the Teutonic care along an evacuation chain. Knights, which did valiant work in the Holy 4 Military Medicine Through The Ages

Land and upon returning home, would later outcast status.’17 As late as the sixteenth exert great influence upon the establishment century, Montluc declared that the best of hospitals in Europe.15 thing that could happen to a fighting man in battle was to be “killed outright by a good As opposing armies arqebusade.”18

marched and counter- It was against this backdrop that Ambroise marched all over Europe, Pare, a barber-surgeon serving with the French Army, distinguished himself. In 1536, the epidemics spread, Pare had witnessed an old sergeant cutting killing countless thousands the throats of three helpless, wounded men of civilians as well. It was ‘gently and without malice’ to put them out of misery.19 The episode affected him as a sober reminder that the profoundly as the boiling oil and red hot irons larger struggle for earthly liberally applied to wounds up till then. Pare introduced gentler, more humane and more existence was with lower effective treatment methods for gunshot forms of life. wounds and amputation of limbs which were revolutionary for his time. He pioneered the In keeping with the medieval spirit of the use of ligature (tying up of the artery following age, the few capable physicians and surgeons amputation) and a multitude of ingenious of the day were attached to great personages innovations, including artificial eyes, arms and such as kings, popes, nobles and other feudal legs, and even implanted teeth. He published overlords. They faithfully accompanied their papers which are classic works, marking a new masters of military campaigns and were era in the history of surgery. Pare is today, richly rewarded for their services. Medical with justification, revered as the father of attendance thus became the privilege of modern surgery. He is also remembered for leaders, not combatants. According to Keegan: his humble line: Je le pansait; Dieu le guarit 20 Men of high rank were brought off the (“I dressed him; God healed him”). field by their squires, and treated rapidly Amidst the unsettling conditions of the by their own surgeons. The overwhelming 16th century (and the early stirrings of the majority of wounded were likely to lie where they had fallen for hours or even Renaissance), another major front opened. days, at the mercy or their wounds, Smallpox, measles, typhus, yellow fever, the weather and, not least, the sinister diphtheria, whooping cough and influenza swarm of pillagers who descended upon erupted with a vengeance, in epidemic 21 battlefields… stealing money, jewellery form. Typhus and smallpox, in particular, and clothing, silencing a wounded man’s became the principal scourges of army pleas or protests with a knife thrust.16 camps and wherever large concentration of troops gathered. Nothing whatsoever was done for the health and well-being of the individual soldier, As opposing armies marched and counter- who was left in the hands of ‘wandering marched all over Europe, the epidemics incisors, barber-surgeons and quacks of spread, killing countless thousands of civilians SAF Medical Corps Monograph 5 Wikipedia/Wellcome Trust Wikipedia/Wellcome

Wood engraving of Ambroise Paré, on the battlefield using a ligature for the artery of an amputated leg of a soldier, by C. Maurand. as well. It was a sober reminder that the larger similar ravages of disease and privation.25 struggle for earthly existence was with lower Typhus, typhoid, dysentery and pneumonia, in forms of life. combination with the wintry cold, decimated Napoleon’s Grande Armee during his ill-fated It was hard to tell which was more lethal— invasion of Russia in 1812.26 Indeed, analyses man or microbe. Apparently, few accounts of statistics compiled for the whole of the 18th were taken. Reliable records of battlefield and 19th Centuries show that on average, at losses during the 16th and 17th centuries are least four soldiers perished from disease scarce, contrasting with the Greek and Roman for every one killed by enemy action.27 historians of earlier periods from whom we Historians are generally in agreement that have firm statistics of battle losses.22 The in the entire history of armed conflict, far Roman practice of numbering the troops greater numbers have been brought down before and after a battle, coupled with the by the minute carriers of disease rather than recruiting of armies by the census, provided perished by the sword. a check against the numbers purportedly engaged and lost.23 Even seemingly innocuous conditions like scabies, the ‘tormenting itch’ caused by The impact of disease on military outcomes tiny mites burrowing into the skin, although should not be underestimated. According to not fatal, can incapacitate whole regiments. Plutarch, Mark Anthony’s army in 35 BC lost During the Seven Years’ War (1756-63), half more than half of its force through disease – “a of the armies of Frederick the Great were proportion not unusual in the ancient world.”24 thus affected – “Hardly anybody escaped, The army of Alexander the Great suffered neither officer, nor physician, nor surgeon”. 6 Military Medicine Through The Ages Wikipedia/FormerBBC

Florence Nightingale (middle) in 1886 with her graduating class of nurses from St Thomas’ outside Claydon House, Buckinghamshire.

