DIEEC'POB OF TEE EO8PfTIIL October l919 REPORT OF THE DTRECTOR OF TEX EOSPI'UZ . 00 tober 1919 To the Corponrtlon OS The Rockefeller Instltut'e for Medical Besearoh 011s ysar ago thr Hospital was yxwtl~ally a . military hospital. The chief autiritlrs conaernsd ths ears of sick soldiers, the instnurtlon of army mediual offlaers and rsslstanae to the government In the solution of ixnediato pmticel problaos. Practically all the mgpl bars of the staff of the Eospital had entersd the smy, many of them wsro in Brano*, and research, u the diligent inquiry and &borious,persIstant search of truthn, was at the lowost level o lnco the Bosyltal was oyened. Today the Hosyitnl is agnln sn institution for Investigation. Some of the men have returned to their old ac tlvities. Some hnvs gone slsewhere, but tholr places have been fllled by capabls, well~tralned znon, Enthusiasm `for obtaining nsw knowledge about disease 1s in the ah; maxiy of the men have already entered diligently won the solution of new problau, d year ago it seemed doubtful whether ot tie /. 1 end of the war any sp$rit of inrostigatloa would rsrmin, or studeatr to ., do the investigsting, . Today it saeme oertain that, this syirit is alSvo, and that men,. IL few years older it lr,tnu,, err still r&y to quietly undertake the rtudy of disease, It is hoped and believed that the reorgsniration of the Hospital is in progress and that the coming year wi1.l be the best we havs ever had. flOSDitd 8tRii. During a large part of the past year the staff has consisted of a for regular members of the staff who did not enter -the army or were assigned to duty here, in addition to the medical of fiasrs who were ordered here for special training. Following the signing of the armistice and the relearns of men from military service, some of the old msmbsrs of the staff returmd,but it was Impossible to satisfactorily reorganise the staff bsfors the beginning of the summer vsroation. During the past months numerous additions and uhanges in ths staff have been made. The most important lose has been that of Dr. Douhes, who goes to Johns Hopkins University, where he and Dr. Palmer, also a former member of the .staff, become Associate Profeaaors of Medic ine. Dr. Docher has been associated with the Hospital since Its opening and he rhould share very largely in any credit for the results of the Hoepikl activities; `. His departure is a dirtinot loam to the Ix&i- : tute; entirely apart from the poreonal loss to all the workers. : ,.. `. Among the n& appointments on *ho rtaf f of the Hospital a& the :foilowi&; most OS these mon are only now undertaking, . . their new duties: . I&. Robert Levy has been appointed Resident Physician, Dr. Levy has had a large clialcal sxperienco ae Assistant Resident Physician at -Johns Hopkins Hospital. Dr. Homer Swift has been appointed an Assoqiate in Medicine. It will be remembered that Dr. Swift was formerly a mm- her of our etaff and made important contributions to the subject of the trsatmeat of tabes and csrabro-spinal eyphilie. Ha left us to become Aesociate Profsrsor bf Hedlcine at Columbia Unlverrlty and later naa appointed Professor of Medicine at Cornell University, but before taking up his duties there, entered the am]r and was rent overseas. Here he did important and dirtiaguished mediaal work, taking an important share in the iavertigationr which rsrultrd in rhowing that trench fever is transmitted by body lies. Dr. Swift will undrrtaka the investigation of acute artic- u1a.r rheumat 185. Dr. Prmcir Blake ha8 been appointed Associate In Ysdic ins. Dr. Blake wan al80 fomerl~ a member of the staff. A graduate of Harvard Yediaal School and intwm at Peter Bent Brigham Hor- pial, he worked one winter In thi8 Rospital under a Harvard Travel,iag Fellowship. While here he carried on intererting rtudfetl concerning pneumonia. &I was later msd0 h8Oaiat8 &Of&8f3Or Of ld8diCine at the Univerlity of liianesota, and sitor a year entered the army. While here .`. he ha8 done extremely important work on pneumorria. Collaborating with Dr. Cecil, he har ruaassdsd ,in inciting the product ion, of PAOUE~OA~~ in monkeys =/ by injecting into the t>achsa very n&ate amount8 of p~8umecocci or strep- toooacl or Mluenra bacilli. The pA8umonia d8VOlOping in each ca8e ha8 groatlp reremblod ihe tne pAOU8OAia In man which ha8 been aomidersd to be due to the aame rerpective organirms. Dr. Blake ir to share in the studier concerning acute respiratory disease and in collaboration with Other8 may' Uadel-take the study of laOaa1e8. Dr. Binger of the University of Harvard and . b!aaeaohueettr General Hoepital becomes an Assistant Resident Physician. He haa had oonaiderable experience in the laboratories of Dr. Folin at Harvard and of Dr. Able at Baltimore, and ha8 already made a nurrber of scientlfio publications. Dr. Auetin of