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Advances in Experimental Medicine and Biology 1039
Neuroscience and Respiration
Mieczyslaw Pokorski Editor
Current Concepts
in Medical
Research and
Practice
Advances in Experimental Medicine
and Biology
Neuroscience and Respiration
Volume 1039
Subseries Editor
Mieczyslaw Pokorski
More information about this series at http://www.springer.com/series/13457
Mieczyslaw Pokorski
Editor
Current Concepts in
Medical Research and
Practice
Editor
Mieczyslaw Pokorski
Opole Medical School
Opole, Poland
ISSN 0065-2598 ISSN 2214-8019 (electronic)

Advances in Experimental Medicine and Biology
ISBN 978-3-319-74149-9 ISBN 978-3-319-74150-5 (eBook)
https://doi.org/10.1007/978-3-319-74150-5
Library of Congress Control Number: 2017964515
# Springer International Publishing AG 2018

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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Preface
The book series Neuroscience and Respiration presents contributions by

expert researchers and clinicians in the multidisciplinary areas of medical
research and clinical practice. Particular attention is focused on pulmonary
disorders as the respiratory tract is up front at the first line of defense for
organisms against pathogens and environmental or other sources of toxic or
disease-causing effects. The articles provide timely overviews of contentious
issues or recent advances in the diagnosis, classification, and treatment of the
entire range of diseases and disorders, both acute and chronic. The texts are
thought as a merger of basic and clinical research dealing with biomedicine
at both the molecular and functional levels and with the interactive relation-
ship between respiration and other neurobiological systems, such as cardio-
vascular function, immunogenicity, endocrinology and humoral regulation,
and the mind-to-body connection. The authors focus on modern diagnostic
techniques and leading-edge therapeutic concepts, methodologies, and inno-
vative treatments in both adults and children. Practical, data-driven options to
manage patients are considered.
Body functions, including lung ventilation and its regulation, are ulti-
mately driven by the brain. However, neuropsychological aspects of
disorders are still mostly a matter of conjecture. After decades of misunder-
standing and neglect, emotions have been rediscovered as a powerful modi-
fier or even the probable cause of various somatic disorders. Today, the link
between stress and health is undeniable. Scientists accept a powerful psy-
chological connection that can directly affect our quality of life and health
span. Psychological approaches, which can decrease stress, can play a major
role in disease therapy.
Disorders related to gene polymorphism and epigenesis, involving both
heritable and non-heritable but functionally relevant changes in the nucleo-
tide sequence of the genome are also tackled.
Clinical advances stemming from molecular and biochemical research are
but possible if research findings are translated into diagnostic tools, thera-
peutic procedures, and education, effectively reaching physicians and
patients. All this cannot be achieved without a multidisciplinary, collabora-
tive, bench-to-bedside approach involving both researchers and clinicians.
The role of science in shaping medical knowledge and transforming it into
practical care is undeniable.
v
vi Preface
Concerning respiratory disorders, their societal and economic burden has

been on the rise worldwide, leading to disabilities and shortening of life-span.
Chronic obstructive pulmonary disease (COPD) alone causes more than three
million deaths globally each year.
Concerted efforts are required to improve this situation, and part of those
efforts are gaining insights into the underlying mechanisms of disease and
staying abreast with the latest developments in diagnosis and treatment
regimens. It is hoped that the articles published in this series will assume a
leading position as a source of information on interdisciplinary medical
research advancements, addressing the needs of medical professionals and
allied health-care workers, and become a source of reference and inspiration
for future research ideas.
I would like to express my deep gratitude to Paul Roos, Tanja Koppejan,
and Cynthia Kroonen of Springer Nature NL for their genuine interest in
making this scientific endeavor come through and in the expert management
of the production of this novel book series.
Mieczyslaw Pokorski
Contents
Electronic Cigarettes and Awareness of Their Health Effects . . 1

A. Daniluk, A. Gawlikowska-Sroka, M. Ste˛pien-Słodkowska,
E. Dzie˛ciołowska-Baran, and K. Michnik
Metachronous Lung Cancer: Clinical Characteristics
and Effects of Surgical Treatment . . . . . . . . . . . . . . . . . . . . . . . 9
Adam Rzechonek, Piotr Błasiak, Beata Muszczyńska-Bernhard,
Konrad Pawełczyk, Grzegorz Pniewski, Maciej Ornat,
Je˛drzej Grzegrzółka, and Anna Brzecka
Healthcare Professionals’ Knowledge of Influenza and Influenza
Vaccination: Results of a National Survey in Poland . . . . . . . . . 19
Ernest Kuchar, Kamila Ludwikowska, Adam Antczak,
and Aneta Nitsch-Osuch
Benign Acute Childhood Myositis During Influenza
B Outbreak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
L. Szenborn, K. Toczek-Kubicka, J. Zaryczański,
M. Marchewka-Kowalik, K. Miśkiewicz, and E. Kuchar
Serum Diamine Oxidase in Pseudoallergy in the Pediatric
Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Joanna Kacik, Barbara Wróblewska, Sławomir Lewicki,
Robert Zdanowski, and Bolesław Kalicki
Spontaneous Elimination of Hepatitis C Virus Infection . . . . . . 45
Maciej Janiak, Kamila Caraballo Cortes, Urszula Demkow,
and Marek Radkowski
Clinical Manifestations of Huge Diaphragmatic Hernias . . . . . . 55
Jan Lesiński, Tadeusz M. Zielonka, Aleksandra Kaszyńska,
Olga Wajtryt, Krystyna Peplińska, Katarzyna Życińska,
and Kazimierz A. Wardyn
The Diagnostics of Human Steroid Hormone Disorders . . . . . . . 67
Małgorzata Dobosz, Aneta Manda-Handzlik, Beata Pyrżak,
and Urszula Demkow
vii
viii Contents
Discriminant Analysis of Intracranial Volumetric Variables

in Patients with Normal Pressure Hydrocephalus and Brain
Atrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Leszek Czerwosz, Ewa Szczepek, Krzysztof Nowiński,
Beata Sokołowska, Jerzy Jurkiewicz, Zbigniew Czernicki,
and Waldemar Koszewski
Hoffa’s Fat Pad Abnormality in the Development of Knee
Osteoarthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Wojciech Paduszyński, Mateusz Jeśkiewicz, Paweł Uchański,
Sebastian Gackowski, Marek Radkowski, and Urszula Demkow
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Advs Exp. Medicine, Biology - Neuroscience and Respiration (2017) 36: 1–8
DOI 10.1007/5584_2017_83
Published online: 12 August 2017
Electronic Cigarettes and Awareness

of Their Health Effects
A. Daniluk, A. Gawlikowska-Sroka, M. Ste˛pien-Słodkowska,

E. Dzie˛ciołowska-Baran, and K. Michnik
Abstract
The use of electronic cigarettes or e-cigarettes is strongly on the rise. The
literature confirms that in the process of quitting smoking using an
electronic device dispensing nicotine should be a transitional stage before
the complete cessation of smoking. The aim of the present study was to
assess the popularity of e-cigarettes, the underlying reasons for use of such
nicotine products, and the level of awareness of health hazards associated
with e-cigarettes. The study is of a survey type. The material consisted of
data collected from an anonymous survey distributed among 46 female
and 23 male users of e-cigarettes in 2015. We used a questionnaire of our
own design. The findings demonstrate that the main reason for a recourse
to e-cigarettes is a desire to use fashionable technological innovations, and
the conviction that such cigarettes are less harmful than the traditional
tobacco products. Some respondents used e-cigarettes to quit smoking;
others to minimize the harmful effects of smoking. Most respondents
acquired information about e-cigarettes from friends or from the Internet.
There was a high awareness of the chemical composition of substances
contained in e-cigarettes. An interest in e-cigarettes is caused by an
increased knowledge on the negative effects of traditional smoking.
Currently, the e-cigarettes remains a technological novelty, so that the
exact health effects of their long-term use are open to conjecture.
A. Daniluk and M. Ste˛pien-Słodkowska

Faculty of Physical Culture and Health Promotion,
University of Szczecin, Szczecin, Poland
A. Gawlikowska-Sroka (*) and E. Dzie˛ciołowska-Baran
Department of Anatomy, Pomeranian Medical
University, 72 Powstańców Wielkopolskich Street,
70-111 Szczecin, Poland K. Michnik
e-mail: [email protected] School of European Integration, Szczecin, Poland
1
2 A. Daniluk et al.
Keywords
Addiction • E-cigarettes • Health effect • Smoking cessation • Survey •
Tobacco smoking
1 Introduction criticism is expressed concerning that belief. In

