4. Relation to Neurocirculatory AstheniaThese symptoms are those of hyperthyroidism, rather than those of a true N. C.-A., a fact more evident from the history of the soldiers. For these hyperthyroid men had been energetic and efficient, and had not had to drop out on hikes nor had they been trying to spare themselves, as the N. C. A.'s regularly did.

Since the N C. A. or "effort syndrome" is new, there is a tendency to make it include too much; and we find grouped under it everything from neurasthenia to sympatheticotonia. To my mind it is axiomatic that there is a definite limit of demarcation between it and hyperthyroidism. To make it clear it may become necessary to establish new objective criteria for hyperthyroidism. Therefore I welcome the adrenin test of Goetsch, the sugar utilization test, and the estimation of the basal metabolism in the clinical calorimeter. The result of their use will be the marking out of many cases of hyperthyroidism such as we saw in France; and the acceptance of the postulate that the thyroid responds by increased activity not only to infections, and endocrine upsets, but also to serious overstrain and exhaustion.

5. Prophylaxis-A practical conclusion from all these facts would be the justification of the administration of the iodides to patients suffer ing from exhaustion (either from overstrain or disease) as a prophylactic measure with the hope that it would prevent the compensatory hyperplasia of the thyroid, somewhat as Kimball and Marine did in the Akron schools (Arch. Int. Med., 1918, 22:41).

715 Bryant Building.

A BRIEF REPORT OF THE MEDICAL WORK OF THE AMERICAN RED CROSS COMMISSION TO PALESTINE

June 22, 1918 to June 1, 1919.

D. V. ASKREN, M. D., Fayum, Egypt.
(Captain P. M. O., Jerusalem)

In writing the report of the medical department of the American Red Cross Commission to Palestine I feel absolutely unable to do justice to the subject, therefore I hope that the many deficiencies will be overlooked.

The American Red Cross Commission to Palestine had its inception in the fertile brain of Dr. E. St. John Ward, Professor of Surgery in the American Medical College, in Beirut, Syria, a branch of the Syrian Protestant College.

Before America's entry into the war, prompted by the humane instincts of the busy physician he aided in the reorganization of the Red Crescent service of the Turkish army; this organization in the Mohammedan world corresponds to the Red Cross of the Christian world.

His duties in connection with this organiza

tion lay largely in Palestine, and during the first Turkish attack on the Suez Canal he was in command of the Turkish Base Hospital at Beersheebaon, the southern frontier of Palestine.

Due to the fact of his having been a missionary in Arabia and in Syria proper for many years, he had an exceptionally good knowledge of the native population of Syria and Palestine, and this knowledge, coupled with his observations of the condition of the inhabitants under the Turkish rule acquired during his work in Lower Palestine with the Red Crescent, showed him how neces

sary it would be for some relief organization to begin work as soon as possible after the conquering of the country by the Allied armies.

Col. Ward, in organizing his first unit in America, was particularly fortunate in knowing of the large number of missionaries, both lay and medical, who had been ordered out of Asia Minor by the Turks on America's entry into the war, and who, after a rest in the United States, were ready to return to their fields of labor or any other fields where they could be of service in relieving the distress in the Near East.

These missionaries in accepting commissions

with the Unit to Palestine, formed an exceedingly valuable nucleus around which the Unit was built as they were thoroughly conversant with the language and customs of the peoples with whom the unit was to work.

It should be stated here that while these members were missionaries they did not do mission work in Palestine unit, but did Red Cross work purely and simply.

On arrival in Jerusalem, almost a year ago, the unit was assigned by the occupied enemy territory administration a group of buildings known as the Russian buildings for the base of the unit's activities.

These buildings comprised a large group of rooms built around a cross shaped chapel known as the Hospice; a second building originally the Russian Hospital, and a third set of buildings in an adjoining compound which were originally the residence and offices of the Russian consul and the house of his dragoman.

These buildings are beautifully located just to the west of the city proper, and through the installation of good American sanitation with proper protective hygienic measure, the unit has been remarkably free from any serious illness among its members.

The buildings had been used by the Turks for hospital purposes and the condition of the buildings when taken over can be better imagined than described, and I shall not attempt any extended description of the cleaning beyond saying that it was successfully performed by members of the unit in the tropical heat of July.

Work was very speedily put under way and the buildings were alloted as follows: The Hospice became the base home where all members have had a bit of American hospitality out where most of the members in Jerusalem have resided during their service with the unit.

The Russian Hospital was made into the surgical hospital and also became the base supply warehouse for drugs and surgical supplies.

The consular building was converted into a children's hospital in the first floor and the ground floor was made into a polyclinic where free clinics were conducted to relieve the distress of a population that had been for many months unable to secure any medical care or medicine.