the Univereity of Pennsylvania becomes an Aelriatant Reeldent Physician. He has had an extensive clin- ical training in the University Horpital and has worked for several years with Dr. Pearce and ha8 made a number of important publications relating to nephritis and blood disearss. Other arslrtant rsrident physicians will be Dr. James Track, coming to UI from Corn811 Univerritg; Dr. Arthur Lyon, from Harvard Medical School, and Dr. Ralph Boots, iron the Unlvereity of Pitts- burgh. PO are therefore starting the new year with a well-trained, eAthU8ia8t ic and capable rtaf f . Training Courree C)iVOn to' Amy Uedic_al OffiCers. . Up to the .time,'of signing the armibtice the following training cour888 ware given in whole or in part by the hospital 8taf f : . . . 1, < . .:. . ._ ." I 1. A courre iA baeterio$ogioal method8 given for medical offi- .: : . c8r8 in the Inrrtituts .laboratoriee. ,' j Thi inetruct ion of the me.n in the j. method8 of rtudying,the ba&sriology.of acute infections has been given : . by Dr. Avery and Dr. Dochef, a88i8t8d by Dr. Still&n, and thi8 ha8 ' rsquimd a conridsrabls amount of their time. II. A. aour8e in chemical method8 I for membere of the Sanitary Corpr ha8 been given in the chemical laboratory of the Horpital. III. A QOUFIO dsrigned to teach women the bacteriological e lotrithetanding thir fact and also that the staff was greatly depleted, an effort wae mado to do what was porriblo in the rtudy of the diseaae and in invsst igat ing the eauoo of the epidemic. Clinioal Features oi Influanra. Although an enormous litmature har devslopod concorning the symptoms and caueo of iaflusnta, there ir at111 much differ- 41x4 of opinion am to ths osssntlal featurer of thr dimam, - lndsed, there Is at111 doubt in the minds ?? o ome whother influenra is a single rpeciflc infectious diroare. During the epidemio of the part winter paeumonla oacurred with very groat frequsncy. In exactly how many pat lent o ruf fering from inf luensa, changer In the lungr ruff icient to jurtify the diagnorlo of pnownonls ocourrod, will probably novor bo known. Even in a horpital like fhir one whore facilitlss for diagnoris are very good, it was lmporriblo under the oonditionr prevailing lart winter to be certain that no oases of pnmmooia wore overlooked, or that no lnfluooral broncho-pnm.rmonia caem were included among the lobar pneumonia ca8oa and vice vmm. Of the 313 pat iento suffering from acut 8 infectiono of the respiratory traot that ware treated, 41 wore considered to have had typiaal lobar pneumonia. Of them 12; or 29 per oent; died. !fbre were 168 came .., `, .- whioh were uonridered-to be influeara, and of there patients, 32, or 13 ior " : ,. j oent s diid. Binert y-one, or eonriderably ovor half of the Anfluema 08101, were b&ieved to have ruffioient inflammatory reaction In the lunge, am indicated by dulnese, tubular breathing etc.; to justify tht diagnosis ,of bronoho-pneumonia, and of those, 32, or 35 per Gent, died. Of ths 77 case8 of influenra without demonrtrable pneumor&a not one died. Of them 77 came diagnored ar influanta and which wor4 not thought to have pneumonia, 29 had ralsr or other signs which indicated rome degroo of pulmonary involv4mrnt. Th4 oxporienco her4 indiaatos that influsnta is a dissaeo of the rsspiratory tract, though In some cases the infsctidn of the lung is of a mild grads and in some possibly, the infection never reaches below the larger bronchi. In the recent opidemio thd lungs bscams involved in many aasoa, and it was among these aaeoa that the mortality was so high.. St is true that after the height of the epidemic had been parsod it was preferred to admit to this Horpital only those pat lent 8 having pulmonary involvomont . For thfa reason it ie probable that a largor psrcentags of our aasri had pneumonia `than wa8 the ea8a in the general hospital or' in uivillan prscrtice. Beverthelses our experienc@ indioatsr that pneumonia wa8 much more oommon in the epldomio than WILI gen- erully ammmd. An offort was made to determine the baotsrla pram- eat in the lung8 in our oases. Thie war done by making a oarsful baotori- ologlcal rtudy of the sputum and by making culturoe from matrridrl rsmovrd from the lung by puncture either during life. or immediately after. dsath, and by making eult.ur88~ from th8 ludg8 at. iutopry i ,+ . m0 'r88Ult8 Of the88 t _ ; . `.. 