Australia, Brazil, and Finland the sale of
The electronic cigarette or e-cigarette was e-cigarettes is prohibited. In Latvia, e-cigarettes
invented by Hon Lik, a Chinese pharmacist, in may only be purchased by consumers aged 18 or
2003 (Kośmider et al. 2012). Within the last older. In Hong Kong, regulations on e-cigarettes
several years the interest of consumers in this are the most restrictive because these products
product has appreciably increased. Currently, cannot be legally purchased or possessed. How-
e-cigarettes are widely available worldwide. It ever, in New Zealand, Malaysia, or Austria
has been estimated that over one billion people e-cigarettes have a status of a medical device
smoke traditional tobacco cigarettes, mainly in and are sold by prescription only. The UK and
developing countries. The introduction of Germany have not established any specific
e-cigarettes on the global scale decreased the regulations in this respect. In Poland, an act
sale of classic tobacco cigarettes. In Poland, a amending the law on the protection of public
steady, albeit slow, decline in the number of health against the effects of tobacco use was
smokers has been observed since 1997, before adopted on 22 July 2016. According to the cur-
the era of e-cigarettes. Currently, ca 29% of the rently existing law, e-cigarettes can only be pur-
entire population smoke cigarettes and the inter- chased by people aged 18 or older. Akin to
est in e-cigarettes is sharply on the rise traditional tobacco products, the use of
(Królikowski and Domagała-Kulawik 2014). In e-cigarettes in public places and the advertising
Europe and the US, it has been estimated that of such cigarettes is prohibited. The Polish law
about 10 m people use this a nicotine delivery has also introduced a ban on the on-line sales of
system. Initially, e-cigarettes were sold and most tobacco-related accessories, as well as
advertised mainly via the Internet, but over some restrictions regarding conventional sales
time specialist shops offering these products in shops.
have cropped up, particularly in popular shop- The e-cigarette is a device that is used for the
ping malls. The most recent studies have delivery of nicotine via the inhalation route. The
indicated that the majority of marketing activities device heats the e-liquid and transforms it into
rely on emphasizing the financial aspects of vapor. E-liquids used in e-cigarettes are either
using e-cigarettes as a less expensive tobacco synthetic or natural. E-liquid usually contains
replacement product, compared with trade mark polypropylene glycol, vegetable glycerine, flavor
medications, and the health-related benefits of and its carriers, nicotine, preservatives, making
these devices, such as the lack of carcinogenic up 95% of it, and some other additives account-
tar, and an aid in quitting smoking traditional ing for the remaining 5%. Some e-liquids also
cigarettes (Zarobkiewicz et al. 2016). A growing contain colorants that do not interfere with the
interest in e-cigarettes results from their ready process of combustion. Most studies published to
availability and the lack of uniform legislation date have indicated a low toxicity of the
in this area, which varies from country to country substances above outlined (Golli et al. 2016).
(Sanders-Jackson et al. 2016). Initially, there was E-liquid does not contain carcinogens such as
a belief that e-cigarettes are not tobacco products benzene or toluene, but recent studies underscore
because they do not contain tobacco but just the probably presence of other highly harmful
nicotine obtained from tobacco. Currently, substances such as formaldehyde. Smokers
Electronic Cigarettes and Awareness of Their Health Effects 3
often look for e-cigarettes having a pleasant fra- Table 1 Demographic characteristics of the study
grance, which counters some unpleasant side population
effects of smoking tobacco cigarettes, such as Age-group (year) Gender (Femal/Male; n)
smelly breath or stinky clothes. Users of < 18 1/0
e-cigarettes often report an improvement in 18–20 1/1
smoking-related symptoms such as shortness of 21–30 26/12
31–40 9/5
breath and cough, and point to having a better
41–50 4/2
chance of fighting the habit of smoking tradi-
51–60 3/3
tional cigarettes (Królikowski and Domagała-
> 60 2/0
Kulawik 2014). The e-cigarette is still a relative Education (n ¼ 69) (n)
novelty on the health-related market, so that the Primary school 2
long-term effects of using these devices are Vocational 4
mostly unsettled and are subject to intense High school 32
research. The present study seeks to define the University 31
level of e-cigarettes use in the general Polish
population, the motivations behind the switch
from smoking traditional cigarettes to Most of them indicated friends (62%); others
e-cigarettes, and the level of awareness of indicated the Internet (19%), television and press
e-cigarette smokers concerning the potential (6%). The majority of respondents (61%) stated
health risks. We addressed this issue across vari- that e-cigarettes were a better choice than tobacco
ous age-groups of smokers in a survey-type cigarettes. Eighty-seven percent smoked tobacco
study. cigarettes for 1 year up to 40 years before using
e-cigarettes. Sixty-one percent of respondents
had tried to quit smoking before using
2 Methods e-cigarettes. Sixty-one percent of respondents
smoked tobacco cigarettes but at the same time
The study material consisted of data collected they used innovative products with nicotine
from an anonymous questionnaire-based diag- e-liquids. Most respondents found e-cigarettes as
nostic survey. The questionnaire was of our fashionable and less harmful to health (Fig. 1). The
own design and it was designed according to respondents differed concerning the awareness
the principles described in relevant publications about health risks associated with the use of
(Babbie 2009). Data were collected from e-cigarettes. The opinion of the majority was that
69 respondents. The surveyed group comprised these devices were less harmful to health compared
46 women (67%) and 23 men (33%). The demo- to tobacco cigarettes (Fig. 2).
graphic characteristics of respondents are Many of the respondents, however, despite
presented in Table 1. The questionnaire was their being regular users of the devices, were
completed either on-line (9 individuals) or in unfamiliar with the exact chemical composition
person by customers shopping for e-cigarettes of e-liquids they inhaled in the vaporized form.
at stalls specializing in selling them, usually They used e-liquids containing from 6 to 18 mg
present in shopping malls (60 individuals). Data of nicotine per ml of fluid, although there are
were statistically elaborated with the help of a e-liquids containing higher concentrations of nic-
MS Excel spread sheet. otine available on the market. They used from
one to six containers of e-liquid per month, each
of 10 to 30 ml volume. Most of them declared the
3 Results financial savings they made through owing to the
use of e-cigarettes instead of tobacco cigarettes,
Respondents participating in the survey were asked ranging from about 15 to 100 euros per months.
about their source of knowledge on e-cigarettes. Respondents who completed questionnaires gave
4 A. Daniluk et al.
%
40
35
30
25
20
15
10
0
Less health Reduced negative Lower price than Fashionable Others
harm effects of smoking that for tobacco novelty
perceived by others cigarettes
Fig. 1 Rationale for using e-cigarettes
Fig. 2 Knowledge of %
respondents on health risks
45
associated with the use of
e-cigarettes
40
35
30
25
20
15
10
0
Safe for health Less harmful than As harmful as More harmful than
tobacco cigarettes tobacco cigarettes tobacco cigarettes
various reasons for the ban of smoking and cultural issues were rarely raised by the
e-cigarettes in public places. The majority of respondents as a reason to ban the e-cigarettes
them indicated the harmfulness of e-cigarettes (Fig. 3). The majority of the respondent also
as being comparable to that of passive smoking conceded that they knew the reasons why
of tobacco cigarettes. Psychological, esthetic, e-cigarettes should be banned (Fig. 4).
Fig. 3 Knowledge of %
respondents on the health 100
and otherwise effects of
chemical composition of 90
e-liquids in e-cigarettes 80
70
60
50
40
30
20
10
0
Harmful to Bad example Esthetic & cultural
non-smokers for others aspects
(Aiche and Frishman 2016; Chatham-Stephens