And, during Napoleon’s Italian campaign and contagious eye . But he is best (1796-97), scabies sufferers could be counted remembered for creating his famous ‘flying by the hundred thousands. According to one ’ i.e., horse-drawn wagons fitted eyewitness, “Whole regiments of soldiers, the with removable stretchers – in effect, re- moment they were encamped for the night, introducing organised casualty evacuation and threw off their knapsacks and scratched en treatment while the battle was on, a practice masse. The officers suffered no less than the that had been lost since Roman times. Each soldiers; their commander-in-chief was no division sent forward was accompanied by exception, scratching himself with a vengeance a troop of personnel headed by until blood appeared.”28 a surgeon. These men and their equipment boosted morale tremendously. Larrey himself The wars of the 19th century, such as the was present in no fewer than 60 battles and Napoleonic wars, the Crimean War and the was wounded at least three times.29 , produced several famous personalities who left lasting impressions on The ambulance concept was further military medicine. developed during the American Civil War by Letterman, Medical Director of the Army of Napoleon’s chief surgeon, Larrey, was the Potomac.30 He had been so appalled by said to have performed no less than 200 the misery caused by fleeing stretcher bearers amputations (speed was of the essence in and unruly ambulance drivers during the an era of limited anaesthesia) during a 24- initial conflicts that he took steps to ensure hour period in the Russian campaign. He also that future ambulance staff were better wrote vivid descriptions of trench foot, scurvy trained and organised. He also introduced SAF Medical Corps Monograph 7 the concept of , i.e., the sorting of treating the war-wounded regardless of casualties by severity, at medical clearing nationality and giving protection to medical stations close to the battle line, from whence personnel and hospitals.32 casualties would be evacuated rearwards to receive echeloned medical care. It was The First World War saw the massive a simple principle which was eventually application of modern medicine—widespread immunisation, ritual delousing, motorised adopted by all armies of the world. ambulances, management of shock, surgery But, perhaps no other practical advance under modern anaesthesia, prevention and has brought greater comfort to millions of treatment of chemical warfare casualties, the sick and injured in the world than the nursing identification of ‘shell-shock’ as a psychiatric profession founded by Florence Nightingale. disorder, and so on. Traditional threats like In 1854, she witnessed the shocking conditions typhus, plague and cholera had been rendered controllable. But, wound was in the military hospital at Scutari where rampant and this led to vigorous developments the British war-wounded were kept. She in antisepsis and antisera. The introduction of imposed her ideas of nursing care on those in the aeroplane and the submarine as weapons authority and on her return from the Crimea, of war also surfaced new medical problems established the first School of Nursing in and gave impetus to the development of the world. She was also responsible for aviation and underwater medicine. When the many later innovations which made military ‘Great War’ ended, the world was by no means barracks safer and more sanitary.31 at peace. Nationalistic revolutions threatened A few years later, another great to re-ignite Europe and large tracts of Asia humanitarian movement was born. In 1859, were still left in disorder. Preparedness was Swiss banker Henri Dunant visited the scene the watchword, following the realisation that of the Battle of Solferino shortly after the “to steal away a nation’s sword is the surest fighting had ceased and witnessed the carnage enemy of peace.”33 But, in terms of overall and gross neglect of the wounded. The sight medical preparedness, the world, in the of tens of thousands of wounded soldiers still words of Taylor, had “not yet attained to a lying unattended on the ground so moved comprehensive grasp of the requirements or him, that he persuaded the victorious French possibilities of military medicine.” 34 commanders to free the captured Austrian military surgeons to care for the injured of all The Second World War, although fought three nations, i.e. France, Italy and Austria. on a larger scale and with more powerful Tuti fratelli (all brothers), he kept repeating weapons, actually incurred a lower casualty when local civilians resisted helping the rate than did World War One (WWI). This was enemy wounded. He later wrote a book called mainly attributed to the dramatic reduction Un souvenir de Solferino in which he described of deaths from infectious diseases from the scenes he had witnessed. The revelations 16.5 per thousand men to less than 1 man so shocked the civilised world that the 35 International Red Cross, mainly through per thousand. The war also stimulated Swiss initiative, came into being five years and accelerated a number of medical later. At Geneva, 16 signatories agreed to advances: Dichlorodiphenyltrichloroethane abide by humanitarian principles such as (DDT) for preventing louse-born typhus, 8 Military Medicine Through The Ages malaria prophylaxis, antibiotics, large-scale demonstrated the problems associated with whole blood transfusion in the field, treatment mothballing of medical services between of burns and from armed conflicts. The Americans faced critical the combat theatre. Still, mistakes were medical manpower shortages and inadequate made, too many to be listed here. But, equipment and drugs. Despite the recent one deserves mention—in North Africa, experience of WWII, there was an expensive re-learning by young inexperienced surgeons disorganised evacuation resulted in massive of the old lessons of wound treatment. over-evacuation and under-return to duty of soldiers with simple, remediable conditions. The Chinese People’s Liberation Army fared In France and Belgium in the fall of 1944, the much worse, experiencing severe problems term ‘million dollar wound’ was coined as the of evacuation in the bitter winter cold and lightly wounded were air-shuttled to England severe shortages of medicine. Lacking efficient while the seriously wounded filled the mobile transportation means, it took an average hospital beds. Combat medicine, improperly of 25 hours for the wounded to reach first- understood and executed, can be a conduit line, division-level field hospitals. As the war that bleeds the fighting force! progressed, this time interval was shortened to 13-14 hours, which was still far from The Second World War, satisfactory.37 For Mao Zedong’s exhortation to ‘rescue the dying, heal the wounded, and although fought on a practise revolutionary humanitarianism,’ to larger scale and with be practicable, better logistics back-up would be needed.38 more powerful weapons, actually incurred a lower Vietnam was undoubtedly the epitome of high-tech combat medicine. Virtually casualty rate than did immediate evacuation by ‘dust-off’ helicopter World War I (WWI). This ambulances, usually within one hour of wounding, was commonplace. Some of the was mainly attributed to best combat surgery ever performed was in the dramatic reduction air-conditioned, semi-permanent hospitals with equipment and medical staff comparable of deaths from infectious to civilian trauma centres in the diseases from 16.5 per (US), but located close to the battle areas. Only 1% of the wounded reaching a medical facility thousand men to less than died, a figure which compares favourably 1 man per thousand. with the 2.2% and 4.5% in WWII.39 Preventive medicine, although not without flaws, was The shattered the uneasy good enough to keep infectious diseases and peace that followed the end of WWII. The non-effectiveness rates at the lowest levels of medical war was about Mobile Army Surgical any war.40 Hospital (MASH) units and helicopters, vascular surgery and blood banks and combating Another major contributor to this success endemic diseases like typhus, infectious was the improved medical command system. In previous wars, US Army medical units were hepatitis, malaria and even frostbite.36 It also SAF Medical Corps Monograph 9 Wikipedia