8mall'number of a$8c, &d Staph~loaoaau8'aukr, i.n.s fei caaeo, who . .found. Influenza'baoilli'rere present In'85 per 04zzS .of th8 m800, a8 . dsmotistrated by cultures made from the throat, from th8 sputum, or by cui-. tursr at autopsf. It ia ari int mertlng fast that inf luenla bacilli were cultivated from 20 of the 32 fatal cams of brokiho-pn8utnonia in ruch number4 and under ruch conditions that it 8eemsd lfkcsly that t'h8y playad at loart a part in the p8thOlOgiC process. The very frequent prosonce of B. influenza0 in cases of the dirsase made it soem important that our chisf attention at ths Hospital should be directsd to learning more concerning this organism and its relation to the dieeaes and the epidemic. As la well known there are two chief opinions concorning the etiology of tho disease and the epidemic: first, that B. influentke plays an otiologic role, and second, that thir organism is a secondary lnvader,csnalogoue to S. haemolyticue, Staphylococcur, Pneumococcus oto., and that the primary organism is unknown, probably a filterable virus. Am the staff of the Hospital was too much dirorganirod to permit 8ny rpoclal investigationa starting from the second of them two premlsee, it rsemo~ bettor to uonfine our stuciiea largely to the influenza bacillus, In order to carry out thou4 studies it was first nooaesary to find improved mothods df cultivating this organism so that w4 could bo reasonably sure that it was not being overlooked when it was actu- ally pr434nt. Dr. Avery undertook this problem and eucceoded in devising a n4w method, employing a inedium containing sodium oleate, In this medium the growth of certain common bacteria ie inhibited, while influenza 68cilli grow with very great luxuriance.' .Sinco influonta bacilli wore fetid to be almost oonetaatly present in the thrbats-of p8rsono` euff4ring from influenza or other acute respiratory disease during the epldsmic, it eeomed @portant to 14am moro concerning their distribution in the throats of healthy persons or in persons who had recovered fro? influenza. Coneequ4nt ly, several eurvsye were made under the direction of Dr. Ernest Stillman of all th4 persona aeeociat4d with the Institute. In the first survey made during the September-Decomber quarter, it was possible to cultivate influonra bacilli from the throats of 42 per.cent of all individual3 associated with the Institute. In January only 11 per cent of tho individuals wore found to be carrying influenta bacilli,but this low porcentago may probably bo aocounted for by certain defects in the medium omployod. In February influsnrs bacilli were cultivated from 30 per cent of the person- ' nol, in March from 50 per cent In April from 36 per cent and in Hay from 41 per cont. The rosults show that a largo number of the individuals in the fnstituto during the part year have been chronic carriers of this organism. From somb individurrls all of the cultures made have been pos- itive; from othors ths culture8 havs been perslstontly negative; while still other individuals, who at first wore negative, later became carriers, and vice voraa. Invostigat ions ~41-4 made to show whether the cultivation of ths organism from thb throat might depend upon some incidental factor; for Instance, whsthsr cultures might be porltive and cultures made a few hours later might be negative. The evidenae so far obtained indicates that this Is not the`caeo, but indicate8 that the truhnique employed may be rOli8d upon to show whether or not a person'ls a carrier of influenra baoilli. , Invest igatione were also made ,to dstsrmins from . . : what part of the naso-pharynx the organisms'rere most readily irolat4d; dr most frequently sncountered. In a reriss of about 90 individual@ three 8 cultures were made from the throat - one culture from each toneil and one from ths postsr+or wall,of the pharynx. In five individuals positive oul- turrs were obtained on plates from all three sources. In five individuals the cultures from the pharynx,and from one or the other tonsil, wore positive. In 13 individuals -only the culture from the ph8rp showed a growth of bflui enra bacilli. In no care were the organisms irolatsd from the tonsil and not ? from the pharynx. In theee 90 individuals, therefore, positive cultures were obtained from 23 or 26 per cent, and the reeults rhor that the organ- lams were most likely to be encountered on the posterior wall of the pharynx. Conrequently in moot of our cultures eincs thsrre obeervationr were made, and in moat of the cultures before, the cultures were made by touching the porterior wall of the pharynx alone. In tabulating the rerults, the. per~onr who gave a hirtory of having had influenza during the preeent epidemic were reparatsd from those personr from whom no ruch hirtory could be obtained. The per- centage of uarriers of fnfluenra bacilli did not differ in these two groups of individual@. The rsrults of cultures from the sick and the well, as mentioned above, indicate that during the epidsmio of acute reepiratory direas of the past winter, influenra bacrilli could be uultivatsd from a muoh larger proportion of the pereon suffering from influenra or acute rerpiratory disease thq from the healthy. Doubt might be thrown on thia rtatsment if we depended entirely upon the observationu of the phyeloians in the