% et al. 2016; Payne et al. 2016; Volesky et al.
70 2016). In Poland, until July 2016, when the law
restricting the sales and use of e-cigarettes was
60
introduced, these products had been praised as an
50 alternative to tobacco cigarettes that can be
legally used in public places. The strong interest
40 is due also to a general increase in the social
knowledge and awareness about the negative
30
effects of tobacco smoking. Heavy smokers are
20 looking for a way to quit smoking, as well as for
replacement products regarded by society as less
10 harmful. A reduction in symptoms such as
coughing and shortness of breath after the switch
0 from tobacco cigarettes to e-cigarettes causes an
Harmful to Esthetic & cultural
non-smokers aspects increasing interest in this form of nicotine deliv-
ery (Królikowski and Kulawik 2014). The use of
Fig. 4 Respondents’ subjective knowledge of reasons for
e-cigarettes is also stimulated by current fashion.
banning the use of e-cigarettes
The literature still does not provide conclusive
data explaining whether this electronic nicotine
4 Discussion delivery system is a better, healthier alternative
to tobacco cigarettes (WHO 2009). It is possible
In recent years, a growing interest in e-cigarettes that future e-cigarettes will become a recognized
in both Poland and other countries has been aid in the fight against addiction. Smoking
observed (Zarobkiewicz et al. 2016; Rostron tobacco cigarettes, due to the presence of many
et al. 2016), which can be attributed to very harmful substances, leads to progressive physical
effective marketing campaigns. E-cigarettes are damage manifested in pathological changes to
advertised as a healthier option than tobacco organs and systems. Users of e-cigarettes do not
cigarettes, cheaper, very easy to handle, and a inhale carbon monoxide that reduces the level of
very effective way to quit tobacco smoking oxygen in the blood, tar, or other chemicals
6 A. Daniluk et al.
released during tobacco combustion. They do child and can negatively affect the development
inhale, however, other possibly toxic chemical of the circulatory system. It also leads to a rapid
substances contained in the e-liquid. increase in blood glucose level, which can result
Manufacturers of the e-liquids which are used in pancreatic disorders and the development of
in e-cigarettes claim that their products are effec- diabetes mellitus. A healthy body is usually able
tive in quitting tobacco smoking, and are much to cope with such fluctuations, unlike the body of
safer for health. Studies that have so far been the developing child (Chivers et al. 2016;
conducted show large differences in reported Holbrook 2016). The currently observed level
results. For example, some researchers have of dependence on e-cigarettes is much lower
found e-cigarettes to be safe products, but others than that of tobacco cigarettes. This is attributed,
show that e-cigarettes can be harmful to health among other things, to the different rates at
and even carcinogenic because e-liquids, apart which nicotine is released into the bloodstream.
from nicotine, contain other chemicals that are Nicotine from traditional cigarettes penetrates
heated to a temperature of 200 C. For instance, into the bloodstream in less than 5 min. The
vaporized e-liquid contains traces of carcino- penetration time for nicotine from e-cigarettes
genic formaldehyde and acrolein (Golli et al. is longer than that, but still shorter compared to
2016). Little is known about the chemicals chewing gum containing nicotine, which is about
contained in e-liquids. Certainly, the symptoms 25 min. Substances contained in the vapor pro-
of nicotine dependence are also observed in users duced by e-cigarettes include nicotine at varying
of e-cigarettes, although they are less pro- concentrations, which is an addictive psychoac-
nounced than in tobacco smokers (Rostron et al. tive substance. Therefore, e-cigarettes are also
2016). addictive, but it is widely believed that the level
Nicotine contained in e-liquids affects the of this dependence is low (Kaisar et al. 2016;
sympathetic nervous system by increasing Sanders-Jackson et al. 2016).
blood pressure, accelerating heart rate, and The emergence of a new product replacing
increasing oxygen consumption by the myocar- tobacco cigarettes has stimulated many different
dium. This may also contribute to the narrowing opinions regarding their positive or negative
of coronary arteries, and consequently reduce impact on the body of dependent users. Research
blood flow (Bandiera et al. 2016). Unfortunately, carried out to date does not allow for a conclusive
information about the toxicity of the vapor cre- assessment of the effects caused by the long-term
ated in e-cigarettes is still inconclusive. The lack use of e-cigarettes. Until this year, such a situa-
of standardized studies in this area makes it diffi- tion was facilitated by the lack of legislative
cult, even impossible, to compare products from solutions limiting the access of underage persons
different manufacturers in terms of their effects to such nicotine delivery devices. The results
on health (Orr 2014). Some manufacturers also obtained in the present study revealed a great
offer nicotine-free e-liquids. Nevertheless, popularity of e-cigarettes among residents of
chemicals contained in these fluids penetrate to the city of Szczecin in Poland. Respondents
the human body (Holbrook 2016; Li et al. 2016). participating in the survey acquired information
During pregnancy, smoking e-cigarettes is as about these devices mostly from friends, who
dangerous as smoking tobacco, since fetal cells themselves have probably used such products.
are very sensitive to any external factors (Chivers Their knowledge also came from the Internet,
et al. 2016). It cannot be claimed with absolute television, and newspapers. The majority of
certainty that e-cigarettes have a negative influ- respondents argued, in line with numerous but
ence on the development of a baby in the mostly non-scientific sources, that the e-cigarette
mother’s womb. However, a pregnant woman it is a better choice than the tobacco cigarette.
should be aware that everything that enters her Respondents reached for these products after a
body accumulates in the fetal body. The intake of period of addiction that ranged from 1 to
nicotine can cause endocrine disorders in the 40 years. Most of them had made unsuccessful
attempts to quit smoking before they started systems to satisfy the needs of a nicotine-
using e-cigarettes. Many respondents continued dependent body.
to smoke tobacco cigarettes but also vaped nico-
tine. Some smokers indicated a current fad as a Conflicts of Interest The authors declare no conflict of
reason for inhaling the chemical substances interest in relation to this article.
contained in e-liquids. Respondents differed in
terms of awareness about the health-related risks
associated with the use of e-cigarettes. Most of References
them argued that these products are less harmful
Aiche BO, Frishman WH (2016) E-cigarettes: questions
to health compared to tobacco cigarettes. Many
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people, despite the regular use of novel Babbie E (2009) Basis for socio-research. PWN, Warsaw,
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Associations between tobacco and nicotine product
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use and depressive symptoms among college students
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(2014) has revealed that as many as 96% of Sarin S (2016) Reasons for trying e-cigarettes and risk
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respondents start using e-cigarettes due to their
2016-0895
lower cost compared to tobacco cigarettes. A Chatham-Stephens K, Law R, Taylor E, Kieszak S,
very alarming fact has been reported by Bold Melstrom P, Bunnell R, Wang B, Day H,
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e-cigarettes are strongly predisposed to become
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2016). That points to the need of developing E-cigarette use among women of reproductive age:
impulsivity, cigarette smoking status, and other risk
prevention campaigns and legislation aimed at
factors. Prev Med 92:126–134
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(Bold et al. 2016; Richter et al. 2016). Poland Neurobehavioral assessment following e-cigarette
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Methods 26(6):435–442
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Hammig B, Daniel-Dobbs P, Blunt-Vinti H (2016) Elec-
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Metachronous Lung Cancer: Clinical

Characteristics and Effects of Surgical
Treatment
Adam Rzechonek, Piotr Błasiak, Beata Muszczyńska-Bernhard,

Konrad Pawełczyk, Grzegorz Pniewski, Maciej Ornat,
Je˛drzej Grzegrzółka, and Anna Brzecka
Abstract
The occurrence of a second lung tumor after surgical removal of lung
cancer usually indicates a lung cancer metastasis, but sometimes a new
lesion proves to be a new primary lung cancer, i.e., metachronous lung
cancer. The goal of the present study was to conduct a clinical evaluation
of patients with metachronous lung cancer and lung cancer metastasis, and
to compare the early and distant outcomes of surgical treatment in both
cancer types. There were 26 age-matched patients with lung cancer
metastases and 23 patients with metachronous lung cancers, who
underwent a second lung cancer resection. We evaluated the histological
type of a resected cancer, the extent of thoracosurgery, the frequency of
early postoperative complications, and the probability of 5-year survival
after the second operation. The findings were that metachronous lung
cancer was adenocarcinoma in 52% of patients, with a different
histopathological pattern from that of the primary lung cancer in 74% of
patients. In both cancer groups, mechanical resections were the most
common surgery type (76% of all cases), with anatomical resections
such as segmentectomy, lobectomy, or pneumectomy being much rarer
A. Rzechonek (*), P. Błasiak, and K. Pawełczyk

Thoracic Surgery Clinic, Wroclaw Medical University,
105 Grabiszynska Street, 53-439 Wroclaw, Poland
e-mail: [email protected]
B. Muszczyńska-Bernhard M. Ornat and J. Grzegrzółka
Department of Pathomorphology, Lower Silesian Center Department of Histology and Embryology, Wroclaw
for Lung Diseases, 105 Grabiszynska Street, 53-439 Medical University, 6A Chałubińskiego Street, 50-368
Wrocław, Poland Wrocław, Poland
G. Pniewski A. Brzecka
Department of Thoracic Surgery, Lower Silesian Center Chair and Clinic of Pulmonology and Lung Cancer,
for Lung Diseases, 105 Grabiszynska Street, 53-439 Wroclaw Medical University, 105 Grabiszynska Street,
Wrocław, Poland 53-439 Wrocław, Poland
9
10 A. Rzechonek et al.
conducted. The incidence of early postoperative complications in

metachronous lung cancer and lung cancer metastasis (30% vs. 31%,
respectively) and the probability of 5-year survival after resection of
either cancer tumor (60.7% vs. 50.9%, respectively) were comparable.
In conclusion, patients undergoing primary lung cancer surgery require a
long-term follow-up due to the risk of metastatic or metachronous lung
cancer. The likelihood of metachronous lung cancer and pulmonary lung
cancer metastases, the incidence of postoperative complications, and the
probability of 5-year survival after resection of metachronous lung cancer
or lung cancer metastasis are similar.
Keywords
Histopathology • Lung cancer • Metachronous cancer • Metastasis • Non-
small cell lung cancer • Survival • Thoracic surgery • Tumor
1 Introduction case of lung cancer metastasis, followed only by

sampling of potentially affected lymph nodes
The appearance of another neoplastic focus after (Sihag and Muniappan 2016). In general, resec-
resection of non-small cell lung cancer (NSCLC) tion of a second pulmonary neoplasm,
is an important clinical problem and requires a irrespective of its histopathological origin,
differentiation between lung cancer metastases presents an enhanced risk of postoperative
and a second primary lung cancer, i.e., complications and may worsen the long-term
metachronous lung cancer. The classic diagnos- outcome.
tic criteria, based on clinical and histological The goal of the present study was to conduct
data, enabling the distinguishing between the a clinical evaluation of patients with
lung cancer metastasis and metachronous lung metachronous lung cancer and with lung cancer
cancer have been established by Martini and metastasis, and to compare the early and distant
Melamed (1975) and are so far used in practice. outcomes of surgical treatment in both lung
Metachronous lung cancer most often has a dif- cancer entities.
ferent histological structure than primary lung
cancer or, in case of a similar structure,
metachronous lung cancer diagnostic criteria
include the occurrence at least 2 years following 2 Methods
primary lung cancer, in situ development, locali-
zation in another lobe, lack of the same path of The study was approved by the Ethics Commit-
spreading, i.e., no tumor lesions in lymph nodes, tee of Wroclaw Medical University in Poland
and no other extrapulmonary metastases. and it was conducted in accord with the
Surgical treatment differs in scope in lung principles of the Declaration of Helsinki for
cancer metastasis and metachronous lung cancer. Human Research of the World Medical Associa-
In case of primary or metachronous lung cancer, tion. The research material for the study
anatomic resection with removal of three layers consisted of 49 thoracosurgical patients, a ran-
of lymph nodes of the pulmonary hilum and dom sample chosen from 6162 patients suffering
mediastinum is necessary (Gamliel 2016; from primary lung cancer metastasis or a second
Maniwa and Kodama 2016; Riquet et al. 2016; metachronous lung cancer, operated on in the
Hytych et al. 2013; Asamura et al. 1999; Riquet years 2001–2015 in the Lower Silesian Center
et al. 1994; Naruke et al. 1988). On the other of Lung Diseases in the city of Wroclaw, Poland.
hand, wedge resection is most often employed in There were 26 patients (53%) with lung cancer
Metachronous Lung Cancer: Clinical Characteristics and Effects of Surgical Treatment 11
metastases and 23 patients (47%) with endobronchial ultrasonography (EBUS) control.