US Marines of Company E, 2nd Battalion, 9th Marines, while under heavy fire within the DMZ on Operation Hickory III, are carrying one of their fellow Marines to the MEDEVAC helicopter during the Vietnam War. subordinated under the control of logistics threats like heat stress, dehydration, snake/ commanders, an arrangement which was also insect bites and infections, as well as in existence from 1964 to 1966 in Vietnam. military threats like chemical and biological But by 1970, the superior effectiveness of weapons.43 As it turned out, many anticipated a separate theatre medical command, with problems did not arise, thanks to the brevity strong professional medical control at teach of the ground war, the non-employment echelon and central control of medical assets of Iraq’s extensive arsenal of chemical by senior medical commanders directly weapons, and the extensive preventive health measures taken. responsible to the supported line commander, was clearly demonstrated and implemented.41 With the emergence of the New World Order—post-Gulf, post-Wall and post-Evil We end, as we began, near the cradle Empire—and despite the promise that it of civilisation. In January 1991, with more holds for greater world disarmament, warfare than a million troops arrayed in the Persian appears now to be entering a new phase of Gulf in readiness to do the ‘mother of all protracted, low-intensity conflicts fuelled battles’, casualty estimates ran high—10,000 by ethnic and religious strife. It is, as yet, too dead and 35,000 wounded for US troops early for nations to beat their swords into alone, according to one source.42 The desert ploughshares. There remains much to be environment was essentially hostile, and fully grasped concerning the ‘requirements or medical concern centred around natural possibilities of military medicine…’44 10 Military Medicine Through The Ages

Endnotes

1. Hippocrates: Volume VIII, Places in Man. 17. Garrison, F. H. : Notes on the history of military Glands. Fleshes. Prorrhetic 1-2. Physician. Use medicine, Association of Military Surgeons, of Liquids. Ulcers. Haemorrhoids and Fistulas Washington DC, 1922; p. 83. (Loeb Classical Library No. 482) 18. Montluc: Cited by Thomas L: Lectures sur 2. Larrey D J: Memoires de chirurgie militaire, l’histoire de la medicine, Paris, 1885, 17. Paris, 1912, ii, 223. 19. Haggard H W: The doctor in history. Dorset 3. Brested J H: The Edwin Smith surgical papyrus, Press, New York, 1989. 2 Vols., Chicago, University of Chicago, 1930. 20. Rhodes P: An outline history of medicine. 4. Thucydides: History of the Peloponnesian war. Butterworths, London, 1985; p. 51. Transl. by Rex Warner, Penguin Books, London, 1972. 21. Mcneill W H: Plagues and peoples. Doubleday, New York, 1976, p. 176-207. 5. Lyrons A S and Petrucelli R J: Medicine – an illustrated history. Abradale Press, New York, 22. Frolich: Ztschr. F. Krankenpflege, Berlin, 1896, 1987 Ed., p. 135. XVIII. 45. Cited in: Garrison F H: Notes on the history of military medicine. Association of 6. Susruta S: Medical treatise. English translation Military Surgeons, Washington DC, 1922, p. by Bhisnagratna K L, Calcullta, 1907, I, 303-307. 106.