rarde, eince in these caaer a very great effort was. made to isolate ; influenra bacilli in every case, while cultures from the healthy persona were made in a more or `lees routine manner. Bowever, Yiee Winohell, who made the ,routine cultures from the ndrmal individuala, also made studies :! `. in a reriea' of patients, .making the cultures idexaatly the same way ar they were made `from the healthy. Whereas among the well person8 influenza I. bacilli were cultivated only from 30 to 40 per dnt of individuals, they `j were obtained by exactly the same technique from over' 85 per Gent of the casea in the warde. pore aan be no doubt, therefore, that during *!he epidemic of influeasa of,the past winter influenrr baoilli have boon fre- quently present in the mduthtr of healthy persona living in Wow York,and almoet ,`invariably prorent in pat iento euf feriag from routs reepiratory disease. Further than this we oannot go at the present time. Whether during the previous winter, or whether during subsequent winters when no spidemic is present, similar conditions existed or will exist, cannot be stated. However, another survey has just been made, September 1919, and it has been possible to cultivate . influenra bacilli from only 13 per cent of the Institute personnel. This is of some interset but gives us little real information, for it is possi- ble that exaotly the same uonditions may have been present in previous years J namely, that when persons return from their vacations during the period when respiratory lnfeot ions are not prevalent, few persons may be found carrying influenra bacilli, but latttr when these iafeot ions beuoms more common, a larger percentage of persons oarry these organisms. Dr. Btillman and Hiss Winohell also during the past winter made observations concerning the prevalence of influenza bacilli in two institutions near New `fork. At the New York State Training School for Girls at Hudioa, II. Y., influenra prevail&l to a aonsiderable extent during January and early in February. On February 16th oulturss were made from the throats of 52 patients still in the hospital, but uonvaleseent . From these 52 patients in!lusnsa baoilli wers cult&ated from 20, or 38 per oat; Cns of the cottages at this institution had been under clors :t quarantine sinca October 1918 on aoco&t of trachoma. 100 case of lnfluenra had developed in this cottage. Cultures'wsre made from 20 inmates of this cottage and of these 5,`or 25.per sent, showed B. influens~. Cultures were also made from a number of children at Mt. Loretta, a Catholic institution for children on Staten Island. This institution was said tq have been under strict quarantine during the influenra epidemic, but invest igat ion showed that the quarantine had been quite lax. The employees went to town from time to time and the doctor and priest -were frequent visitors to the institution, and the population was more or lass shifting. No definite history was obtained, however, of the occurrence of influsnsa: Cultures were made from 190 of the children, and from 74, or 39 per oent, influenza bacilli were cultivated. The results of all these studies indicate that it will be very difficult by this line of investigation to damonstrats any etiologic relation of influenza baillus to this type of infection, unless It can be shown that influenza baa1111 are not all identical, but that different types or variet lea exist. A study to detsnnine if possible by immunologic methods whether all lnfluenra bacilli are or are not of the same type has been undertaken by Dr. Lyon. He has immunited a considerable number of rabbits to 8. influenrae and now also has a sheep in proosrs of immunisa- t ion. By paying attention to certain faotors,such as salt concentration of the medium, it has been possible to devise a method by which agglutina- t ion reactions of- influenra bacilli oan be readily dietlhguished. Sera have bean obtained which cauue charaoteristio agglutination, but in our experience all races of influenza bacilli agglutinate bqually well. ThiO reaction, however, has not been found to be absolutely epecif ic. This study is o t ill in progress but so far no definite evidence .of dif ferentia- tion of influenra bacilli into types har been obtained. During the studies `of infiuensa bacilli in normal ,,,r throat8 a haemoglobinophilic bacterium has been frequently encountered which differs from B. influenaae in being hemolytic for red blood corpuscles. It la usually slightly larger than B. influenrae but otherwise resembles it very closely. It has been tentatively called B. X. It has not been found under ciroumstances in which it seems to have pathological significance. In summsxiring our studies concerning influenra we may say that considerable knowledge has been obtained concerning the clinical feature8 of the dioeaae and the