metachronous lung cancers. Gender and age of Surgical treatment was abandoned in case of
patients, and the stage of lung cancer were simi- mediastinal lymph node or remote metastases.
lar in both groups. Adenocarcinoma was the most The surgical procedures employed are listed
common cancer type in both groups. A few more in Table 2. In both groups, mechanical wedge,
patients with lung cancer metastasis had more tangent, and laser resections were the most com-
than one metastasis. The detailed figures are mon – in 76% of all cases. Anatomical resections
given in Table 1. consisting of segmentectomy or lobectomy were
Diagnostic tests performed in all patients prior rarer – in 16% of all cases, and pneumectomy
to surgery included the following: bronchofi- was conducted only in individual cases. The
beroscopy, chest X-ray, thoracic computed examples are illustrated in Figs. 1 and 2. The
tomography, and abdominal ultrasonography. resection failed to be radical in two patients
Since 2007, also positron emission tomography treated for lung cancer metastasis.
(PET) was performed. Mediastinoscopy was Lymphadenectomy was performed with similar
performed in case of the possible involvement frequency in both groups of patients; in 43%
of mediastinal lymph nodes, i.e., their enlarge- cases in total (Table 2).
ment of more than 10 mm or grouping into Continuous data were presented as means
packages seen in the imaging scans. Since SD or medians, as indicated, and discrete data
2008, mediastinoscopy was replaced with the as counts and percentages. The Mann-Whitney U
needle biopsy of mediastinal nodes under the was used to assess differences between the two
Table 1 Demographics, histological diagnosis, stage, and the number of primary tumors in patients operated on due to
primary lung cancer metastasis (LCM) and metachronous lung cancer (MLC)
LCM (n ¼ 26) MLC (n ¼ 23)a
Age (year) 66.4 4.9 66.5 5.1
Range (year) 50–77 54–79
Men 16 (62%) 15 (65%)
Women 10 (38%) 8 (35%)
Adenocarcinoma 15 (58%) 12 (52%)
Squamous cell carcinoma 9 (35%) 6 (26%)
Other histological types 2 (8%) 5 (22%)
Stage I 16 (62%) 17 (74%)
Stage II 4 (15%) 3 (13%)
Stage III 3 (11.5%) 2 (9%)
Missing data on staging 3 (11.5%) 1 (4%)
T1 12 14
T2 10 8
T3 1 0
T4 1 1
Tx 2 0
N0 19 18
N1 2 2
N2 2 2
Missing data on N 3 3
1 tumor 20 (77%) 20 (87%)
2 tumors 6 (23%) 2 (9%)
Missing data on number of tumors 0 1
Cancer staging was performed according to Edge and Compton (2010)
a
All differences between MLC and LCM patients failed the test of significance at p < 0.05
Table 2 Surgical treatment in patients with primary lung cancer metastases (LCM) and metachronous lung cancer
(MLC)
LCM (n ¼ 26) MLC (n ¼ 23) p
Surgery type
Mechanical resection 18 (69%)a 19 (83%) ns
Segmentectomy 3 (11%) 1 (4%) ns
Lobectomy 2 (8%) 2 (9%) ns
Pneumectomy 1 (4%) 1 (4%) ns
Non-radical resection 2 (8%) 0 (0 %) ns
Surgery side
Right-sided surgery 10 (38%) 16 (70%)b 0.03
Left-sided surgery 16 (62%) 7 (30%)b 0.03
Lymph node N1 or N2 surgery
Resected 10 (38%) 11 (48%) ns
Non-resected 16 (62%) 12 (52%) ns
a
including one mechanical resection combined with radical segmental resection of a rib
b
significant difference between LCM and MCL groups, ns, non-significant difference
Fig. 1 (a) Wedge resection of tumor (green arrow) with 14, 13, and sometimes 12; (b) resected tumor tissue
a margin of lung parenchyma (yellow arrow). In the (green arrow), with a margin of lung parenchyma (yellow
resection area there usually are the lymph nodes of groups arrow)
Fig. 2 (a) Anatomical resection: postoperative loge with groups 11, 10, and the mediastinal nodes of group 7 (b)
Satynski clamp (yellow star) closing the bronchus stump Resected lung lobe with cancer foci (green arrow);
is seen in the left-hand part of the photograph. Anatomical atelectatic neighboring lung parenchyma (yellow arrow)
resection usually involves removal of the lymph nodes of
independent groups of patients and the different cellular organization of cancer tissue,
Chi-squared test to compare features between compared with primary lung cancer, in
the groups such as histopathological changes, 17 patients (77%). In the remaining six patients
cancer stages, and surgical treatments. The metachronous cancer was histologically the same
Kaplan-Meier estimator was used to assess the as the primary tumor. However, since the
probability of patient survival, and the difference metachronous cancer appeared after more than
between the two survival curves was assessed 2 years from the detection and surgery of the
with the Mantel-Cox test. A Cox regression anal- primary tumor, it was considered metachronous.
ysis also was performed to determine the differ- The detailed data are presented in Table 3.
ence in patient survival with respect to clinical The median time elapsing from the resection
and pathological data. A p-value < 0.05 defined of a primary tumor to lung cancer metastasis
the statistically significant differences. Commer- resection was 24.5 months and it was signifi-
cial StatSoft v1.3 (Statsoft, Cracow, Poland) and cantly shorter than that elapsing from the resec-
GraphPad Prism v5.0 (La Jola, CA) statistical tion of a primary tumor to metachronous lung
packages were used for all data analysis. cancer resection, which was 49 months
( p < 0.05). The early results of surgical treat-
ment in patients treated for both lung cancer
3 Results metastasis and metachronous lung cancer were
similar (Table 4). The incidence of postoperative
Among 49 patients who underwent the second complications was noted in 31% patients with
resection of a lung cancer, metachronous cancer lung cancer metastasis and 30% patients with
was diagnosed in 23 (47%) of patients. A metachronous lung cancer.
histopathological examination revealed a
Table 3 Histological type of metachronous lung cancer and primary lung cancer in the same patient (n ¼ 23)
Metachronous cancer Primary cancer n
Squamous cell carcinomaa Squamous cell carcinoma 2
Mixed adenocarcinoma and squamous cell carcinoma Squamous cell carcinoma 2
Adenocarcinoma Squamous cell carcinoma 4
Unspecified Squamous cell carcinoma 1
Large cell carcinoma Squamous cell carcinoma 1
Squamous cell carcinoma Adenocarcinoma 3
Large cell carcinoma Adenocarcinoma 1
Adenocarcinomaa Adenocarcinoma 4
Adenocarcinoma Neuroendocrine carcinoid 1
Adenocarcinoma Large cell carcinoma 1
Adenocarcinoma Unspecified 2
Squamous cell carcinoma Unspecified 1
a
New tumor unraveled after more than 2 years from the previous cancerous episode; although histologically same, was
considered metachronous cancer; figures in bold depict these six histologically same cases
Table 4 Early postoperative complications in patients with primary lung cancer metastases (LCM) and metachronous
lung cancer (MLC)
Complication LCM (n ¼ 26) MLC (n ¼ 23)
Atelectasis caused by bronchial secretion 0 1 (4%)
Unexpandable lung 6 (23%) 3 (13%)
Cardiac arrhythmias and circulatory insufficiency 1 (4%) 2 (9%)
Bleeding into the post-treatment chamber 1 (4%) 1 (4%)
Fig. 3 Probability of 100