As this report is purely descriptive of the medical work and written by one who joined the unit almost six months after the work was started, much of the description of the early activities will necessarily be hearsay.

During the time requiring to get the base hospitals ready several members of the unit were assigned to out duties, some to hospitals ready. established, notably at Jaffa, where an infectious hospital was temporarily staffed by a Red Cross physician and nurse and others went out with improvised field equipment and opened clinics

and hospitals at Mejdel, Wadi Surrar and Ludd and Ramleh.

These clinics did wonderful service down in the coastal plain in August and September, under the most trying conditions in a broiling hot cli

mate.

Later in the fall, when military operations were again resumed, it was possible to establish work in Haifa and Acre on the coast, and a short time after that to push workers over across the Jordan to Es Salt where a large number of the Arab population were in an exceedingly needy condition.

In these three stations it was possible to use fairly satisfactory buildings for hospitals though much equipment and all drugs and expendables had to be supplied from the base.

During all the work the very pleasant cooperation between the occupied territory administration and the Red Cross can be best illustrated by a brief history of the outbreak of cholera at Tiberias on the Sea of Galilee in the month of October.

This disease is one of the most dreaded in the East, and is particularly difficult to control among a Mohammedan people owing to the fact that the Mohammedan religion requires five daily ablutions before each prayer, and the devotee repairs to running living water, if possible.

Tiberias lies on the Sea of Galilee about five hundred feet below the sea level, and is one of the hottest spots imaginable during the sum

mer.

It has a large Jewish population, and its sanitation is not modern in any sense of the word.

Upon discovery of the outbreak of cholera, the Red Cross was asked by the military authorities to aid in combating the epidemic by sending 36 beds, 2 doctors, 2 A. R. C. nurses, 2 native nurses, an interpreter and an expert laboratory worker.

this time this small staff successfully treated The epidemic lasted three weeks, and during seventy-three men, one hundred and two women, and thirty-six children, a total of two hundred and ten people, that would have probably died. had it not been for the efficient treatment and care that they received through the Red Cross.

The epidemic, by the very efficient sanitary measures of Major Sibley, R. A. M. C., late of the London School of Tropical Medicine, was confined to one portion of the city that had been drawing its water from the Sea of Galilee and by supplying a proper water and patrolling the beach the epidemic was very speedily stamped

out.

The medical relief soon settled down to two centers, one comprising Acre and Haifa for the coastal plains and Jerusalem for the mountain dwellers, with Es Salt reaching much of the population east of the Jordan though Jerusalem

drew large numbers of patients from the country east of the Jordan particularly south of the Es Salt region. Jerusalem being the largest city of Palestine, was the seat of the greatest activities of the unit, and the five workrooms, the Russian women on Mount of Olives and at Ain Karim, and the three orphanages were placed under daily medical supervision and clinics held in each institution where all needing treatment were supplied free medicines.

The orphanages and other relief work of a sister organization, the Syrian and Palestine relief fund which had preceded the Red Cross into the field were taken over by the medical staff and daily clinics conducted.

The various clinics and dispensaries treated in the past eleven months 23,753 men, 46.285 women, and 69,499 children, a grand total of 139,537 patients who received advice and free medicines.

Most of these patients were of the very poorest and most needy classes and they form perhaps the brightest spot in the medical history of the unit.

A slight digression should be made to mention that most of the cities and villages of Palestine are very heavily infected with malaria, which owing to the tight blockade maintained against Turkey and her allies, made it almost impossible to obtain quinine and as no attempt was made by the Turkish sanitary authorities to control the disease by screening standing water or destroying the mosquitoes in the houses, the disease was practically universal.

From personal experience in the clinics and hospital fully 75 per cent of the patients presented palpable spleens showing an almost complete saturation of the population, both young and old.

The present military authorities have been fully alive to the situation and have closed, screened or treated all the cisterns of Jerusalem. a total of about three thousand, and had the Red Cross remained there would have been instituted a very active campaign under the able management of Major Groeniger, the sanitary expert of the unit.

The pumps and piping necessary to close all these cisterns did not arrive, however, until after our orders had been received to withdraw from the field, but the plan was adopted by the military authorities and the pumps purchased so that we have the satisfaction of knowledge that the good work goes on and endemic malaria wil shortly cease to exist in Jerusalem; thanks purely to the Red Cross and its sanitary engineer.

Among the illiterate population literature does not really reach many of the people, therefore practically no attempt was made to reach them by such a means, though one malarial pre

ventative measure was printed and distributed. The malarial situation had been met and relieved and the enlarged spleen is not so often seen now in the clinics dealing with the Jerusalemites though many of the patients from the villages are still malarial.

The writer feels that this malarial situation had been so largely relieved through two factors, the preventative malarial measures of the military authorities and the free distribution of quinine to all by the Red Cross.