pneumonia associated with it. The bacteria present have been carefully determined in a series of cases. It has been shown that B. influenzas was almost conatmtly present in casea of the dieease,and during the past winter was very frequently pree- ent in the mouths of normal pereone. Whether this organism bears any etlologic relationship to the disease has not been determined, but this poesibility has not been excluded. Some new knowledge concerning the characteristics of this organism has been obtained. StraDtococcue hacmol;tic~. In view of the severe epidemic of pneumonia during the winter of 1917-18 which was apparently demoaetrated to be due to infec- tion with S. haemolyticus, it seemed most important that the study of thle organism should be continued during the past winter, especially as we were in poseseeion of a very large number of strains collected from cases of pneumonia occurring during the previous epidemic. : 1 This work has been carried on by Dr. Dbchei and Dr. `Avery and has involved a very large `mount of work, and has necessitated . the employment of a larg: number of smaller animals. The work has resulted in the demonstration of certain principles which apply to the development of pathogenicity in organisms belonging to other groups of bacteria,as well as to the bacteria of this group. Ae regards streptococci it has been possible to show that: I. Immunological differences exist between strains of 6. hasmo- lyticue of the human type. II. Four biological typea have been identified by means of the reaction8 of agglutination and protection. III. At least two other types have been encountered and the lndicat iona are that more exist. Yuch of our knowledge concerning the epidemiology of etreptococcus pneumonia has been dbtained by means of throat culturae. `I'he question arosa aa to whether wrong conclusions might not be dravn,owing to the cult ivat ion from the throat of haemolytic streptococci of the bovine type derived from milk and cheeee which had been previously eaten. Dr. Stillman has thoroughly studied this question and has shown that error is not likely to occur from the cultivation of milk streptococci, owing to the alight degree of haemolyeis which these organisma cause when they are grown on the surface of blood agar plates. Cheeee streptococci are mcrs likely to cause confusion, but it has been ehown that by employing proper methods in any case where doubt existe,the origin of the streptococci may be determined without great difficulty. Acute Lobar Pneumonig. _.. .a' .A,, : :, Although during the past two years many more case8 . .,c .: ..' of acute)res~iratcry disease were `treated in the Hospital-than ever before,`,, I . ,.I :' . : : ' : the number of' `caees of typio'al .lobar pneumonia has been &mparativsly small; .I . . All cases of Type I infection have been treated with immune serum and ths results have.continued `to be a! good .ae those previouely reported. This experience has'also been repeated in certain army camps where it was possi- ble to carry out the method prop'erly. Unfortunately this was possible in only a few places owing to the prevalence of the epidemics of streptococcus pneumonia and of influenta. In the autumn of 1918 Dr. Stlllman made a further study of a large number of etrains of so-called atypical type II pneumococci. It rae found that organism8 belonging to certain groups were encountered very frequently in cases of dieeaee and probably are quite pathogenic for man, while other organiome belonging in other groups are frequently prerent In normal mouthr, but are seldom found in Fat iente with pneumonia. Dr. Avery and Dr. Cullen have carried on extenrlve rtudler with pneumococci, to determine the final hydrogen ion concentration of pneumococcus aulturee and also the optimum hydrogen ion' concentration for growth of these organieme. The reeulte obtained have a practical bearing on the best methods for cultivating these bacteria,as well as on * the more ready and certain identification of them. Dr. Barber haa rtudied further the question of so-called antiblaetic immunity, employing for this problem the method which he har devised for isolating and cultivating single bacterial cells. He hae not been able to demonstrate that anti-pneumococcus eerum has any power to inhibit the growth of theee organlame, either in artificial culture medium or in th& body of the animal. , We are c.ompelled therefore to believe that the'action of the serum is chiefly dependent upon some activity of the . protected animal, jrobabiy in part at least upon phagocytoeis. Dr. `Barber'8 1 rtudy, which was carried out with great care and attention to detail, is of much theoretical importance. . Treatment of Sn;hilis with A 189. The study of the therapeutic effect of the drug A 189 was commenced in January 1918 and continued until January 