5-year survival in patients
with primary lung cancer
80
metastases (LCM) and with
metachronous lung cancer 60.7%
Survival (%)
(MLC) 60
50.9%
40
20 LCM
MLC
0
0 20 40 60 80
Age (years)
Table 5 Prognostic factors in patients with metachronous lung cancer (MLC) – univariate Cox regression analysis.
Risk factor RR (95%CI) p
Size of metachronous lung cancer 0.99 (0.93–1.06) 0.81
Localization: Intrapulmonary or subpleural 0.80 (0.19–3.35) 0.76
Co-morbidities 1.00 (0.98–1.01) 0.67
Age of patient 0.93 (0.82–1.05) 0.26
RR (95%CI) relative risk with the lower and upper limits of 95% confidence interval
The analysis of long-term surgery results average, 49 months after the first surgery. The
showed that the probability of the 5-year survival majority of metachronous cancers were
rate in patients with lung cancer metastasis adenocarcinomas, and their histological pattern
(50.9%) and those with metachronous lung can- usually was different from that present in the
cer (60.7%) was similar. The survival results are primary lung cancer. Metachronous lung cancer
displayed in Fig. 3. Concerning the prognostic was subject to mechanical resection in most
factors in patients with metachronous lung can- cases. The outcome of surgical treatment of
cer after surgical treatment we failed to demon- metachronous lung cancers was akin to that of
strate any effect of such factors as tumor size or lung cancer metastases, with a similar rate of
its localization in the lung, age of patient, or complication (30% and 31%, respectively) and
co-morbidities on the survival rate (Table 5). the similar probability of the 5-year survival rate
(60.7% and 50.9%, respectively).
Martini and Melamed (1975) criteria were
4 Discussion adopted in the present study for distinguishing
between metachronous lung cancer and lung can-
The major finding of this study was that a second cer metastasis, including the time lapse of at least
operation of lung cancer concerned 2 years between the resection of a primary lung
metachronous lung cancer in 47% of cases, i.e., cancer and the appearance of metachronous lung
in about one half of operations occurring after cancer. These criteria are commonly used,
surgical resection of the primary lung cancer; the although they are sometimes subject to critical
other half being due to lung metastases of the evaluation and modification. For example, some
primary cancer. Metachronous lung cancer was studies have adopted the criterion of at least a
observed mostly in men and appeared, on 4-year disease-free time after primary lung
cancer resection, which enables the diagnosis of The recommended method of surgical treat-
metachronous lung cancer (Ha et al. 2015). In the ment of metachronous lung cancer is an
present study, the mean time from resection of anatomical resection with removal of regional
primary lung cancer to resection of lymph nodes (Wen et al. 2016; Zuin et al.
metachronous lung cancer amounted to 4.6 2013). In the present study, lymph nodes were
2.1 years. Currently, the classical criteria for removed in 48% of metachronous lung cancer
the diagnosis of metachronous lung cancer cases. A low percentage of lymphadenectomy
provided by Martini and Melamed (1975) are was often caused by a misleading treatment of
more often replaced by an extended imaging, metachronous lung cancer as lung cancer
histological, genetic, and molecular diagnostics metastases. The decision on the extent of resec-
(Stiles 2017; Liu et al. 2016). The differentiation tion was made on the basis of an ad-hoc intra-
of metachronous lung cancer from lung cancer operative inspection of a resected tumor; the
metastasis, when both have the same inspection that usually is capable of providing
histopathological cancer tissue structure, can be only the information on the tumor’s neoplastic
assisted with comparative genomic hybridization character. The anatomical resection was
and somatic mutation testing (Arai et al. 2012; performed in just 17% of cases metachronous
Girard et al. 2010; Moffat-Bruce et al. 2010; lung cancer. In the present study, no patient
Wang et al. 2009). Genetic studies, however, passed away in the perioperative period. In liter-
have a limited value due to the possibility of ature, perioperative mortality associated with
different mutations in multiple tumors in the metachronous lung cancer resection ranges
same patient. Such tests also are seldom from 1.4% (Yang et al. 2014) to 2.5% (Zuin
employed since they are not commonly available et al. 2013). We found other postoperative
and pricey. complications following metachronous lung can-
The risk of metachronous lung cancer devel- cer surgery in about one third of patients, as
opment in patients after NSCLC resection is described also by other authors who noted the
1–2% per patient per year (Johnson 1998; John- perioperative occurrence of complications rang-
son et al. 1997). The literature demonstrates that ing from 19% (Zuin et al. 2013) to 34.3% (Yang
the incidence of metachronous lung cancer et al. 2014).
among patients operated on due to primary lung The probability of 5-year survival in the
cancer is about 5% (Ishigaki et al. 2013; patients of the present study treated for
Vansteenkiste et al. 2013). In Poland, the inci- metachronous lung cancer was evaluated as
dence of multiple cancers, most commonly a 60.7%. Almost the identical 5-year survival rate
second lung cancer, has also been reported at of 60.8% has been shown in a study of Hamaji
5% in patients with lung cancer (Romaszko et al. (2013). A higher survival rate of 69.5% has
et al. 2016). In the present study, however, this been shown in a most recent study of Zhao et al.
risk appeared at just 0.4%, which may have been (2017). In that study, however, only were the
due to erratic and insufficient patient attendance patients examined in whom metachronous lung
to follow-up examinations after the surgery. cancer was of adenocarcinoma type. In other
In our opinion, greater attention should be studies, the 5-year survival rate after surgical
paid to the results of a histopathological exami- treatment of metachronous lung cancer has been
nation of metachronous lung cancer. In the pres- calculated at a somehow lower level. Yang et al.
ent study, adenocarcinoma was the most (2014) have demonstrated a 54.5% survival rate,
common histological metachronous cancer type, whereas Koezuka et al. (2015) have found it at
found in 57% of patients. Similar data on the 56.5%. Zuin et al. (2013) have demonstrated a
adenocarcinoma prevalence among 42% survival rate in 121 patients with
metachronous lung cancers are provided by metachronous lung cancer diagnosed according
other authors (Yang et al. 2014; Hamaji et al. to Martini and Melamed’s (1975) criteria. The
2013; Zuin et al. 2013). 2014 meta-analysis of nine studies demonstrates
that the 5-year survival rate after surgery of a Acknowledgements Funded by the statutory budget of
second primary NSCLC is 46% (Hamaji et al. Wroclaw Medical University.
2015). There is a clear relationship between the
5-year survival rate and the stage of Conflicts of Interest The authors declare no conflicts of
interest in relation to this article.
metachronous lung cancer (Koezuka et al.
2015), or the extent of surgery: from 57% in
patients with lobectomy to 36% in patients who
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DOI 10.1007/5584_2017_78
Healthcare Professionals’ Knowledge

of Influenza and Influenza Vaccination:
Results of a National Survey in Poland
Ernest Kuchar, Kamila Ludwikowska, Adam Antczak,

and Aneta Nitsch-Osuch
Abstract
In Poland, the seasonal influenza vaccination rate is just barely 3% which
may be related to the unsatisfactory knowledge of influenza among
healthcare professionals, poor recognition of the benefits of influenza
immunization and the fear of side effects. To address these issues, we
surveyed healthcare professionals through an online questionnaire
consisting of 18 closed-ended items. The questionnaire was completed
by 495 healthcare professionals, mostly physicians (83%). The results
revealed gaps in the knowledge concerning influenza diagnosis,
complications, risk groups, and prognostic factors. On average,
respondents only answered 4.8 of the 18 questions correctly (27%).
Only 10% of respondents passed the threshold of 50% correct answers.
The knowledge of contraindications to vaccination far outweighed the
knowledge of indications for vaccination. Poor knowledge with a focus on
the adverse effects of immunization may be a significant factor responsi-
ble for the low vaccination rate in Poland. To increase vaccination rate,
healthcare professionals need to be educated about influenza-related risks
and benefits of vaccination.
Keywords
Decision making • Healthcare professionals • Immunization • Influenza •
Recommendations • vaccination
E. Kuchar
Department of Pediatrics with Clinical Assessment Unit,
Medical University of Warsaw, Warsaw, Poland
K. Ludwikowska
Department of Pediatric Infectious Diseases, Wroclaw
A. Nitsch-Osuch (*)
Medical University, Wroclaw, Poland
Department of Social Medicine and Public Health,
A. Antczak Medical University of Warsaw, 3 Oczki Street,
Department of General and Oncological Pulmonology, 02-007 Warsaw, Poland
Lodz Medical University, Lodz, Poland e-mail: [email protected]
19
20 E. Kuchar et al.
1 Introduction detail, vaccination rate is about 9% among

healthcare professionals, 0.5–1% in children
Influenza viruses are Orthomyxoviridae and are aged 6 months to 4 years, and 7–13% among
classified into three distinct types: A, B, and the elderly aged over 65 (Czarkowski et al.
C. Epidemics of influenza A and B occur annu- 2016). Since healthcare professionals are crucial
ally during the winter season in temperate to the implementation and execution of
regions of the northern hemisphere, including recommendations for the vaccination, its low
Poland, while influenza C viruses cause sporadic coverage rate may be related to their unsatisfac-
respiratory tract infections. Influenza viruses tory knowledge of influenza, poor recognition of
cause a broad spectrum of respiratory tract immunization benefits, and unjustified fears of
diseases, ranging from asymptomatic infection side effects. To address these issues, we exam-
to pneumonia and acute respiratory distress syn- ined physicians’ knowledge of influenza, its
drome, and they are responsible for significant complications and treatment, and the indications
morbidity, hospitalizations, and mortality world- and contraindications to vaccination.
wide. During the latest influenza season of 2016/
2017, approximately 3.79 m cases of influenza-
like illness were registered in Poland, with
13,000 hospitalizations and 24 deaths being
2 Methods
attributed to influenza (National Influenza Center
This survey-type study was approved by the
2017).
Ethics Committee of Warsaw Medical Univer-
Influenza A has a potential to cause global
sity in Poland and it was conducted in accord
pandemics. Five pandemics occurred in the last
with the principles of the Declaration of Helsinki
century: A/H1N1 (‘Spanish flu’ in 1918),
for Human Research of the World Medical Asso-
A/H2N2 (‘Asian flu’ in 1957), A/H3N2 (‘Hong
ciation. The population sample surveyed
Kong flu’ in 1968), A/H1N1 (‘Russian flu’ in
consisted of 495 random healthcare professionals
1977), and most recently, A/H1N1pdm09
from Poland, mostly women (70%). Four hun-
(‘Swine flu’ in 2009) (RCPCH 2016; CDC
dred and eleven respondents (83%) were
2015, 2016). The threat of a new influenza pan-
physicians, notably general practitioners, while
demic is always present. For the aforementioned
rheumatologists and cardiologists were the most
reasons, knowledge of influenza, possible
commonly represented subspecialists. Table 1
complications, treatment, and prevention is cru-
summarizes the basic demographic information
cial for healthcare practitioners. The effective
and characteristics of the participants.
prevention with immunization and a rapid diag-
An online questionnaire consisting of
nosis, followed by administration of antivirals
18 mostly multiple-answer, closed-ended items
when necessary, and the isolation of infectious
was designed explicitly for the purpose of this
patients are fundamental for the limiting of influ-
enza spread and burden. The annual influenza
vaccination is the most effective preventive mea- Table 1 Demographics and professional qualifications
sure. Polish and other national guidelines are of study participants
updated regularly and, in recent years, n (%)
indications for the vaccine use have become Gender
broader and cover, apart from the healthy popu- Men 149 (30.1)
lation aged over 6 months, such risk groups as Women 346 (69.9)
pregnant women and immunocompromised Profession
individuals (Grohskopf et al. 2016). Despite the Doctors 411 (83.0)
broad indications, influenza vaccination rate Nurses 18 (3.7)
remains very low in Poland, amounting to Medical students 20 (4.0)
Others 46 (9.3)
2.2–3.4% of the general population. In more
Healthcare Professionals’ Knowledge of Influenza and Influenza. . . 21
study by two members of the Polish Expert Com- (10.3% of correct answers), vaccine administra-
mittee of the National Program for Influenza tion routes (11.3% of correct answers), influenza
Prevention. The items contained a variable list diagnosis tests (12.1% of correct answers), and
of correct choices. When more than one choice interpretation of rapid test (13.9% of correct
was correct, all correct choices in an item had to answers). Only did 9.7% of respondents give
be checked off to include the item into correct correct answers concerning the symptoms raising
responses. The questionnaire items, along with a specter of a severe or progressive course of
the responses provided by the interviewees, are influenza. Healthcare professionals also had a
displayed in Table 2. The survey was conducted difficulty in defining the proper vaccine dosing
on-line via social media or email among a in the pediatric population (16.3% of correct
varied group of healthcare professionals. The answers). However, a low number of
questionnaire was anonymous and voluntary, pediatricians participating in the study (4% of
and the participants were informed about its respondents) could bear on this matter. Finally,
aim. Answers were scored as correct based on only did 10% of respondents pass the survey with
published literature and current the threshold set at 50% of correct answers
recommendations of the Advisory Committee (Table 2).
on Immunization Practices (ACIP) of the Centers
for Disease Control and Prevention (CDC).
4 Discussion
3 Results Every year, approximately 5–20% of the popula-