7. Deuteronomy 23:12, 13. New International 23. Garrison F H: Notes on the history of military Version of the Holy Bible. medicine, Association of Military Surgeons, Washington DC, 1922; p. 60. 8. Garrison, F. H. : Notes on the history of military medicine, Association of Military Surgeons, 24. Jackson R: Doctors and diseases in the Roman Washington DC, 1922; p. 45 Empire. Norman, Oklahoma, University of Oklaoma Press, 1988. 9. Sudhoff: Internationale Hygiene-Austellung, Dresden, 1911, I, Historische Abteilung. 25. Ruffin J R: The efficacy of medicine during the campaigns of Alexander the Great. Military 10. Withington E T: Medical history, London, 1894, Medicine, Vol. 157, September, 1992; p. 467-75. p.74. 26. Zinsser H: . Little Brown & Co., Boston, 1934, p. 11. Scarborough J: Roman medicine, Camelot, 128-149. London, 1969, Cited by Joy R J T in: Doctor on the Battlefield, unpublished lecture notes. 27. Major R H: Fatal partners: war and disease. Doubleday, Dortan & Co. Inc., New York, 1941; 12. Leo: Tactica, epilogue, Leyden, 1612, p. 281. p. 239.

13. Nuland S B: Medicine, the art of healing. 28. Williams G: The age of agony. Academy Chicago Macmillan Publishing Company, New York, Publishers, Chicago, Illinois, 1986; p. 200. 1992. 29. Williams G: The age of agony. Academy Chicago 14. Schuster J: Deutsche mil-arzil. Ztschr., Berlin, Publishers, Chicago, Illinois, 1986; p. 206. 1916, XLV, 123-131, cited by Garrison F H in: Notes on the history of military medicine, 30. Letterman J: Medical recollections of the Army Association of Military Surgeons, Washington of the Potomac, Appleton, New York, 1866. DC, 1922; p.119. 31. Lyons S L and Petrucelli R J: Medicine – an 15. Haggard H W: Doctors in history. Dorset Press, illustrated history, Abradale Press, New York, New York, 1989; p. 138. 1978; p. 544.

16 Keegan J and Holmes R: Soldiers – a history of 32. Gumpert M: Dunant: the story of the Red Cross, men in battle. Viking, New York, 1986; p. 146. Oxford University, New York, 1938. SAF Medical Corps Monograph 11

33. Garrison F H: Notes on the history of military medicine, Association of Military Surgeons, Washington DC, 1922; p. 206.

34. Taylor J S: United States Naval Bulletin, Washington, 1921, xv, No. 139.

35. Hume E E: Introduction to military medicine.The Military Surgeon, January 1948, p. 17-24

36. Cowdrey A E: United States in the Korean War – The Medics War. US Government Printing Office, Washington DC, 1987.

37. Wu Z L and Wu Z L: Battle casualties and medical support of the Chinese People’s Volunteer Army in Korean War. Sixth International Conference of Wound Ballistics, Chongqing, China, November 1988.

38. Wu Z L: China’s evolving Medical Service PLA. Medical Corps International, Vol 3. No. 5, 1988; p. 28-36.

39. Keegan J and Holmes R: Soldiers – a history of men in battle. Viking Pengin Inc, New York, 1986, p. 154.

40. Neel S: Vietnam Studies – Medical support of the US Army in Vietnam 1965-1970. Superindendant of Documents, US Government Printing Office, Washington DC, 1975.

41. Llewellyn CH: Medical support for a short war strategy. Military Review, June 1977, p. 78-86.

42. The Centre for Defense Information, Washington DC, cited in Boatman J: Crisis in the Gulf – planning for the worst. Jane’s Defence Weekly, 19 January 1991; p. 83-86.

43. Caldwell J A: A brief survey of chemical defense, crew rest, and heat stress/physical training issues related to Operation Desert Storm. Military Medicine, Vol. 157 No. 6, June 1992; p. 275-281.

44. Taylor J S: United States Naval Medical Bulletin, Washington, 1921, XV, No. 139.