The two base hospitals should receive a brief mention, and I therefore attach the report of the Children's Hospital, written by the lady physician, Dr. Lawrence, who opened it and was in charge during its entire history; she was also in charge of the children's clinic.

The work of this lady has been one of the ablest, self sacrificing and efficient in the unit, and thanks to her very skillful treatment and watchful care hundreds of children in Jerusalem and surrounding villages have been tided over an acute period in their lives and will now live to be useful citizens of this country.

Miss Spelman, the matron of the hospital, and Miss Haslam, assistant matron, by their watchful care over the native staff of nurses and their made it possible for the doctor to achieve such skillful nursing of the patients in the hospital wonderful results with the poor, ill, more than half starved babies that came into the hospital.

The second base hospital in the old Russian hospital building, was made into a surgical hospital at the desire of the military authorities, as at the time there were no other institutions doing surgery among the civilian population and its history contains many cases of mangled farmers and children injured through the accidental explosion of shells and other explosive weapons lost by the armies in the open warfare of this country that prevented the close salvaging of the battlefields that obtained in the trench warfare of Europe.

This hospital was opened on the the twentythird of September, 1918, and was turned over to the military Public Health Department of Jerusalem on the first of May, 1919, having had an existence as a Red Cross institution of exactly seven months, as last patient was admitted on the twenty-third of April.

This hospital was staffed by Red Cross physicians, one a lady, Dr. Hall, an A. R. C nurse, Miss MacQuaide as matron with A. R. C. nurses as ward nurses in charge of the staff of native nurses who were secured from local sources, and while very willing, required very much training and continual supervision; the last member of the hospital staff was Miss Wood, the A. R. C. nurse in charge of the operating

room.

During the seven months of its existence this

hospital treated a total of 668 patients of whom 402 were surgical and 266 were medical, with a total death list of only 25, giving a death rate of only 3.7 per cent.

This is a really wonderful record when it is considered that most of the cases were drawn from the poorest and underfed classes with their resistance worn down by the four years of privation they had endured, and I think this result was due to two factors:

The efficient dieting and nursing of Miss MacQuaide and her staff of nurses.

The second factor is due to Miss Wood in the operating room, who made sure every detail of the aseptic technique which we were able to employ in all surgical operations and dressings.

The total number of operations performed were 286, and comprised all classes of surgery, but particularly were abdominal and bomb cases sent to this hospital.

Dr. Hall's services were invaluable in the wards as the arranging of all the pathological speciments devolved on her as well as general wounds and dressings, but her best work was in connection with two gynecological clinics where she did very excellent work.

Two medical men come forcibly to my mind in connection with the work in Jerusalem, and they are Major Dodd, who was chief of the entire unit medical staff and to whose tactful and skillful arranging of the assignments is due the large results achieved in the clinics and dispensaries; the second member is Capt. Marden, upon whom devolved the hospital and to whose skill and mature judgment is due the professional results achieved and the reputation acquired among the people of this portion of Palestine.

It was with great regret that these two men left the unit early in February to go further north to open up new fields of immediate relief in districts where the need was more acute.

The work of the dispensaries was very satisfactorily performed by the various medical men, but especially so by those members who had not. previously been in the country and were compelled to take all case histories through an interpreter, many of whom had but a fair knowledge of elemental English.

The spirit of co-operation between the various medical men was very great, and the mutual benefit obtained through the interchange of the fresh western ideas and the more mature clinical knowledge of those who had been previously in the country led to results of great value to both physicians and patients.

The refugee situation required a passing comment as they were partially a medical problem.

A disinfecting plant was established, and 4,992 refugees were passed through the cleansing process, being given new clothing and bedding, and after a second medical examination were segre

gated into classes to prevent double inspections. and after ten clean days of isolation were passed into the clean classes.

Scabies and relapsing fever were the two most prevalent diseases among the refugees who were largely Armenian in nationality and who have now been practically all repatriated by the military authorities.

This refugee work was assigned to one of the A. R. C. nurses, Miss Ellen Hamilton, and she deserves great credit for the heroic manner in which she worked day after day among these refugees coming in the most filthy condition and swarming with vermin.

About the last of February, at a conference between Gen. Money and members of his staff of the occupied enemy territory administration and Col. Finley and Ward and Major Stoner and Reed of the Red Cross, it was decided that the greatest good would accrue to the country as a permanent monument to the Red Cross should the medical work with the equipment of the hospitals at Haifa, Acre and the two hospitals in Jerusalem be given to the medical department of the O. E. T. A.

Therefore, early in March, the preparation of the various inventories and the negotiations necessary for the arranging of the various details of the turn over began and it is my pleasure to record a very pleasant spirit of cooperation on the part of the military authorities in aiding to make all details work out smoothly and without friction.