tion acquires influenza. Although the majority of
On average, respondents gave correct answers to influenza infections are benign, self-limiting, and
4.8 out of the 18 survey items, i.e., each item was require only symptomatic care, a substantial
correctly addressed by about a quarter of number of cases result in complications,
respondents (133/495 or 26.9%). The majority hospitalizations, and deaths. The analysis of
of correct responses (88.5%) concerned the long-term data in the US population of approxi-
contraindications to influenza vaccination and mately 300 m people has revealed that the num-
the recommendations for use of antivirals in ber of annual influenza-related deaths from
influenza treatment (63.0%). More than half of respiratory and circulatory causes ranged from
respondents (56.6%) knew the cardiovascular 3349 to 48,614, with an average of 23,607 deaths
indications for immunization against influenza, (CDC 2010, 2015). In the EU, the annual number
but a sunstantial number (44.4%) failed to recog- of individuals of all ages infected with influenza
nize the general recommendations for immuniza- is estimated at 25–100 m, with approximately
tion as set out in the Polish Immunization 38,500 deaths (CDC 2016). In Poland, there
Program of 2014. were 3,793,770 cases of influenza and
The knowledge of subspecialists about influ- influenza-like illness reported in the most recent
enza virus was far from being sufficient as well, 2016/17 epidemic season, with 13,779
with just 5% of respondents being able to hospitalizations or 0.36% of patients being
correctly name the virus type that was responsi- hospitalized, and 24 deaths. The incidence was
ble for ‘avian flu’. Only did 8.9% of respondents estimated at 9842 per 100,000 people (National
give correct answers concerning the transmission Influenza Center 2017). Although these figures
routes of influenza virus. Outstandingly, the change in a variable manner every next year,
majority appeared unaware of the possibility of there is a consistent impression that the disease
vertical transmission, for instance from mother to incidence increases (Table 3), which may likely
child. The gaps in practical knowledge were par- be due to persistently low vaccination rate. These
ticularly worrisome in some specific areas such data, even though they are likely underestimated
as influenza complications in pregnant women due to the imperfect, passive reporting system,
Another random document with
no related content on Scribd:
We hadn’t more than got out of New York than you
could see submarines bobbing up all around us. The
periscopes were as thick as cat-tails in a swamp. I
counted seventy-five and then the ships began to fire. The
gunner near me fainted. Shell shock, I guess. I sprang to
the gun and began shooting. The first shot I fired hit a
submarine square on top of the back and tore out its
whole back-bone, just like tearing out a whale’s back-
bone. There was blood all over the water, and some oil.
I kept on shooting. I sank twelve of the submarines
myself. The battle lasted a good while and I heard that fifty
of the submarines had been destroyed. None of us was
killed. The submarines, what was left, finally quit us. We
haven’t seen any more of them. Give this to the
newspapers.
Love to all the folks, from your soldier boy
Bill
At this early period of the naval war, the employment of the depth
charge as the most efficient weapon against the submarine had not
been fully developed. The traditions of accurate gunfire as the best
offensive were not easily set aside. It was true of the destroyers at
Queenstown, as of these yachts bound to France, that their crews
felt sublimely certain of smashing Fritz with the batteries at which
they drilled like so many skilled football teams. Soon they came to
realize, however, that the chance of catching the enemy napping on
the surface was extremely remote and that shooting at periscopes,
even when they were not imaginary, was futile business.
The Corsair was armed with four three-inch rifles, and their crews
were very capably trained under the direction of Ensign Schanze.
This armament was not heavy enough to match the guns of a U-boat
if the latter had been plucky enough to stand up to a duel, but it
served to drive him under and to inspire a wholesome respect. The
superior speed of the yacht made her particularly well fitted for using
depth charges, but at the outset she was equipped with no more
than ten of the small and rather crude “Sperry mine” loaded with
from thirty to fifty pounds of TNT. This device was exploded by
means of a buoy and wire cable which unwound as the steel canister
plunged through the water, releasing the detonator at the proper
depth. These mines frequently failed to function and the destructive
effect was feeble.
The Navy Department later perfected a terrific “ash can” packed
with three hundred pounds of high explosive which was set off by
means of a hydrostatic valve and could be relied upon to devastate a
submarine a hundred feet below the surface of the sea. These great
bombs were dropped, not one or two in an attack, but fairly dumped
overboard by the dozen or the score in a cataclysmic barrage, after
listening devices had located and “fixed” the enemy. The “Y gun,” or
twin mortar, was also invented to hurl these metal kegs a
considerable distance from the ship. Such were the perfected tactics
learned from experience, which would surely have doomed the U-
boat to extinction if the armistice had not intervened. The Corsair
was fitted out in this manner later in her service, but she blithely
sailed for the war zone with her four small guns and a few “Sperry
pills” and could have felt no more pride in her task if she had been a
first-class battleship.
Concerning the voyage, Commander Kittinger reported as follows,
in the War Diary of the yacht:
Got under way at 4 a.m., June 14th, and stood down the
river, anchoring at 6 a.m. off Governor’s Island on account
of fog. Got under way again at 9.40 a.m. Laid to off
Ambrose Light Vessel at 1.20 p.m. Joined Group No. 1 at
1.50 p.m. and took departure from Ambrose Light Vessel at
2.09 p.m., standard speed 12 knots. At 2.30 p.m. weather
became misty again which necessitated closing in to keep
the convoy in sight. The 4 to 8 p.m. watch had difficulty in
keeping steam for 12 knots. Blowers were used to assist.
Ship lost distance which was recovered in the next watch
and position maintained.
At 11.40 p.m. the fog set in thick and lasted until about
1.25 a.m., June 15th. At 3.20 a.m. the convoy was sighted
on the port bow, distance four miles. During the watch the
ship logged over 12 knots by revolutions of main engines,
but due to deep draft was unable to keep up. The blowers
were run continually to assist. The forward boiler could not
be lighted off as it was banked in with reserve coal supply.
Between 4 and 5 a.m. while cleaning fires the speed by
revolutions dropped to 11 knots. A moderate sea was
running which caused seasickness among the firemen.
The firemen were drafted from the U.S.S. Delaware
through the receiving ship at New York and were
unfamiliar with firing Scotch boilers and not accustomed to
the quick and deep roll of small ships. Most of them
became useless during the cleaning fire period and their
places were taken by petty officers of the engine and fire-
room watch. The ship continued to lose distance astern of
convoy, a logged speed of 10½ knots being maintained. I
gave this matter my personal attention and every effort
was made to rejoin the convoy. From noon to midnight an
average speed of 11¾ knots was logged. At 4.45 p.m. the
Wilkes came within hail and made inquiries as to the
cause of the Corsair’s inability to keep in position.
June 16th. An average speed of 10½ knots was logged
for the day. I found that the seasoned men, most of them
petty officers, were showing fatigue due to the hard
steaming qualities of the ship. A number of volunteers
from the deck force went below and passed coal and
handled ashes to assist. The reserve coal from the dead
fire-room was removed to allow the forward boiler to be
lighted off. Group No. 1 was not seen this day. Group No.
2 was sighted astern at 3.40 a.m. Lighted fires in boiler
No. 1 at 6 p.m.
June 17th. Maintained about 11 knots (by revolutions).
Some of the firemen who had suffered from seasickness
were back at useful work and the ship had become
considerably lighter. At 5 p.m. cut in boiler No. 1 and
increased speed to 13 knots. Between 1 and 2 p.m. two
U.S. destroyers passed six miles to the southward, one
heading east and one west.
June 18th. Averaged 13½ knots until 10.40 a.m. when
speed was reduced to 10 knots to lose distance and join
Group No. 2.
June 19th. Proceeding at reduced speed to allow Group
No. 2 to overhaul.
June 20th. Proceeding at reduced speed, about 9 knots,
to allow Group No. 2 to overhaul. It was desirable to keep
a speed that was low but economical to get the mileage
for the fuel.
June 21st. Proceeding at reduced speed, about 7 knots.
At 3.45 a.m. sighted Group No. 2 on port quarter,—
distance four miles. Changed course to intercept. At 5.15
a.m. took position on starboard beam of Henderson,
distance 2000 yards. At 6 p.m. sighted U.S.S. Maumee
and U.S.S. Henley on starboard bow. The Burrows joined
the Maumee and refueled. At 8.22 a.m. stopped and
lowered a boat and boarded the Birmingham for orders. At
9.35 a.m. proceeded in formation at 12 knots. Had no
trouble in keeping position from this time on with natural
draft. Zigzagged during the afternoon.
June 22nd and 23rd. Proceeding with Group No. 2.
Zigzagged during daylight.
June 24th. Momus broke out break-down flag and
dropped astern of formation. At 8.17 a.m. sighted three
destroyers one point on port bow. Five destroyers joined
escort during the morning.
June 25th. Proceeding as before. At 5.30 a.m. steamed
at 14 knots. At noon steamed at 13 knots. Zigzagged
during daylight.
June 26th. Proceeding with Group No. 2, steaming at 13
knots. The U.S.S. Cummings let go a depth charge at 2.00
p.m. about 600 yards ahead. Manœuvred for attack.
Nothing sighted. Returned to formation. Two French
torpedo craft joined escort about 4 p.m.
June 27th. Entered port during mid-watch. Anchored
during morning watch with 32 tons of coal remaining.
Arrived at Saint-Nazaire, France, with Group No. 2 of
Expeditionary Force.
THE KIND OF “GOBS” THE COUNTRY WAS PROUD OF MOST