1919. he the toxic doee for man was entirely unknown the work had to proceed at firet with great care in order that no harm might be done. Varioue mode8 of adminietration had to be tried out in order to learn the moet effective one. Without going Into details, it may be eaid that it was demonrtrated that thie drug 18 effective in curing syphilis. It wae decided from our rtudier that probably the most effective'mathod of trsatuent would consist in the administration of 7 mg. of the drug per kilogram body weight every ten daye, combined with treatment with mercury, If the drug were given in larger dose8 or more frequently, toxic sffecte might re8ult; If Bmaller dose8 were employed,the therapeutic reeulte were not eatisfactory. Having obtained thie information, it reamed advisable to.discontinue the rtudiee here and have the drug tested on a larger ecale elrewher8. Chemical Laborat orx. During the early part of the year research actlv- . . itie in the chemical' laboratory were very greatly diminished' &ng to Dr. Van Slyke'e &lneer and" the employment. of Dr.' &llrn `in the War Demon- ; ._ `. st&ion IzGrpitdl., . . .-The laboraky ip& and equipment `&re iargeip `. ,I . . .`, ; t:,, : Sinoe the oignikg of the `aifnistioe and the,,retu+n .' ,, `.$_ `. `$3,`# .,., `";".2. .L ..*. `,"`) : . . i- : .-: ,* -.;,, *' <..-: I,? .:;". -4 ,I A,. ;, ^ I.> `, I`,".;: of Dr. Van Slyke &d Dr."&ll&, `ihe laboiatory has been g&dually. reor- : ,,q ' \,. I .4 a;` F ganised and new problame have been under&ken., . ., . . .> :.a , In spite of all the diff ioult lee and dieorianization during the war; a considerable number of . . studies were made and resulta of importance obtained. A brief survey of.thie work followe: a Dr. Van Slyke,with the assistance of Lt. Donleavy, ha8 devised an improved method for estimation of blood chlorides. He hae also devised a method for titration of the organ10 acids in ths urine. With Dr. Stillman and Dr. Cullen he has improved the method for determining . planma bicarbonates. Mirr Hiller ha8 continued her work .ar8i8ting Dr. Van Slyks in tha rtudy of proteinr. she hu brought about oertain improvement8 in the methods employed in the hydrolysis of protsinr and har besn rtudying a new method for the dStSnniD&tiOn of hlrt idine. Dr. Stedie, in connection with the study of A 189, har invertigated the quertion of the dirtribution of arsenic in the body after intravsnous in)ectian of A 189, and ths mode and rats of it8 excrs- tion. ' Dr. Salvssen, of Chrirtiania, who since April has worked in the laboratory a8 a voluntary aerietant, ha8 devised an improved method for measuring the oarbon dioxide content of the blood. This work is an eXtOn8iOn of the study of methods for estimation of blood gases so suaoerrfully undertaken by Dr. Van slyks. The porseo8lon of an accurate s and simple method for detsrnining carbon monoxide has permitted a further development of the Ealdane method for determining blood iolume. In measured amount of aarbon aonoride,and thi iMo& pro&t- per oa. of .blodd ir then determined. and in man, and with the. improvements in technique which he has devised, the method seema both reliable and oomparativoly simple. CvanO8iS in Pneumonia. Dr. Stadie ha8 demonstrated that the wfthdrawal _ -~.- . .._ of emall amounts of arterial . ,od from man La perfectly safe and ham- \ less procedure, and for the f iret time detetiinatione of the blood garer in arterial blood in a reriee of patients have been made. These studies have led to much increase in knowledge concerning cyanosis, about which there had been a great deal of differsncs of opinion. It has now been demonstrated that cyanosis in pneumonia Is due to incomplete oxygenation of arterial blood and that a low oxygen saturation is of bad prognostic importance. This m&hod har already been applied by others to the study of cyanosis in heart disease and it is planned to extend the inve'rtigation along this line here during the coming year. Dr. Stadie has also devised a gasometric method for the determination of methaemoglobin. This will pern;it a more accurate study of the qusetlon of methaemoglobin format ion in vivo and in vitro by pneumococcl. Circulator-v Dlrturbancee. Dr; *Cohn was absent with the knerickn Expedition- * ary Forces until February. Since hie return he has made ad extensive rtudy of the #ire and functional capacity of the heart in 2CO returned moldlore. Hs ir alro engaged with Dr. Peabody in writing a ,Nook concera- i ing the cardiac disability whish occurs QO often In soldiers,' and concerning: which he haa had except ional opportunity to gain info&at ion, . . Dr. Iky has been studying, both in a@mals and in man ,the mode'-of action and doeage of rtrophanthin. It is` hoped that this inforaation will permit a much more accurats and rational therapy with this drug of the digitalis series.