The pathological laboratory was turned over on the fifteenth of April on which also Haifa and Acre were turned over owing to the sudden recall of Dr. Greely, the A. R. C. P. M. O. in charge of the two hospitals.

The laboratory and its equipment divided by the military authorities and part of it sent to Haifa giving two laboratories from the one stock. This laboratory was invaluable in diagnosing the peculiar diseases of this country and the services of Miss Hamilton were very much appreciated not only by the A. R. C. physician but also by all physicians of Jerusalem, both civilian and military.

On May the first the surgical hospital in the old Russian hospital building passed over to the medical department of the O. E. T. A. without a hitch, our staff leaving in the morning and the other staff coming at the same time though transfer of most of the patients from the Government Hospital had been proceeding for several days previously.

The Children's Hospital was transferred on the first of June, finally closing almost all the medical activities of the Red Cross as the workrooms and dispensaries had been closing gradually throughout the entire month.

Likewise as many of the children from the

orphanages as possible had been sent home to relatives wherever they were willing to assume responsibility for the child and such others as had no relatives able to take care of them were concentrated in the Syrian Orphanage.

The Syrian and Palestine Relief Fund Institution and the Syrian Orphanage continue under the care of the Red Cross medically until the end of June when most, if not all, will be closed; the Syrian Orphanage will, however, pass over under the control of the American Relief Committee in the Near East.

In concluding this report I would like to record the inestimable good that has been bestowed on Palestine and Syria by the Red Cross in the eleven months of its service here.

It has been with sincere regret that we have watched our work close down, and we each wish that we could justifiably continue the good work

we have been carrying on.

I wish to record the fine spirit of fraternity and fellowship we have enjoyed among ourselves and our exceedingly pleasant relations with our British friends and associates in the O. E. T. A., in both social and business relations.

A brief summary of the work for the children, medically:

These statistics differ very slightly from those in the doctor's report, evidently due to an error in transcribing.

The number of beds in the Children's Hospital were 30, and 101 patients were treated, of which 71 were cured, with a death list of only 15, which considering the condition of the babies on admission is a testimony to the care and feeding that they received in the hospital.

The Children's Clinic, of which only one was held, treated a total of 2,462 children actually ill, but 12,601 cases, visited the clinic of whom 7,118 received tins of milk which in many cases was much more essential than medicine, as the war killed off practically all the milk animals of the country, so that milk was almost unobtainable.

At the present time milk is selling at 30 cents a small quart, which is very high for a grazing country as this one is.

EDITOR'S NOTE-This very interesting report was written by a former St. Joseph boy, who will be remembered by many Herald readers. He was graduated from the Central Medical College, class of '96, and has practiced for nineteen years in Egypt. Dr. Askren writes us he volunteered as soon as the United States went into the war, but did not succeed in being accepted, so he joined the American Red Cross in Palestine, where he was elevated to the office of chief surgeon and served for six months. Dr. Askren says that his children were still in Egypt when the trouble broke out, and his wife had returned to get their summer clothes for the family. She was attacked at Wastaand, had a terrible experience (which was written up in the Globe-Democrat), barely escaping with her life. Dr. Askren wishes to be remembered to all his old friends and classmates and hopes to visit the United States at an early date.

The indications for the use of physostigma are nearly the same as those for agaricus.

Reconstruction in the Army-Col. H. M. Evans gave an excellent illustrated talk at the recent meeting of the Missouri Valley Medical Society, at Des Moines, on this subject. The big thing in the government's vocational work for disabled former soldiers now is supervision of the men in training in the various schools. The work is divided into three periods, all of which overlap more or less. The first was the advisory period, now nearly completed. It took the disabled men as they were released, advised them as to future activity, and started them in vocational work in the various schools. The second covers their school period, and the third takes them when their courses are completed and gives them "placement" training in the jobs that will best serve to carry them on. (W. I. Potter, 412 Mass. Bldg., is in charge of the placement work in by the government for certain periods in school. Kansas City.) The men have been recommended where they are, that they receive proper attenThe training section sees that they are satisfied tion, that their disability does not unfit them. for their course-is a sort of a substitute father for them, in fact. Men in training are allowed, if single, $80 a month, their tuition, books and the like, and $115 if they are married. The Federal Board for Vocational Education has an office in Kansas City under the charge of Mr. W. M. Godwin. Kansas City employers have almost without exception, been eager to help in placing the men after their training, or to give them part time jobs during training.

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Loss of Nurses Through Influenza-According to figures made public by the Red Cross headquarters at Washington, more than 200 American Red Cross nurses have died of influenza contracted while ministering to soldiers stricken with the disease. It is also reported that there are returning to America many New York Red Cross nurses who have contracted tuberculosis at the front and whose condition demands immediate treatment.