OF THIS GROUP WON COMMISSIONS
Photograph by Underwood and Underwood, N.Y.
THE GERMAN SUBMARINE WAS A TINY TARGET EVEN WHEN

ON THE SURFACE
These were tired and grateful sailors aboard the Corsair, for the
slow-gaited transports, thirteen days on the voyage, had caused
continual anxiety among the war vessels of the escort. The first
group had been attacked by submarines, as reported by Rear
Admiral Gleaves, and it was an auspicious omen that every ship and
every soldier had been carried across unharmed. The Corsair had
been compelled to drop back and join the second group, but it was
not her fault. As her skipper in former days, Lieutenant Commander
Porter was unhappy, as you may imagine, although he knew that the
yacht would vindicate herself when in proper trim and with a “black
gang” that could make steam and hold it.
Extra coal and stores had made the draft two feet deeper than
normal. One boiler-room was used for coal stowage, but a speed of
fourteen knots was to be expected under these conditions. The
firemen, trained in a battleship, were green to their task and were
bowled off their pins by seasickness. It indicated the spirit of the ship
when the petty officers, deck force and all, and as many other
volunteers as could find space to swing slice-bar and shovel, toiled
in the sultry heat of the furnaces to shove the ship along. Never
again was the Corsair a laggard. Month after month on the Breton
Patrol or with the offshore convoys, the destroyers were the only
ships that could show their heels to her.
The process of “shaking down,” of welding a hundred and thirty
men into a crew, and teaching them what the Navy was like, had
begun with the hard routine at the docks in Hoboken and Brooklyn.
The voyage was the second lesson and it wonderfully helped to
hammer home the doctrines of team-work and morale, of cheerful
sacrifice and ready obedience. Those who grumbled repented of it
later and held it as a privilege that they were permitted to play the
great game. It was while they sweltered to make more steam and
urge the ship to greater speed that an Irish stoker expressed himself
as follows:
“I have heard tell of the meltin’-pot, but ’tis me first experience with
it. Hotter than hell wid the lid off, and ye can see thim all meltin’, and
will ye listen to the names of the brave American lads, Brillowski,
Schlotfeldt, Aguas, and Teuten that signed on to juggle the coal. An’
will ye pipe off the true-blue Yankee sailors, Haase, and Skolmowski,
Fusco, Kaetzel, and Balano, not to mintion such good old Anglo-
Saxon guys as De Armosolo, Thysenius, and Wysocki. I will make
no invidjous distinctions, but what kind of a fightin’ ship would this be
if ye hadn’t Gilhooley, Mullins, Murphy, Mulcahy, Egan, Sullivan, and
Flynn? The meltin’-pot! ’Tis a true word. An’ may the domned old
Kaiser sizzle in a hotter place, if there is wan.”
One of the boyish bluejackets noted his own change of heart in a
diary which contained such entries as these:
June 19th. At 6 a.m. we sighted an empty lifeboat. Don’t
know where it came from, as there was no name. We also
saw two objects floating quite far off and thought they
were corpses, but were not sure.... Stood two watches
and had an abandon ship drill and gun practice. Wrote
some letters, but don’t know when we can mail them.
Sighted a big whale not fifty yards from the ship. It scared
me. I was at the wheel and thought it was a submarine.
Sleeping in my bunk for the first time since leaving New
York.
21st. We are having a typical northeaster and the ship is
burying her rails in the sea now and then. We have joined
the second group of the fleet. It consists of the
Birmingham, four transports, a destroyer, ourselves, and
the Aphrodite.... 22nd. The northeaster is still on in full
blast and the sea is running high. We hope to reach
France Tuesday. The food and the life on this ship are
pretty bad, and when this war is over and I sign off I shall
devoutly thank God.
23rd. A pretty bad day all round. High sea, rain, and fog.
We are now in the war zone and zigzagging back and
forth across the ocean. The Birmingham has kept us busy
all day with signals. The ship has been very hard to steer
and I am tired out. Broke a filling out of my tooth and it
hurts. Hope I will get a chance to have it fixed in France. A
toothache out here would certainly be bad. Have been
unable to take a bath for a week. Am washing in a bucket
of water.
24th. Another day of nasty weather. The mid-watch was
the worst I ever stood. The fog was awful and when I was
at the wheel we almost rammed the Antilles. We also
dodged two suspicious-looking steel drums that looked
very much like mines.... 25th. Our coal is getting low and
we will surely land some time to-morrow morning. I wish I
could talk French. Everybody is writing letters home to-
day. Stood a terrible watch with Mr. Tod on the bridge. He
and Captain Kittinger took turns bawling me out. I almost
rammed a destroyer twice by obeying orders to the letter,
but the officers were in a bad temper and blamed me.
Gad, but I’ll be glad to set foot on dry land.
Somewhat later this same young man was jotting down:
Whoever reads this diary will probably notice my
changed attitude toward what we have to put up with.
What seemed unbearable a few months ago amounts to
nothing, now that we have become hardened to all things.
I have read the whole diary through and laughed at my
early grouches.
And so the Corsair came to France and rested in the quaint old
port of Saint-Nazaire while her men beheld the troops of Pershing’s
First Division stream down the gangways and receive a welcome
thrilling beyond words, the cheers and outstretched hands, the
laughter and the tears of a people who hailed these tall, careless
fighting men as crusaders come to succor them. This was a sight
worth seeing and remembering. And when the American sailors went
ashore there was an ovation for them, flowers and kisses and
smiles, and if such courtesies were bestowed upon the bluejackets
of the Corsair, they gallantly returned them, it is quite needless to
say.
Seven of the crew were granted liberty for a hasty trip to Paris.
Seaman Arthur Coffey was in the party and his written impressions
convey a glimpse of what it meant to these young Americans to
come into contact with the sombre realities of the struggle which
France was enduring with her back to the wall. It surprised and
amused them to find the American infantrymen already so much at
home in Saint-Nazaire that their liveliest interest was in shooting
craps at the street corners:
Here were soldiers and sailors who had just crossed an
ocean full of hidden terrors [observed Arthur Coffey], and
most of them were to face worse terrors later on, but did
they consider these things? Not for a minute! They had
money in their pockets and beer under their belts and this
“spiggoty” currency, as they called the wads of paper
notes, made them feel like millionaires. The marines had
not arrived to police the streets, so they rattled the dice in
crowds. For all they saw or cared, they might have been in
their own home towns, perfectly indifferent to their
surroundings. The French onlookers were different. They
were appraising these new comrades-in-arms, whispering
among themselves, admiring the equipment and the
rugged stature of these soldiers from beyond the seas. We
watched the fun until it was time to find the train for Paris
and moved away with cries of, “Shoot the cinq-froncs,”
“Fade him for a cart-wheel, Bill,” “Come on, you baby,”
ringing in our ears.
We got aboard the right train with the kind assistance of
a French lady who interpreted for us. It was great luck to
get the seventy-two-hour leave, and the crowd was
congenial, five men from Princeton, one from Yale, and
one from Cornell. The trip to Paris was lengthy because
we had to travel second class and sit up all night, being
Navy gobs and not officers. The French took us for plain,
ordinary bluejackets and fraternized at once. Their style of
opening a conversation was to sit and look at you for a
time, smile, and then having attracted your attention, with
a terrifying grimace ejaculate: “Le boche, ah-h-h-k!”
drawing a hand across the throat. This done they would
beam expectantly and, needless to say, we responded
with grimaces even more terrifying and repeated the
formula. Having mutually slit the gullet of the hated foe, I
would add, to show off my French, “Je n’aime pas le
boche!” Then the way was opened for a conversation.
“Parlez-vous français, monsieur?” “Mais un peu,
monsieur,” I would say, and then bang away with the
stereotyped sentence, “I have studied French two years at
school and I can understand the language pretty well, but I
cannot speak it.” As soon as my friend, the French soldier,
heard me rip off this sentence he would open his eyes and
say, “Parlez bien français, monsieur” and then start talking
so fast that I could not understand a word, and this would
be the end of the conversation, on my part, at least.
Some of my companions, however, were even worse
performers than I. Poor old Bill Rahill, who was in my class
in college, had taken economic courses and so knew no
modern languages. All he could say was “Oui” and “Non
comprenny, monsieur,” at which I would nudge him and
ask if it were not better, perhaps, to have a little culture
and know something about a foreign language than to be
cluttered up with the Malthusian theory or some other rot
like that.
We had a great time on that train to Paris. At the first
long stop almost everybody got out and went into the
waiting-room, or saloon, and bought various refreshments.
We had seen no grass or green trees for two weeks, so
we piled out and made for the beautiful lawn near the
station. We rolled on the grass and sniffed the pine trees.
We were like cats that had been shy of catnip for a long
time. I suppose the French people thought we were crazy,
but we didn’t care, and it certainly did feel good to have
the green earth under our feet again.
BOATSWAIN’S MATE THE TALL ONE IS
SEGER, FROM PASSAIC PHARMACIST’S MATE
FEELEY HIS FRIEND IS
MESS ATTENDANT
MARTINEZ
Then we wandered into the restaurant and loaded up

with cheese and a couple of yards of war bread, and one
of the fellows bought several bottles of champagne at a
ridiculously low price. Thus armed, we climbed into the
train where we met two French soldiers who were
returning to the trenches. They let us try on their helmets
and gas-masks and they spoke a little English, so with
plenty of gestures we got on very well. They said they
knew we were Americans because we talked through our
noses. We took that good-naturedly, but I noticed that my
brother gobs began to speak way down in their throats
right after that. We chewed on the war bread and washed
it down with champagne. That is a great breakfast
combination, you can take my word for it. And then some
one piped up a song. “Buck” Bayne, Yale 1914, was handy
at fitting words to college airs and we soon had a fine
concert going. One of the ditties, I remember, went like
this, to the tune of “Cheer for Old Amherst”:
“Good-night, poor U-boats,

U-boats, good-night!
We’ve got your number;
You’re high as a kite.
Good-night, poor U-boats,
You’re tucked in tight.
When the U.S. fleet gets after you,
Kaiser, good-night!!”
Before long we had a crowd around that train

compartment that you couldn’t get through to save your
neck. The Frenchmen all applauded the Corsair glee club
and yelled for more, but we felt too conspicuous and so
we persuaded the poilus to sing some funny trench songs,
which we couldn’t understand, but we laughed and
slapped them on the back as though we knew every word.
Next morning we arrived in Paris, and, with a few other
men from our ship, were the first American sailors in that
city since our country had declared war. You can imagine
what that meant to us, how the people greeted us with
cordial affection and kindness. Thank God, the Frenchmen
did not try to kiss us! If the Paris girls had insisted, we
should have submitted like gentlemen. We put up at the
Hotel Continental, and were more than amused at the
expressions on the faces of several dignified English
officers when they saw seven common bluejackets of the
American Navy blow in and eat breakfast next to them.
That day we ran into lots of friends who were in the
American Field Ambulance Service, attached to the
French Army, and they told us gloomy tales about the war
outlook. They said the Russians were through, that the
French were literally shot to pieces, and that the job of
finishing the war was up to us. Imagine it—I, who had
hoped in May that the Russians would keep on retreating
so that I could get a chance to see the show before it was
over, was now wishing that the war would end. I have
seen the light since that day. We fellows were really
feeling the war for the first time when we noticed that the
streets of Paris were filled with crippled men and with
women in mourning.
We spent two busy days in mixing with soldiers of all
nations and doing Paris. The troops who impressed us
most, even more than the French, and that is going some,
were the Canadians. They gave us such a rousing
welcome that it was like being home again. They were so
glad to see us that they almost wrapped themselves
around our necks. “Hello, Jack,” was their invariable
greeting. “How are things over in the States?” “It’s sure
good to see you.” “When are your troops coming over?”
“What, you came across with some of them?” “The devil
you say!” “Well, all I hope is that they give us a chance to
fight alongside the Yanks. We’ll go through Fritz so fast
that he won’t know what hit him.”
While we were knocking about Paris with the
Canadians, our money was no good. They insisted on
buying us drinks, cigarettes, and acted as interpreters.
There was nothing they wouldn’t do for us. Our spirits
began to rise at once. We asked them about all the
pessimistic rumors. Were they true? “Hell, no,” said they.
“Why, there’s nothing to it. Shell ’em a bit, then shell ’em
some more, and when you go over the top, Fritz just sticks
up his hands and yells that he’s your kamerad.” “As soon
as he sees the cold steel, up goes his bloody hands,” one
little chap confided to me. And he had such a look in his
eye when he said it that I think my blooming hands would
have been up if he had said the word.
They were the most confident lot of men I ever saw.
This was the first visit to Paris for most of them. They had
been out there for two years, getting leave only among the
little villages back of the line, but they didn’t seem to mind
going back to the trenches. And they were always talking
about the war and their campaigns. The soldiers of other
nations seemed fed up with it, but not so with the
Canadians. Why, I heard two of them, a private and a
captain, in a heated argument across a table as to how
they could capture Lens without letting the Germans
destroy the coal mines. The private leaned over and
poked the captain in the stomach to emphasize a point,
and the captain tried to out-shout his companion. One
would have thought them to be a couple of privates.
On the morning of the third day we left Paris for our
port. Dave Tibbott, a classmate of mine, practiced talking
French to a lad in the train, and Bill Rahill said “Oui” and
“Voilà” to a pretty girl who shared the compartment. She
seemed to be partial to Bill’s smile, for we all had him
beaten on slinging the French. When she left the train, Bill
helped her out and kissed her hand by way of farewell.
When we kidded him about it, he defended himself on the
ground that they did such things in France and one must
follow the customs of the country.
We had many yarns to spin when we boarded our ship
and we were careful to tell the boys about the fine baths in
the hotel, although we omitted the fact that there was no
hot water. When we described the wonderful soft beds, it
looked as though there might be a lot of desertions from
the Corsair.
I saw many interesting sights during my stay in French

waters, but my eyes went bad and they put me ashore
where I stayed a month and a half waiting for a ship to
take me home. I was finally sent back to the United States
in August and, to my great sorrow, received a medical
discharge. The life is hard in the Navy in the war zone,
harder than anything I had ever done before, but I would
give ten years of my life to have been able to stick it out
with the boys on the old Corsair and do my share.
FOOTNOTES:
[1] See Chapter xiv.
[2] Returned home on ship twenty-three months later.
[3] Destroyer Cummings.
CHAPTER III
AT SEA WITH THE BRETON PATROL
W HEN the Corsair arrived on the French coast there was nothing
to indicate the vast American organization, military and naval,
which was soon to be created with a speed and efficiency almost
magical. Supply bases, docks, fuel stations, railroads were, at the
outset, such as France could provide from her own grave
necessities. Marshal Joffre and Lord Balfour had convinced the
Government at Washington that if the United States delayed to
prepare, it might be too late. Troops were demanded, above all else.
Man power was the vital thing. And so these early divisions were
hurried overseas to Pershing with little more than the equipment on
their backs.
The Navy was aware of its own share of the problem which was to
extend its fighting front to the shores of France as well as to the Irish
Sea. To protect the ocean traffic to and from the United States,
small, swift ships were required by the dozens and scores, but they
could not be built in a day, and, as a British admiral expressed it,
“This rotten U-boat warfare had caught all the Allies with their socks
down.” Of the naval escort with the First Expeditionary Force, the
cruisers returned to the United States for further convoy duty and the
destroyers went either with them or were ordered to join the flotilla at
Queenstown. For a short time the Corsair and another large yacht,
the Aphrodite, were left to comprise the American naval strength on
the French coast. On June 30th, Commander Kittinger received the
following instructions from Rear Admiral Gleaves:
When in all respects ready for sea, proceed with the
vessel under your command to Brest, France, and report
to the Senior French Naval Officer for duty. Exhibit these
orders to the Senior United States Naval Officer in Brest.
Upon the arrival of Captain W. B. Fletcher, U.S. Navy,
report to him for duty.
The tenor of these orders indicated the wise and courteous policy
which Vice-Admiral Henry B. Wilson was later to develop with
brilliant success—that of coöperation with and deference to the
French naval authorities instead of asserting the independence of
command which, in fact, he exercised. At this time Captain Fletcher
had been appointed to organize the American “Special Patrol Force,”
and he was daily expected to arrive in the yacht Noma. The ancient
port of Brest was selected as the chief naval base because the
French had long used it for this purpose, maintaining dockyards,
repair shops, and arsenals, and also because the largest transports
afloat could be moored in its deep and spacious harbor. Saint-
Nazaire and Bordeaux became the great entry ports for cargo
steamers during the war, while into Brest the huge liners carried
twenty thousand or forty thousand troops in a single convoy.
WINNING BOAT CREW IN FOURTH OF JULY RACE WITH

APHRODITE
“THE BRIDGE GANG”
The Corsair steamed into Brest on July 2d in company with the

Aphrodite and duly reported to Vice-Admiral Le Brise, of the French
Navy. Two days later a fleet of other yachts arrived from home and
were warmly welcomed, the Noma, Kanawha, Harvard, Christabel,
Vidette, and Sultana. With this ambitious little navy it was possible to
operate a patrol force which Captain Fletcher promptly proceeded to
do, acting in concert with the French torpedo boats, armed trawlers,
submarines, and aircraft.
The Corsair lay in port ten days to coal, paint ship, and otherwise
prepare for the job of cruising in the Bay of Biscay. An unofficial log,
as kept by one of the seamen, briefly notes:
July 2nd. Sailed for Brest from Saint-Nazaire at 4 a.m.
Arrived at 3 p.m. and received four submarine warnings on
the way. We thought we saw two periscopes, but they may
have been buoys. We have added a French pilot to our
crew. No shore liberty, as we are too tired. We hear we are
to be over here a long time, with Brest as our base.
July 3rd. I spent the day painting the bridge. The ship
looks fine. I am also standing a twelve-hour watch in order
to give the other signal-men shore liberty. We caught a
bunch of mackerel over the side to-day and will fry them.
The Aphrodite has challenged us to row them a race to-
morrow. A big French dirigible went out to sea to look for
submarines.
July 4th. A national holiday, but not for us. We won the
race from the Aphrodite. The Noma and the Kanawha
arrived this morning. They fought a submarine, but no
damage was done on either side. We expect to get under
way any minute and will look for the U-boat that shot at
the Noma. We had water sports in the afternoon and they
were good fun.
July 5th. The Sultana arrived to-day. She picked up all
the survivors of the S.S. Orleans which was torpedoed on
the 3rd. Five of them were put aboard this ship and their
description of the sinking was harrowing. Only two
lifeboats got away. Four men were killed. The ship sank in
ten minutes. According to the dope, the Corsair will sink in
three minutes, if struck. Cheerful, what?
July 6th. This was my first liberty in Brest. It is a very old
town high on the cliffs. We went through the Duke of
Brittany’s old castle which dates back some fifteen
hundred years and was once the homestead of Anne of
Brittany. The dungeons were mighty interesting. They
surely did treat ’em rough in those days. These rooms are
more than two hundred feet down in the solid rock and
have been dark for ages. I should call them unhealthy. The
tortures they used to inflict on the prisoners were
diabolical. And yet you’ll hear gobs growling about the
Navy. All of which reminds me that life on shipboard has

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